All practice questions

A 75-year-old man with a history of heart failure and osteoarthritis presents to the emergency department with a 3-day history of fever, productive cough, and acute confusion. Vital signs show a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure of $85/50$ mm Hg, heart rate of $115$/min, and respiratory rate of $32$/min. Laboratory studies reveal a blood urea nitrogen (BUN) of $40$ mg/dL. He is diagnosed with severe community-acquired pneumonia. Over the subsequent weeks, his infection is successfully treated, but he experiences profound deconditioning. Prior to admission, he was entirely independent with his activities of daily living. Currently, he requires moderate assistance to transfer from a bed to a chair and tolerates a maximum of $45$ minutes of physical therapy daily. His long-term goal is to return to his baseline level of independent living in the community.

Arrange the following care settings in the most appropriate chronological sequence for this patient's complete transition of care, from initial emergency department disposition to final community recovery, based on standard risk stratification and functional assessment guidelines.

A 16-year-old girl is evaluated in the clinic for heavy menstrual bleeding. She reports that since menarche at age 12, her menstrual periods have consistently lasted 8 to 10 days, frequently requiring her to change pads every 2 hours on the heaviest days. She also recalls an episode of prolonged bleeding following a dental extraction two years ago. The patient takes no daily medications, though she occasionally uses ibuprofen for cramps. Family history is notable for a maternal aunt who required a blood transfusion after childbirth. Physical examination reveals normal vital signs, no joint deformities, and no petechiae or ecchymoses. The physician suspects von Willebrand disease (vWD) and plans to initiate a laboratory workup. Arrange the following tiers of laboratory testing in the most appropriate sequential diagnostic order, from initial screening to definitive disease subtyping.

A 28-year-old woman, G2P1, at 26 weeks gestation presents to the emergency department complaining of sudden-onset right-sided pleuritic chest pain, dyspnea, and a swollen right calf that began 6 hours ago. Her temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $118/76$ mmHg, heart rate is $112$/min, and respiratory rate is $22$/min. Oxygen saturation is $96\%$ on room air. Physical examination reveals an enlarged, tender right calf with pitting edema. The physician highly suspects a pulmonary embolism. Assume that for each sequential imaging study performed, the results return as negative or indeterminate, necessitating progression to the next appropriate imaging modality to definitively evaluate for pulmonary embolism.

Arrange the following imaging modalities in the most appropriate step-wise sequence according to evidence-based diagnostic algorithms for pregnant patients.

A 42-year-old woman presents to the emergency department with a sudden, "thunderclap" headache that began 18 hours ago. She reports associated neck stiffness, photophobia, and nausea. Blood pressure is 160/95 mmHg, and heart rate is 98/min. Neurologic examination demonstrates marked nuchal rigidity but no focal motor or sensory deficits. A spontaneous subarachnoid hemorrhage is highly suspected.

Arrange the following diagnostic modalities and procedures in the most appropriate sequential order for the evaluation of this patient, from the initial diagnostic test to the definitive preoperative vascular characterization (assuming the initial radiological test does not definitively demonstrate acute hemorrhage).

A 62-year-old asymptomatic woman who has smoked one pack of cigarettes daily for the past 40 years undergoes a routine chest radiograph for a life insurance policy. The radiograph reveals a newly discovered, non-calcified 14-mm solitary nodule in the periphery of the left upper lobe. Arrange the following diagnostic steps in the most appropriate chronological sequence for evaluating this patient's pulmonary finding, starting from the immediate next step to the definitive diagnostic procedure.

A 51-year-old woman is brought to the emergency department by her husband due to a sudden-onset, severe occipital headache that began two hours ago while she was gardening. She states, 'It feels like something exploded in my head.' She had one episode of vomiting en route to the hospital. Vital signs are temperature 37.0°C (98.6°F), blood pressure 178/102 mmHg, pulse 104/min, and respirations 18/min. Physical examination shows photophobia and mild nuchal rigidity. She is alert and fully oriented with no focal neurologic deficits.

Arrange the following diagnostic modalities in the correct stepwise sequence for evaluating this patient's condition, starting from the initial test to the definitive preoperative imaging study. Assume the initial non-invasive imaging is equivocal, but clinical suspicion remains high.

An 82-year-old female with a history of osteoporosis is brought to the emergency department reporting severe left groin pain and an inability to bear weight on her left leg after slipping on a rug at home. On physical examination, her left lower extremity is shortened and externally rotated. Current clinical guidelines dictate a specific step-wise diagnostic imaging algorithm to ensure rapid diagnosis while minimizing unnecessary radiation and costs. Arrange the following diagnostic imaging modalities in the correct hierarchical sequence for establishing the diagnosis of a suspected occult hip fracture. Sequence the modalities progressing from the mandated initial investigation to subsequent alternative modalities, which are strictly reserved for use only if the preceding preferred test is negative, indeterminate, or contraindicated.

A $34$-year-old woman presents to the clinic with new-onset headaches, palpitations, and severe muscle cramps. Her blood pressure is $172/106$ mmHg. A basic metabolic panel reveals a serum sodium of $144$ mEq/L and a serum potassium of $2.8$ mEq/L. She is not taking any medications and has no family history of early-onset hypertension. The physician suspects an endocrine etiology for her secondary hypertension. Assuming each investigative step confirms the indication for the next and the patient is a candidate for surgical management, arrange the following diagnostic steps in the correct, guideline-directed chronological sequence from initial workup to preoperative planning.

An evaluation is requested for a 30-year-old female patient complaining of progressive shortness of breath over the past two months. She notes that she feels increasingly weak towards the evening, to the point where her vision occasionally becomes double. A plain chest radiograph reveals a widened mediastinum, and a subsequent contrast-enhanced computed tomography (CT) scan of the chest localizes a well-circumscribed, lobulated mass to the anterior mediastinal compartment. Arrange the following differential diagnoses for this anterior mediastinal mass in order of their pre-test probability, from highest (most likely) to lowest (least likely), based on her demographic profile and clinical syndrome.

A $42$-year-old female high school teacher presents to the clinic reporting progressive weight gain of $12$ kg over the past $1$ year, easy bruising, and new-onset facial hair growth. She also reports worsening fatigue and difficulty climbing stairs due to proximal muscle weakness. On examination, her blood pressure is $164/96$ mmHg. She exhibits prominent supraclavicular fat pads, facial plethora, and wide, purplish abdominal striae. A diagnostic evaluation for suspected hypercortisolism is initiated.

Arrange the following diagnostic tests in the most appropriate chronological sequence for evaluating this patient, from initial diagnostic screening to the most advanced localization study.

A 54-year-old right-handed woman is brought to the emergency department by emergency medical services 3 hours after the sudden onset of profound left-sided weakness, facial asymmetry, and slurred speech. On physical examination, her blood pressure is 175/95 mm Hg, and her pulse is 88/min and irregularly irregular. Neurological evaluation reveals a dense left hemiparesis, left-sided sensory loss, and left-sided hemineglect. The clinical team suspects an acute ischemic cerebrovascular event and initiates a rapid stroke code response. Arrange the following diagnostic imaging modalities in the correct chronological sequence utilized to evaluate this patient, establish the diagnosis, and guide acute reperfusion therapies.

A 26-year-old man presents to the urgent care clinic complaining of a 5-day history of high fever, severe sore throat, profound fatigue, and a diffuse maculopapular rash on his trunk. He reports having unprotected receptive anal intercourse with a new partner approximately 3 weeks ago. Vital signs are temperature 38.8°C (101.8°F), blood pressure 118/76 mmHg, heart rate 104/min, and respiratory rate 16/min. Physical examination reveals generalized non-tender lymphadenopathy and exudative pharyngitis. The physician strongly suspects acute retroviral syndrome and wishes to initiate the standard diagnostic workup. Arrange the following laboratory investigations in the most appropriate sequential order to establish the diagnosis and direct initial management, assuming typical results for this specific clinical stage.

A 58-year-old woman with metastatic ovarian cancer is evaluated during a home hospice visit for a 4-day history of absent bowel movements and worsening lower abdominal discomfort. She has been taking escalating doses of oral morphine for severe pelvic pain over the past two weeks. Arrange the following steps in the correct chronological sequence for the evaluation and stepwise escalation of management for this patient's suspected opioid-induced constipation.

A 78-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) and mild cognitive impairment is being prepared for discharge home after receiving treatment for community-acquired pneumonia. He will be returning to live with his daughter. To optimize patient safety and minimize the risk of readmission, arrange the following transitional care and discharge planning steps in the most appropriate chronological sequence.

A hospital system's medical director is reviewing disposition and care transition protocols to ensure compliance with federal guidelines. To optimize resource utilization and prevent unsafe discharges, physicians must accurately match patients to post-acute care settings based on regulatory criteria. Arrange the following care settings in descending order of their mandated medical intensity, starting from the HIGHEST level of required physician oversight and complex medical care down to the LOWEST level.

A 29-year-old woman is admitted to the medical ward for an acute flare of known ulcerative colitis. On admission, she reports 11 bloody bowel movements per day. Her vital signs show a heart rate of 115/min, blood pressure of 110/70 mm Hg, and a temperature of 38.1°C (100.6°F). Laboratory results reveal a hemoglobin of 9.8 g/dL and a C-reactive protein (CRP) of 65 mg/L. The patient is designated as having acute severe ulcerative colitis. Arrange the following steps in the optimal sequential protocol for her diagnostic evaluation, treatment monitoring, and therapeutic escalation.

A 76-year-old woman is evaluated in the ambulatory care setting for a 1-week history of severe right-sided scalp pain, jaw fatigue when eating, and two episodes of transient visual obscuration in her right eye. Initial laboratory assessment reveals an erythrocyte sedimentation rate (ESR) of 88 mm/h and a C-reactive protein (CRP) level of 45 mg/L. The physician formulates a highly suspicious working diagnosis of giant cell arteritis (GCA).

Arrange the following patient management, monitoring, and therapeutic de-escalation steps in the most appropriate chronological sequence.

A 70-year-old man is admitted to the medical intensive care unit with severe septic shock secondary to ischemic bowel. He is endotracheally intubated, hemodynamically unstable, and lacks decision-making capacity. His clinical condition is rapidly deteriorating despite maximal medical therapy. The primary care team determines that a discussion regarding the potential withdrawal of life-sustaining treatment and transition to comfort-focused care is medically indicated. A thorough chart review confirms the patient has no documented advance directive and has not explicitly designated a healthcare proxy. Several individuals have arrived at the intensive care unit, each asserting their right to make medical decisions on the patient's behalf. According to the standard legal hierarchy of surrogate decision-makers in most United States jurisdictions, arrange the following individuals in the correct order of priority to act as the patient's surrogate, from highest priority (first) to lowest priority (last).

A 55-year-old patient with newly diagnosed chronic obstructive pulmonary disease is seen in the primary care clinic. She continues to smoke one pack of cigarettes daily. When the topic of smoking cessation is raised, she states, "I know smoking is worsening my lungs, but my job as a project manager is incredibly stressful right now, and cigarettes are the only way I can cope." The physician plans to utilize the core principles of Motivational Interviewing to address her tobacco use. Arrange the following physician responses in the correct chronological sequence to appropriately execute the four fundamental processes of Motivational Interviewing.

A 45-year-old man is brought to the intensive care unit after suffering a severe anoxic brain injury following a prolonged out-of-hospital cardiac arrest. He remains comatose, ventilator-dependent, and the medical team determines that he lacks decision-making capacity. A thorough search of his medical records and personal belongings reveals no advance directive or designated durable power of attorney for healthcare. Several family members have arrived at the hospital and are in disagreement regarding whether to continue aggressive life-prolonging measures or transition to comfort care. To proceed legally with medical decision-making, the physician must identify the appropriate surrogate according to the standard state statutory hierarchy.

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