All practice questions

A 3-year-old girl is brought to the emergency department by her parents because she has been refusing to walk since waking up this morning. The parents note she was entirely well yesterday but developed a fever overnight. On examination, her temperature is 39.2°C (102.6°F), heart rate is 130/min, and blood pressure is 95/60 mm Hg. She is holding her right leg in a flexed, abducted, and externally rotated position. She cries inconsolably with any passive range of motion of the right hip. There is no history of trauma.

Arrange the following steps in the most appropriate sequential order for the diagnostic and therapeutic management of this patient.

A $45$-year-old man presents to the clinic for follow-up of resistant hypertension. He currently takes amlodipine, lisinopril, and chlorthalidone at maximal doses, but his office blood pressure remains $168/98$ mm Hg. He has recently experienced episodes of severe muscle cramps and generalized weakness. Laboratory studies show a serum potassium level of $2.8$ mEq/L and a serum sodium level of $144$ mEq/L. Suspecting a secondary endocrine etiology, the physician plans a comprehensive diagnostic workup. Assume the patient is a surgical candidate and that each consecutive diagnostic test in the algorithm yields abnormal results consistent with a unilateral adrenal source. Arrange the following diagnostic steps in the correct chronological sequence for the evaluation of this patient.

An $82$-year-old man is evaluated on postoperative day $3$ following an open reduction and internal fixation of a right femoral neck fracture. The nursing staff reports that he has developed severe abdominal distension and worsening nausea over the last $24$ hours. His medical history includes hypertension, benign prostatic hyperplasia, and osteoarthritis. He is currently receiving intravenous morphine for pain control.

Vital signs are temperature $37.2^\circ\text{C}$, blood pressure $110/70\text{ mmHg}$, pulse $105/\text{min}$, and respirations $18/\text{min}$. Physical examination reveals a massively distended, tympanitic abdomen with markedly decreased bowel sounds. There is diffuse mild tenderness to palpation but no guarding, rigidity, or rebound tenderness.

Laboratory studies reveal:
- Leukocytes: $8,500/\text{mm}^3$
- Sodium: $138\text{ mEq/L}$
- Potassium: $3.1\text{ mEq/L}$
- Calcium: $8.4\text{ mg/dL}$

An abdominal radiograph demonstrates marked gaseous distension of the cecum to $10.5\text{ cm}$, as well as dilation of the ascending and transverse colon. There is no distinct transition point and no free intraperitoneal air.

Based on the diagnosis of acute colonic pseudo-obstruction (Ogilvie syndrome), arrange the following therapeutic interventions in the correct chronological sequence, from initial management to the definitive treatment of last resort, assuming each preceding step fails to achieve clinical resolution.

A 52-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department after vomiting a large volume of bright red blood. His blood pressure is 88/50 mmHg and pulse is 124/min. Arrange the following steps for the management of this patient in the most appropriate chronological order, from first to last.

A 54-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department by his family after vomiting a large amount of bright red blood. Upon arrival, he appears pale and lethargic but is adequately protecting his airway. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $85/55$ mmHg, and pulse is 120/min. Physical examination reveals shifting dullness, spider angiomas, and palmar erythema. Arrange the following steps in the optimal chronological sequence for the management of this patient's condition, from most immediate to subsequent.

A $32$-year-old woman is brought to the emergency department by her husband due to severe confusion, agitation, and repeated vomiting over the past $12$ hours. She had an uncomplicated spontaneous vaginal delivery $3$ days ago. Her past medical history is notable for Graves disease, for which she discontinued her antithyroid medications during the third trimester. Her temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), blood pressure is $165/75\text{ mmHg}$, pulse is $152/\text{min}$ and irregular, and respirations are $28/\text{min}$. Physical examination reveals a staring gaze, diaphoresis, marked fine tremor, and a diffusely enlarged, non-tender thyroid gland. An electrocardiogram shows atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is made, and the patient is admitted to the intensive care unit.

Arrange the following interventions in the most appropriate chronological sequence for the management of this patient's condition.

A 74-year-old woman presents to the emergency department with a 3-day history of severe right-sided headache and jaw pain while chewing. She reports that 2 hours ago, she experienced sudden, painless vision loss in her right eye. Physical examination reveals a tender, nonpulsatile right temporal artery. Laboratory studies show an erythrocyte sedimentation rate of $110$ mm/h. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the management of this patient's condition, from immediate (first) to long-term (last).

A 37-year-old woman presents to the clinic with an 8-month history of progressive shortness of breath. She reports initially feeling winded only during heavy exertion, but her dyspnea now occurs when walking short distances on flat ground. Last week, she experienced a syncopal episode while climbing stairs. She has no significant past medical history, takes no medications, and has never smoked. Vital signs show temperature 37.0°C (98.6°F), blood pressure 110/72 mm Hg, pulse 94/min, and respirations 18/min. Oxygen saturation is 96% on room air. Physical examination reveals clear breath sounds bilaterally. Cardiovascular examination is notable for a palpable left parasternal heave and a prominently accentuated pulmonic component of the second heart sound (P2). Jugular venous pressure is estimated at 9 cm H2O. There is trace bilateral lower extremity edema.

Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's condition, starting from the initial evaluation step to the final confirmatory assessment.

A 32-year-old woman with a history of severe pelvic inflammatory disease and bilateral tubal occlusion is preparing to undergo in vitro fertilization (IVF). She and her partner are reviewing the upcoming treatment protocol with their reproductive endocrinologist. Arrange the following steps of a standard IVF cycle in the correct chronological order from first to last.

A $58$-year-old man is brought to the emergency department by his wife due to severe headache, high fever, and confusion that started $12$ hours ago. On examination, his temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, and heart rate is $112\text{/min}$. The patient is lethargic and oriented only to his name. Nuchal rigidity is present. There are no focal neurologic deficits. The physician suspects acute bacterial meningitis.

Arrange the following steps in the most appropriate chronological order for the management of this patient.

A 5-year-old girl is brought to the emergency department by her parents due to a severe headache, high fever, and worsening lethargy over the past 12 hours. She has not received any childhood vaccinations. On examination, her temperature is 39.8°C (103.6°F), heart rate is 150/min, respiratory rate is 28/min, and blood pressure is 85/50 mm Hg. She is somnolent, responding only to painful stimuli. Physical examination reveals nuchal rigidity and a rapidly expanding, non-blanching purpuric rash on her lower extremities. Fundoscopic examination demonstrates bilateral papilledema. Arrange the following steps in the most appropriate sequential order for the acute management of this patient.

A 68-year-old man is brought to the emergency department by his family due to a 24-hour history of high fever, severe generalized headache, and progressive confusion. His medical history is significant for type 2 diabetes mellitus and hypertension. On presentation, his temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, heart rate is $115/\text{min}$, and respiratory rate is $22/\text{min}$. The patient is somnolent and oriented only to person. Neurologic examination reveals marked nuchal rigidity. Fundoscopic examination demonstrates bilateral blurring of the optic disc margins.

Arrange the following steps in the most appropriate chronological order for managing this patient.

A 42-year-old woman is admitted to the intensive care unit with confusion, petechiae, and dark urine. Laboratory testing reveals a hemoglobin of $7.2 \text{ g/dL}$, a platelet count of $18,000/\mu\text{L}$, an elevated indirect bilirubin, and an elevated lactate dehydrogenase (LDH). Her prothrombin time and activated partial thromboplastin time are normal. You strongly suspect thrombotic thrombocytopenic purpura (TTP). Arrange the following steps in the most appropriate sequential order for the immediate diagnostic and therapeutic management of this patient.

A 62-year-old man is brought to the emergency department by his family due to sudden-onset confusion, severe right upper quadrant abdominal pain, and high fever that began earlier today. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $88/54\text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals marked scleral icterus and significant right upper quadrant tenderness with guarding. Laboratory studies demonstrate a leukocyte count of $18,500/\text{mm}^3$, total bilirubin of $6.2\text{ mg/dL}$, direct bilirubin of $4.8\text{ mg/dL}$, and alkaline phosphatase of $450\text{ U/L}$. A right upper quadrant ultrasound shows a dilated common bile duct measuring $11\text{ mm}$ and multiple echogenic foci with posterior acoustic shadowing within the gallbladder. Arrange the following management steps in the most appropriate chronological order for this patient.

A 22-year-old man is brought to the emergency department by his roommate due to progressive lethargy, diffuse abdominal pain, and repeated vomiting for the past 24 hours. He has a history of type 1 diabetes mellitus but ran out of his insulin prescriptions three days ago. On examination, he is obtunded. Temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $86/54\text{ mm Hg}$, pulse is $128/\text{min}$, and respirations are $28/\text{min}$ and deep. Mucous membranes are extremely dry.

Arrange the following interventions in the most appropriate chronological sequence for the management of this patient.

A $48$-year-old patient who was admitted $3$ weeks ago with severe acute pancreatitis secondary to cholelithiasis now exhibits sudden clinical deterioration. The patient's temperature is $39.2^\circ \text{C}$ ($102.6^\circ \text{F}$) and white blood cell count is $22,000/\mu \text{L}$. An abdominal contrast-enhanced computed tomography scan demonstrates a large, encapsulated complex fluid collection replacing the pancreatic body, measuring $10 \times 8 \text{ cm}$, and notably containing multiple small gas bubbles. Arrange the following interventions in the most appropriate chronological sequence for managing this patient's current condition and preventing future recurrences.

Following an uncomplicated, precipitous vaginal delivery of a 4,300-g (9-lb 8-oz) neonate, a multiparous patient develops massive vaginal bleeding. The placenta was delivered intact 15 minutes ago. Physical examination reveals a maternal heart rate of 115/min and a blood pressure of 92/58 mm Hg. The uterus feels enlarged, soft, and poorly contracted on abdominal palpation. Arrange the following management steps for this patient's condition in the correct sequential order of escalation, from the most appropriate initial intervention to the definitive final procedure.

A 72-year-old woman is brought to the emergency department by ambulance after being found unresponsive in her home. According to her family, she has a history of hypothyroidism but stopped taking her medications a year ago. On arrival, she is unarousable. Vital signs show a temperature of $34.2^\circ\text{C}$ ($93.6^\circ\text{F}$), a heart rate of $46/\text{min}$, a blood pressure of $85/50\text{ mm Hg}$, and a respiratory rate of $6/\text{min}$ with shallow breathing. Her oxygen saturation is $82\%$ on room air. Physical examination reveals periorbital puffiness, generalized non-pitting edema, and cold, dry skin. Arrange the following steps in the most appropriate chronological sequence for the acute evaluation and management of this patient.

A 45-year-old man presents to the gastroenterology clinic for chronic, watery diarrhea and recurrent abdominal pain. Over the past year, he has been treated for peptic ulcer disease with a high-dose proton pump inhibitor, but his symptoms have persisted and worsened. Upper gastrointestinal endoscopy reveals thickened gastric folds and multiple ulcerations in the stomach, distal duodenum, and proximal jejunum. A diagnosis of Zollinger-Ellison syndrome (gastrinoma) is suspected. Arrange the following steps in the most appropriate diagnostic and therapeutic sequence for this patient.

A 45-year-old woman is evaluated in the post-anesthesia care unit 2 hours after undergoing an uncomplicated total thyroidectomy for a multinodular goiter. The nurse urgently requests an evaluation because the patient has become extremely agitated and is complaining of difficulty breathing. Her blood pressure is 142/88 mmHg, pulse is 115/min, and oxygen saturation is 86% on room air. Physical examination reveals audible inspiratory stridor and a tense, rapidly expanding swelling beneath the cervical incision. Arrange the following management steps in the most appropriate chronological order.