All practice questions

A 45-year-old woman is evaluated in the outpatient clinic for a 6-month history of progressive shortness of breath on exertion and profound fatigue. She recently experienced an episode of lightheadedness that nearly resulted in syncope while climbing stairs. She has no significant past medical history, takes no medications, and has never smoked. Vital signs show a heart rate of $92/\text{min}$, blood pressure of $118/74\text{ mmHg}$, and oxygen saturation of $97\%$ on room air. Physical examination reveals a palpable right ventricular heave and a prominently accentuated $P_2$ component of the second heart sound. The lungs are clear to auscultation bilaterally. An electrocardiogram demonstrates right axis deviation and right ventricular hypertrophy. Chest radiography shows prominent central pulmonary arteries with rapid tapering of the peripheral vessels and clear lung fields.

Arrange the following diagnostic and management steps in the most appropriate chronological order according to guideline-directed evaluation of suspected pulmonary hypertension.

A 28-year-old man is brought to the emergency department after a high-speed motorcycle collision. He is unresponsive and making gurgling respiratory sounds. His blood pressure is $72/40 \text{ mm Hg}$, pulse is $142\text{/min}$, and respiratory rate is $34\text{/min}$. Physical examination reveals severe maxillofacial crush injuries with active oropharyngeal hemorrhage. The trachea is deviated to the left, and breath sounds are absent over the right hemithorax. The pelvis is mechanically unstable on anteroposterior compression.

Arrange the following acute management steps in the correct chronological sequence according to standard trauma resuscitation protocols.

A 56-year-old male patient is rushed to the emergency department following two episodes of voluminous vomiting of bright red blood at home. He has a past medical history significant for chronic hepatitis C infection and resultant portal hypertension. Upon arrival, he is lethargic but protecting his airway. His blood pressure is 82/48 mm Hg, and his pulse is 126/min. Physical examination reveals conjunctival pallor, prominent abdominal veins, and splenomegaly. Laboratory studies show a hemoglobin level of 6.8 g/dL and a platelet count of 65,000/mm³. Arrange the following steps in the management of this patient's acute bleeding episode in the most appropriate chronological order from first (most immediate) to last (salvage therapy).

An emergency medicine physician is managing a 26-year-old female patient who presents with acute respiratory distress, diffuse polyphonic expiratory wheezing, and prominent accessory muscle use. Supplemental oxygen is applied via nasal cannula. To prevent impending respiratory failure, the physician must escalate her treatment in a stepwise fashion based on her clinical response. Arrange the following therapeutic interventions in the standard sequential order of escalation for a severe asthma exacerbation, from the initial first-line step to the final intervention of last resort.

A 58-year-old man with a history of cavitary pulmonary tuberculosis presents to the emergency department after coughing up approximately 600 mL of bright red blood over the last 2 hours. He appears anxious and is in visible respiratory distress. His blood pressure is 88/55 mmHg, pulse is 122/min, and respiratory rate is 28/min. Auscultation reveals prominent coarse crackles over the right upper and middle lung fields, with clear breath sounds on the left. Arrange the following steps in the most appropriate sequential order for the management of this patient's condition.

A 45-year-old woman is receiving a transfusion of packed red blood cells for severe anemia secondary to abnormal uterine bleeding. Thirty minutes into the transfusion, she develops sudden-onset chills, severe flank pain, and dyspnea. Her temperature is 39.2°C (102.6°F), blood pressure is 85/50 mm Hg, and heart rate is 120/min. Arrange the following management steps in the most appropriate chronological sequence.

A 2-month-old male infant is brought to the clinic for evaluation of frequent, forceful regurgitation after almost every feed. His parents report that he frequently arches his back, cries during feedings, and seems generally irritable. Review of his growth chart shows he has dropped from the 50th percentile for weight at birth to the 10th percentile currently. Physical examination is unremarkable, with a soft, non-tender abdomen and normal bowel sounds. There are no signs of acute infection. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient's condition, from the initial intervention to the final option for severe, refractory disease.

The triage nurse calls a physician to evaluate a newly arrived patient in the emergency department. The patient, a 34-year-old woman with no significant past medical history, describes a rapidly progressive, profound exhaustion over the last 72 hours, accompanied by intermittent episodes of confusion and 'purple spots' appearing on her legs.

Vital signs include a heart rate of 108/min, blood pressure of 142/88 mmHg, temperature of 37.8°C (100.0°F), and oxygen saturation of 98% on room air. Examination shows widespread lower extremity petechiae, mild scleral icterus, and temporal disorientation without focal neurological deficits.

Based on the clinical presentation and initial laboratory data, arrange the following diagnostic and therapeutic steps in the strictly required chronological sequence to properly manage this patient's suspected hematologic emergency.

Immediately following an uncomplicated spontaneous vaginal delivery of a macrosomic neonate, a multiparous patient develops heavy, continuous vaginal bleeding. The placenta was delivered spontaneously and appears grossly intact. Her blood pressure is 95/60 mm Hg and her heart rate is 115/min. Abdominal palpation reveals a soft, boggy uterus resting above the level of the umbilicus. Speculum examination demonstrates an intact lower genital tract with no lacerations. Arrange the following management interventions in the correct sequential algorithm for this patient's complication, starting with the immediate initial response and progressing step-by-step to definitive surgical care if hemorrhage remains uncontrolled.

A 6-year-old boy is newly diagnosed with Burkitt lymphoma. He presents with a large abdominal mass, and laboratory studies reveal a significantly elevated serum lactate dehydrogenase (LDH) and uric acid level. The oncology team is preparing to begin his treatment but must first address his high risk for developing tumor lysis syndrome (TLS). Arrange the following management steps in the most appropriate sequential order, starting from the most critical initial preventive measure to the intervention reserved for severe, refractory complications.

A $28$-year-old woman with a history of ulcerative colitis presents to the emergency department with a $4$-day history of $8$ to $10$ bloody bowel movements daily, severe abdominal cramps, and subjective fever. Her temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), pulse is $112/\text{min}$, and blood pressure is $105/65\text{ mm Hg}$. Physical examination reveals diffuse lower abdominal tenderness without rebound or guarding. Laboratory studies show a hemoglobin of $9.8\text{ g/dL}$, leukocyte count of $14,500/\text{mm}^3$, and C-reactive protein of $65\text{ mg/L}$. She meets the Truelove and Witts criteria for acute severe ulcerative colitis. Arrange the following diagnostic and therapeutic steps in the optimal chronological sequence for the management of this patient.

A $6$-day-old term neonate is brought to the pediatric emergency department presenting with progressive lethargy, a weak suck, and recurrent emesis over the past $24$ hours. On physical examination, the infant is hypotonic, difficult to arouse, and exhibits deep, rapid respirations. Initial laboratory studies reveal a severe high anion gap metabolic acidosis, significant ketonuria, and a plasma ammonia level of $320 \mu\text{mol/L}$ (normal: $10-50 \mu\text{mol/L}$). The clinical picture is highly suspicious for an acute metabolic crisis secondary to an underlying organic acidemia.

Arrange the following management and diagnostic steps in the most appropriate, chronologically prioritized sequence for this patient.

During an uncomplicated spontaneous vaginal delivery, the fetal head must navigate the rigid maternal bony pelvis through a predictable series of biomechanical adaptations. Consider a singleton fetus presenting in the left occipitotransverse position that progresses to a normal delivery. Arrange the following fetal cardinal movements in the correct chronological sequence, starting with the initial entry into the maternal pelvis and ending with the movements immediately following head delivery.

An evaluation is requested for a 38-year-old G2P2 woman presenting with progressive right breast enlargement and erythema over the past three weeks. She recently completed a 10-day course of cephalexin for a presumptive diagnosis of mastitis, but her symptoms have worsened. The patient is not pregnant and last breastfed 4 years ago. She has no personal or family history of cancer. Her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mm Hg, and pulse is 76/min. Physical examination reveals a globally swollen, erythematous right breast with prominent skin dimpling and thickening over the dependent portion. A 5-cm firm, ill-defined area of induration is palpated deep to the areola. A 2-cm, hard, mobile lymph node is palpable in the right axilla. Arrange the following steps in the most appropriate sequential order for the diagnostic workup and management of this patient's most likely condition.

A 28-year-old surgical resident sustains a deep, bleeding puncture wound to her left index finger from a hollow-bore needle immediately after drawing arterial blood. The source patient is known to be HIV-positive with a high viral load and is concurrently infected with hepatitis C. The resident has previously received the complete hepatitis B vaccine series and has a documented positive surface antibody titer. Arrange the following steps in the most appropriate chronological order for managing this healthcare worker's occupational exposure.

A 55-year-old woman with a history of alcohol-associated cirrhosis presents to the emergency department with a 1-day history of fever, diffuse abdominal pain, and confusion. Her temperature is 38.2°C (100.8°F), blood pressure is 90/60 mmHg, and pulse is 110/min. Physical examination reveals a distended abdomen with shifting dullness and diffuse tenderness to palpation without rebound or guarding. Asterixis is present. Laboratory studies show a serum creatinine of 1.6 mg/dL, blood urea nitrogen of 32 mg/dL, and total bilirubin of 4.5 mg/dL. You suspect spontaneous bacterial peritonitis (SBP).

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

A 52-year-old woman is brought to the emergency department by emergency medical services after being involved in a head-on motor vehicle collision. She is confused, tachypneic, and has blood on her face from a scalp laceration. Her vital signs show a blood pressure of 90/50 mmHg, a heart rate of 118/min, and a respiratory rate of 26/min. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial management steps in the correct chronological order.

A 55-year-old hospitalized man collapses while walking in the telemetry unit hallway. He is unresponsive, and no carotid pulse is palpable. A code blue is activated, and high-quality cardiopulmonary resuscitation (CPR) is initiated. The defibrillator pads are applied, and the monitor displays coarse ventricular fibrillation.

Arrange the following critical management steps in the chronological order they should be performed according to advanced cardiovascular life support (ACLS) protocols, assuming the patient remains in refractory ventricular fibrillation throughout the resuscitation.

A $55$-year-old woman is brought to the emergency department due to severe right flank pain, fever, and chills for the past $24$ hours. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $88/55\text{ mm Hg}$, and pulse is $122/\text{min}$. Laboratory studies show a leukocyte count of $18,000/\text{mm}^3$. A noncontrast computed tomography scan of the abdomen and pelvis reveals a $9\text{-mm}$ obstructing calculus in the right proximal ureter with moderate hydronephrosis and perinephric stranding. Arrange the following management steps in the most appropriate chronological order.

An adolescent girl is brought to the pediatric gynecology clinic by her mother due to the absence of menarche. She is $15$ years and $6$ months old. The patient's mother expresses concern that all of her daughter's peers have already started menstruating. The patient denies cyclical abdominal cramping, pelvic pain, or any prior sexual activity. Her medical history is unremarkable, and she takes no medications. Her height is at the $5$ th percentile for her age, and her weight is at the $25$ th percentile. Vital signs are within normal limits. Physical examination reveals a broad chest with widely spaced nipples and a low posterior hairline. Tanner stage $1$ is noted for breast development, and Tanner stage $2$ for pubic hair. A normal-appearing vaginal introitus is present.

Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient's evaluation, from initial mandatory testing to post-diagnostic screening.