All practice questions

Match each epidemiological measure of disease frequency or association to its correct definition and defining clinical characteristic.

An $82$-year-old woman is evaluated in the emergency department due to a $48$-hour history of worsening abdominal distension, failure to pass flatus, and multiple episodes of dark green emesis. She resides in a skilled nursing facility and has a medical history significant for Alzheimer dementia, coronary artery disease, and an open appendectomy performed three decades ago. On presentation, she appears lethargic and moans during the examination. Temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse is $124/\text{min}$, blood pressure is $88/54\text{ mm Hg}$, and respirations are $24/\text{min}$. Physical examination reveals a markedly distended abdomen that is rigid, with diffuse rebound tenderness and absent bowel sounds.

Laboratory results:
Leukocyte count: $18,200/\text{mm}^3$ with $15\%$ bands
Serum lactate: $5.4\text{ mmol/L}$
Creatinine: $1.8\text{ mg/dL}$

An upright chest radiograph reveals no free air under the diaphragm. A supine abdominal radiograph demonstrates multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of colonic gas. After initiating aggressive intravenous fluid resuscitation, the patient's blood pressure remains $90/56\text{ mm Hg}$.

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

A 42-year-old woman is brought to the emergency department after tripping over a rug and falling onto her right arm. She reports severe, sharp pain and an inability to move her right arm. Vital signs are within normal limits. Physical examination reveals an obvious deformity and significant swelling over the middle-to-distal aspect of the right arm. Upon initial neurologic evaluation, the patient has full active extension of the right wrist and fingers, and sensation is intact to light touch over the dorsum of the hand. Radial and ulnar pulses are 2+ and capillary refill is less than 2 seconds. Radiographs of the right upper extremity demonstrate a displaced, spiral fracture of the distal third of the humeral shaft. An orthopedic surgery resident performs a closed reduction in the emergency department, and a coaptation splint is applied. Post-reduction radiographs confirm acceptable alignment of the fracture fragments. Thirty minutes later, during a routine neurovascular reassessment, the patient is unable to actively extend her right wrist or digits. Sensation to light touch is now decreased over the dorsal web space between the thumb and index finger. Distal pulses remain 2+. Which of the following is the most appropriate next step in management?

A 64-year-old man is evaluated in the emergency department for severe perineal and scrotal pain that has progressively worsened over the past 3 days. He has a history of poorly controlled type 2 diabetes mellitus and hypertension. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $118/\text{min}$, respirations are $22/\text{min}$, and blood pressure is $88/54\text{ mmHg}$. Physical examination reveals a markedly swollen, tense, and erythematous scrotum with areas of dusky discoloration. Palpation of the scrotum and perineum elicits exquisite tenderness, and distinct crepitus is felt within the subcutaneous tissues. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$ and a serum glucose of $310\text{ mg/dL}$. Which of the following is the most appropriate next step in the management of this patient?

Match each epidemiological concept or bias with its defining characteristic.

Match each of the following patient clinical presentations and breast biopsy findings with the most appropriate definitive surgical management.

An 80-year-old female resident of a nursing facility is brought to the emergency department due to a sudden onset of generalized, severe abdominal pain. She has a history of persistent atrial fibrillation and is not taking anticoagulants due to a prior gastrointestinal bleed. On examination, her blood pressure is $75/45 \text{ mmHg}$, heart rate is $125/\text{min}$ and irregular, and respiratory rate is $24/\text{min}$. Her abdomen is rigid with diffuse involuntary guarding and rebound tenderness. Arterial blood gas shows a pH of $7.15$, $\text{pCO}_2$ of $30 \text{ mmHg}$, and calculated bicarbonate of $10 \text{ mEq/L}$. Serum lactate is $8.5 \text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

A $29$-year-old primigravida at $15$ weeks of gestation is referred to the surgery clinic for evaluation of a prominent neck lump. The patient noticed the swelling three weeks ago. She reports mild heat intolerance and fatigue but feels otherwise well. Her pregnancy has been uncomplicated. Vital signs show a blood pressure of $118/74\text{ mmHg}$ and a pulse of $92\text{/min}$. Physical examination reveals a palpable, firm, $2.4\text{-cm}$ nodule in the right thyroid lobe that moves with swallowing. No cervical lymphadenopathy is present.

Laboratory results are as follows:
Thyroid-stimulating hormone (TSH): $0.05\text{ \mu U/mL}$ (Reference: $0.4\text{--}4.0\text{ \mu U/mL}$)
Free thyroxine (T4): $1.9\text{ ng/dL}$ (Reference: $0.8\text{--}1.8\text{ ng/dL}$)

An ultrasound of the neck shows a $2.4\text{-cm}$ completely solid, hypoechoic nodule with irregular borders and internal microcalcifications in the right lobe.

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

A 68-year-old man is evaluated on postoperative day 2 following an elective open repair of a 6.5-cm infrarenal abdominal aortic aneurysm. The surgical note indicates that the inferior mesenteric artery was ligated during the procedure. Today, the patient reports the sudden onset of left lower quadrant abdominal pain. Two hours later, he passes a large volume of bright red blood mixed with stool. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $135/85\text{ mmHg}$, heart rate is $98/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals a soft abdomen with tenderness to deep palpation in the left lower quadrant. There is no rebound tenderness, guarding, or rigidity. The midline laparotomy incision is clean and intact. Laboratory studies show a leukocyte count of $14,500/\text{mm}^3$ and a serum lactate level of $1.8\text{ mmol/L}$ (normal: $0.5-2.2\text{ mmol/L}$). Which of the following is the most appropriate next step in management?

A prospective cohort study is conducted to evaluate the association between long-term proton pump inhibitor (PPI) therapy and the incidence of chronic kidney disease (CKD) in adults over age 50. After 5 years of follow-up, the investigators calculate the unadjusted (crude) relative risk of CKD. Suspecting that baseline diabetes mellitus might influence the outcome, they subsequently stratify the data by diabetes status. The results are shown in the table below:

Based on these statistical findings, which of the following is the most appropriate next step for the investigators when reporting their results?

An investigator is designing a prospective observational cohort study to evaluate the association between a newly approved CD40L-targeted monoclonal antibody and the development of severe opportunistic infections in patients with systemic lupus erythematosus (SLE). During the study's planning phase, the investigator identifies two critical variables that must be addressed:

1. High-dose corticosteroid use: The investigator notes that baseline high-dose corticosteroid use is associated with both a higher likelihood of being prescribed the new monoclonal antibody and an independently increased risk of opportunistic infections.
2. Baseline neutropenia: The investigator hypothesizes that the magnitude of the relative risk of opportunistic infections associated with the monoclonal antibody is significantly greater in patients with baseline neutropenia compared to those with normal neutrophil counts.

The investigator wishes to implement methodological and analytical strategies that will definitively remove the confounding effect of high-dose corticosteroid use, while simultaneously allowing for the formal statistical assessment of baseline neutropenia as an effect modifier.

Which of the following approaches would successfully accomplish BOTH of these objectives? (Select all that apply)

Match each patient's clinical presentation and imaging findings of an adrenal mass with the most appropriate definitive surgical and perioperative management plan.

Match the following distinct clinical presentations of urologic conditions to their most appropriate definitive surgical management.

A 32-year-old female arrives at the emergency department via ambulance following a high-speed motorcycle collision. She has an obvious deformity of her right lower leg with a 5-centimeter laceration over the anterior tibia exposing the underlying bone. Active oozing of blood is noted. Her pulse is 110/min, and blood pressure is 115/75 mm Hg. Arrange the following initial management steps in the most appropriate chronological sequence for this patient.

A $59$-year-old man is brought to the emergency department by his partner due to severe, worsening perineal pain and fever for the past $24\text{ hours}$. He has a $15$-year history of type 2 diabetes mellitus complicated by peripheral neuropathy and nephropathy. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $84/52\text{ mmHg}$, pulse is $124/\text{min}$, and respirations are $22/\text{min}$. Physical examination demonstrates marked edema, erythema, and induration of the perineum extending to the scrotum. There are several dark, necrotic bullae on the scrotal skin. Palpation of the affected area elicits exquisite pain and a crackling sensation beneath the skin. Laboratory evaluation reveals a leukocyte count of $26,000/\text{mm}^3$ and serum glucose of $480\text{ mg/dL}$. Aggressive intravenous fluid resuscitation and broad-spectrum antibiotics are initiated. Which of the following is the most appropriate next step in management?

A 45-year-old woman is brought to the emergency department by her partner after developing a sudden-onset, excruciating headache that she describes as the 'worst of my life.' The headache began abruptly 2 hours ago while she was moving heavy furniture. She reports associated nausea, photophobia, and neck stiffness. Her temperature is 37.2°C (99.0°F), blood pressure is 168/94 mm Hg, and heart rate is 92/min. Neurological examination reveals intact cranial nerves, normal symmetric strength, and marked nuchal rigidity. Arrange the following steps in the correct sequential order for the standard diagnostic workup and definitive management of this patient, assuming the initial head imaging does not demonstrate an acute hemorrhage.

A team of epidemiologists has recently concluded data collection for a large retrospective case-control study investigating the potential association between chronic proton pump inhibitor use and the development of chronic kidney disease. Before conducting the final statistical evaluation, the investigators identify that a history of type 2 diabetes mellitus is highly prevalent among proton pump inhibitor users and is also a well-established independent risk factor for chronic kidney disease. The investigators must now ensure that the reported association is not spuriously driven by this factor. Given that the study is currently strictly in the data analysis phase, which of the following methodological strategies are appropriate to control for or assess this identified variable? (Select all that apply)

Match each specific orthopedic injury with the most likely corresponding acute neurovascular physical exam finding.

A $58$-year-old right-handed woman is evaluated in the neurosurgical intensive care unit for new-onset neurological deficits. Six days ago, she underwent successful surgical clipping of a ruptured left middle cerebral artery aneurysm. Her postoperative course had been uncomplicated, and she was alert and fully oriented this morning. Over the past hour, the nurse noted that the patient developed right-sided hemiparesis and severe expressive aphasia.

Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate is $82 \text{ /min}$, blood pressure is $112/74 \text{ mmHg}$, and respirations are $14 \text{ /min}$. A stat noncontrast head computed tomography scan shows expected postsurgical changes with no evidence of new hemorrhage, cerebral edema, or hydrocephalus. Continuous electroencephalography reveals no epileptiform activity.

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

A multicenter observational study is investigating the impact of a novel targeted biologic therapy, compared to conventional disease-modifying antirheumatic drugs (DMARDs), on the 3-year incidence of severe infectious complications in adults with seropositive rheumatoid arthritis.

Initial unadjusted analysis reveals that patients receiving the biologic therapy have a significantly lower risk of severe infections (Relative Risk [RR] = 0.70, 95% CI 0.62-0.79, p < 0.01).

Concerned about potential demographic influences on immune function, the research team categorizes the cohort based on patient age at enrollment (< 65 years vs. ≥ 65 years). The subsequent stratified analysis yields the following results:

Based on these epidemiological findings, which of the following is the most appropriate approach for the investigators to adopt regarding the age variable in their final analysis?