All practice questions

Paramedics arrive at the trauma bay with a commercial roofer who plummeted two stories onto concrete. Initial assessment reveals profound bradycardia at 48/min, marked hypotension at 76/40 mm Hg, and shallow respirations at 8/min. Pulse oximetry reads 85% on room air. He is unresponsive to verbal stimuli. Gurgling sounds are audible with each breath, and pooled blood is visible in his posterior pharynx. His extremities are unusually warm and pink despite the severe hypotension. Arrange the following initial stabilization and diagnostic steps in the most appropriate chronological order of execution for this patient.

A 45-year-old male is evaluated in the pulmonology clinic for progressive dyspnea on exertion and a chronic, nonproductive cough that has worsened over the last 6 months. He works as a sandblaster and ship fitter at a local commercial shipyard. He has never smoked and has no other notable medical history. Vital signs are within normal limits. Physical examination reveals normal breath sounds bilaterally without wheezes or crackles. High-resolution computed tomography (HRCT) of the chest reveals diffuse, small nodular opacities predominantly in the upper lobes, along with distinct "eggshell" calcification of the hilar lymph nodes.

Arrange the following interstitial lung diseases in order of pre-test probability for this patient, from highest probability (most likely) to lowest probability (least likely).

Paramedics rush a cyanotic, gasping male patient into the resuscitation bay after he collapsed in a local park. Bystanders reported the patient was swarmed by yellow jackets approximately 15 minutes prior. The patient's spouse, who arrives shortly after, provides a medication list indicating he takes carvedilol, sacubitril-valsartan, empagliflozin, and apixaban for a history of heart failure with reduced ejection fraction. Vital signs on the monitor display a blood pressure of 68/36 mmHg, a pulse of 115/min, and an oxygen saturation of 85% on room air. Examination shows profound periorbital and labial edema, audible stridor, widespread urticaria, and poor air entry bilaterally with faint wheezing. Establish the most appropriate chronological sequence of pharmacologic interventions to stabilize this patient.

A 32-year-old man is brought to the emergency department with a severe head injury and a Glasgow Coma Scale score of 6 following a motorcycle collision. He is spontaneously breathing but unable to protect his airway. His blood pressure is 110/70 mm Hg and heart rate is 115/min. The trauma team decides to proceed with rapid sequence intubation (RSI).

Arrange the following pharmacologic interventions in the correct chronological sequence of administration for this patient's airway management, from earliest to latest.

A 32-year-old woman is evaluated in the preoperative clinic prior to an elective laparoscopic cholecystectomy. She has no significant past medical history and takes no medications. She reports normal menstrual periods and denies any history of easy bruising, epistaxis, or prolonged bleeding after minor cuts or prior dental extractions. Routine preoperative laboratory testing reveals a normal prothrombin time (PT) of 11.5 seconds and an isolated, significantly prolonged activated partial thromboplastin time (aPTT) of 62 seconds (reference range: 25-35 seconds). Her platelet count is $210,000/\mu L$.

Arrange the following laboratory tests in the most appropriate sequential order to establish the etiology of this patient's isolated prolonged aPTT, from the initial evaluation step to the final diagnostic confirmation.

A $48$-year-old woman is referred to the endocrinology clinic due to refractory hypertension. Her blood pressure has remained uncontrolled despite documented adherence to maximal tolerated doses of amlodipine, valsartan, and hydralazine. She reports occasional muscle weakness and severe leg cramps. Her vital signs today show a blood pressure of $165/102$ mm Hg. A basic metabolic panel reveals a serum sodium of $144$ mEq/L, a serum potassium of $2.9$ mEq/L, and a serum bicarbonate of $30$ mEq/L. The clinician strongly suspects primary hyperaldosteronism as the etiology of her presentation. Arrange the following diagnostic steps in the most appropriate sequential order to establish the diagnosis, confirm the etiology, and determine surgical candidacy.

A male patient, aged $58$ years, with documented hepatic cirrhosis and portal hypertension, is evaluated in the emergency department following an episode of massive hematemesis. Upon arrival, he is obtunded, opening his eyes only to sternal rub, and actively vomiting bright red blood. His temperature is $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), blood pressure is $74/42 \text{ mm Hg}$, heart rate is $128 \text{ /min}$, and respiratory rate is $24 \text{ /min}$. Pulse oximetry demonstrates an oxygen saturation of $92\%$ on ambient air. Physical examination reveals a pale, diaphoretic patient with cool extremities and a distended abdomen with shifting dullness.

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

A 63-year-old man with a 45-pack-year smoking history is evaluated in the pulmonary clinic. A routine preoperative chest radiograph reveals an incidental 14-mm noncalcified nodule in the peripheral right upper lobe. He has no hemoptysis, weight loss, or prior history of malignancy. To appropriately guide management, assume that the results of each subsequent diagnostic test continue to raise the suspicion for a primary lung malignancy without confirming a definitive diagnosis. Arrange the following radiological evaluations and image-guided procedures in the most appropriate chronological sequence for the diagnostic workup of this patient's solitary pulmonary nodule.

A 42-year-old woman is brought to the emergency department after experiencing the sudden onset of a severe, diffuse headache that she describes as the 'worst of my life,' accompanied by vomiting and photophobia. On physical examination, she is lethargic but arousable, with marked nuchal rigidity. Her vital signs show a blood pressure of 170/95 mmHg, heart rate of 98/min, and oxygen saturation of 99% on room air. The emergency physician suspects an aneurysmal subarachnoid hemorrhage (SAH) and initiates a diagnostic workup. Assuming positive or localizing findings at each diagnostic stage that necessitate further characterization, arrange the following imaging modalities in the most appropriate chronological sequence for the comprehensive diagnosis, etiological mapping, and subsequent intensive care monitoring of this patient.

A 35-year-old man presents to the clinic with a 3-month history of progressive fatigue, unintentional weight loss, and diffuse arthralgias. He also reports intermittent low-grade fevers and night sweats. Physical examination reveals generalized, non-tender lymphadenopathy and a newly auscultated grade 3/6 holosystolic murmur at the cardiac apex. Laboratory studies show a normocytic, normochromic anemia, an elevated erythrocyte sedimentation rate, and a positive rheumatoid factor. Arrange the following differential diagnoses in order from most likely to least likely based on the patient's clinical presentation.

An established patient, a 72-year-old male with a 6-year history of Parkinson disease, presents to the outpatient neurology clinic accompanied by his wife. Over the past three weeks, he has experienced new-onset visual hallucinations, frequently reporting that strangers are standing in their living room. These episodes cause him significant distress. His motor symptoms remain well-controlled. His current daily medication regimen consists of carbidopa-levodopa, pramipexole, selegiline, and trihexyphenidyl. He takes no other medications. Vital signs include a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $134/76\text{ mmHg}$, pulse of $72\text{/min}$, and respiratory rate of $16\text{/min}$. Physical examination is remarkable for a mild resting pill-rolling tremor and slight bradykinesia, unchanged from previous visits. Laboratory results, including a complete blood count, comprehensive metabolic panel, and urinalysis, show no abnormalities.

Arrange the following pharmacologic interventions in the chronological sequence they should be implemented (from first step to last step) to appropriately manage this patient's new-onset psychosis.

A 24-year-old nulliparous woman is brought to the emergency department by her partner due to the sudden onset of severe, right-sided lower abdominal pain that began 2 hours ago. She reports one episode of vomiting and scant, dark vaginal spotting. Her last menstrual period was 6 weeks ago, although she notes her cycles are occasionally irregular. Her medical history is notable for a Chlamydia trachomatis infection complicated by pelvic inflammatory disease 3 years ago. On presentation, her temperature is 37.1°C (98.8°F), blood pressure is 88/54 mmHg, pulse is 122/min, and respirations are 22/min. Physical examination reveals a pale, diaphoretic patient in acute distress. Abdominal examination demonstrates marked right lower quadrant tenderness with involuntary guarding and rebound tenderness. Pelvic examination reveals significant cervical motion tenderness and a palpable, exquisitely tender, 5-cm right adnexal mass. Serum human chorionic gonadotropin (hCG) results are pending.

Arrange the following differential diagnoses in order from the MOST likely to the LEAST likely to explain this patient's acute clinical presentation.

Following the initiation of oral ferrous sulfate for newly diagnosed iron deficiency anemia, a structured follow-up plan is necessary to ensure therapeutic efficacy and replenish physiologic reserves. Arrange the following laboratory assessments and clinical actions in the appropriate chronological sequence for monitoring this patient's treatment response over time.

A 58-year-old woman is evaluated in the outpatient clinic to discuss the results of a recent screening colonoscopy and subsequent biopsy. The physician has already arranged for a private room, ensured the patient's wife is present with her consent, and minimized interruptions. According to established protocols for delivering bad news (e.g., the SPIKES framework), arrange the following physician actions in the most appropriate chronological order.

A 68-year-old man comes to the clinic to discuss the results of a recent prostate biopsy. The pathology report indicates high-grade prostate adenocarcinoma. The physician prepares to disclose this diagnosis using the established six-step framework for delivering bad news. Arrange the following physician actions in the correct chronological sequence according to this standardized communication protocol.

A 65-year-old man with metastatic prostate cancer presents to the palliative care clinic with severe, constant lower back and pelvic pain. He is currently opioid-naive, and his pain is poorly controlled despite maximum scheduled doses of nonsteroidal anti-inflammatory drugs (NSAIDs). An evaluation confirms the pain is primarily nociceptive secondary to osseous metastases. The physician decides to initiate strong opioid therapy.

Arrange the following steps in the most appropriate chronological sequence for safely establishing and optimizing a long-term opioid regimen for this opioid-naive patient, from initial prescribing to long-term maintenance.

A $24$-year-old man with a history of type 1 diabetes mellitus is brought to the emergency department with abdominal pain, nausea, and vomiting. Laboratory studies show a serum glucose of $580 \text{ mg/dL}$, bicarbonate of $12 \text{ mEq/L}$, and an anion gap of $22$. He is diagnosed with diabetic ketoacidosis. Assuming his initial serum potassium is $4.5 \text{ mEq/L}$, arrange the following management steps in the correct sequential order according to standard treatment protocols.

A 59-year-old man is admitted to the neurocritical care unit following a severe subarachnoid hemorrhage. He is currently comatose, lacks decision-making capacity, and is ventilator-dependent. The primary care team determines that a tracheostomy is necessary for prolonged airway management. A thorough review of the patient's medical records and discussions with family reveal that he never completed an advance directive or appointed a healthcare power of attorney. Several family members are present at the hospital and have differing views on whether the procedure should be performed. One family member states they should be in charge because they hold a valid Durable Power of Attorney for Finances. In the absence of a designated healthcare proxy, standard United States legal consensus dictates a specific hierarchy of individuals who can act as the medical surrogate decision-maker.

Arrange the following family members in the standard statutory order of priority to act as the patient's medical surrogate decision-maker, from highest priority (first) to lowest priority (last).

A 65-year-old man with a 40-pack-year smoking history presents to the clinic for a routine health maintenance visit. He has no symptoms of lung disease. The physician initiates a discussion regarding lung cancer screening with low-dose computed tomography (LDCT) and employs the SHARE approach for shared decision-making. Arrange the following physician statements in the correct sequential order according to the steps of the SHARE protocol.

A 45-year-old man is hospitalized for native mitral valve infective endocarditis due to methicillin-susceptible Staphylococcus aureus. He has been receiving intravenous cefazolin for the past week. He is now afebrile, his surveillance blood cultures are negative, and he is deemed medically stable. The multidisciplinary team decides to transition him to Outpatient Parenteral Antimicrobial Therapy (OPAT) to complete his remaining 5-week course of antibiotics at home. Arrange the following discharge planning and care transition steps in the most appropriate chronological sequence to ensure a safe transition to the home setting.