All practice questions

A 30-year-old man is brought to the trauma bay after a high-speed motorcycle collision. On arrival, he has active, pulsatile bleeding from a partially amputated right lower extremity. He is moaning, his eyes remain closed, and he exhibits abnormal flexion posturing to painful stimuli. His respiratory rate is 32/min, and oxygen saturation is 84% on room air. Auscultation of the chest reveals absent breath sounds on the right side. Arrange the following initial management steps in the most appropriate chronological order according to current trauma resuscitation protocols.

An emergency department physician evaluates a patient presenting with severe, unrelenting mid-back pain that has progressively worsened over the past week. The patient, who has a history of type 2 diabetes mellitus and injection drug use, now reports new-onset bilateral leg weakness and an inability to urinate for the past $6 \text{ hours}$. Vital signs show a temperature of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), heart rate of $110/\text{min}$, and blood pressure of $130/80\text{ mmHg}$. Physical examination demonstrates tenderness to percussion over the thoracic spine, $3/5$ motor strength in both lower extremities, and absent deep tendon reflexes at the knees and ankles. A bedside bladder ultrasound reveals a post-void residual volume of $600\text{ mL}$.

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

A 38-year-old man is evaluated in the clinic for a 3-month history of episodic, severe headaches, excessive sweating, and palpitations. He reports that these spells occur spontaneously, last 15 to 20 minutes, and leave him feeling exhausted. During a recent episode, he checked his blood pressure at home, and it was 195/110 mm Hg. Today, he is asymptomatic. His temperature is 37.1°C (98.8°F), blood pressure is 142/90 mm Hg, and pulse is 82/min. Physical examination is unremarkable. The physician strongly suspects a catecholamine-secreting tumor.

Arrange the following steps in the most appropriate chronological order for the diagnostic workup and optimal management of this patient.

A 62-year-old man comes to the physician due to a 3-month history of progressive early satiety, postprandial epigastric pain, and an unintentional weight loss of 9 kg (20 lb). His past medical history is significant for a peptic ulcer associated with Helicobacter pylori infection treated 10 years ago. Vital signs are within normal limits. Physical examination reveals conjunctival pallor and mild epigastric tenderness on deep palpation, without rebound or guarding. Laboratory studies show a hemoglobin concentration of 9.2 g/dL and a mean corpuscular volume of 74 fL. Fecal occult blood testing is positive.

Arrange the following diagnostic and management steps in the most appropriate chronological order for this patient's suspected condition. Assume that each successive staging modality demonstrates localized, potentially curable disease without evidence of dissemination.

A 24-year-old woman presents to the outpatient clinic with a 3-month history of severe fatigue, symmetric pain in her bilateral wrists and metacarpophalangeal joints, and a photosensitive erythematous rash over her cheeks and nasal bridge. She is suspected of having a new-onset systemic autoimmune connective tissue disease. Arrange the following diagnostic and therapeutic steps in the appropriate clinical and chronological sequence for her suspected condition, starting from initial screening to the management of potential severe complications.

A 22-year-old woman presents to the clinic for evaluation of easy bruising and prolonged bleeding following minor cuts. She reports a history of heavy menses since menarche, which occasionally requires iron supplementation. Her mother experiences similar mucosal bleeding symptoms. Physical examination reveals several small ecchymoses on her lower extremities but no petechiae. Vital signs are within normal limits. Arrange the following clinical steps in the most appropriate chronological sequence for the diagnostic workup and management of this patient's most likely condition.

An 81-year-old male resident of a skilled nursing facility is transported to the acute care unit following an episode of massive rectal bleeding. The nursing staff reports he passed several large clots of dark red blood and subsequently experienced presyncope. Upon arrival, he is pale, diaphoretic, and lethargic. Vital signs demonstrate a temperature of 36.1°C (97.0°F), a blood pressure of 78/42 mm Hg, and a pulse of 134/min. His medical history includes ischemic cardiomyopathy, chronic kidney disease, and advanced osteoarthritis, for which he takes daily naproxen and apixaban. Abdominal examination reveals normal bowel sounds and no guarding, rigidity, or focal tenderness. The rectal vault contains abundant fresh blood without palpable masses. Arrange the following interventions in the most appropriate sequential order for the management of this patient's acute presentation.

A 58-year-old man presents to the emergency department complaining of sudden-onset, severe, crushing substernal chest pain that began 45 minutes ago and radiates to his left jaw. His blood pressure is 140/90 mmHg, heart rate is 92/min, respiratory rate is 16/min, and oxygen saturation is 98% on room air. Physical examination reveals an anxious, diaphoretic patient with normal heart sounds and clear lungs. Arrange the following initial management steps in the most appropriate chronological sequence for this patient.

Emergency medical services bring a 26-year-old male construction worker to the trauma center after he was crushed under a collapsed retaining wall. The patient's primary survey reveals a patent airway, clear breath sounds bilaterally, and stable hemodynamics with a blood pressure of 118/76 mm Hg and a heart rate of 92/min. Secondary survey is notable for severe pelvic instability, marked perineal ecchymosis, and fresh blood visible at the urethral meatus. Digital rectal examination demonstrates a high-riding prostate. Assuming sequential workup eventually reveals a complete posterior urethral transection accompanied by an intraperitoneal bladder rupture, arrange the following management steps in the correct chronological sequence.

A 50-year-old male seeks medical attention at the emergency department after two days of progressively worsening, crampy periumbilical pain, progressive abdominal distension, and an inability to pass flatus or stool. He reports multiple episodes of bilious emesis. His surgical history is notable for an exploratory laparotomy following blunt abdominal trauma a decade ago. Vital signs show a heart rate of 98/min, blood pressure of 135/85 mm Hg, and respiratory rate of 16/min. The patient is afebrile. Abdominal examination demonstrates marked distension, hyperactive high-pitched bowel sounds, and generalized tympany without rigidity or rebound tenderness. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 42-year-old woman is evaluated for poorly controlled blood pressure despite adherence to a three-drug antihypertensive regimen consisting of amlodipine, lisinopril, and chlorthalidone. Her blood pressure is 162/98 mm Hg, and laboratory studies reveal a serum potassium level of 3.1 mEq/L. Primary hyperaldosteronism is suspected. She is an appropriate surgical candidate and wishes to pursue a definitive surgical cure if eligible. Assuming each test in the diagnostic pathway yields results consistent with a surgically correctable unilateral aldosterone-producing adenoma, arrange the following steps in the correct chronological order for her diagnostic workup and management.

A 62-year-old man with a 15-year history of poorly controlled type 2 diabetes mellitus and peripheral neuropathy is evaluated in the clinic for a chronic right foot ulcer. He first noticed the ulcer 6 weeks ago. The patient is afebrile, and his vital signs are strictly within normal limits. On physical examination, there is a $3 \times 3$ cm non-tender ulcer on the plantar surface of the right first metatarsal head. There is no surrounding erythema, warmth, fluctuance, or purulent drainage. A sterile metal probe is introduced into the ulcer and easily palpates a hard, gritty surface at the base. The physician highly suspects underlying osteomyelitis.

Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the standard medical management of this patient.

A 58-year-old man is brought to the emergency department by his wife due to fever, severe headache, and confusion that started 12 hours ago. His wife reports that he has also been dragging his right leg since the onset of symptoms. His temperature is 39.2°C (102.6°F), blood pressure is 145/90 mm Hg, and pulse is 110/min. Physical examination reveals marked nuchal rigidity and right-sided hemiparesis. He is lethargic but arouses to verbal stimuli. Arrange the following management steps in the most appropriate chronological order.

A 55-year-old man presents to the emergency department reporting the sudden onset of agonizing epigastric pain that rapidly generalized to his entire abdomen. The pain began approximately 2 hours ago. His past medical history is significant for osteoarthritis, for which he takes diclofenac regularly. On arrival, his temperature is 38.3°C (100.9°F), blood pressure is 108/68 mm Hg, and pulse is 112/min. Physical examination demonstrates a patient lying completely still on the stretcher. His abdomen is markedly rigid and board-like, with diffuse involuntary guarding and rebound tenderness. Arrange the following management steps in the most appropriate chronological order for this patient.

While recovering on the surgical ward six days after an emergency laparotomy for a perforated duodenal ulcer, a patient experiences a sudden 'popping' sensation in his abdomen during an intense coughing spell. The evaluating nurse notes that the surgical staples have separated, and segments of the small intestine are visibly protruding through the fascial defect onto the skin surface. The patient is tachycardic but maintaining his airway. Arrange the following medical interventions in the correct chronological order to appropriately manage this acute complication.

A patient receiving cytotoxic chemotherapy for acute myeloid leukemia arrives at the oncology triage unit reporting severe chills and a recorded temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$). Her blood pressure is $100/60\text{ mm Hg}$, and her heart rate is $112/\text{min}$. She has an indwelling totally implantable venous access device. Laboratory analysis reveals an absolute neutrophil count of $350/\text{mm}^3$.

Arrange the following interventions in the most appropriate sequential order for managing this patient's condition according to standard clinical guidelines for high-risk febrile neutropenia.

A 60-year-old man suddenly collapses in the hospital cafeteria. You are the first healthcare provider on the scene. Arrange the following initial steps of Basic Life Support (BLS) in the correct chronological order for managing this patient.

A 62-year-old male is brought to the emergency department with a 2-day history of severe right upper quadrant abdominal pain, fever, and yellowing of his skin. In the triage area, he becomes increasingly lethargic and confused. Vital signs show a temperature of 39.2°C (102.6°F), blood pressure of 86/50 mmHg, pulse of 118/min, and respirations of 22/min. Physical examination reveals pronounced scleral icterus and right upper quadrant tenderness with involuntary guarding. Laboratory studies show a leukocyte count of 18,500/mm³, total bilirubin of 6.8 mg/dL, direct bilirubin of 5.1 mg/dL, and alkaline phosphatase of 480 U/L.

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

A 22-year-old collegiate athlete is brought to the emergency department immediately after sustaining a severe hyperextension injury to his left leg during a rugby match. He is in agonizing pain. On physical examination, there is a gross step-off deformity at the left knee joint. The left foot is cold and pale. The dorsalis pedis and posterior tibial pulses are absent on the left side but are robust on the right. Capillary refill time in the left toes is delayed at 5 seconds. Assuming evidence of arterial compromise persists throughout the initial evaluation, arrange the following management steps in the most appropriate sequential order.

A 45-year-old woman is newly diagnosed with highly active rheumatoid arthritis. She presents with symmetric swelling of her metacarpophalangeal and proximal interphalangeal joints, along with 2 hours of morning stiffness. Radiographs show early marginal erosions. Assuming an inadequate clinical response to each preceding step over several months, arrange the following interventions in the standard sequential order of therapy escalation for the management of her disease.