All practice questions

A 24-year-old man is brought to the emergency department after a severe hyperextension injury to his right knee sustained during a rugby match. He is in severe pain. Physical examination reveals gross deformity of the right knee with a prominent medial femoral condyle. The right foot is slightly cool, and the right dorsalis pedis and posterior tibial pulses are palpable but noticeably weaker than those on the left. Capillary refill is 3 seconds in the right toes. Motor and sensory functions in the right foot are intact. Arrange the following steps in the most appropriate chronological sequence for evaluating and managing this patient's limb.

An 81-year-old gentleman arrives at the emergency department accompanied by his daughter after experiencing three episodes of massive, painless, bright red blood per rectum over the past 4 hours. His medical history is significant for coronary artery disease, atrial fibrillation, and hypertension. Current medications include apixaban, metoprolol, and lisinopril. On arrival, he is lethargic and pale. Temperature is 36.8°C (98.2°F), blood pressure is 82/50 mm Hg, and pulse is 124/min. Physical examination reveals a distended abdomen with hyperactive bowel sounds but no focal tenderness or guarding. Digital rectal examination shows gross bright red blood. Arrange the following critical steps in the management of this patient's acute presentation in the most appropriate chronological sequence.

A 62-year-old man with a 40-pack-year smoking history is found to have a 1.5-cm solitary pulmonary nodule in the right upper lobe on a routine chest radiograph obtained prior to an elective inguinal hernia repair. He has no current respiratory symptoms. Arrange the following steps in the most appropriate sequence for evaluating and managing this finding, from first to last.

A $61$-year-old woman is evaluated in the intensive care unit for a new fever and worsening oxygenation. She was admitted $7$ days ago following a severe motor vehicle collision that resulted in multiple long-bone fractures and acute respiratory distress syndrome (ARDS) requiring endotracheal intubation. Her fraction of inspired oxygen ($\text{FiO}_2$) had been weaned to $0.35$, but over the past $24$ hours, it was increased to $0.60$ to maintain an oxygen saturation of $93\%$. Her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $110/65\text{ mm Hg}$, and pulse is $115/\text{min}$. The endotracheal tube is producing abundant, thick, greenish secretions. Auscultation reveals coarse rhonchi predominantly at the right lung base. A portable chest radiograph demonstrates a new consolidation in the right lower lobe.

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

A 61-year-old woman presents to the emergency department after a minor motor vehicle collision. She reports mild right-sided chest wall pain. She has a 35-pack-year smoking history. Vital signs are temperature 37.0°C (98.6°F), blood pressure 130/82 mm Hg, pulse 88/min, and respiratory rate 16/min. Physical examination reveals focal tenderness over the right anterior ribs but normal breath sounds bilaterally. A chest radiograph shows no rib fractures but incidentally reveals a $15\text{ mm}$ well-circumscribed, non-calcified nodule in the periphery of the left upper lobe. She is discharged home with adequate pain control and follows up in the pulmonary clinic the next week. Arrange the following subsequent steps in the most appropriate chronological sequence for the evaluation and management of this patient's pulmonary nodule.

A 29-year-old woman at 28 weeks gestation presents to the emergency department with acute-onset right-sided pleuritic chest pain and shortness of breath. Her heart rate is 110/min, respiratory rate is 24/min, blood pressure is 112/68 mm Hg, and oxygen saturation is 96% on room air. Physical examination reveals normal heart sounds, clear lungs bilaterally, and no lower extremity edema. A portable chest radiograph is unremarkable. The clinical suspicion for pulmonary embolism is high. Arrange the following diagnostic modalities in the most appropriate sequential order for evaluating this patient, from the FIRST indicated step to the LAST resort if preceding tests are non-diagnostic.

A 62-year-old man presents to the emergency department complaining of severe, sudden-onset tearing chest pain that radiates to his back. His blood pressure is 196/112 mm Hg in the right arm and 188/108 mm Hg in the left arm. His heart rate is 114/min. On physical examination, a decrescendo diastolic murmur is heard at the right upper sternal border. An electrocardiogram shows sinus tachycardia with no ischemic changes. A chest radiograph reveals a widened mediastinum. Arrange the following management steps in the most appropriate sequential order for this patient, from initial stabilization to definitive treatment.

Emergency medical services bring a 49-year-old male with decompensated cirrhosis to the trauma bay following an episode of voluminous hematemesis at home. He appears lethargic and pale. Initial vital signs reveal a heart rate of 128/min and a blood pressure of 82/48 mmHg. Arrange the following interventions in the most appropriate sequential order for managing this patient's condition.

A $68$-year-old man with severe chronic obstructive pulmonary disease is admitted to the intensive care unit for an acute exacerbation requiring invasive mechanical ventilation. On the second day of admission, the ventilator alarm suddenly indicates high peak airway pressures. The patient becomes acutely unstable with a heart rate of $145$/min, blood pressure of $70/38$ mm Hg, and oxygen saturation dropping to $81\%$. Physical examination reveals tracheal deviation to the left, distended neck veins, and absent breath sounds over the right hemithorax. Arrange the following interventions in the most appropriate chronological order for managing this patient's acute decompensation.

A 58-year-old man with a history of treated pulmonary tuberculosis presents to the emergency department after expectorating approximately 600 mL of bright red blood over the past two hours. He is in severe respiratory distress, tachypneic, and diaphoretic. His oxygen saturation is 84% on room air. A portable chest radiograph reveals a large cavitary lesion in the right upper lobe with surrounding new alveolar opacities, consistent with the source of bleeding. Arrange the following management steps for this patient's massive hemoptysis in the most appropriate sequential order, from the initial life-saving intervention to the definitive therapy of last resort.

A 62-year-old man with a 40-pack-year smoking history and type 2 diabetes mellitus presents with reproducible, severe cramping pain in his right calf after walking two blocks. The pain reliably resolves with 5 minutes of rest. He has no rest pain, ulceration, or gangrene. Examination reveals diminished pedal pulses on the right. His ankle-brachial index (ABI) is 0.65 in the right leg and 1.05 in the left leg. Assuming his symptoms remain persistently lifestyle-limiting despite strict patient compliance with each preceding intervention, arrange the following management steps in the correct guideline-directed sequential order.

A 64-year-old man is brought to the emergency department due to massive hemoptysis. Over the past $2$ hours, he has expectorated approximately $700\text{ mL}$ of bright red blood. He has a medical history significant for cavitary pulmonary tuberculosis treated $15$ years ago, which left residual scarring in his right upper lobe. On presentation, the patient is lethargic, in severe respiratory distress, and coughing weakly with ongoing blood expectoration. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $88/54\text{ mm Hg}$, pulse is $132/\text{min}$, and respiratory rate is $32/\text{min}$. Oxygen saturation is $80\%$ on room air. Auscultation reveals prominent coarse gurgling sounds over the right hemithorax, with diminished but clear breath sounds on the left. Intravenous access is established.

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

A 58-year-old man is brought to the emergency department for sudden, excruciating chest pain radiating to his interscapular region. He appears diaphoretic and in severe distress. Blood pressure is 210/110 mm Hg in the right arm and 170/95 mm Hg in the left arm. Heart rate is 118/min. A new early diastolic decrescendo murmur is heard at the right upper sternal border. Neurologic examination reveals no focal deficits. Electrocardiogram shows sinus tachycardia and left ventricular hypertrophy without acute ischemic changes. Chest radiograph demonstrates a widened mediastinum. Arrange the following next steps in the management of this patient in the most appropriate chronological order.

A 38-year-old man comes to the clinic reporting a three-month history of intermittent, burning epigastric pain that is frequently relieved by eating. He has no history of nonsteroidal anti-inflammatory drug (NSAID) use and no alarm symptoms such as weight loss, dysphagia, or melena. Physical examination is unremarkable. Arrange the following steps in the most appropriate chronological order for the diagnosis and management of this patient's most likely condition.

A 42-year-old woman presents to the clinic with progressively worsening exertional dyspnea and fatigue over the past 6 months. She has no significant past medical history and takes no medications. Physical examination reveals a prominent jugular venous a-wave, a loud pulmonic component of the second heart sound (P2), a right ventricular heave, and trace bilateral pedal edema. Her lungs are clear to auscultation. Pulmonary function testing demonstrates normal spirometry with an isolated reduction in the diffusing capacity of the lungs for carbon monoxide (DLCO). Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for evaluating and managing this patient's condition.

A $74$-year-old woman is brought to the emergency department via ambulance with acute, severe respiratory distress that awoke her from sleep $30$ minutes ago. She is profoundly diaphoretic, anxious, and sitting bolt upright on the stretcher. Her blood pressure is $240/130$ mm Hg, heart rate is $128$/min, and respiratory rate is $38$/min. Oxygen saturation is $82\%$ on room air. Physical examination reveals a hyperdynamic precordium and diffuse, coarse crackles auscultated throughout all lung fields bilaterally. There is no significant lower extremity edema. Arrange the following therapeutic interventions in the most appropriate chronological sequence for the optimal acute management of this patient's condition.

A 55-year-old man is evaluated in the intensive care unit on his fourth day of mechanical ventilation for acute respiratory distress syndrome secondary to severe pneumonia. Over the past 48 hours, his clinical status has markedly improved. His fraction of inspired oxygen (FiO2) requirement has decreased to 35%, his positive end-expiratory pressure (PEEP) is at a minimal setting, and he no longer requires vasopressor support. The critical care team decides to initiate the protocol to liberate him from the ventilator. Arrange the following steps in the standard sequential order for evaluating and performing ventilator liberation.

A $28$-year-old woman is brought to the emergency department after coughing up approximately $800 \text{ mL}$ of bright red blood over the past two hours. She has a history of cystic fibrosis and recurrent respiratory tract infections. On arrival, she is in severe respiratory distress, actively expectorating blood, and appears cyanotic. Vital signs are temperature $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), heart rate $135/\text{min}$, respiratory rate $34/\text{min}$, and blood pressure $85/50 \text{ mm Hg}$. Oxygen saturation is $82\%$ on room air. Breath sounds are diminished bilaterally with coarse rhonchi. Arrange the following interventions in the most appropriate sequential order for managing this patient's condition.

A 68-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) presents to the emergency department with worsening dyspnea, increased sputum purulence, and lethargy. Arterial blood gas analysis indicates acute-on-chronic hypercapnic respiratory failure. Arrange the following respiratory support interventions in the most appropriate sequential order of clinical escalation, from initial first-line management to the most advanced long-term support.

Paramedics transport a 70-year-old male with a known history of severe chronic obstructive pulmonary disease to the acute care bay. His wife activated emergency services after noting a two-day history of progressively darkening sputum and profoundly labored breathing. Triage assessment reveals an oxygen saturation of 85% on ambient air, though the patient remains fully awake, interactive, and able to answer questions in short phrases. Assume his clinical trajectory over the subsequent week encompasses initial stabilization, progressive decompensation requiring maximal life support, and eventual recovery. Arrange the following clinical interventions in the appropriate chronological sequence of standard care.