All practice questions

A 22-year-old male is brought to the emergency department after diving headfirst into a shallow lake. He is conscious but in severe respiratory distress, using accessory muscles to breathe. He reports an inability to feel or move his arms or legs. Vital signs include a temperature of 36.5°C (97.7°F), heart rate of 52/min, blood pressure of 80/40 mmHg, respiratory rate of 34/min with shallow effort, and oxygen saturation of 85% on room air. Physical examination demonstrates prominent diaphragmatic breathing, flaccid paralysis of all four extremities, and absent deep tendon reflexes.

Arrange the following steps in the most appropriate sequential order for the initial stabilization and diagnostic workup of this patient.

A 32-year-old woman is brought to the emergency department via ambulance for a generalized tonic-clonic seizure. Her husband states the seizure began 15 minutes ago at home, and she has not regained consciousness or ceased convulsing since onset. She has a known history of medication-refractory focal impaired awareness seizures. Upon arrival, she is actively seizing, tachycardic to 128/min, and blood pressure is 142/88 mm Hg. She is maintaining her airway, with an oxygen saturation of 92% on room air. Two large-bore intravenous lines are immediately established.

Assuming the patient's generalized convulsive seizure activity continues unabated despite each successive intervention, arrange the following pharmacologic therapies in the correct guideline-directed escalation sequence, from initial management to treatment of super-refractory status epilepticus.

A 32-year-old man with no known medical history is brought to the emergency department by emergency medical services (EMS). His roommate found him unresponsive and experiencing generalized tonic-clonic movements. EMS reports that the continuous seizure activity began 25 minutes ago. Paramedics established peripheral intravenous access en route but did not administer any medications. Upon arrival, the patient remains unresponsive with ongoing rhythmic jerking of his extremities. His blood pressure is 145/88 mm Hg, heart rate is 132/min, and oxygen saturation is 94% on a non-rebreather mask. Fingerstick blood glucose is 102 mg/dL. The emergency physician initiates a protocolized escalation for status epilepticus. Assuming the patient's seizures remain completely refractory to each successive pharmacological intervention, arrange the following therapies in the correct chronological sequence of administration, progressing from initial emergent therapy to salvage therapy for super-refractory status epilepticus.

A 26-year-old man comes to the clinic requesting screening for sexually transmitted infections. He reports a new male sexual partner 3 weeks ago and notes one episode of unprotected insertive and receptive anal intercourse. He feels well and has no fever, rash, sore throat, or lymphadenopathy. Vital signs are within normal limits. The physician plans to evaluate the patient for human immunodeficiency virus (HIV). Arrange the following diagnostic laboratory tests in the correct sequential order according to the standard HIV testing algorithm.

Arrange the following diagnostic modalities in the most appropriate chronological sequence for the evaluation and staging of a 65-year-old man who presents to the outpatient clinic with a 3-week history of painless jaundice, acholic stools, weight loss, and a palpable, non-tender gallbladder. Initial laboratory results show a total bilirubin of 12.4 mg/dL and an alkaline phosphatase of 650 U/L.

Emergency medical services bring a 19-year-old college student to the emergency department after he fell approximately 15 feet from a balcony. Paramedics report he was briefly conscious at the scene but rapidly became unresponsive during transport.

On arrival, his eyes are closed, he makes no vocal sounds, and he extends his upper extremities in response to painful stimuli.

Vital signs include a blood pressure of 190/100 mmHg, a heart rate of 48/min, a respiratory rate of 8/min with an irregular pattern, and an oxygen saturation of 89% despite a non-rebreather mask.

Primary survey reveals a boggy swelling over the right parietal area. Neurologic examination shows a right pupil measuring 7 mm and unreactive to light, while the left pupil is 3 mm and reactive.

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

A 29-year-old man is brought to the trauma resuscitation bay following a high-speed motor vehicle collision. Emergency medical services report a prolonged extrication time. Upon arrival, the patient is unresponsive. Vital signs show a pulse of 135/min, blood pressure of 82/50 mm Hg, and a respiratory rate of 35/min. Pulse oximetry indicates an oxygen saturation of 85% despite high-flow supplemental oxygen. Physical examination reveals significant maxillofacial trauma with active bleeding pooling in the oropharynx. The right hemithorax is hyperresonant to percussion with absent breath sounds. The abdomen is distended and rigid. Arrange the following management steps in the most appropriate sequential order according to standardized trauma resuscitation protocols.

A 65-year-old man is evaluated in the clinic after a routine preoperative chest radiograph for an elective inguinal hernia repair reveals a 15-mm solid nodule in the periphery of the right upper lung lobe. He has a 40-pack-year smoking history and quit 2 years ago. He reports no cough, hemoptysis, or weight loss. Vital signs are normal, and physical examination is unremarkable. Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's pulmonary nodule, from the immediate next step to the definitive diagnostic procedure.

A 68-year-old man presents to the clinic with progressive fatigue, tingling in both feet, and mild memory impairment over the past 6 months. He has a past medical history of primary hypothyroidism and vitiligo. Physical examination reveals a smooth, beefy-red tongue, pale conjunctivae, and diminished vibratory and position sensation in his bilateral lower extremities. Arrange the following diagnostic laboratory tests in the most appropriate sequential order to evaluate and establish the precise etiology of this patient's condition.

A $28$-year-old woman is brought to the emergency department via ambulance after being the unrestrained driver in a high-speed motor vehicle collision. Upon arrival, her blood pressure is $78/45$ mmHg, heart rate is $135$/min, and respiratory rate is $28$/min. Pulse oximetry shows $88\%$ on room air. Primary survey reveals a patent airway, and the trachea is midline. Chest examination demonstrates severely decreased breath sounds and dullness to percussion over the right hemithorax. The remainder of the examination shows no obvious external bleeding or pelvic instability.

Place the following surgical and procedural interventions in the most appropriate chronological order for the optimal management of this patient.

A 45-year-old man is evaluated for treatment-resistant hypertension, episodic severe headaches, and diaphoresis. Laboratory testing reveals markedly elevated plasma fractionated metanephrines. Magnetic resonance imaging of the abdomen demonstrates a 5-cm right adrenal mass. The patient is scheduled for a laparoscopic adrenalectomy in 14 days.

Arrange the following interventions in the correct chronological sequence for this patient's perioperative pharmacologic management.

A 58-year-old man with a history of stage 5 chronic kidney disease is brought to the emergency department due to profound generalized weakness. He reports missing his last two scheduled hemodialysis sessions due to transportation issues. His blood pressure is 110/70 mmHg, and his pulse is 42/min. Physical examination shows flaccid muscle weakness in all four extremities. An electrocardiogram (ECG) reveals a heart rate of 42/min, absent P waves, a markedly widened QRS complex, and tall, peaked T waves. Point-of-care testing shows a serum potassium level of 8.6 mEq/L. Arrange the following pharmacologic interventions in the correct chronological sequence for the acute management of this patient, ordered from the most immediate priority to the subsequent steps.

A 64-year-old man with a 45-pack-year smoking history undergoes lung cancer screening with a low-dose computed tomography (CT) scan of the chest. The scan reveals a new, incidental 25-mm, noncalcified, solid lung mass with spiculated margins in the apical segment of the right upper lobe. No prior imaging is available for comparison. He is currently asymptomatic, and his physical examination is unremarkable. His estimated pretest probability for primary lung malignancy is considered very high. Arrange the following diagnostic modalities in the most appropriate chronological sequence for the stepwise clinical evaluation and initial staging of this patient's pulmonary mass.

A 48-year-old agricultural worker is brought to the emergency department triage area by his coworkers in a private truck after he accidentally spilled a concentrated organophosphate pesticide on his clothing 20 minutes ago. He is confused, profusely sweating, and vomiting. Vital signs are temperature 36.5°C (97.7°F), heart rate 42/min, blood pressure 88/55 mm Hg, respiratory rate 28/min, and oxygen saturation 86% on room air. Physical examination reveals pinpoint pupils, excessive salivation, and diffuse wheezing with copious crackles. Widespread muscle fasciculations are noted.

Arrange the following initial stabilization and management steps in the most appropriate chronological order, from first to last.

A $65$-year-old man is hospitalized for an acute exacerbation of severe chronic obstructive pulmonary disease (COPD). He has been receiving nebulized bronchodilators, intravenous glucocorticoids, and antibiotics. On hospital day $3$, he experiences a sudden onset of sharp, right-sided chest pain and an acute worsening of dyspnea. Vital signs show a blood pressure of $105/65$ mmHg, heart rate of $128$/min, respiratory rate of $28$/min, and oxygen saturation of $84\%$ on a $4$ L/min nasal cannula (decreased from $92\%$ on $2$ L/min earlier that day). Physical examination reveals hyperresonance to percussion and absent breath sounds over the right lung fields. The trachea is midline. Heart sounds are distant but regular with no murmurs or gallops. There is no jugular venous distention.

Arrange the following differential diagnoses for his sudden clinical deterioration from highest pre-test probability to lowest pre-test probability based on his presentation.

A 72-year-old man with a history of severe ischemic cardiomyopathy is brought to the emergency department with progressive dyspnea, orthopnea, and worsening confusion over the past 24 hours. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 74/50 mm Hg, heart rate of 118/min, and respiratory rate of 28/min. Physical examination reveals cool, mottled extremities, significant jugular venous distention, and coarse bilateral crackles extending to the mid-lung fields. Urine output since arrival has been minimal. A bedside echocardiogram demonstrates a left ventricular ejection fraction of 20% with severe global hypokinesis and a dilated, non-collapsible inferior vena cava. Arrange the following pharmacologic interventions in the most appropriate sequential order for the management of this patient, starting with the most immediate stabilizing action.

A 27-year-old man is brought to the emergency department by paramedics following a high-speed motorcycle collision without a helmet. Upon arrival, the patient is unresponsive with massive facial crush injuries and copious bleeding into his oropharynx. He exhibits gurgling respiratory efforts. Vital signs reveal a blood pressure of 72/40 mm Hg, a pulse of 135/min, and a respiratory rate of 8/min. Oxygen saturation is 81% on high-flow oxygen. Physical examination is notable for absent breath sounds on the right hemithorax and distended neck veins. His pelvis is stable to palpation, and paramedics have effectively placed a tourniquet on a mangled left lower extremity. Arrange the following steps in the most appropriate sequential order for the initial stabilization and management of this patient.

A gastroenterology consultation is requested for a 42-year-old male who has developed severe, recurrent peptic ulcer disease despite strict adherence to maximal high-dose proton pump inhibitor therapy. He additionally reports a six-month history of high-volume, watery diarrhea that improves only slightly with fasting. A recent esophagogastroduodenoscopy demonstrated markedly hypertrophic gastric folds and multiple atypical ulcerations extending into the distal duodenum and proximal jejunum. Vital signs are stable: temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 74/min, and respiratory rate 14/min. Laboratory results reveal a normal basic metabolic panel, intact parathyroid hormone, and a serum calcium level of 9.2 mg/dL. The clinical team strongly suspects a functional neuroendocrine tumor and plans a comprehensive evaluation. Arrange the following diagnostic modalities in the correct, guideline-directed sequence, progressing from initial biochemical screening to precise anatomic localization.

A 72-year-old man is brought to the emergency department from a skilled nursing facility with altered mental status, fever, and a productive cough. His temperature is $39.2^{\circ} \text{C}$ ($102.6^{\circ} \text{F}$), heart rate is $124/\text{min}$, respiratory rate is $26/\text{min}$, and blood pressure is $72/40 \text{ mmHg}$. His oxygen saturation is $88\%$ on room air. The patient is diagnosed with severe community-acquired pneumonia complicated by septic shock. After securing the airway and obtaining appropriate cultures, empirical broad-spectrum antimicrobial therapy is prescribed.

Arrange the following hemodynamic interventions in the correct sequential order according to standard protocolized management of septic shock, starting from the initial intervention to salvage therapy for refractory hypotension.

A 64-year-old woman arrives at the emergency department with a 24-hour history of severe right-sided flank pain, intense chills, and acute confusion. Vital signs reveal a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure of 88/54 mmHg, and a heart rate of 118/min. Physical examination is notable for exquisite right costovertebral angle tenderness. Initial laboratory evaluation demonstrates a leukocyte count of $18,500/\text{mm}^3$ and a serum creatinine level of $1.9 \text{ mg/dL}$. A non-contrast CT scan of the abdomen and pelvis shows a 9-mm calculus in the proximal right ureter accompanied by severe hydronephrosis and perinephric fat stranding.

Arrange the following patient management and procedural interventions in the most appropriate chronological sequence for this patient.