All practice questions

A $67$-year-old woman with a severe history of emphysema is brought to the emergency department reporting a three-day history of increasing cough, purulent sputum, and breathlessness. Upon arrival, initial therapies including supplemental oxygen via nasal cannula, nebulized short-acting bronchodilators, and intravenous glucocorticoids are administered. Reevaluation ninety minutes later reveals that the patient is markedly fatigued and utilizing accessory muscles of respiration. She remains fully conscious and cooperative but struggles to speak in full sentences. Vital signs show a respiratory rate of $28$/min and an oxygen saturation of $89\%$ on $4$ L/min of oxygen. Arrange the following clinical interventions in the most appropriate chronological sequence for escalating the management of this patient's respiratory deterioration.

A 64-year-old man is brought to the emergency department due to sudden-onset, severe, "tearing" chest pain that radiates to his back between the shoulder blades. His blood pressure is 210/115 mm Hg in the right arm and 170/95 mm Hg in the left arm. His pulse is 115/min. Physical examination reveals an early diastolic decrescendo murmur at the right upper sternal border. Electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy without acute ischemic changes. Chest x-ray reveals a widened mediastinum. A presumptive diagnosis of acute aortic dissection is made. Arrange the following steps in the most appropriate clinical sequence for managing this patient.

A 22-year-old male college student is brought to the emergency department by his roommate due to a 24-hour history of severe headache, high fever, and progressive confusion. His temperature is 39.4°C (102.9°F), blood pressure is 110/65 mm Hg, pulse is 118/min, and respirations are 22/min. Physical examination reveals marked nuchal rigidity and a positive Brudzinski sign. Funduscopic examination demonstrates blurring of the optic disc margins bilaterally. Which of the following represents the most appropriate chronological sequence of management steps for this patient?

A 64-year-old retired teacher with a history of chronic hepatitis C viral infection and cirrhosis is brought to the emergency department after vomiting a large amount of bright red blood at home. Her husband reports she has been increasingly fatigued over the last week but had no prior episodes of bleeding. Upon arrival, the patient is lethargic but arousable. Vitals show a temperature of 36.8°C (98.2°F), pulse of 132/min, and blood pressure of 82/48 mm Hg. Physical examination reveals scleral icterus, palmar erythema, and a distended abdomen with a positive fluid wave. Capillary refill is delayed. Arrange the following interventions in the most appropriate chronological sequence for managing this patient's acute presentation.

A 39-year-old woman is evaluated for a 1-year history of progressive central obesity, facial plethora, and new-onset hypertension. She also reports menstrual irregularities and easy bruising. Physical examination reveals violaceous striae on her abdomen and prominent proximal muscle weakness in her lower extremities. She does not use any prescription, over-the-counter, or topical medications. Suspecting an endogenous hypercortisolism disorder, her physician decides to initiate a comprehensive diagnostic workup. Arrange the following diagnostic modalities in the correct sequential order for the evaluation of this patient's condition, starting from the initial screening to the definitive localization of the source.

A $58$-year-old male patient is recovering in the cardiac intensive care unit following an anterior wall myocardial infarction. On hospital day $2$, the telemetry alarms sound. The nurse finds the patient unresponsive and apneic, with no palpable carotid pulse. The bedside cardiac monitor displays a regular, wide-complex tachycardia at a rate of $210/\text{min}$. Arrange the following resuscitation interventions in the most appropriate chronological sequence from first to last according to standard adult advanced cardiovascular life support (ACLS) algorithms.

A $22$-year-old tall, thin man is brought to the emergency department by emergency medical services after a high-speed motorcycle collision. He is in severe respiratory distress and appears cyanotic. His blood pressure is $80/50$ mm Hg, heart rate is $135$/min, and oxygen saturation is $84\%$ on a non-rebreather mask. Physical examination reveals obvious tracheal deviation to the left, significantly distended neck veins, and completely absent breath sounds over the right hemithorax. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order for managing this patient's life-threatening condition.

A patient presents with treatment-resistant hypertension and is found to have unprovoked hypokalemia on routine laboratory testing. The physician suspects primary hyperaldosteronism. Arrange the following steps of the diagnostic evaluation in the correct chronological order.

A 45-year-old man presents to the clinic for chronic diarrhea and recurrent severe abdominal pain for the past 6 months. He states that he has been taking high-dose over-the-counter omeprazole with minimal relief. Vital signs are within normal limits. Physical examination reveals mild epigastric tenderness to deep palpation. An upper gastrointestinal endoscopy is performed, revealing prominent gastric folds and multiple ulcerations in the gastric body, duodenal bulb, and distal duodenum. A gastric aspirate obtained during the endoscopy shows a pH of 1.4. The physician suspects a neuroendocrine tumor as the underlying cause of the patient's presentation.

Arrange the following subsequent steps in the most appropriate chronological sequence for the definitive diagnosis and management of this patient's suspected condition.

A $54$-year-old man is brought to the emergency department via ambulance after his wife found him lethargic at home. She reports that he has a medical history of hypertension, major depressive disorder, and hyperlipidemia. Empty bottles of metoprolol and hydrochlorothiazide were found near his bed. On arrival, the patient is minimally responsive. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $70/40$ mmHg, pulse is $34$/min, and respiratory rate is $14$/min. The $12$-lead electrocardiogram demonstrates sinus bradycardia with a first-degree atrioventricular block and no acute ST-segment changes. Intravenous access is established, and a $1$-liter bolus of normal saline is rapidly infused with no improvement in hemodynamics.

Arrange the following subsequent interventions in the most appropriate chronological sequence for the emergency management of this patient's condition.

A 24-year-old pregnant woman at 14 weeks gestation presents for her initial prenatal visit. Routine prenatal screening reveals a positive rapid plasma reagin (RPR) test at a titer of 1:32. The patient reports a history of severe generalized urticaria and wheezing immediately after taking amoxicillin during childhood. She currently has no genital lesions or neurological symptoms. Arrange the following management steps in the most appropriate sequential order for this patient.

A 68-year-old man is evaluated in the clinic for progressive fatigue and a 6-kg (13.2-lb) weight loss over the past four months. He reports occasional dark stools but denies abdominal pain, nausea, or vomiting. His past medical history is unremarkable, and he has not had a colonoscopy in the past 15 years. Vital signs are within normal limits. Laboratory results show a hemoglobin of 9.4 g/dL, mean corpuscular volume of 74 fL, and ferritin of 10 ng/mL. Based on his presentation, a lower gastrointestinal malignancy is highly suspected. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order for the evaluation and management of this patient.

A 52-year-old woman is evaluated in the emergency department for an 8-hour history of severe, steady right upper quadrant abdominal pain that radiates to her back, accompanied by nausea. Her temperature is 37.2°C (99.0°F), blood pressure is 130/80 mm Hg, and pulse is 88/min. Physical examination shows scleral icterus and right upper quadrant tenderness without guarding or rebound. Laboratory studies show:

- Leukocyte count: $8,500/\text{mm}^3$
- Total bilirubin: $2.4 \text{ mg/dL}$
- Alkaline phosphatase: $260 \text{ U/L}$
- Aspartate aminotransferase (AST): $115 \text{ U/L}$
- Alanine aminotransferase (ALT): $120 \text{ U/L}$
- Lipase: $40 \text{ U/L}$

Arrange the following clinical interventions in the most appropriate chronological sequence for the complete evaluation and management of this patient, starting from her immediate arrival. Assume that any diagnostic imaging performed reveals findings consistent with an intermediate probability for choledocholithiasis (e.g., a dilated common bile duct without a definitively visualized ductal stone).

A 45-year-old man with a history of cavitary pulmonary tuberculosis is brought to the emergency department coughing up copious amounts of bright red blood. He expectorates approximately $700 \text{ mL}$ of blood over the next hour. He is in severe respiratory distress, breathing at $28/\text{min}$, and his oxygen saturation is $86\%$ on room air. The bleeding is suspected to originate from a cavity in the right lung. Arrange the following acute interventions in the correct sequential order of prioritization for managing this life-threatening massive hemoptysis.

A 32-year-old woman is brought to the emergency department by her family due to severe agitation, confusion, and palpitations that started earlier today. She has a known history of Graves disease but admits to abruptly stopping her antithyroid medications three months ago. Her temperature is $40.0^\circ\text{C}$ ($104.0^\circ\text{F}$), blood pressure is $165/95\text{ mmHg}$, pulse is $155/\text{min}$ and irregular, and respiratory rate is $24/\text{min}$. Physical examination reveals a delirious, severely diaphoretic patient with a diffusely enlarged and non-tender thyroid gland. Fine tremors are noted in her extremities. An electrocardiogram shows atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is made, and the patient is admitted to the intensive care unit.

Arrange the following therapeutic interventions in the most appropriate chronological sequence for managing this patient's condition.

A 62-year-old man is brought to the emergency department complaining of sudden-onset, severe, tearing chest pain that radiates to his back. His blood pressure is 210/115 mm Hg in the right arm and 170/95 mm Hg in the left arm. His pulse is 115/min and regular. Physical examination reveals a new decrescendo diastolic murmur at the right upper sternal border. An electrocardiogram shows non-specific ST-segment changes. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient.

A 72-year-old man with a history of hypertension and coronary artery disease is brought to the emergency department after passing three large, dark red, liquid bowel movements at home. On arrival, he is confused, pale, and diaphoretic. His temperature is 36.8°C (98.2°F), blood pressure is 82/52 mm Hg, and heart rate is 126/min. Abdominal examination reveals a soft and non-tender abdomen. Rectal examination shows copious amounts of maroon-colored stool.

Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient's acute presentation.

A 62-year-old man with a history of advanced non-small cell lung cancer is brought to the emergency department due to progressive shortness of breath and lightheadedness over the past three days. Today, he had a syncopal episode. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $78/48\text{ mmHg}$, pulse is $122/\text{min}$, and respiratory rate is $24/\text{min}$. Pulsus paradoxus is $18\text{ mmHg}$. Physical examination reveals distended jugular veins and distant, muffled heart sounds. Lungs are clear to auscultation bilaterally. An electrocardiogram shows sinus tachycardia with low QRS voltage and electrical alternans.

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

A 58-year-old man is admitted to the hospital with a 4-day history of fever, productive cough, and right-sided pleuritic chest pain. Chest radiography reveals a right lower lobe consolidation and a large, freely flowing right-sided pleural effusion. He is initiated on empiric intravenous antibiotics. Over the course of his hospitalization, his pleural space infection proves to be highly refractory, requiring a continuous stepwise escalation of interventions. Arrange the following procedures in the standard chronological sequence utilized for the evaluation and escalating management of a progressive parapneumonic effusion, from initial assessment to definitive rescue therapy.

A 58-year-old man suddenly collapses while walking in the hospital hallway. He is unresponsive, apneic, and has no palpable carotid pulse. The emergency response team arrives immediately with a resuscitation cart. The cardiac monitor displays coarse ventricular fibrillation. According to the Advanced Cardiovascular Life Support (ACLS) guidelines, arrange the following management steps in the correct chronological order for this patient.