All practice questions

A $72$-year-old woman is brought to the emergency department from a skilled nursing facility due to severe lethargy and confusion over the past $12$ hours. Transport personnel report that she had a productive cough and foul-smelling urine for $3$ days prior to this acute decline. On arrival, she is unarousable to verbal stimuli but moans in response to painful stimuli. Vital signs include a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure of $76/40\text{ mm Hg}$, pulse of $128/\text{min}$, and respiratory rate of $28/\text{min}$. Oxygen saturation is $86\%$ on room air. Capillary refill time is $5$ seconds. Arrange the following initial stabilization and management steps in the most appropriate chronological sequence for this patient.

A 45-year-old woman presents to the emergency department with a sudden-onset "thunderclap" headache, severe photophobia, and nuchal rigidity that began 12 hours ago. Her blood pressure is 155/90 mmHg, and her heart rate is 98/min. Neurologic examination reveals no focal deficits. Arrange the following diagnostic modalities and confirmatory protocols in the most appropriate sequential algorithm for the evaluation of this patient, starting with the initial diagnostic test.

A 54-year-old man presents to the emergency department with a 3-hour history of sudden, severe, and diffuse abdominal pain. He has a history of chronic knee osteoarthritis and takes high-dose naproxen daily. He appears in acute distress and lies completely still on the stretcher. His temperature is 38.2°C (100.8°F), blood pressure is 102/64 mm Hg, pulse is 118/min, and respirations are 22/min. Abdominal examination reveals a rigid, board-like abdomen with diffuse guarding and rebound tenderness. Arrange the following steps in the most appropriate sequence for the management of this patient.

A 65-year-old man is evaluated in the surgical intensive care unit for acute right lower extremity pain and swelling. He underwent a coronary artery bypass graft 7 days ago. Since his surgery, he has been receiving subcutaneous unfractionated heparin for deep venous thrombosis (DVT) prophylaxis. Vital signs are stable. Physical examination reveals a swollen, erythematous, and tender right calf. Laboratory studies show a platelet count of $55,000/\mu L$, a significant decline from his baseline of $260,000/\mu L$ immediately post-operation. A compression Doppler ultrasound of the right lower extremity confirms a new occlusive DVT in the popliteal vein. A serotonin release assay is strongly positive. Arrange the following pharmacologic management steps in the correct chronological sequence to optimally treat this patient's acute thrombosis and safely transition him to long-term oral anticoagulation.

A 35-year-old man is brought to the emergency department by emergency medical services due to ongoing generalized shaking of his extremities. The paramedics report that the seizure activity began 20 minutes ago and has been continuous without any periods of responsiveness. His past medical history is significant for a traumatic brain injury two years ago. His blood pressure is 142/88 mmHg, heart rate is 118/min, and oxygen saturation is 95% on a non-rebreather mask. Intravenous access is established, and fingerstick blood glucose is 108 mg/dL (6.0 mmol/L).

Arrange the following pharmacologic interventions in the most appropriate escalating sequence for managing this patient's condition, assuming the seizure activity remains refractory to each preceding step.

A 45-year-old woman is evaluated in the clinic for follow-up of difficult-to-control hypertension. Her blood pressure today is 168/102 mmHg despite documented adherence to maximal doses of amlodipine, lisinopril, and hydrochlorothiazide. She reports occasional muscle weakness but is otherwise asymptomatic. Fundoscopy shows no papilledema, and her neurological examination is normal. Laboratory studies reveal a serum potassium of 3.1 mEq/L and a serum sodium of 142 mEq/L. The physician suspects a specific secondary cause of her hypertension. Arrange the following diagnostic steps in the correct sequential order from initial screening to definitive pre-surgical evaluation.

A 26-year-old man is brought to the emergency department via ambulance after being ejected from a motorcycle at highway speeds. He was not wearing a helmet. On arrival, the patient is unresponsive with a Glasgow Coma Scale score of 6. He has massive midface crush injuries with active, brisk hemorrhage into the oropharynx. He is making gurgling respiratory sounds with poor chest rise. Vital signs are temperature $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$), blood pressure 78/48 mm Hg, heart rate 135/min, and respiratory rate 8/min. Oxygen saturation is 84% on room air. The bilateral radial pulses are weak and thready. An attempt at bag-valve-mask ventilation is unsuccessful due to severe facial deformity and continuous bleeding.

Arrange the following management steps in the most appropriate chronological sequence for this patient's initial stabilization and triage.

A 68-year-old woman is brought to the emergency department by emergency medical services at 07:30 due to sudden neurological deficits. Her husband reports that they went to bed at 22:00 the previous night, at which time she was at her baseline. Upon waking at 07:00, she was found to have dense right-sided weakness and severe difficulty speaking. On examination, her blood pressure is 165/90 mmHg, heart rate is 88/min, and oxygen saturation is 98% on room air. Neurologic examination reveals right-sided hemiplegia, a right facial droop, and expressive aphasia. The clinical team activates the acute stroke protocol for a suspected 'wake-up' ischemic stroke. Arrange the following imaging modalities and confirmatory protocols in the most appropriate sequential order for the diagnostic workup and management of this patient, from first to last.

A 42-year-old male with a history of HIV (last CD4 count $80$ cells/mm $^3$ evaluated $6$ months ago; non-adherent to antiretroviral therapy) presents to the emergency department with a 2-week history of progressively worsening headache, low-grade fever, and mild confusion. Over the past 24 hours, he has developed left-sided hemiparesis. Vital signs are temperature $38.2^\circ$ C ($100.8^\circ$ F), blood pressure $125/82$ mmHg, heart rate $98$/min, and respiratory rate $16$/min. Neurological examination confirms $3/5$ strength in the left upper and lower extremities with hyperreflexia and a positive Babinski sign on the left. A non-contrast head CT demonstrates multiple hypodense focal lesions in the right basal ganglia and right frontal lobe with significant surrounding vasogenic edema.

Arrange the following differential diagnoses from highest pre-test probability to lowest pre-test probability based on this patient's clinical presentation and imaging findings.

An emergency department evaluates a 68-year-old man who reports progressive generalized weakness and perioral numbness over the past 48 hours. He recently began taking lisinopril and spironolactone for newly diagnosed heart failure with reduced ejection fraction. His blood pressure is 118/72 mm Hg, heart rate is 54/min, and respiratory rate is 16/min. He continues to produce adequate urine.

Laboratory studies show:
Serum sodium: 136 mEq/L
Serum potassium: 7.8 mEq/L
Serum chloride: 104 mEq/L
Serum bicarbonate: 18 mEq/L
Blood urea nitrogen: 48 mg/dL
Serum creatinine: 2.9 mg/dL (baseline 1.8 mg/dL)

An electrocardiogram demonstrates absent P waves, widening of the QRS complex, and tall, peaked T waves.

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

A 67-year-old woman with end-stage renal disease on hemodialysis is admitted for a severe diabetic foot infection. She is treated with intravenous vancomycin and prophylactic subcutaneous unfractionated heparin. On hospital day 7, she develops sudden-onset dyspnea and pleuritic chest pain. Vital signs show a heart rate of 112/min, blood pressure of 130/80 mmHg, and oxygen saturation of 89% on room air. Computed tomography pulmonary angiography confirms a new segmental pulmonary embolism. Laboratory studies reveal a platelet count of 65,000/mm³, which has fallen from a baseline of 240,000/mm³ on admission. The 4Ts score is calculated as 7, indicating a high probability of heparin-induced thrombocytopenia (HIT). The clinical team decides to manage her acute thrombosis and bridge her to long-term oral anticoagulation with a vitamin K antagonist.

Arrange the following pharmacologic orders in the strict chronological sequence required to safely manage this patient's coagulopathy from the acute phase through the transition to outpatient therapy.

A 19-year-old male university student is transported to the trauma bay after falling approximately 15 feet from a balcony. Paramedics note that he was initially conversing and complaining of a severe headache, but his mental status rapidly deteriorated en route. Upon arrival, he is deeply obtunded and withdraws only to painful stimuli. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $185/105\text{ mmHg}$, pulse $42/\text{min}$, and respirations $6/\text{min}$ and irregular. Physical examination reveals a right pupil that is $7\text{ mm}$ and unreactive to light; the left pupil is $3\text{ mm}$ and briskly reactive. Intravenous access was established in the field. Arrange the following patient management steps in the most appropriate chronological order.

A 65-year-old man is brought to the emergency department by emergency medical services after vomiting bright red blood at home. He has a history of osteoarthritis for which he takes daily naproxen. Upon arrival, he appears pale, anxious, and diaphoretic. His temperature is 37.1°C (98.8°F), blood pressure is 92/58 mmHg, pulse is 118/min, and respiratory rate is 18/min. Physical examination reveals conjunctival pallor and mild epigastric tenderness. Digital rectal examination shows melena. Arrange the following procedural and management steps in the most appropriate chronological sequence for this patient.

A 9-year-old boy is evaluated in the pediatric clinic for worsening right thigh pain, limp, and fever over the past several days. Physical examination shows focal tenderness and warmth over the distal right femur. Blood cultures are drawn, and acute hematogenous osteomyelitis is suspected. Arrange the following plain radiographic findings of the affected bone in the chronological order they typically manifest during the natural progression of the disease, from earliest appearance to latest appearance.

A 24-year-old woman with type 1 diabetes mellitus is admitted to the intensive care unit with diabetic ketoacidosis. Initial laboratory studies show a blood glucose of $520$ mg/dL, an arterial pH of $7.12$, an anion gap of $22$, and a serum potassium of $2.9$ mEq/L. Arrange the following steps regarding her ongoing management, monitoring, and therapeutic transition in the correct chronological sequence.

A 58-year-old man with a history of adequately treated cavitary pulmonary tuberculosis presents to the emergency department coughing up copious amounts of bright red blood. He reports expectorating approximately 600 mL of blood over the past 4 hours. On presentation, his blood pressure is 90/60 mm Hg, heart rate is 118/min, respiratory rate is 28/min, and oxygen saturation is 86% on room air. He appears in severe respiratory distress and is coughing continuously, struggling to clear his airway. Coagulation studies are within normal limits. Chest radiograph demonstrates a residual cavity in the right upper lobe with new surrounding airspace opacities. Arrange the following procedural and surgical interventions in the most appropriate sequential order for managing this patient's life-threatening condition.

A 42-year-old male truck driver is evaluated in the emergency department after experiencing sudden-onset profound bilateral lower extremity weakness. Triage vital signs demonstrate a blood pressure of 205/115 mmHg and a heart rate of 92/min. Initial point-of-care laboratory testing reveals a critical serum potassium level of 1.9 mEq/L. Following acute correction of his electrolyte derangement and stabilization of his blood pressure using verapamil and doxazosin, the attending physician outlines a comprehensive diagnostic pathway to evaluate for the suspected underlying endocrine disorder.

Arrange the following diagnostic investigations in the correct clinical sequence, starting with the most immediate necessary step during his acute presentation and progressing through the definitive pre-surgical evaluation.

A 35-year-old man is brought to the emergency department after diving into the shallow end of a swimming pool and striking his head. He complains of severe posterior neck pain and bilateral upper extremity paresthesias. He is immobilized on a rigid backboard with a cervical collar. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $128/82 \text{ mmHg}$, pulse $88/\text{min}$, and respiratory rate $16/\text{min}$. Neurological examination reveals $4/5$ motor strength in both upper extremities and $5/5$ strength in the lower extremities. There is decreased sensation to pinprick in the C5 and C6 dermatomes bilaterally. Deep tendon reflexes are $1+$ in the upper extremities and $2+$ in the lower extremities.

Arrange the following imaging modalities in the correct chronological sequence for the step-wise diagnostic evaluation of this patient's suspected cervical spine injury, from the initial emergency assessment to delayed stability testing.

A 68-year-old woman is evaluated in the emergency department for severe abdominal pain, high fever, and confusion that began earlier today. Her family reports she has had intermittent mild right-sided abdominal pain for the past few weeks. Temperature is 39.4°C (102.9°F), blood pressure is 82/50 mm Hg, pulse is 122/min, and respirations are 24/min. Physical examination reveals scleral icterus and marked tenderness to palpation in the right upper quadrant with involuntary guarding. Laboratory studies show a leukocyte count of 22,000/mm³, total bilirubin of 6.2 mg/dL, and alkaline phosphatase of 450 U/L. Arrange the following management steps in the most appropriate chronological order.

A 62-year-old woman is evaluated in the hospital for new-onset right lower extremity swelling. She was admitted 7 days ago for a non-ST-segment elevation myocardial infarction and has been receiving a continuous intravenous unfractionated heparin infusion. Her vital signs are stable. Physical examination reveals a swollen, erythematous, and tender right calf. Laboratory studies show a platelet count of $95,000/\mu L$ (down from $260,000/\mu L$ on admission). A lower extremity venous duplex ultrasound confirms an acute deep vein thrombosis in the right popliteal vein. Heparin-induced thrombocytopenia is highly suspected. Arrange the following pharmacologic management steps in the correct chronological sequence to appropriately treat this patient and safely transition her to long-term outpatient anticoagulation.