All practice questions

A 62-year-old man presents to the emergency department reporting continuous, crushing left-sided chest pain that began two hours ago. He is diagnosed with an acute ST-segment elevation myocardial infarction (STEMI) and is monitored closely. Arrange the following classic electrocardiographic (ECG) changes in the typical chronological order that they appear during the natural evolution of an untreated transmural myocardial infarction.

A $71$-year-old woman is brought to the emergency department by her family due to a $2$-day history of worsening severe right upper quadrant abdominal pain, shaking chills, and yellowing of her skin. Upon arrival, her temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $86/50 \text{ mmHg}$, and heart rate is $118 \text{/min}$. The patient appears severely lethargic and is oriented only to person. Physical examination reveals marked scleral icterus and significant right upper quadrant tenderness without rebound or guarding. Laboratory studies show:

Leukocytes: $19,200/\text{mm}^3$
Total bilirubin: $5.8 \text{ mg/dL}$
Direct bilirubin: $4.5 \text{ mg/dL}$
Alkaline phosphatase: $510 \text{ U/L}$
Aspartate aminotransferase (AST): $142 \text{ U/L}$
Alanine aminotransferase (ALT): $155 \text{ U/L}$

A bedside right upper quadrant ultrasound demonstrates a dilated common bile duct measuring $14 \text{ mm}$ containing an echogenic focus with posterior acoustic shadowing.

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

A 28-year-old medical resident sustains a deep percutaneous needle-stick injury to her hand while drawing blood from a patient in the emergency department. The source patient has a documented history of poorly controlled HIV with a high viral load. The hollow-bore needle was visibly contaminated with blood. What is the most appropriate chronological sequence of interventions for this occupational exposure?

A $46$-year-old woman is hospitalized for induction chemotherapy for newly diagnosed acute myeloid leukemia. On hospital day $12$, she develops a new-onset fever. She reports feeling chilled and fatigued but has no cough, dysuria, abdominal pain, or skin changes. Her temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $105/65\text{ mm Hg}$, pulse is $115/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination is unremarkable, with clear lungs and no induration around her central venous catheter. Laboratory studies reveal an absolute neutrophil count of $120/\mu\text{L}$.

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

A 68-year-old man is brought to the emergency department via ambulance with a 30-minute history of sudden-onset, severe, "tearing" chest pain that radiates to his back between his shoulder blades. His blood pressure is 210/115 mm Hg in the right arm and 175/95 mm Hg in the left arm, and his heart rate is 112/min. He appears visibly distressed and diaphoretic. An ECG shows sinus tachycardia with voltage criteria for left ventricular hypertrophy, but no acute ischemic changes. A chest radiograph demonstrates a widened mediastinum. The clinical presentation is highly suspicious for an acute aortic dissection. Arrange the following management steps in the most appropriate sequential order for the optimal care of this patient.

A 55-year-old man with a history of decompensated alcohol-associated cirrhosis is brought to the emergency department by ambulance after vomiting a large amount of bright red blood. On arrival, he is lethargic and oriented only to his name. His temperature is 36.8°C (98.2°F), blood pressure is 80/50 mmHg, pulse is 128/min, and respiratory rate is 22/min. Physical examination reveals scleral icterus, spider angiomas, and a distended abdomen with a positive fluid wave. Active hematemesis is ongoing. Arrange the following interventions in the correct chronological sequence of escalation for managing this patient's condition, assuming continued need for intervention at each stage:

A 62-year-old woman is admitted to the hospital with a 3-day history of severe left lower quadrant abdominal pain, fever, and nausea. Her temperature is $38.7^{\circ}\text{C}$ ($101.7^{\circ}\text{F}$), blood pressure is $118/76\text{ mmHg}$, and heart rate is $92/\text{min}$. Physical examination reveals marked tenderness in the left lower quadrant without diffuse rebound tenderness or guarding. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$. A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast reveals acute sigmoid diverticulitis complicated by a $5.5\text{ cm}$ peridiverticular abscess. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A rapid response is called for a 67-year-old male inpatient recovering from an emergent open sigmoid colectomy performed 5 days ago for perforated diverticulitis. He has a history of severe chronic obstructive pulmonary disease and obesity (BMI $41 \text{ kg/m}^2$). His vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $145/85 \text{ mmHg}$, heart rate $110/\text{min}$, and respiratory rate $22/\text{min}$. The nursing staff reports that while the patient was having a violent coughing fit, his abdominal binder became saturated with copious amounts of a pink, salmon-colored fluid. Upon removal of the binder and surgical dressings, it is immediately apparent that the midline abdominal incision has dehisced and multiple loops of small intestine are protruding outside the abdominal cavity onto the skin.

Arrange the following steps for the definitive management of this patient's surgical complication in the most appropriate chronological order.

An elderly resident of a skilled nursing facility is transferred to the intensive care unit following the sudden onset of high-volume, painless hematochezia. Initial assessment reveals profound hypotension (blood pressure $78/48 \text{ mm Hg}$) and marked tachycardia (heart rate $128/\text{min}$). Following aggressive intravenous volume expansion with isotonic crystalloids and transfusion of uncrossmatched type O-negative packed red blood cells, the patient's hemodynamic status normalizes. However, the passage of copious maroon-colored stool continues.

Arrange the following diagnostic and therapeutic interventions in the correct algorithmic sequence according to current clinical guidelines for the management of severe hematochezia.

Assume that each successive diagnostic step fails to isolate the source, subsequent non-invasive imaging successfully localizes the lesion but endovascular techniques fail to achieve definitive hemostasis, and open surgical rescue is ultimately mandated.

A 48-year-old man is evaluated for resistant hypertension and muscle cramps. He currently takes maximum tolerated doses of amlodipine, lisinopril, and chlorthalidone. His blood pressure is 168/104 mmHg. Laboratory evaluation reveals a serum potassium of 2.8 mEq/L and a serum sodium of 145 mEq/L. A secondary cause of hypertension is suspected. Assuming the patient's condition is ultimately driven by a unilateral aldosterone-producing adenoma, arrange the following steps in the correct chronological sequence required for the definitive diagnosis and management of this condition.

A $59$-year-old man is evaluated in the post-anesthesia care unit $8$ hours after an elective bilateral laparoscopic inguinal hernia repair. He reports significant lower abdominal pressure and a distressing inability to urinate since the procedure. During the surgery, he received intravenous fluid resuscitation and general anesthesia. His postoperative pain is currently being managed with intravenous hydromorphone. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $135/85$ mm Hg, pulse $88$/min, and respirations $14$/min. Physical examination reveals a palpable, tender mass in the suprapubic region. Arrange the following steps in the most appropriate chronological sequence for the management of this patient's condition, starting with the immediate next step.

An evaluation is requested for a $45$-year-old woman suffering from resistant hypertension. Her current daily medication regimen includes maximal tolerated doses of amlodipine, valsartan, and hydrochlorothiazide. In the clinic, her blood pressure is persistently elevated at $172/104\text{ mm Hg}$, with a heart rate of $78\text{ /min}$. A basic metabolic panel reveals a serum potassium concentration of $2.8\text{ mEq/L}$. The physician suspects primary hyperaldosteronism as the underlying etiology. Arrange the following clinical steps in the most appropriate chronological sequence for the definitive workup and management of this patient.

A 62-year-old postmenopausal woman is found to have an incidental elevated serum total calcium of 11.4 mg/dL during a routine health maintenance examination. She has no history of nephrolithiasis, bone pain, or abdominal discomfort. Assuming her clinical evaluation ultimately leads to a diagnosis of primary hyperparathyroidism requiring surgical intervention, arrange the following clinical steps in the most appropriate chronological sequence for her workup and management.

A 40-year-old man is brought to the emergency department after being rescued from a house fire. He has full-thickness burns involving his entire anterior chest, abdomen, and both upper extremities (approximately 36% total body surface area). He is awake but agitated. On primary survey, he has singed nasal hairs, a hoarse voice, and carbonaceous sputum. Vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mmHg, heart rate 115/min, and respiratory rate 24/min. Arrange the following management steps in the optimal chronological order according to standard Advanced Trauma Life Support (ATLS) and burn protocols.

A 45-year-old man is brought to the emergency department after being ejected from a vehicle during a high-speed rollover collision. On arrival, he is unresponsive. His blood pressure is 65/40 mm Hg, heart rate is 142/min, and respiratory rate is 8/min. Examination reveals active, pulsatile arterial bleeding from a severe crush injury to the right thigh. The patient has snoring respirations and significant maxillofacial trauma. Breath sounds are markedly decreased over the left hemithorax, and the trachea is deviated to the right. The pelvis is mechanically unstable on physical examination. Arrange the following steps in the most appropriate chronological sequence of management according to current Advanced Trauma Life Support (ATLS) principles.

A 58-year-old man is found unresponsive on the floor of his hospital room. He has no palpable pulse and is not breathing. The emergency response team arrives with a crash cart. Arrange the following actions in the correct sequential order for managing this patient's cardiac arrest, assuming the initial rhythm identified on the monitor is ventricular fibrillation.

A 62-year-old man with a 40-pack-year smoking history presents to the emergency department with a 2-week history of progressive facial swelling, a dry cough, and a feeling of "fullness" in his head that worsens when he leans forward. On physical examination, his temperature is 37.1°C (98.8°F), blood pressure is 134/82 mmHg, heart rate is 98/min, and respiratory rate is 18/min. Oxygen saturation is 96% on room air. He has plethora of the face and marked distension of the jugular veins that do not collapse with inspiration. The patient is conversant, has no stridor, and is in no acute respiratory distress. Arrange the following steps in the most appropriate chronological order for the management of this patient's condition.

A 62-year-old male is brought to the emergency department by his family due to a severe headache, confusion, and a high fever that began 18 hours ago. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $138/82\text{ mmHg}$, heart rate is $112\text{/min}$, and respiratory rate is $20\text{/min}$. Physical examination reveals nuchal rigidity and a positive Brudzinski sign. Neurologic examination is notable for a left-sided hemiparesis and bilateral papilledema on fundoscopy. The physician suspects acute bacterial meningitis and prepares to manage the patient.

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

An otherwise healthy $52$-year-old male seeks immediate medical attention for sudden-onset shortness of breath and a sharp, right-sided chest pain that worsens with deep inspiration. His vitals show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), a blood pressure of $130/80$ mm Hg, a heart rate of $102$/min, and a respiratory rate of $20$/min. Pulse oximetry indicates an oxygen saturation of $96\%$ on room air. Cardiopulmonary auscultation is unremarkable. The evaluating physician calculates a Wells score of $1.5$, which places him in the low clinical probability category for a pulmonary embolism. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence for the standard management of this patient.

Emergency medical services bring a 70-year-old female resident of an assisted living facility to the acute care unit with acute-onset lethargy and severe shivering. The patient's caregivers noted she was complaining of right-sided abdominal pain earlier in the day. Vital signs on arrival are: temperature 39.6°C (103.3°F), heart rate 128/min, respirations 22/min, and blood pressure 82/46 mm Hg. The patient is stuporous. Abdominal palpation elicits grimacing when the right subcostal region is pressed. Her skin and mucous membranes appear visibly jaundiced. Initial point-of-care testing reveals a marked leukocytosis of 22,000/mm³ and severe hyperbilirubinemia with a predominant conjugated fraction.

Arrange the following clinical interventions in the correct chronological order for managing this patient's condition.