All practice questions

A 62-year-old man is brought to the emergency department with sudden-onset, severe, "tearing" chest pain that radiates to his interscapular region. His blood pressure is 210/115 mm Hg, and his heart rate is 118/min. A bedside transesophageal echocardiogram demonstrates an intimal flap in the descending aorta. The clinical team prepares to initiate aggressive medical management prior to definitive vascular surgery evaluation. Arrange the following pharmacologic interventions in the most appropriate sequential order for managing this patient's acute presentation.

A 45-year-old man visits his primary care provider due to worsening joint pain, generalized fatigue, and excessive sweating over the past three years. He mentions having to buy larger shoes and a new wedding band recently because his old ones no longer fit. His wife notes that his snoring has become exceptionally loud and he occasionally gasps for air during sleep. Vital signs show a blood pressure of 158/96 mmHg. Physical examination reveals a prominent brow ridge, a widened jaw, an enlarged tongue, and broad, fleshy hands. The physician suspects a specific hypersecretory endocrine disorder.

Arrange the following diagnostic steps in the most appropriate sequence to properly evaluate this patient's suspected condition, proceeding from the initial screening test to final anatomical localization.

A 62-year-old woman is brought to the emergency department after being found unresponsive by her family. She is diagnosed with a large left middle cerebral artery (MCA) ischemic stroke. She undergoes successful mechanical thrombectomy but is left with right-sided hemiplegia and expressive aphasia. She is expected to make a gradual but significant recovery over the next few months. Arrange the following care settings in the most appropriate chronological sequence for this patient's anticipated recovery and rehabilitation pathway, starting immediately after her acute intervention.

An obstetric rapid response team is managing a 34-year-old G3P3 patient who developed massive, life-threatening hemorrhage shortly after the uncomplicated vaginal delivery of a 4.2-kg infant. The placenta delivered intact. Initial evaluation revealed severe uterine atony. Despite vigorous bimanual massage and the administration of intravenous oxytocin, intramuscular methylergonovine, intramuscular carboprost, and rectal misoprostol, the patient continues to experience profuse bleeding. Her current blood pressure is 82/45 mm Hg with a heart rate of 130/min. A massive transfusion protocol has been initiated. Bedside ultrasound shows an empty uterine cavity, and speculum examination reveals no vaginal or cervical lacerations.

Arrange the following procedural and surgical interventions in the most appropriate sequential order for escalating the management of this patient's refractory postpartum hemorrhage, proceeding from the initial next step to the definitive intervention of last resort.

During a comprehensive annual wellness exam, an asymptomatic postmenopausal patient discusses her current osteoporosis regimen. She has been strictly adherent to weekly oral alendronate for the past 5 years. She has remained physically active and reports no history of clinical fractures, bone pain, or loss of height. A dual-energy x-ray absorptiometry (DEXA) scan obtained prior to this visit reveals a femoral neck T-score of $-2.1$, indicating stability compared to her prior assessments. Her renal function and serum calcium levels are normal.

Based on current clinical guidelines, arrange the following management and monitoring steps in the most appropriate chronological sequence for this patient's ongoing care.

A 65-year-old woman is evaluated in the intensive care unit for refractory shock. She was admitted two days ago for severe community-acquired pneumonia and initially improved on broad-spectrum intravenous antibiotics. Over the past 4 hours, her condition has deteriorated. Her blood pressure is 70/40 mmHg despite the administration of 3 liters of intravenous isotonic crystalloids. The decision is made to initiate a continuous norepinephrine infusion via a central venous catheter. The physician prepares the right internal jugular vein site with chlorhexidine, applies sterile drapes, and utilizes ultrasound guidance for the procedure. Arrange the following procedural steps of the Seldinger technique for central venous catheter placement in the correct chronological sequence.

A 61-year-old woman is recovering on the medical step-down unit after a prolonged intensive care course for severe acute respiratory distress syndrome (ARDS). She has been successfully extubated but has developed significant critical illness myopathy and profound deconditioning. She is now medically stable and ready for discharge planning. Arrange the following steps of the care transition process in the most appropriate chronological sequence to ensure a safe and effective discharge.

A $58$-year-old woman is brought to the emergency department by her husband due to progressive confusion, lethargy, and a witnessed generalized tonic-clonic seizure at home. She has a history of small cell lung cancer and is currently undergoing chemotherapy. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $134/82 \text{ mmHg}$, pulse is $88/\text{min}$, and respiratory rate is $16/\text{min}$. She is somnolent but arousable to painful stimuli. Laboratory testing reveals a serum sodium concentration of $110 \text{ mEq/L}$, serum osmolality of $240 \text{ mOsm/kg}$, and urine osmolality of $650 \text{ mOsm/kg}$. A diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) causing severe, symptomatic hyponatremia is made.

Arrange the following monitoring and therapeutic evaluation steps in the most appropriate chronological sequence for managing this patient's acute presentation.

A 68-year-old woman is brought to the emergency department via ambulance after a witnessed generalized tonic-clonic seizure. Her husband reports that she recently started taking hydrochlorothiazide for hypertension and has been drinking large volumes of water due to medication-induced dry mouth. On presentation, she is unresponsive, and shortly after arrival, she develops a recurrent generalized tonic-clonic seizure. A point-of-care basic metabolic panel reveals a serum sodium concentration of 114 mEq/L. The physician immediately initiates management for severe symptomatic hyponatremia.

Arrange the following steps for the treatment and ongoing monitoring of this patient's condition in the most appropriate chronological sequence.

A 68-year-old woman is brought to the emergency department by her family due to progressive confusion, fever, and severe right upper quadrant abdominal pain that began 24 hours ago. On presentation, her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$, pulse is $124/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals scleral icterus, severe right upper quadrant tenderness with involuntary guarding, and lethargy. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$, total bilirubin of $6.2\text{ mg/dL}$, direct bilirubin of $4.8\text{ mg/dL}$, and alkaline phosphatase of $450\text{ U/L}$. A bedside right upper quadrant ultrasound demonstrates a dilated common bile duct measuring $12\text{ mm}$ and gallstones within the gallbladder. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 28-year-old woman is brought to the emergency department after being stung by a bee while hiking. She is profusely sweating and reports difficulty breathing along with a feeling of impending doom. On physical examination, she has diffuse coalescing urticaria, marked facial angioedema, and audible biphasic wheezing. Her blood pressure is $78/40$ mmHg, heart rate is $135$/min, and oxygen saturation is $88\%$ on room air. Large-bore intravenous access is rapidly established.

Assuming her hemodynamic instability and symptoms persist despite each successive intervention, arrange the following pharmacologic therapies in the correct sequential order of administration according to anaphylaxis resuscitation guidelines.

A 24-year-old man is evaluated in the emergency department for severe right lower leg pain. Two hours ago, he sustained a closed mid-shaft tibial fracture during a soccer game and was subsequently placed in a circumferential long-leg cast. He now reports excruciating, throbbing pain in the right leg that is rapidly worsening and completely unrelieved by intravenous morphine. Vital signs are temperature 37.1°C (98.8°F), blood pressure 138/86 mm Hg, heart rate 112/min, and respiratory rate 18/min. On examination, the leg feels intensely tight, and passive extension of the toes elicits agonizing pain. Paresthesias are noted over the dorsum of the foot. Distal dorsalis pedis and posterior tibial pulses are palpable. What is the most appropriate sequential order of management steps for this patient?

A 24-year-old woman with a history of type 1 diabetes mellitus is admitted to the intensive care unit for the management of diabetic ketoacidosis (DKA). On presentation, she has a serum glucose of $580 \text{ mg/dL}$, an anion gap of $24 \text{ mEq/L}$, and a serum potassium of $4.8 \text{ mEq/L}$. She has received an initial intravenous fluid bolus of 0.9% sodium chloride.

Arrange the following monitoring and therapeutic steps in the correct chronological sequence required for the safe resolution of her DKA and transition to maintenance therapy.

A 45-year-old man with a history of poorly controlled type 2 diabetes mellitus presents to the emergency department with a 24-hour history of severe left knee pain, swelling, and subjective fevers. He reports no recent trauma to the area. Vital signs show a temperature of 39.1°C (102.4°F), blood pressure of 110/70 mm Hg, heart rate of 112/min, and respiratory rate of 18/min. On physical examination, the left knee is markedly swollen, erythematous, and warm to the touch. Severe pain is elicited with minimal passive range of motion, and the patient refuses to bear weight on the affected limb. Arrange the following surgical and medical management steps in the most appropriate chronological order for this patient.

A $72$-year-old man with a history of small cell lung cancer is brought to the emergency department after a witnessed generalized tonic-clonic seizure. His family reports that he has been progressively confused and lethargic over the past $3$ days. On arrival, he is postictal but protecting his airway. His vital signs are within normal limits. Laboratory studies reveal:

* Serum sodium: $112$ mEq/L
* Serum potassium: $4.0$ mEq/L
* Serum osmolality: $240$ mOsm/kg
* Urine osmolality: $600$ mOsm/kg
* Urine sodium: $50$ mEq/L

Arrange the following steps in the correct chronological sequence for the acute management and ongoing monitoring of this patient's condition.

A 61-year-old male is currently in the medical intensive care unit undergoing treatment for a severe exacerbation of chronic obstructive pulmonary disease. He was placed on prophylactic subcutaneous unfractionated heparin upon admission. On day 6 of hospitalization, routine complete blood count reveals a platelet count of $85,000/\mu L$, a significant decline from his admission baseline of $210,000/\mu L$. Concurrently, he complains of new-onset right calf pain, and venous duplex ultrasonography confirms a new deep vein thrombosis. A presumptive diagnosis of heparin-induced thrombocytopenia (HIT) with thrombosis is made.

Arrange the following steps for the immediate management, subsequent monitoring, and treatment evaluation of this patient in the correct chronological sequence.

A 72-year-old man develops massive abdominal distension on postoperative day 4 following a right total knee arthroplasty. He is currently receiving intravenous hydromorphone for pain control. He reports nausea and diffuse abdominal discomfort but denies severe sharp pain or vomiting. He is still passing flatus. His temperature is $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure is $130/80\text{ mmHg}$, and heart rate is $88/\text{min}$. On physical examination, the abdomen is markedly distended and tympanitic, with high-pitched bowel sounds. There is no involuntary guarding or rebound tenderness. Laboratory studies show a serum sodium of $138\text{ mEq/L}$, potassium of $4.0\text{ mEq/L}$, and calcium of $9.2\text{ mg/dL}$. A CT scan of the abdomen and pelvis with intravenous contrast reveals massive dilation of the cecum, ascending colon, and transverse colon with a maximum cecal diameter of $11.0\text{ cm}$. There is no mechanical transition point, free intraperitoneal air, or bowel wall pneumatosis. Arrange the following procedural and management steps in the correct sequential order for this patient according to standard guidelines, assuming each preceding intervention fails to resolve the condition.

A 62-year-old female is hospitalized for an exacerbation of chronic obstructive pulmonary disease. She has been receiving subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. On hospital day 6, her right leg becomes acutely swollen and painful. Venous duplex ultrasonography reveals a new popliteal vein thrombosis. Her platelet count, which was $240,000/\text{mm}^3$ on admission, is now $95,000/\text{mm}^3$. The clinical team suspects heparin-induced thrombocytopenia (HIT).

Arrange the following pharmacologic management steps in the strict chronological sequence required to safely treat this patient and transition her to long-term anticoagulation.

An internal medicine resident is outlining the longitudinal care plan for a $55$-year-old patient who was recently diagnosed with severe non-ischemic cardiomyopathy. The patient's initial echocardiogram revealed a left ventricular ejection fraction of $22\%$. Prior to hospital discharge yesterday, the patient was successfully stabilized and transitioned to oral quadruple guideline-directed medical therapy, including an angiotensin receptor-neprilysin inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist, and a sodium-glucose cotransporter-$2$ inhibitor. Arrange the following outpatient monitoring and treatment evaluation steps in the most appropriate chronological order.

An otherwise healthy $71$-year-old female is evaluated in the emergency department for severe unilateral head pain that began $3$ days ago. She notes exquisite tenderness when brushing her hair and describes an aching fatigue in her jaw muscles during meals. Blood tests demonstrate an erythrocyte sedimentation rate (ESR) of $98 \text{ mm/h}$ and a C-reactive protein (CRP) of $45 \text{ mg/L}$. Order the following therapeutic and surveillance interventions in the correct chronological sequence for the longitudinal management of this condition.