All practice questions

An ambulance brings a $32$-year-old woman to the emergency department due to severe agitation, palpitations, and confusion. She has a history of Graves disease but reports stopping her medications $3$ months ago. Her temperature is $39.6^{\circ}\text{C}$ ($103.3^{\circ}\text{F}$), blood pressure is $150/70\text{ mmHg}$, and heart rate is $148\text{/min}$ and irregular. Physical examination reveals a diffuse goiter, bilateral proptosis, diaphoresis, and a fine resting tremor. An electrocardiogram shows atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is established.

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

An unresponsive patient is admitted to the intensive care unit following a severe anoxic brain injury. The clinical team determines that the patient completely lacks decision-making capacity. A review of the electronic health record reveals no advance directive, and the patient has never formally designated a durable power of attorney for healthcare. Several individuals who know the patient have arrived at the hospital, each wishing to direct the goals of care. According to the standard legal hierarchy for surrogate decision-makers in most US jurisdictions, arrange the following individuals in the correct order of priority from highest (first in line to make decisions) to lowest (last in line).

Immediately following the vaginal delivery of a 3900-g neonate and the placenta, a 26-year-old primiparous patient experiences a sudden, massive gush of vaginal bleeding accompanied by severe lower abdominal pain. The delivering clinician notes that the umbilical cord was subjected to strong traction during the third stage of labor. On physical examination, a smooth, round, beefy-red mass is protruding from the vaginal introitus. The uterine fundus cannot be palpated transabdominally. The patient is pale, with a blood pressure of 78/45 mm Hg and a heart rate of 142/min. Intravenous access is rapidly secured and aggressive fluid resuscitation is begun. Arrange the following subsequent management steps in the most appropriate chronological sequence for this patient's condition.

A 68-year-old man with a history of metastatic prostate cancer is brought to the emergency department by his wife due to a 2-day history of progressively worsening lower back pain and new-onset difficulty walking. This morning, he also experienced an episode of urinary incontinence. Vital signs are within normal limits. Neurologic examination shows 3/5 strength in both lower extremities, diminished pinprick sensation below the T10 dermatome, and bilateral Babinski signs. Anal sphincter tone is markedly decreased. Arrange the following management steps in the most appropriate chronological order for this patient.

A 32-year-old G3P3 woman experiences severe vaginal bleeding immediately following the vaginal delivery of a 4,300 g neonate. Her pulse is 122/min, and blood pressure is 85/50 mm Hg. Abdominal examination reveals a soft, poorly contracted uterus palpated above the umbilicus. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated.

Arrange the following management steps for this patient's condition in the correct sequential order, from the most appropriate initial intervention to the definitive final procedure for refractory hemorrhage.

A $38$-year-old man is brought to the emergency department due to a severe nosebleed that has not stopped for $2$ hours, along with bleeding gums and profound fatigue over the past week. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $110/70$ mm Hg, and heart rate is $112$/min. Physical examination reveals diffuse petechiae across his chest and large ecchymoses on his extremities. Laboratory studies show:

A peripheral blood smear reveals pancytopenia and several large, atypical promyelocytes containing multiple needle-like intracytoplasmic inclusions.

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

A 27-year-old woman presents to the gynecology clinic due to the absence of menses for nine months accompanied by spontaneous milky bilateral nipple discharge. She and her husband are hoping to have a child and have been having regular, unprotected intercourse for a year. A point-of-care urine pregnancy test is negative.

Arrange the following steps in the most appropriate chronological order for the evaluation and management of this patient to facilitate a safe pregnancy.

A 72-year-old woman is brought to the emergency department due to severe dizziness, confusion, and near-syncope. Her heart rate is 32/min, and blood pressure is 75/40 mm Hg. The 12-lead electrocardiogram reveals third-degree atrioventricular block. Arrange the following interventions in the optimal chronological sequence for managing this patient's symptomatic bradycardia, from initial emergency stabilization to definitive treatment.

A 52-year-old woman is hospitalized for induction chemotherapy for acute myeloid leukemia. On hospital day 12, she develops a new-onset fever of $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$). Her blood pressure is 118/74 mm Hg, pulse is 98/min, and respirations are 16/min. Physical examination reveals no focal source of infection, and the exit site of her right internal jugular central venous catheter is clean without erythema or induration. Laboratory studies show an absolute neutrophil count of $150/\text{mm}^3$. She is hemodynamically stable and appears fatigued.

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

A 45-year-old man is evaluated for resistant hypertension and persistent muscle cramps. His blood pressure is $168/102$ mm Hg despite strict adherence to a three-drug antihypertensive regimen that includes a thiazide diuretic. Laboratory testing reveals a serum potassium of $2.9$ mEq/L and a normal serum sodium. The physician suspects an endocrine etiology for his secondary hypertension. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence for establishing the diagnosis and managing this patient's condition.

A 52-year-old male is recovering in the intensive care unit on postoperative day 3 following an open pancreaticoduodenectomy. He has had an uneventful recovery thus far. The surgical team decides to discontinue his right internal jugular central venous catheter. The nurse removes the catheter while the patient is sitting upright in his bed. Immediately after the catheter is pulled, the patient gasps and becomes unresponsive. His blood pressure drops to $65/40 \text{ mmHg}$, heart rate increases to $138 \text{ /min}$, and oxygen saturation falls to $76\%$ on room air. Auscultation of the chest reveals a loud, churning, machinery-like murmur over the precordium. Arrange the following immediate management steps in the most appropriate chronological order.

An $8$-year-old boy is brought to the emergency department due to a $2$-day history of worsening headache, high fever, and generalized lethargy. Over the last $12$ hours, he has become increasingly difficult to arouse. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, pulse is $125/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals a somnolent child who only opens his eyes to painful stimuli. He has marked nuchal rigidity. Funduscopic examination shows bilateral blurring of the optic disc margins. There are no focal neurologic deficits or purpuric rashes. Arrange the following steps in the most appropriate sequential order for managing this patient's acute presentation.

A $58$-year-old man presents to the emergency department with a $4$-day history of progressively worsening left lower quadrant abdominal pain, subjective fever, and decreased appetite. He has no prior history of similar episodes. His temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, and pulse is $98\text{/min}$. Physical examination demonstrates marked focal tenderness and voluntary guarding in the left lower quadrant, but no generalized rigidity. Laboratory evaluation reveals a leukocyte count of $16,500\text{/mm}^3$. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated.

Assume the patient's clinical course progresses appropriately through standard management. Arrange the following steps in the most appropriate chronological sequence for the optimal diagnosis and long-term management of this patient.

A 62-year-old man is brought to the emergency department via ambulance due to the sudden onset of severe, tearing chest pain that radiates to his interscapular region. His blood pressure is 195/115 mm Hg in the right arm and 170/100 mm Hg in the left arm. Heart rate is 110/min. Physical examination reveals a new diastolic decrescendo murmur at the right upper sternal border. Arrange the following steps in the most appropriate chronological order for the initial evaluation and management of this patient.

A $28$-year-old man with no significant past medical history is undergoing an elective open reduction and internal fixation of a right femur fracture. Anesthesia is induced with propofol and succinylcholine, and maintained with sevoflurane. Approximately $45$ minutes into the surgery, the anesthesiologist notes a sudden, unexplained rise in end-tidal carbon dioxide (ETCO2) from $35$ mmHg to $68$ mmHg. The patient's heart rate increases to $142$/min, and generalized masseter muscle rigidity is observed. His core body temperature begins to rise rapidly and is currently $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$). Arrange the following steps in the most appropriate chronological sequence for the immediate management of this patient's suspected complication.

A 45-year-old woman is admitted for severe symptomatic anemia secondary to abnormal uterine bleeding. Her hemoglobin is 6.2 g/dL. A transfusion of packed red blood cells is initiated. Fifteen minutes into the infusion, she complains of sudden-onset chills, severe lower back pain, and nausea. Her temperature is 38.9°C (102°F), blood pressure is 88/50 mmHg, pulse is 118/min, and respirations are 22/min. The Foley catheter bag shows a sudden change in urine color to dark reddish-brown. Arrange the following steps in the most appropriate chronological order for managing this patient's acute complication.

A 54-year-old man undergoes an upper gastrointestinal endoscopy for the evaluation of persistent dyspepsia and early satiety. The procedure reveals abnormal, thickened gastric folds in the antrum. Biopsies of the affected area show a dense infiltrate of atypical small lymphocytes in the lamina propria with characteristic lymphoepithelial lesions. Immunohistochemical staining confirms gastric extranodal marginal zone B-cell (MALT) lymphoma. Histologic examination of the non-neoplastic mucosa demonstrates the presence of curved, flagellated, gram-negative bacilli.

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

A 62-year-old man is brought to the emergency department due to sudden-onset, severe chest pain that he describes as "tearing" and radiating to his upper back. He has a 20-year history of poorly controlled hypertension. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $215/115\text{ mm Hg}$ in the right arm and $178/92\text{ mm Hg}$ in the left arm, pulse is $112/\text{min}$, and respirations are $22/\text{min}$. Oxygen saturation is $97\%$ on room air. Physical examination reveals a bounding pulse and an early diastolic decrescendo murmur at the right upper sternal border. Electrocardiogram demonstrates sinus tachycardia and voltage criteria for left ventricular hypertrophy, but no acute ST-segment changes. A portable chest radiograph reveals a widened mediastinum. Arrange the following management steps in the most appropriate chronological order.

A 76-year-old man is evaluated in the emergency department for a sudden onset of severe lightheadedness and confusion that began one hour ago. His wife reports that he briefly lost consciousness before arrival. He has a history of hypertension and osteoarthritis. Current medications include lisinopril and acetaminophen. His temperature is 36.8°C (98.2°F), blood pressure is 82/50 mm Hg, and pulse is 32/min. Physical examination reveals delayed capillary refill and cool extremities. A 12-lead electrocardiogram demonstrates marked sinus bradycardia with no ischemic changes. He remains hypotensive despite an initial rapid infusion of intravenous fluids. Arrange the following management steps in the correct chronological sequence, from the most appropriate immediate intervention to the definitive long-term treatment assuming the underlying etiology is irreversible.

A $54$-year-old woman with a history of metastatic lung cancer is brought to the emergency department with severe shortness of breath, lightheadedness, and confusion. Her blood pressure is $80/52$ mmHg, heart rate is $124$/min, and respiratory rate is $26$/min. Pulse oximetry is $94\%$ on ambient air. Physical examination demonstrates visibly distended jugular veins, clear lung fields bilaterally, and distant, muffled heart sounds. Her systolic blood pressure drops by $18$ mmHg during inspiration. Arrange the following management steps in the most appropriate chronological sequence for this patient's acute cardiovascular emergency.