All practice questions

A 58-year-old man is brought to the emergency department after sustaining a severe traumatic brain injury in a fall from a roof. He is comatose, requires emergent intubation, and lacks decision-making capacity. A review of his electronic medical record and discussions with his family confirm that he does not have an advance directive, nor has he designated a healthcare proxy or durable power of attorney for healthcare. He does not have a court-appointed guardian. Several family members have arrived at the hospital and wish to be involved in his care decisions. In most US jurisdictions, arrange the following individuals in the correct legal order of priority to act as the patient's surrogate decision-maker, from highest priority (first) to lowest priority (last).

A hospital's hematology-oncology clinic is preparing to launch a new outpatient blood transfusion service. Recognizing that this introduces a high-risk procedure to an ambulatory setting, the department leadership decides to conduct a Failure Mode and Effects Analysis (FMEA) to prospectively identify and mitigate risks before treating the first patient. Arrange the following steps of the FMEA process in the correct chronological sequence from initiation to final implementation.

Following a catastrophic subarachnoid hemorrhage, an adult female patient in the surgical intensive care unit permanently loses decision-making capacity. The clinical team determines that a tracheostomy is medically indicated and must seek consent. The patient's medical record does not contain a living will, and she does not have a court-appointed guardian. Several individuals are present in the waiting room, each insisting they have the authority to direct her care. Arrange the following individuals in the legally recognized order of priority for surrogate decision-making, from highest priority (first) to lowest priority (last).

A local health department receives multiple reports of severe acute gastroenteritis among attendees of a large community festival. As the lead public health physician, you are tasked with initiating the formal outbreak investigation. Arrange the following fundamental steps of the epidemiological investigation in the standard chronological sequence recommended by public health guidelines.

A 45-year-old man comes to the clinic to establish care. He has not seen a physician in over a decade and feels entirely well. He has no history of injection drug use, tattoos, or blood transfusions. Physical examination is unremarkable. According to current United States Preventive Services Task Force (USPSTF) guidelines, universal screening for Hepatitis C is indicated. Assuming all diagnostic findings are positive, arrange the following steps in the most appropriate chronological sequence for the screening, confirmation, and management of Hepatitis C in this patient.

An occupational health clinic observes a sudden spike in employees presenting with severe respiratory symptoms and bilateral pulmonary infiltrates at a large industrial manufacturing plant over a four-day period. The state public health epidemiologist is called in to direct the response to this suspected point-source exposure. Arrange the following standard epidemiological outbreak investigation steps in the correct chronological sequence, starting with the earliest action that should be taken.

A 10-year-old girl is diagnosed with localized osteosarcoma of the right distal femur. The pediatric oncology and surgical teams recommend neoadjuvant chemotherapy followed by limb-sparing resection, a regimen that offers a highly favorable prognosis and high probability of cure. The patient's parents adamantly refuse both chemotherapy and surgery, citing their religious belief that prayer alone will heal the tumor. The patient is currently in no acute distress and is hemodynamically stable, but the malignancy will inevitably metastasize and become fatal without standard medical intervention. Arrange the following steps in the most appropriate chronological order for managing this parental refusal of life-saving care.

A physician working in a large group practice observes that a peer colleague is consistently arriving late, resulting in rushed patient encounters and delayed review of critical laboratory results. No adverse patient outcomes have occurred yet, but the pattern of behavior is creating an unsafe clinical environment. Assuming each preceding action fails to change the colleague's behavior, arrange the following steps in the most appropriate sequence for escalating this professionalism concern, from the initial action to the final recourse.

A 72-year-old man with a history of moderate vascular dementia is admitted to the medical ward with a severe diabetic foot infection. The surgical team recommends a below-the-knee amputation to prevent life-threatening sepsis. The patient refuses the procedure, stating, 'My foot is fine, it just needs a good wash.' The attending physician decides to evaluate the situation further, as the patient's refusal poses a high risk to his life. Arrange the following clinical and ethical steps in the most appropriate sequential order for managing this patient's refusal of care, starting from the initial bedside assessment to the final steps of identifying a substitute decision-maker.

A 68-year-old woman is admitted to the intensive care unit with severe septic shock secondary to ischemic bowel disease. She is intubated, mechanically ventilated, and deeply sedated, rendering her without decision-making capacity. The surgical team determines that an emergent exploratory laparotomy is required to improve her chances of survival. The patient does not have an advance directive, and there is no record of a legally appointed healthcare proxy or durable power of attorney for healthcare in her medical file. The clinical social worker locates several family members in the waiting room who all wish to be involved in her care. According to the standard statutory hierarchy of surrogate decision-makers in most US jurisdictions, arrange the following family members in the correct order of priority to provide informed consent for the surgery, from highest priority to lowest priority.

A 28-year-old man presents to the clinic complaining of a painless, enlarging lump in his right neck that he noticed two months ago. He also reports drenching night sweats and a 5-kg (11-lb) weight loss over the past six weeks. On physical examination, a 3.5-cm, firm, rubbery, mobile lymph node is palpated in the right anterior cervical chain. The remainder of the examination is unremarkable. Basic laboratory studies reveal a normocytic anemia and an elevated erythrocyte sedimentation rate. The physician suspects a hematologic malignancy.

Arrange the following steps in the most appropriate clinical sequence for the definitive diagnosis, staging, and initial management of this patient.

An anesthesiologist is observed pocketing partial vials of fentanyl during surgery and later appears drowsy and uncoordinated in the staff lounge. Arrange the following steps in the correct chronological sequence for addressing and managing this suspected physician impairment according to professional and ethical guidelines.

A 72-year-old man is admitted to the intensive care unit with severe septic shock and acute respiratory distress syndrome. He is intubated, sedated, and lacks decision-making capacity. The critical care team must make immediate decisions regarding the initiation of renal replacement therapy. The medical record contains no advance directive or designated healthcare proxy. Several individuals who care about the patient are present in the family meeting room, but they disagree on the goals of care. According to the standard statutory hierarchy of surrogate decision-makers in most US jurisdictions, arrange the following individuals in the correct legal order of priority to act as the primary decision-maker, from highest priority (first) to lowest priority (last).

A 58-year-old man with chronic limb-threatening ischemia is advised to undergo urgent revascularization. He refuses the procedure, stating he does not want surgery. The physician decides to formally assess the patient's decision-making capacity. Arrange the following components of the capacity evaluation in the hierarchical order they must be demonstrated, progressing from the most basic foundational requirement to the most complex cognitive task.

A hospitalised 68-year-old female is evaluated on postoperative day 6 following an elective right total knee arthroplasty. She reports new-onset pain and tightness in her right calf. She has been receiving subcutaneous unfractionated heparin for chemical thromboprophylaxis since her surgery. Vital signs are within normal limits. Physical examination reveals an erythematous, swollen right lower extremity with tenderness to palpation over the popliteal fossa. A venous duplex ultrasonography confirms an acute occlusive thrombus in the right popliteal vein. Laboratory studies show a current platelet count of $55,000/\text{mm}^3$. Her preoperative baseline platelet count was $250,000/\text{mm}^3$. The patient has no history of liver disease or other bleeding disorders. Based on the calculated clinical probability score, arrange the following management steps in the correct chronological sequence for this patient.

A 62-year-old man with a history of end-stage renal disease comes to the emergency department due to severe muscle weakness and palpitations. He reports missing his last two scheduled hemodialysis sessions because of transportation issues. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $112/68\text{ mmHg}$, pulse is $52\text{/min}$, and respiratory rate is $16\text{/min}$. Physical examination reveals diminished deep tendon reflexes in both lower extremities. An electrocardiogram demonstrates widened QRS complexes and tall, peaked T waves. A point-of-care basic metabolic panel reveals a serum potassium level of $7.9\text{ mEq/L}$. Arrange the following therapeutic interventions in the most appropriate sequential order of execution, from the most immediate priority to the definitive management step.

A 68-year-old man presents to the clinic with a 2-year history of progressive right knee pain. The pain typically worsens at the end of the day or after prolonged walking, and it improves with rest. He reports about 10 to 15 minutes of joint stiffness in the morning. His medical history is significant for hypertension. Physical examination reveals bony enlargement, decreased range of motion, and crepitus of the right knee without significant effusion, erythema, or warmth. Radiographs show medial joint space narrowing, subchondral sclerosis, and osteophyte formation. Arrange the following interventions in the generally recommended, step-wise sequence for the management of this patient's condition, assuming an inadequate response to each preceding step.

A 38-year-old woman is admitted to the medical ward due to a sudden onset of severe headache, palpitations, and profuse diaphoresis. Her blood pressure is 185/115 mm Hg, and her heart rate is 118/min. She reports experiencing three similar episodes over the past month. The clinical presentation is highly suspicious for a catecholamine-secreting neuroendocrine tumor. Arrange the following steps in the most appropriate chronological sequence for the comprehensive diagnostic evaluation and perioperative management of this patient's suspected condition. Assume each step yields confirmatory findings that warrant progression to the subsequent step.

A male college student, aged $19$, is brought to the emergency department after his roommate found him confused and vomiting. He has been complaining of abdominal pain for the past day. On physical examination, he appears lethargic and has dry mucous membranes. Vital signs demonstrate a heart rate of $120$ beats per minute and a blood pressure of $90/60$ mmHg. Point-of-care capillary glucose testing shows a level of $480$ mg/dL. An arterial blood gas analysis reveals a pH of $7.12$. A dipstick urinalysis is strongly positive for ketones. The patient is diagnosed with diabetic ketoacidosis. Arrange the following interventions in the most appropriate chronological order for his initial management.

A 24-year-old man with a history of type 1 diabetes mellitus is brought to the emergency department with altered mental status, vomiting, and diffuse abdominal pain. His blood pressure is 90/60 mmHg, heart rate is 125/min, and respiratory rate is 28/min with deep, rapid breaths. Laboratory studies reveal a blood glucose of 650 mg/dL, arterial pH of 7.12, serum bicarbonate of 10 mEq/L, and a high anion gap. Urinalysis is strongly positive for ketones. Arrange the following steps in the management of this patient's condition in the most appropriate chronological order.