All practice questions

A 68-year-old man presents to the clinic with a 3-month history of difficulty swallowing. Initially, he had trouble only with solid foods such as meat and bread, but recently he has also developed difficulty swallowing liquids. He reports an unintentional weight loss of 9 kg (20 lb) over this period. Medical history is significant for gastroesophageal reflux disease (GERD) and hypertension. He has a 40-pack-year smoking history. Vital signs are within normal limits. Physical examination reveals temporal wasting but is otherwise unremarkable.

Arrange the following steps in the most appropriate sequential order for the diagnostic evaluation, staging, and management of this patient's condition.

A 28-year-old woman, G2P1, at 20 weeks gestation presents to the emergency department with a 12-hour history of worsening right lower quadrant abdominal pain, nausea, and anorexia. Her temperature is 38.1°C (100.6°F), heart rate is 108/min, and blood pressure is 112/72 mm Hg. Physical examination reveals tenderness superior and lateral to McBurney's point with localized guarding. Fetal heart tones are 145/min. Laboratory studies show a leukocyte count of 16,500/mm³ with 85% neutrophils. Assuming each diagnostic study is sequentially indicated due to inconclusive prior results, arrange the following steps in the most appropriate chronological order for evaluating and managing this patient.

Paramedics rush a 58-year-old man to the resuscitation bay after he experienced a sudden, agonizing, 'tearing' chest pain that radiated directly to his interscapular region. The patient is visibly distressed, diaphoretic, and clutching his chest. His spouse reports that he has a long history of medication nonadherence for hypertension. Initial vital signs reveal a temperature of 37.2°C (99.0°F), a right arm blood pressure of 220/125 mm Hg, a left arm blood pressure of 180/100 mm Hg, a heart rate of 124/min, and a respiratory rate of 24/min. Cardiac auscultation identifies a loud, early diastolic decrescendo murmur best heard at the right second intercostal space. A bedside portable chest radiograph displays significant widening of the superior mediastinum. Large-bore intravenous access is immediately established. Arrange the following critical interventions in the exact sequential order required for the optimal management of this patient, from immediate initial stabilization to definitive treatment.

A 22-year-old woman is brought to the emergency department due to progressive confusion, nausea, and severe abdominal pain over the past 24 hours. She was diagnosed with type 1 diabetes mellitus during childhood. Vital signs show a blood pressure of 90/60 mm Hg, pulse of 124/min, and deep, rapid respirations at 26/min. Laboratory evaluation reveals a serum glucose of 560 mg/dL, arterial pH of 7.12, serum bicarbonate of 10 mEq/L, and significantly elevated serum ketones. Arrange the following interventions in the most appropriate chronological order for the acute management of this patient's condition.

A 68-year-old man presents to a rural clinic with severe substernal chest pain. He is diagnosed with an acute ST-segment elevation myocardial infarction (STEMI). Due to limited resources and transport delays, definitive revascularization is significantly delayed, allowing the infarction to follow its natural clinical course. Arrange the following electrocardiographic (ECG) changes in the typical chronological order in which they appear during the evolution of an untreated acute transmural myocardial infarction.

A 45-year-old man with a history of alcohol use disorder is admitted to the hospital with acute-onset, severe epigastric pain radiating to his back. His serum lipase is markedly elevated at $4,500 \text{ U/L}$. Over the next four weeks, his hospital course is complicated by the development of infected necrotizing pancreatitis. Based on the current standard of care and the evidence-based 'step-up approach' for necrotizing pancreatitis, arrange the following interventions in the most appropriate chronological sequence from his initial presentation to his definitive management.

A 71-year-old man presents to the emergency department with rapidly worsening respiratory failure secondary to severe bilateral pneumonia. Despite a trial of non-invasive ventilation, his oxygenation continues to decline, and the decision is made to secure his airway. Arrange the following steps of rapid sequence intubation (RSI) in the correct chronological order.

A $58$-year-old man is brought to the emergency department after coughing up approximately $600 \text{ mL}$ of bright red blood over the past two hours. He has a history of treated pulmonary tuberculosis with known residual cavitary disease in the right upper lobe. On arrival, he is in severe respiratory distress, coughing continuously, and expectorating fresh blood. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $105/65 \text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $86\%$ on room air. Physical examination reveals coarse crackles over the right hemithorax, while the left lung field is relatively clear. The patient is unable to speak in full sentences due to the ongoing hemoptysis.

Arrange the following interventions in the most appropriate sequential order for managing this patient's condition.

A 24-year-old man is brought to the emergency department after being involved in a high-speed motor vehicle collision. He is in severe respiratory distress and complains of right-sided chest pain. His blood pressure is 80/50 mm Hg, heart rate is 135/min, and respiratory rate is 32/min. Oxygen saturation is 86% on room air. Physical examination reveals significantly decreased breath sounds over the right hemithorax, hyperresonance to percussion on the right, and distended neck veins. The trachea is deviated to the left. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $48$-year-old man is brought to the emergency department via ambulance due to a severe episode of coughing up blood. The patient has a history of treated pulmonary tuberculosis $10$ years ago, which left residual cavitary lesions in his right upper lobe. Over the last $4$ hours, he estimates coughing up approximately $600$ mL of bright red blood. Upon arrival, he has another paroxysm of coughing, producing an additional $250$ mL of fresh blood. He appears distressed and diaphoretic. Vital signs show a blood pressure of $105/65$ mm Hg, heart rate of $122$/min, respiratory rate of $28$/min, and oxygen saturation of $88\%$ on room air. Auscultation reveals coarse rhonchi and gurgling sounds predominantly over the right hemithorax, with relatively clear breath sounds on the left. The patient is immediately placed on high-flow supplemental oxygen.

Arrange the following subsequent interventions in the most appropriate sequential order for managing this patient's life-threatening condition.

A 62-year-old man collapses while walking in the hospital corridor. He is unresponsive, apneic, and has no palpable carotid pulse. A crash cart is immediately brought to the scene, and chest compressions are initiated. The cardiac monitor displays coarse ventricular fibrillation. Arrange the following critical resuscitation steps in the most appropriate chronological order according to standard advanced cardiovascular life support (ACLS) guidelines.

A 48-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department after vomiting a large amount of bright red blood. On arrival, he is lethargic but actively protecting his airway. His blood pressure is 85/50 mm Hg, and his pulse is 120/min. Physical examination reveals scleral icterus, spider angiomas, and a distended abdomen with a positive fluid wave. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient's acute presentation.

A $72$-year-old man presents to the emergency department complaining of severe lightheadedness, generalized weakness, and near-syncope that started one hour ago. His blood pressure is $78/50$ mmHg, heart rate is $32$/min, and respiratory rate is $16$/min. Oxygen saturation is $96\%$ on room air. An electrocardiogram (ECG) reveals sinus bradycardia with a heart rate of $32$/min. The patient remains persistently hypotensive and symptomatic despite initial intravenous fluid resuscitation. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient, from the most immediate initial step to definitive long-term therapy.

A 54-year-old man collapses in an airport terminal and is unresponsive. Bystanders immediately initiate cardiopulmonary resuscitation (CPR). Emergency medical services (EMS) arrive shortly after and confirm the patient is pulseless and apneic. The cardiac monitor displays coarse ventricular fibrillation. Arrange the following critical interventions in the correct chronological sequence for the management of this patient according to standard cardiac arrest algorithms.

A 28-year-old woman presents to the clinic with an 8-month history of progressive exertional dyspnea, fatigue, and one episode of syncope while climbing stairs. She has no significant past medical history and takes no medications. Her blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 16/min. Pulse oximetry shows 97% on room air. Physical examination reveals clear lungs, a prominent right ventricular heave, and a loud pulmonic component of the second heart sound. There is trace lower extremity edema. A transthoracic echocardiogram demonstrates right ventricular dilation, septal flattening during systole, and an estimated right ventricular systolic pressure of 55 mm Hg. The left ventricular size and systolic function are normal, with no significant valvular abnormalities. Pulmonary function testing and high-resolution computed tomography (HRCT) of the chest are unremarkable.

Arrange the following steps in the most appropriate sequential order for the continued diagnostic evaluation and management of this patient's condition.

A 58-year-old man was intubated and mechanically ventilated 5 days ago for severe community-acquired pneumonia. Today, his clinical condition has significantly improved. He is afebrile, his oxygen saturation is 96% on a fraction of inspired oxygen (FiO2) of 0.35, and he requires no vasopressor support. The critical care team decides to initiate the process of liberating the patient from mechanical ventilation.

Arrange the following steps in the correct chronological sequence for standard mechanical ventilation liberation.

A 54-year-old male is currently hospitalized for a right lower lobe community-acquired pneumonia. On hospital day 4, he develops worsening pleuritic chest pain and a persistent fever of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$). A repeat chest radiograph demonstrates a new, moderate-sized right pleural effusion. Over the subsequent two weeks, his pleural disease becomes increasingly complex, requiring a step-wise escalation of therapy. Arrange the following interventions in the correct chronological order of standard management for an evolving parapneumonic effusion, from initial evaluation to the definitive treatment of refractory multi-loculated empyema.

A $62$-year-old woman who has been mechanically ventilated for $6$ days due to severe acute respiratory distress syndrome (ARDS) following a viral infection develops a new fever of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), leukocytosis, and increased purulent endotracheal secretions. A portable chest radiograph reveals a new right lower lobe alveolar infiltrate. The patient is hemodynamically stable. Arrange the following steps in the correct chronological order for the standard diagnostic and therapeutic management of suspected ventilator-associated pneumonia (VAP) in this patient.

A 65-year-old man presents to the emergency department with sudden-onset, severe, tearing chest pain that radiates to his back. His blood pressure is 190/110 mmHg in the right arm and 140/80 mmHg in the left arm. His heart rate is 112/min. A bedside chest radiograph shows a widened mediastinum. Suspecting an acute aortic dissection, arrange the following management steps in the most appropriate chronological order.

A 39-year-old woman is evaluated for progressive weight gain, proximal muscle weakness, and new-onset facial hair growth over the past year. Physical examination reveals central adiposity, facial plethora, a dorsocervical fat pad, and wide violaceous abdominal striae. Her blood pressure is 158/96 mm Hg. Initial screening with two separate 24-hour urine free cortisol measurements and an overnight low-dose dexamethasone suppression test confirm the diagnosis of endogenous hypercortisolism.

Arrange the following diagnostic steps in the most appropriate chronological sequence to determine the specific etiology of her condition. Assume each test is performed sequentially and its result dictates the necessity of the immediate next step in this patient's diagnostic pathway.