All practice questions

A 62-year-old man is evaluated in the hospital for new-onset right leg swelling and pain. He was admitted 8 days ago for a severe exacerbation of chronic obstructive pulmonary disease and has been receiving subcutaneous unfractionated heparin for venous thromboembolism prophylaxis. His platelet count today is 42,000/μL, which represents a significant decline from his admission baseline of 260,000/μL. A lower extremity duplex ultrasound reveals an acute deep vein thrombosis in the right femoral vein. The patient's 4T score indicates a high probability of heparin-induced thrombocytopenia (HIT).

Arrange the following management steps in the correct chronological sequence to appropriately treat this patient's condition and transition him to long-term outpatient therapy.

During a scheduled evaluation at the transplant hepatology clinic, a 51-year-old male who received an orthotopic liver transplant 7 weeks ago reports new-onset fatigue, dark urine, and mild right-sided abdominal aching. His immunosuppressive regimen consists of tacrolimus, mycophenolate mofetil, and low-dose prednisone. Vital signs are stable, and physical examination reveals mild scleral icterus. Laboratory evaluation demonstrates an alanine aminotransferase (ALT) of 450 U/L, aspartate aminotransferase (AST) of 380 U/L, total bilirubin of 3.8 mg/dL, and an alkaline phosphatase of 210 U/L. Serum tacrolimus trough levels are strictly within the therapeutic range. The physician strongly suspects acute cellular rejection. Arrange the following diagnostic and management steps in the most appropriate clinical sequence.

A 48-year-old woman is undergoing a course of adjuvant localized radiotherapy following a lumpectomy for invasive ductal carcinoma of the breast. The targeted high-energy radiation is intended to eradicate any residual microscopic disease by inducing irreversible cellular injury in the rapidly dividing neoplastic cells. Arrange the following subcellular events in the chronological order that leads to the death of the targeted cells.

A 25-year-old man comes to the clinic reporting a 10-day history of fever, sore throat, severe fatigue, and a generalized rash. He reports unprotected sexual intercourse with a new male partner approximately 3 weeks ago. His temperature is 38.2°C (100.8°F). Physical examination reveals bilateral cervical lymphadenopathy and a faint, nonpruritic, erythematous macular rash on the trunk. The physician suspects acute human immunodeficiency virus (HIV) infection. Arrange the following laboratory tests in the most appropriate sequential order to establish the diagnosis, according to the standard evidence-based diagnostic testing algorithm.

A 31-year-old man is brought to the trauma resuscitation bay following a high-speed motorcycle collision where he was thrown 30 feet. He is hemodynamically stable with a blood pressure of 118/78 mmHg and a heart rate of 105/min. His primary survey is intact. The secondary survey is notable for a mechanically unstable 'open book' pelvic fracture, significant perineal ecchymosis, and frank blood visible at the urethral meatus. A focused assessment with sonography for trauma (FAST) exam shows no free intraperitoneal fluid. Urinalysis from a spontaneously voided small sample prior to arrival showed gross hematuria.

Arrange the following diagnostic imaging steps in the correct mandated sequence to properly evaluate this patient's genitourinary injuries while minimizing iatrogenic harm and diagnostic artifact.

A 72-year-old woman is brought to the emergency department at 07:00 by emergency medical services. Her husband found her awake but with profound right-sided weakness and an inability to speak when they woke up at 06:30. She was last known well at 22:30 the previous night. On presentation, her blood pressure is 165/90 mm Hg and her heart rate is 88/min and irregularly irregular. Neurologic examination reveals global aphasia, a right facial droop, and right hemiplegia (NIH Stroke Scale score of 18).

Arrange the following neuroimaging modalities and interventional procedures in the most appropriate step-wise sequence for evaluating this patient for acute reperfusion therapy.

During a routine morning round on the telemetry unit, a hospitalized patient suddenly loses consciousness, and the central monitor instantly displays coarse ventricular fibrillation. No carotid pulse is palpable. Arrange the following emergency interventions in the correct chronological sequence according to standard Advanced Cardiac Life Support (ACLS) protocols for this specific presentation.

A 32-year-old rock climber is brought to the emergency department by paramedics after an estimated 30-foot fall. He arrives immobilized on a backboard with a rigid cervical collar in place. He is agitated, tachycardic, and has an obvious deformity of his right femur. Arrange the following steps of his initial trauma resuscitation in the correct chronological order according to standard Advanced Trauma Life Support (ATLS) primary survey principles.

A 42-year-old woman is brought to the emergency department after experiencing a sudden, excruciating headache, which she describes as the 'worst of her life.' The headache started 4 hours ago and is accompanied by severe nausea, vomiting, and photophobia. Vital signs show a blood pressure of 165/95 mm Hg, a heart rate of 98/min, and a temperature of 37.2°C (99.0°F). Neurologic examination reveals neck stiffness but no focal motor or sensory deficits. Clinical suspicion for a spontaneous subarachnoid hemorrhage is high.

Arrange the following diagnostic steps in the most appropriate chronological sequence for this patient's evaluation. Assume the initial imaging scan is normal, the secondary test confirms a subarachnoid hemorrhage, and the first non-invasive vascular imaging modality fails to identify an aneurysm.

A 42-year-old woman is brought to the emergency department after falling from a 15-foot ladder. She is confused, pale, and diaphoretic. Vital signs show a blood pressure of 85/50 mm Hg, heart rate of 122/min, respiratory rate of 26/min, and oxygen saturation of 91% on room air. She has evident facial swelling, a visibly deformed mandible, and blood pooling in her oropharynx causing stridorous breathing. Arrange the following initial management steps in the most appropriate chronological order according to standard trauma resuscitation protocols.

In her third trimester (28 weeks gestation), a 31-year-old pregnant patient arrives at the acute care unit complaining of abrupt-onset shortness of breath accompanied by right-sided pleuritic chest pain. Upon evaluation, her vital signs reveal a heart rate of 118/min, respiratory rate of 24/min, and an oxygen saturation of 94% on ambient air. Physical examination demonstrates a swollen, tender right calf, though her lung fields are clear to auscultation. Given the high clinical suspicion for a pulmonary embolism, arrange the following imaging modalities in the chronological sequence they should be ordered and interpreted to establish a definitive diagnosis while optimally minimizing maternal and fetal radiation exposure.

A 58-year-old man with a 30-pack-year smoking history undergoes a routine preoperative chest radiograph prior to an elective inguinal hernia repair. The radiograph reveals a newly noted 1.4-cm circumscribed opacity in the periphery of the right upper lobe. He has no cough, hemoptysis, shortness of breath, or weight loss. Physical examination is unremarkable. Vital signs are within normal limits.

Arrange the following diagnostic and management steps in the most appropriate, evidence-based chronological sequence for evaluating this pulmonary finding.

An 81-year-old man is brought to the emergency department from a nursing facility due to severe respiratory distress. He is rapidly intubated and placed on mechanical ventilation. The patient is comatose, lacks decision-making capacity, and needs a percutaneous endoscopic gastrostomy tube for long-term enteral nutrition. A review of his records reveals no advance directive and no prior designation of a healthcare proxy. Arrange the following individuals or entities in the standard legally recognized hierarchy for surrogate decision-making, from highest priority (first to be consulted) to lowest priority.

A 54-year-old man with acute liver failure and progressive encephalopathy presents to a rural critical access hospital. The local physician determines the patient requires urgent evaluation for possible liver transplantation and initiates a transfer request to your tertiary care center. You are the admitting physician taking the transfer call.

Arrange the following steps of the inter-facility transfer process in the most appropriate, safety-concordant sequence to ensure a safe transition of care.

A 68-year-old man with a known history of advanced non-small cell lung cancer presents to the emergency department reporting severe, progressive thoracic back pain over the past week. Over the last 24 hours, he has developed profound weakness in both legs and states he has been unable to urinate since yesterday evening. His vital signs are stable. On observation, he is in significant discomfort and is unable to bear weight on his lower extremities.

Arrange the following diagnostic and therapeutic interventions in the most appropriate chronological sequence for managing this patient's acute oncologic emergency.

A 21-year-old man presents to the emergency department 18 hours after intentionally ingesting an unknown but massive quantity of over-the-counter pain medication. He complains of mild nausea, diaphoresis, and anorexia. Laboratory studies reveal an aspartate aminotransferase (AST) of 1,250 U/L and an alanine aminotransferase (ALT) of 1,400 U/L. The patient is diagnosed with severe acetaminophen hepatotoxicity. Arrange the following biochemical and subcellular events in the correct chronological sequence that leads to this patient's hepatocellular injury.

A 34-year-old woman presents to the clinic with a 2-month history of unintentional weight loss, frequent palpitations, and heat intolerance. On physical examination, her heart rate is $112/\text{min}$, and she has a fine resting tremor. Neck examination reveals a diffusely enlarged, non-tender thyroid gland. Laboratory evaluation demonstrates a thyroid-stimulating hormone (TSH) level of $0.01 \text{ }\mu\text{U/mL}$ (reference: $0.4-4.0 \text{ }\mu\text{U/mL}$) and a free thyroxine ($T_4$) level of $3.2 \text{ ng/dL}$ (reference: $0.9-1.7 \text{ ng/dL}$). She is diagnosed with Graves disease and prescribed methimazole. To understand the cellular mechanism of this patient's disease and her new medication, the physician reviews the physiological sequence of thyroid hormone synthesis. Arrange the following steps of normal thyroid hormone synthesis and release in the correct chronological order, beginning with the initial uptake of the raw material from the bloodstream.

A 29-year-old man presents to an outpatient clinic with a 5-day history of fever, severe pharyngitis, profound fatigue, and a nonpruritic maculopapular rash on his trunk and extremities. He has no significant past medical history. Social history is notable for unprotected receptive anal intercourse with a new male partner 16 days ago. His temperature is 38.3°C (100.9°F), blood pressure is 118/76 mmHg, pulse is 102/min, and respirations are 16/min. Physical examination reveals generalized cervical and axillary lymphadenopathy. The physician suspects acute retroviral syndrome and initiates the standard diagnostic algorithm and pre-treatment evaluation.

Arrange the following laboratory tests in the most appropriate chronological sequence for establishing the definitive diagnosis, evaluating the baseline disease state, and preparing for the initiation of antiretroviral therapy.

A 38-year-old woman is evaluated in the clinic for progressive weight gain, severe proximal muscle weakness, and easy bruising over the past 14 months. Blood pressure is 158/98 mm Hg. Physical examination reveals pronounced central adiposity, facial plethora, and wide, violaceous abdominal striae. Basic laboratory testing shows a fasting blood glucose of 145 mg/dL. The physician suspects Cushing syndrome and plans a comprehensive biochemical diagnostic workup.

Arrange the following diagnostic tests in the most appropriate sequential order to establish the diagnosis and etiology of this patient's condition, starting with the initial screening step and concluding with the definitive invasive localization test.

A 55-year-old man presents to the transplant clinic with a 3-day history of fatigue, dark urine, and low-grade fever. He underwent an orthotopic liver transplant 8 weeks ago for alcohol-associated cirrhosis. His current immunosuppressive regimen includes tacrolimus, mycophenolate mofetil, and prednisone. His temperature is 38.1°C (100.6°F), blood pressure is 130/80 mmHg, and heart rate is 90/min. Physical examination reveals scleral icterus and mild right upper quadrant tenderness. Laboratory tests show significantly elevated aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total bilirubin compared to his baseline from two weeks ago. Tacrolimus trough levels are within the target therapeutic range. The physician suspects acute cellular rejection. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for evaluating and managing this patient's presentation.