All practice questions

Match each clinical presentation of genitourinary trauma with the most appropriate next step in management or definitive treatment.

Emergency medical services bring a $68$-year-old male to the trauma bay due to the abrupt onset of occipital head pain and intractable vomiting. The patient's wife notes he was previously healthy except for a long-standing history of medication nonadherence for hypertension. In the triage area, his blood pressure is $215/115$ mm Hg with a heart rate of $54$/min. While being evaluated, his level of consciousness rapidly declines; he only opens his eyes to painful stimuli and mumbles incomprehensibly. Neurological assessment demonstrates pronounced left dysmetria and gaze-evoked nystagmus. A stat noncontrast head CT demonstrates a $4.5$-cm hyperdense collection in the left cerebellar hemisphere, accompanied by compression of the fourth ventricle and dilatation of the supratentorial ventricular system. Based on these findings, which of the following is the most appropriate next step in management?

A prospective cohort study is conducted to evaluate the risk of incident hepatocellular carcinoma (HCC) in patients treated with a novel antiviral medication compared to standard therapy for chronic hepatitis C infection. The unadjusted (crude) relative risk (RR) for HCC in the novel medication group is $1.6$ ($95\%$ CI: $1.2-2.1$).

The investigators suspect that baseline liver cirrhosis may be influencing the results. They perform a stratified analysis based on the presence or absence of cirrhosis at the time of treatment initiation. The stratum-specific results are as follows:

Based on these data, which of the following is the most appropriate next step for the investigators to report their findings?

Match each epidemiological study scenario to the most appropriate measure of disease frequency or association it is designed to calculate.

Match each clinical presentation of lower extremity vascular disease to its most likely underlying anatomical pathology or diagnosis.

A 74-year-old man is brought to the emergency department by ambulance after being found unresponsive on the floor of his apartment by a neighbor. His medical history is significant for hypertension, type 2 diabetes mellitus, and atrial fibrillation, for which he has recently been noncompliant with his anticoagulant medication. His temperature is 37.1°C (98.8°F), pulse is 112/min and irregularly irregular, blood pressure is 110/70 mm Hg, and respiratory rate is 16/min. Physical examination of the right lower extremity reveals a cold, pale, and mottled leg from the mid-thigh distally. The skin staining does not blanch to pressure. The calf muscles are stiff and rigid to palpation. Neurologic examination shows a complete loss of sensation and motor function in the right foot and leg. Palpation of the femoral pulse is normal, but the popliteal, dorsalis pedis, and posterior tibial pulses are absent. Handheld Doppler ultrasound reveals no arterial or venous signals in the right lower extremity. Which of the following is the most appropriate next step in management for this patient?

A 42-year-old woman is evaluated in the surgical oncology clinic after a 2.5-cm left thyroid nodule was discovered during a routine physical examination. Fine-needle aspiration of the nodule reveals malignant cells with amorphous, eosinophilic extracellular material that stains positive with Congo red. She is scheduled for a total thyroidectomy and central neck lymph node dissection. The patient has no history of neck radiation and no family history of endocrine disorders. Her blood pressure is 125/80 mm Hg and pulse is 76/min. Which of the following is the most appropriate next step in the preoperative evaluation of this patient?

Investigators at a state department of health are investigating a sudden increase in cases of acute kidney injury (AKI) among young adults in a specific county. They identify $50$ patients who were hospitalized with idiopathic AKI over the past month. To evaluate potential risk factors, they randomly select $150$ healthy young adults from the same county to serve as a comparison group. A detailed survey regarding recent dietary and lifestyle exposures is administered to all participants.

The survey results reveal that $40$ of the patients with AKI and $30$ of the healthy individuals report regular consumption of a newly introduced, heavily marketed energy drink.

Which of the following represents the most appropriate measure of association for this study design and its calculated value?

A 13-year-old boy is brought to the emergency department by his parents due to severe right-sided leg pain. For the past month, he has complained of a dull, intermittent ache in his right anterior thigh and knee, which he attributed to playing basketball. This morning, while walking down the stairs, he felt a sudden "pop" and experienced exquisite pain. He is now completely unable to bear weight on the right leg. His body mass index is $33 \text{ kg/m}^2$. Vital signs are within normal limits, and he is afebrile. Physical examination reveals a well-appearing boy in moderate discomfort. Inspection of the right knee shows no swelling, erythema, or localized tenderness. When the examiner attempts to passively flex the right hip to $90^\circ$, the thigh obligately rotates externally. There is significantly limited internal rotation of the right hip compared to the left. Which of the following is the most appropriate next step in management?

Match each clinical presentation and underlying pathophysiological mechanism to the correct brain herniation syndrome.

Emergency medical personnel transport an 83-year-old female resident of a skilled nursing facility to the acute care unit for intractable bilious vomiting and progressive abdominal distension over the past three days. Her medical history includes severe chronic obstructive pulmonary disease, type 2 diabetes mellitus, and osteoarthritis. She has not passed flatus or stool for 48 hours. Vital signs reveal a temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), a pulse of $112/\text{min}$, a blood pressure of $105/65\text{ mm Hg}$, and respirations of $22/\text{min}$. Physical examination shows a markedly distended, tympanitic abdomen with high-pitched, tinkling bowel sounds. There is diffuse tenderness to deep palpation, but no guarding or rigidity. Laboratory studies indicate a leukocyte count of $11,500/\text{mm}^3$ and a serum creatinine of $1.8\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$). A non-contrast computed tomography scan of the abdomen and pelvis reveals significantly dilated loops of small intestine with a transition point in the distal ileum. An ovoid, $3.5\text{-cm}$ calcified structure is impacted at this transition point. Furthermore, linear branching lucencies are noted centrally within the hepatic shadow. Which of the following is the most appropriate next step in the management of this patient?

A trauma surgery team frequently evaluates patients with acute spinal cord injuries following motor vehicle collisions and falls. Depending on the mechanism of injury and the specific anatomical tracts involved, distinct clinical patterns emerge. Match the following incomplete spinal cord and nerve root syndromes with their most characteristic neurological deficits.

A 20-year-old college student comes to the university-affiliated outpatient clinic with a 3-day history of dysuria and increased vaginal discharge. Nucleic acid amplification testing is positive for *Chlamydia trachomatis*. The physician provides a prescription for doxycycline. The patient's care is being billed to her parents' health insurance plan, on which she is a dependent. She appears anxious and says, "My parents have very strict religious beliefs. If they find out I am sexually active, they will cut off my college tuition. You must promise me that they will never find out about this visit." Which of the following is the most appropriate response by the physician?

Researchers are designing a randomized, double-blind, placebo-controlled trial to evaluate the efficacy of a novel anti-obesity medication. Initially, the trial is designed to detect a mean weight loss difference of $5.0\text{ kg}$ between the treatment and placebo groups. Based on pilot data, the expected standard deviation of weight loss is estimated at $10.0\text{ kg}$ in both groups. Using a two-sided $\alpha$ of $0.05$ and $80\%$ power, the investigators calculate a required sample size of $64$ participants per group.

Prior to patient enrollment, a newly published meta-analysis indicates a larger population variability, suggesting the true standard deviation is $15.0\text{ kg}$. In light of this, the investigators revise their protocol to ensure even more conservative clinical benefits can be detected, setting the new minimum detectable mean difference at $3.0\text{ kg}$.

Assuming the type I error rate ($\alpha$) and statistical power remain unchanged, what is the newly calculated required sample size per group?

A 28-year-old woman is hired as a healthcare worker and presents to the occupational health clinic for baseline tuberculosis screening. She is entirely asymptomatic but received the Bacille Calmette-Guérin (BCG) vaccine as an infant in her home country. Assume her initial screening test is positive and her subsequent imaging reveals no abnormalities. Place the following clinical steps in the correct chronological sequence for her screening, diagnosis, and management.

Identify the precise methodological flaw or bias described in each of the following research study vignettes by pairing them with the correct epidemiological term.

A previously healthy 52-year-old male is evaluated in the trauma bay after complaining of a sudden, ripping sensation in his anterior chest that rapidly progressed to his interscapular region. Vital signs show a pulse of 118/min and blood pressures of 185/105 mm Hg in the right upper extremity and 145/88 mm Hg in the left upper extremity. Physical examination demonstrates a new high-pitched early diastolic murmur along the right sternal border. An electrocardiogram demonstrates sinus tachycardia and left ventricular hypertrophy. Arrange the following steps in the most appropriate chronological order for the management of this patient.

A $71$-year-old man presents to the emergency department with a $4$-day history of progressive abdominal distension, crampy lower abdominal pain, and an inability to pass stool or flatus. He has had two episodes of bilious vomiting today. He has not seen a physician in over ten years and has never undergone colorectal cancer screening. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $138/86\text{ mmHg}$, pulse of $88\text{/min}$, and respirations of $16\text{/min}$. Examination reveals marked abdominal distension with hyperactive, high-pitched bowel sounds. The abdomen is tympanic to percussion but soft, with no rebound tenderness, rigidity, or palpable masses. Digital rectal examination reveals an empty rectal vault and no gross blood. Assume advanced institutional capabilities (including interventional endoscopy) are available. Arrange the following steps in the most appropriate chronological sequence for the comprehensive evaluation and management of this patient's condition.

Public health officials are reviewing data from a large cross-sectional database to determine if there is an association between urban noise pollution exposure and the prevalence of generalized anxiety disorder. Early in the protocol development, the team identifies household income as an extraneous factor that correlates with both noise exposure levels and anxiety risk, but does not lie on the causal pathway between them. The principal investigator mandates that the team handle this variable strictly during the statistical evaluation of the collected data, rather than altering how participants are selected or enrolled beforehand.

Which of the following methods are appropriate to fulfill this requirement? (Select all that apply)

A 68-year-old man is evaluated in the hospital for right knee pain and swelling that has progressively worsened over the past 3 months. He underwent a right total knee arthroplasty 2 years ago for severe osteoarthritis. His medical history includes hypertension and diet-controlled type 2 diabetes mellitus. His temperature is 37.2°C (99.0°F), blood pressure is 132/82 mmHg, and pulse is 78/min. Physical examination of the right knee reveals a moderate effusion, erythema, and warmth over the joint. Range of motion is significantly limited by pain. Radiographs of the right knee demonstrate periprosthetic radiolucency. Joint aspiration is performed, and synovial fluid analysis reveals a leukocyte count of 65,000/mm³ with 85% neutrophils. Synovial fluid culture grows methicillin-susceptible *Staphylococcus aureus* (MSSA). The patient was started on empiric intravenous vancomycin upon admission. Which of the following is the most appropriate definitive management for this patient?