All practice questions

A 72-year-old man is evaluated on postoperative day 3 following a right total hip arthroplasty for a femoral neck fracture. He reports progressive abdominal distention, nausea, and an inability to pass flatus or stool for the past 48 hours. His medical history includes hypertension and benign prostatic hyperplasia. Current medications include lisinopril, tamsulosin, and intravenous morphine for pain control. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $130/80\text{ mm Hg}$, pulse of $92\text{/min}$, and respiratory rate of $16\text{/min}$. Abdominal examination reveals massive, tympanitic distension with diminished bowel sounds; there is no guarding or rebound tenderness. Laboratory studies show a serum potassium of $3.1\text{ mEq/L}$ and magnesium of $1.3\text{ mg/dL}$. A CT scan of the abdomen confirms diffuse dilation of the colon with a cecal diameter of $10.5\text{ cm}$ and no evidence of mechanical obstruction or perforation. The patient is diagnosed with acute colonic pseudo-obstruction (Ogilvie syndrome).

Arrange the following management interventions in the correct standard sequential order for this condition, progressing from the most appropriate initial action to the final therapeutic option for refractory disease.

A 28-year-old woman with a history of systemic lupus erythematosus presents to the clinic with new-onset bilateral lower extremity edema. Her blood pressure is 150/92 mm Hg. Laboratory studies show a serum creatinine of 1.5 mg/dL (baseline 0.8 mg/dL), positive anti-dsDNA antibodies, and decreased C3 and C4 levels. Urinalysis reveals 3+ protein, 15-20 red blood cells/hpf, and the presence of red blood cell casts.

Arrange the following steps in the standard chronological sequence for the definitive diagnostic evaluation and long-term pharmacologic management of this patient's renal disease.

A 45-year-old man who recently emigrated from an area highly endemic for tuberculosis presents to the emergency department with a 4-week history of productive cough, blood-tinged sputum, drenching night sweats, and unintentional weight loss. Vital signs show a temperature of 38.3°C (100.9°F). A chest radiograph reveals a large cavitary lesion in the apical segment of the right upper lobe. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $68$-year-old man with a history of metastatic prostate cancer is brought to the emergency department by his family due to a $2$-day history of progressively worsening mid-back pain. This morning, he developed weakness in both legs and has been unable to void his bladder for the past $10$ hours. His temperature is $37.1^\circ \text{C}$ ($98.8^\circ \text{F}$), blood pressure is $142/88$ \text{mmHg}, and pulse is $92$/\text{min}. Neurologic examination reveals $3/5$ motor strength in the bilateral lower extremities, diminished deep tendon reflexes at the knees and ankles, and decreased sensation to pinprick below the level of the umbilicus. Anal sphincter tone is decreased. Bladder ultrasound reveals $600$ \text{mL} of retained urine.

Based on the clinical presentation, arrange the following steps in the most appropriate chronological order for the acute management and diagnostic workup of this patient.

A 4-year-old boy is brought to the emergency department by his parents due to the sudden onset of severe throat pain, a muffled voice, and difficulty breathing. His parents note that he has not been able to swallow his saliva for the past two hours and has been leaning forward continuously. He has missed several childhood vaccinations. On observation, the patient is toxic-appearing, drooling, and exhibits inspiratory stridor. His temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), heart rate is $155/\text{min}$, and respiratory rate is $36/\text{min}$. He becomes highly agitated when a nurse approaches him with a blood pressure cuff. Arrange the following management steps in the most appropriate chronological order for this patient.

A 48-year-old male presents to the emergency department after vomiting a large amount of coffee-ground material. He reports feeling lightheaded, dizzy, and fatigued over the past several hours. His blood pressure is 88/55 mm Hg and his heart rate is 118/min. Physical examination shows pale conjunctivae and mild epigastric tenderness. He has a significant history of daily ibuprofen use for chronic lower back pain. Arrange the following management steps in the most appropriate chronological order for this patient.

A 42-year-old man comes to the clinic for evaluation of sudden, severe headaches associated with profuse sweating and heart palpitations. These episodes occur 2 to 3 times a week, typically lasting for 15 to 20 minutes. He has no significant past medical history and takes no medications. His blood pressure during the visit is 172/105 mm Hg, and his pulse is 105/min. The rest of his physical examination is unremarkable. Arrange the following steps in the most appropriate chronological order for the evaluation and management of this patient's suspected condition.

Paramedics bring a pregnant patient to the emergency department after she suffered a witnessed generalized tonic-clonic convulsion at home. The patient's partner reports that she has been experiencing severe headaches and visual changes for the past two days. She is currently at 37 weeks gestation. Upon arrival in the trauma bay, the patient is actively seizing. Her blood pressure is 176/114 mmHg. Oxygen saturation is 96% on room air, and her airway remains patent. Fetal heart rate monitoring is not yet established. Arrange the following acute management steps in the most appropriate chronological sequence for this patient.

A 68-year-old woman is brought to the emergency department from a skilled nursing facility due to altered mental status, fever, and right upper quadrant abdominal pain for the past 24 hours. Her temperature is 39.2°C (102.6°F), blood pressure is 86/52 mm Hg, pulse is 118/min, and respirations are 22/min. Physical examination demonstrates scleral icterus, dry mucous membranes, and significant tenderness to palpation in the right upper quadrant with involuntary guarding. Laboratory studies reveal a leukocyte count of 18,500/mm³, total bilirubin of 5.8 mg/dL, direct bilirubin of 4.2 mg/dL, and alkaline phosphatase of 450 U/L.

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

A $54$-year-old man is admitted to the hospital with a $5$-day history of fever, productive cough, and right-sided pleuritic chest pain. His temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), pulse is $112/\text{min}$, and respiratory rate is $24/\text{min}$. A portable chest radiograph demonstrates a right lower lobe consolidation and a moderate, free-flowing right-sided pleural effusion. He is initiated on empiric intravenous ceftriaxone and azithromycin. Over the next $48$ hours, he remains persistently febrile and tachycardic, and his oxygen requirement increases.

Assume that the patient's clinical condition requires sequential escalation of interventions due to the failure of each preceding step. Arrange the following management steps in the most appropriate chronological order according to standard treatment guidelines.

During a winter clinic visit, a 34-year-old female with known limited cutaneous systemic sclerosis reports increasingly painful episodes where her fingers turn stark white, then blue, when exposed to the cold. Physical examination reveals taut skin over the digits but no active ulceration. She is currently not taking any medications for this specific symptom. Arrange the following management steps in the standard escalating sequence for this condition, starting from initial baseline interventions and progressing to therapies reserved for severe, refractory digital ischemia.

A 42-year-old man presents to a gastroenterology clinic with a 1-year history of severe, burning epigastric pain and chronic high-volume watery diarrhea. The abdominal pain frequently awakens him at night and is only minimally relieved by high-dose pantoprazole, which he has taken reliably for the past 6 months. He has no personal or family history of nephrolithiasis, hypercalcemia, or pituitary disease. An upper endoscopy performed prior to referral revealed remarkably prominent gastric folds and multiple deep ulcerations in the duodenal bulb and the descending duodenum. The physician highly suspects Zollinger-Ellison syndrome (ZES) and plans to initiate a comprehensive diagnostic and management algorithm.

Arrange the following steps in the strictly correct chronological order for the evaluation and definitive management of this patient's condition.

A 29-year-old woman with a body mass index of $34 \text{ kg/m}^2$ and a known diagnosis of polycystic ovary syndrome (PCOS) presents for an infertility evaluation. She and her partner have been unable to conceive after 18 months of regular, unprotected intercourse. Her partner's semen analysis is normal, and a hysterosalpingogram confirms patent fallopian tubes bilaterally. Arrange the following management steps in the correct sequential order from the most appropriate initial intervention to the most advanced therapy.

A 62-year-old woman is evaluated on postoperative day 6 following an elective open sigmoid colectomy for recurrent diverticulitis. She reports new-onset chills and increasing incisional pain over the past 24 hours. Her temperature is 39.1°C (102.4°F), heart rate is 112/min, and blood pressure is 110/70 mmHg. Examination of the surgical site reveals marked erythema, induration, and purulent drainage seeping from between the surgical staples. The patient is admitted to the progressive care unit for close monitoring.

Arrange the following management steps in the most appropriate chronological sequence for the care of this postoperative complication.

A 42-year-old man with a history of poorly controlled HIV infection presents to the emergency department with a 2-day history of worsening headache, severe photophobia, and confusion. On presentation, his temperature is 39.4°C (102.9°F), blood pressure is 115/75 mm Hg, pulse is 118/min, and respirations are 18/min. Physical examination reveals marked nuchal rigidity. He is oriented only to his name. Funduscopic examination shows blurring of the optic disc margins bilaterally.

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

A 4-year-old boy is brought to the emergency department by his parents for a 1-day history of high fever, severe right hip pain, and an inability to bear weight. His temperature is 39.2°C (102.6°F), heart rate is 130/min, respiratory rate is 24/min, and blood pressure is 95/60 mm Hg. Examination reveals the right hip is held in flexion, abduction, and external rotation. Passive movement of the joint elicits severe pain and guarding. There is no history of trauma. Assuming the patient remains hemodynamically stable, arrange the following steps in the most appropriate sequential order for the diagnostic and therapeutic management of this patient.

A 28-year-old woman is brought to the emergency department by her family due to severe agitation, confusion, and palpitations that have progressively worsened over the past 24 hours. She has a history of Graves disease but stopped taking her medications three months ago. On physical examination, her temperature is 39.8°C (103.6°F), blood pressure is 160/90 mm Hg, heart rate is 148/min and irregular, and respiratory rate is 24/min. She is delirious, diaphoretic, and has a noticeable fine tremor. Neck examination reveals a diffusely enlarged, non-tender thyroid gland with a bruit. ECG shows atrial fibrillation with rapid ventricular response. Laboratory studies confirm a TSH level of < 0.01 µU/mL and a free T4 of 5.8 ng/dL. Arrange the following interventions in the most appropriate chronological order for the comprehensive management of this patient, from initial acute stabilization to long-term definitive care.

A 52-year-old woman presents to the emergency department with severe, sudden-onset epigastric pain radiating to her back, accompanied by intractable nausea. Her heart rate is 112/min and blood pressure is 105/65 mm Hg. Laboratory studies reveal a serum lipase level of 1,250 U/L and an alanine aminotransferase (ALT) level of 185 U/L. She is diagnosed with acute gallstone pancreatitis. Assuming her clinical course is complicated by new-onset fever and worsening jaundice on hospital day 2, arrange the following interventions in the most appropriate chronological sequence for her overall management.

A 28-year-old woman comes to the clinic reporting right calf pain that started 2 days ago. She states the pain began the day after she participated in a new high-intensity jump-rope workout class. She has no significant past medical history, takes no medications, and has no personal or family history of venous thromboembolism. She does not use tobacco or illicit drugs. Her vital signs are within normal limits. Physical examination reveals mild localized tenderness in the right posterior calf muscle. There is no erythema, warmth, prominent superficial veins, or pitting edema. The right calf circumference is $1.5\text{ cm}$ larger than the left calf when measured $10\text{ cm}$ below the tibial tuberosity. Arrange the following steps in the most appropriate sequential order for the evidence-based diagnostic evaluation and management of this patient.

A 52-year-old man is brought to the emergency department via ambulance after vomiting a large amount of bright red blood at home. He has a history of alcohol use disorder and was diagnosed with decompensated cirrhosis two years ago. On arrival, his blood pressure is 85/55 mm Hg, and his pulse is 120/min. Physical examination reveals scleral icterus, multiple spider angiomas on the upper chest, and a distended abdomen with a positive fluid wave. Arrange the following steps in the most appropriate chronological order for managing this patient's acute presentation.