All practice questions

Match the following common musculoskeletal injuries with their classic, diagnostic physical examination findings.

Following a high-velocity motorcycle collision, a 26-year-old male driver is evaluated in the trauma resuscitation unit. He was intubated at the scene for a Glasgow Coma Scale score of 7. On arrival, his temperature is $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), blood pressure is $85/50 \text{ mm Hg}$, and heart rate is $132\text{/min}$. Primary survey reveals decreased breath sounds on the right. A tube thoracostomy is performed, yielding a large rush of air and $50 \text{ mL}$ of blood; his oxygen saturation improves to 94%, but his blood pressure remains $90/55 \text{ mm Hg}$ despite the rapid infusion of $2 \text{ L}$ of warmed crystalloids. The focused assessment with sonography for trauma (FAST) is negative. A pelvic radiograph shows no fractures. Examination of the extremities reveals a grossly deformed and swollen right thigh with intact overlying skin. Dorsalis pedis and posterior tibial pulses are palpable and symmetric. A portable chest radiograph shows bilateral patchy infiltrates and a right-sided chest tube in good position. A radiograph of the right femur confirms a comminuted diaphyseal fracture. Arterial blood gas analysis reveals a pH of $7.21$, $\text{PaCO}_2$ of $48 \text{ mm Hg}$, $\text{PaO}_2$ of $65 \text{ mm Hg}$, and a lactate level of $5.2 \text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient's femur fracture?

A 62-year-old male arrives at the urgent care clinic reporting sudden, agonizing pain in his left lower extremity that started two hours prior. His medical background is significant for an anterior wall myocardial infarction three weeks ago. Vital signs are within normal limits. Examination of the left lower extremity reveals a pale, cool leg distal to the knee. While the left femoral pulse is easily palpable, both popliteal and pedal pulses are absent. The patient exhibits a newly developed inability to dorsiflex his left foot and reports numbness over the dorsal aspect. Bedside handheld continuous-wave Doppler demonstrates absent arterial signals in the distal left leg. An intravenous heparin infusion is promptly started. Which of the following is the most appropriate next step in management?

During a high school basketball game, a $16$-year-old adolescent boy suddenly experiences excruciating left-sided scrotal pain and collapses on the court. He is immediately transported to the hospital by his coach. The patient reports severe, unrelenting pain radiating to his lower abdomen and has vomited twice in the triage area. He is otherwise healthy and takes no medications. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $130/85\text{ mm Hg}$, and a pulse of $110/\text{min}$. Physical examination reveals a swollen, exquisitely tender left hemiscrotum. The left testicle is firm, positioned higher than the right, and lies in a transverse orientation. The cremasteric reflex is absent on the left side but intact on the right. There is no relief of pain upon manual elevation of the scrotum. Which of the following is the most appropriate next step in the management of this patient?

A rapid response is called for a $65$-year-old man on the medical ward due to acute hemodynamic deterioration. Two days prior, he was admitted for severe right flank pain. A non-contrast computed tomography (CT) scan at admission demonstrated a $9$-mm calculus in the proximal right ureter with moderate hydroureteronephrosis. At that time, he was afebrile and hemodynamically stable. A urine culture was obtained, and he was started on intravenous normal saline and empirical ceftriaxone.

Currently, his temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), blood pressure is $82/50$ mm Hg, and pulse is $128$/min. He is lethargic, diaphoretic, and minimally responsive. Physical examination reveals exquisite right costovertebral angle tenderness. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ with $15\%$ bandemia. The admission urine culture has just resulted, demonstrating $>10^5$ CFU/mL of *Escherichia coli*. Susceptibility testing indicates the organism is sensitive to cefazolin, ceftriaxone, and ciprofloxacin, but resistant to ampicillin. He is receiving aggressive intravenous fluid resuscitation.

Which of the following is the most appropriate next step in management?

A 72-year-old man undergoes an elective thoracic endovascular aortic repair (TEVAR) for an expanding descending thoracic aortic aneurysm. The procedure is technically successful, and no endoleaks are identified on the final angiogram. Four hours after arriving in the intensive care unit, the patient reports a new-onset inability to move his legs. His blood pressure is 110/70 mm Hg, and his heart rate is 86/min. Physical examination reveals 0/5 motor strength in both lower extremities and flaccid muscle tone. There is a complete loss of pain and temperature sensation below the umbilicus. However, proprioception and vibratory sensation are fully preserved in the bilateral toes. Bilateral femoral, popliteal, and pedal pulses are 2+ and symmetric. In addition to optimizing systemic mean arterial pressure, which of the following is the most appropriate next step in management?

Public health officials investigate a cluster of an unusual neurological syndrome in a rural county. They identify 120 patients diagnosed with the syndrome over the past year. They also recruit 240 healthy individuals from the same county, matched for age and sex, to serve as a comparison group. All participants complete detailed questionnaires regarding their dietary habits, occupational exposures, and residential history over the previous 5 years.

The data regarding the frequent consumption of unpasteurized dairy products are summarized in the table below:

Based on the design of this investigation, which of the following is the most appropriate measure of association, and what is its calculated value?

To evaluate a suspected link between maternal fluoxetine use and neonatal pulmonary hypertension, investigators identify 100 neonates diagnosed with this respiratory condition at a tertiary care center over a five-year period. For comparison, they randomly select 400 healthy neonates born at the same center during the same timeframe.

A retrospective review of maternal electronic health records reveals that 20 mothers of affected neonates and 40 mothers of healthy neonates were prescribed fluoxetine during their third trimester.

Which of the following is the most appropriate measure of association for these findings, and what is its calculated value?

For each of the following patients presenting with a surgical condition of the breast or endocrine system, select the most appropriate operative intervention.

Correlate each of the described high-acuity cardiothoracic and vascular surgical scenarios with the most appropriate definitive therapeutic intervention.

Paramedics rush a 24-year-old male to the trauma bay following a high-velocity car crash. He is comatose upon arrival. Vital signs show a blood pressure of 185/100 mm Hg and a heart rate of 48/min. His Glasgow Coma Scale score is 6 (Eyes 1, Verbal 2, Motor 3). Neurological assessment reveals a left pupil that measures 7 mm and does not react to light, whereas the right pupil is 3 mm and reactive. The patient's right arm and leg exhibit rigid extension when a painful stimulus is applied.

Arrange the following interventions in the optimal chronological order for managing this patient:

Match each patient's clinical presentation with the most appropriate next step in surgical or medical management.

A 73-year-old female patient arrives at the emergency department reporting a sudden onset of severe, unrelenting pain in her left leg that began two hours ago. She has a medical history of nonvalvular atrial fibrillation. She takes a beta-blocker for rate control but admits to stopping her oral anticoagulant medication three weeks ago. On physical examination, her left lower extremity is pale and cold from the knee down. She reports reduced sensation over the dorsum of her left foot and has difficulty moving her toes. Bilateral femoral pulses are palpable and bounding. Doppler ultrasound confirms the complete absence of popliteal and dorsalis pedis pulses in the left leg. The right lower extremity has normal palpable pulses and is warm to the touch. Vital signs show an irregular heart rate of 112/min and a blood pressure of 138/86 mmHg. Which of the following is the most appropriate initial intervention for this patient's current condition?

While recovering in the surgical intensive care unit, a 35-year-old male patient demonstrates a precipitous decline in his level of consciousness. He sustained a severe traumatic brain injury in a high-speed vehicular collision $48$ hours prior. Current vital signs reveal a blood pressure of $185/110 \text{ mmHg}$, a heart rate of $46 \text{ min}^{-1}$, and an irregular respiratory rate of $8 \text{ min}^{-1}$. Neurologic evaluation reveals that the right pupil is $8 \text{ mm}$ and nonreactive to light, whereas the left pupil is $3 \text{ mm}$ and briskly reactive. The right globe is deviated inferiorly and laterally. Application of a painful stimulus elicits rigid extension of the left arm and leg. What is the most appropriate immediate pharmacologic or procedural intervention for this patient?

A retrospective cohort study evaluates the efficacy of a novel oral anticoagulant (NOAC) compared to warfarin for the prevention of ischemic stroke in patients with nonvalvular atrial fibrillation. The investigators analyze the initial data and report a crude relative risk (RR) of 0.70 (95% CI: 0.55-0.88), suggesting that the NOAC is associated with a significantly lower risk of stroke compared to warfarin.

During peer review, concerns are raised that patient age may be distorting the observed association. In response, the investigators perform a stratified analysis, separating the cohort into two groups based on age. The results of the stratified analysis are presented below:

Which of the following epidemiological phenomena best explains the discrepancy between the crude relative risk and the stratified relative risks?

Match each traumatic cervical spine fracture to its most characteristic mechanism of injury, primary structural finding, and major clinical consequence.

A physician is directing the care of a newly admitted patient who has a history of prior gynecologic surgery and now presents with obstipation, bilious vomiting, and severe, paroxysmal abdominal cramping. Physical examination reveals marked abdominal distension with high-pitched bowel sounds, but no rebound tenderness or rigidity. The physician asks the surgical team to outline the standard algorithmic pathway for this condition, assuming the patient does not exhibit immediate signs of clinical deterioration but eventually fails to resolve the obstruction with nonoperative measures.

Arrange the following interventions in the correct sequential order from initial presentation to final surgical resolution.

Match each patient's genitourinary trauma presentation to the most appropriate definitive management strategy or next required intervention.

Post-operative complications following major cardiothoracic and vascular surgery require precise recognition and immediate intervention. Match each post-operative clinical scenario to the single most appropriate next step in patient management.

A team of public health researchers is designing an observational case-control study to evaluate the relationship between artificial sweetener use and the development of bladder cancer. They identify cigarette smoking as a major potential confounder in this relationship. Which of the following methods can be appropriately utilized during the design phase of this study to minimize the confounding effect of smoking? (Select all that apply)