All practice questions

A 22-year-old female university student visits the ambulatory care center for an annual wellness check. She has a history of Crohn disease involving the colon, which was diagnosed 2 years ago and is currently in clinical remission. Her daily medications include azathioprine and intravenous infliximab infusions every 8 weeks. She recently became sexually active with a single male partner and relies on oral contraceptives for birth control. She feels well and denies abdominal pain, diarrhea, or intermenstrual bleeding. Her temperature is 37.0°C (98.6°F), blood pressure is 110/70 mmHg, and body mass index is 22 kg/m². Her immunization records indicate she completed all routine pediatric vaccines, but she has not received any clinical preventive services since age 17. Which of the following is the most appropriate next step in preventive care for this patient?

A 75-year-old man is brought to the emergency department by his family due to worsening confusion and severe lower abdominal pain over the past 24 hours. His family reports he has not urinated since yesterday morning. His medical history is significant for benign prostatic hyperplasia (BPH) and bipolar disorder, for which he takes tamsulosin and lithium. On presentation, his blood pressure is $155/95\text{ mm Hg}$, and his heart rate is $98/\text{min}$. Physical examination reveals a firm, tender suprapubic mass extending to the umbilicus.

Laboratory studies reveal:
Blood urea nitrogen: $88\text{ mg/dL}$
Serum creatinine: $4.8\text{ mg/dL}$ (baseline $1.1\text{ mg/dL}$)
Serum potassium: $6.3\text{ mEq/L}$
Urinalysis: negative for leukocyte esterase and nitrites

A urethral Foley catheter is placed, immediately yielding $1,800\text{ mL}$ of clear urine. He is admitted for monitoring. Over the next 4 hours, his urine output consistently remains between $1,000\text{ mL}$ and $1,200\text{ mL}$ per hour. His repeat blood pressure drops to $84/52\text{ mm Hg}$, and his heart rate increases to $122/\text{min}$. The patient appears pale, and his mucous membranes are severely dry.

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

A 50-year-old woman presents to the clinic after a 2.5-cm palpable nodule was found in the right lobe of her thyroid during a routine physical examination. She reports no palpitations, weight changes, dysphagia, or hoarseness. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient. Assume that her initial laboratory testing reveals a subnormal serum TSH level and that subsequent cytological testing indicates malignancy.

A 2-month-old girl is brought to the clinic for a routine well-child evaluation. She was born at 39 weeks gestation via an uncomplicated vaginal delivery. Her mother has severe Crohn disease and was maintained on infliximab therapy throughout her pregnancy, including the third trimester. The infant is exclusively breastfed, feeding well, and gaining weight appropriately. Both parents are non-smokers, and the family history is otherwise unremarkable. Vital signs show a temperature of 37.1°C (98.8°F), heart rate of 128/min, and respiratory rate of 28/min. Physical examination reveals a well-appearing, alert infant with normal growth parameters and a normal abdominal examination. According to the standard immunization schedule, the infant is due for several immunizations today. Which of the following is the most appropriate immunization strategy for this patient?

A multicenter randomized controlled trial investigates a novel lipid-lowering medication for the primary prevention of myocardial infarction. Over a 5-year follow-up period, the research team reports several statistical findings to describe the drug's efficacy. Match each clinical interpretation reported by the researchers to the corresponding epidemiological measure of effect.

Match each clinical presentation of a urologic condition to the most appropriate definitive surgical or procedural intervention.

An investigator is studying the association between occupational exposure to a specific organic solvent and the subsequent development of peripheral neuropathy. The investigator queries a large manufacturing plant's employee database spanning the past 20 years.

The study population is identified and grouped based on whether their documented job classification during their first year of employment involved direct handling of the organic solvent. The investigator then reviews the occupational health and medical records of these employees from their first year of employment up to the present day to determine the incidence of peripheral neuropathy in both groups.

The findings are summarized in the table below:

Based on the study design, which of the following represents the most appropriate primary measure of association and its correctly calculated value?

A team of neurologists is conducting a retrospective observational study using electronic health records to evaluate the association between a newly approved calcitonin gene-related peptide (CGRP) antagonist and the incidence of ischemic stroke in patients with chronic migraines. During the planning phase, the investigators identify that a history of severe hypertension is associated with both the likelihood of being prescribed this new medication and an increased risk of ischemic stroke. To prevent this variable from distorting the study's findings, the study protocol explicitly excludes any patient with a prior diagnosis of hypertension from the cohort. Which of the following epidemiological methods are the researchers using to control for this variable?

A 10-year prospective cohort study is conducted to evaluate the association between occupational exposure to silica dust and the development of pulmonary fibrosis. The study enrolls 1,500 healthy employees at a large manufacturing and mining corporation. Of these, 500 are miners exposed to high levels of silica dust, while 1,000 are administrative staff with no silica exposure. Over the 10-year follow-up period, the occurrence of newly diagnosed pulmonary fibrosis is recorded. The results are summarized in the table below:

Assuming a causal relationship exists between silica dust exposure and pulmonary fibrosis, what percentage of the disease in the exposed group is directly attributable to the silica exposure?

A $52$-year-old man with a history of poorly controlled diabetes mellitus presents to the emergency department with a $24$-hour history of severe right knee pain, swelling, and subjective fevers. His temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure is $130/80\text{ mm Hg}$, and pulse is $110/\text{min}$. Physical examination reveals a markedly erythematous, warm, and swollen right knee held in slight flexion. Any passive range of motion of the knee elicits excruciating pain. A large joint effusion is palpable.

Arrange the following management steps in the correct chronological order for this patient.

A 28-year-old male is brought to the emergency department via ambulance after being struck by a motor vehicle. He is confused and complains of severe right-sided chest pain and difficulty breathing. His blood pressure is $75/45$ mm Hg, heart rate is $135$/min, and respiratory rate is $28$/min. Oxygen saturation is $88\%$ on room air. Physical examination reveals large abrasions and severe bruising over the right lateral chest wall. The trachea is deviated to the left. Examination of the right hemithorax demonstrates decreased tactile fremitus, dullness to percussion, and absent breath sounds. The jugular veins are flat. Which of the following is the most appropriate next step in management?

Match each patient profile with the most appropriate United States Preventive Services Task Force (USPSTF) Grade A or B screening recommendation.

An academic neurology department conducts a prospective cohort study to evaluate a novel disease-modifying therapy for patients with secondary progressive multiple sclerosis. The primary outcome is the time to first documented persistent disability progression. Initial unadjusted survival analysis comparing the novel therapy to the institutional standard of care yields a hazard ratio (HR) of 0.72 (95% CI: 0.48 - 1.08, p = 0.11).

Subsequently, the investigators perform a pre-specified multivariate Cox proportional hazards regression, adjusting for patient age at diagnosis, baseline Expanded Disability Status Scale (EDSS) score, and T2 lesion volume on initial MRI. This adjusted analysis demonstrates an HR of 0.61 (95% CI: 0.41 - 0.90, p = 0.01).

Based on these statistical findings, which of the following is the most accurate conclusion regarding the study results?

Match each patient presentation of a lower extremity orthopedic injury with the most likely associated neurovascular complication and physical exam finding.

Paramedics bring a $31$-year-old male construction worker to the trauma bay shortly after he plunged $9$ meters ($30$ feet) off a roof. On primary survey, he is unresponsive, prompting immediate endotracheal intubation for airway protection. Before induction, his Glasgow Coma Scale score was calculated at $6$ (Eyes $1$, Verbal $2$, Motor $3$). Current vital signs demonstrate severe hemodynamic instability with a blood pressure of $72/40$ mm Hg and a heart rate of $142$/min. Cranial nerve assessment shows anisocoria; the right pupil is dilated to $8$ mm and fixed, whereas the left pupil is $3$ mm and sluggish. Palpation of the abdomen reveals board-like rigidity and significant distension. The pelvis is stable. Which of the following is the most appropriate next step in management?

Two hours following a total thyroidectomy for a large, compressive multinodular goiter, a nurse urgently pages the surgical resident to evaluate a patient in the recovery ward. The patient, a 54-year-old female, is profoundly agitated and exhibiting labored breathing. Vital signs show a heart rate of 115/min, blood pressure of 158/92 mm Hg, and an oxygen saturation of 86% on ambient air. Physical examination reveals prominent inspiratory stridor. The anterior cervical incision site demonstrates a tense, rapidly enlarging swelling beneath the surgical dressing, accompanied by fresh blood seeping through the bandages. Which of the following is the most appropriate immediate intervention for this patient?

A group of investigators is assessing the efficacy of a newly approved oral anticoagulant compared to warfarin in preventing ischemic stroke among patients with non-valvular atrial fibrillation. They conduct a multi-center retrospective cohort study using electronic medical records of $10,000$ patients over a $2$-year follow-up period.

The initial unadjusted relative risk (RR) for ischemic stroke with the new anticoagulant compared to warfarin is $0.80$ ($95\%$ CI: $0.72$-$0.89$).

Suspecting that concurrent chronic kidney disease might impact the outcomes, the investigators stratify the patient population based on the presence or absence of stage 3 or 4 chronic kidney disease. The subsequent analysis yields the following results:

Which of the following epidemiological concepts is best demonstrated by the difference between the unadjusted and stratified relative risks?

A 68-year-old man is evaluated in the surgical step-down unit on postoperative day 6 following a coronary artery bypass grafting procedure. He reports worsening retrosternal pain and subjective chills over the past 24 hours. The pain is sharp, is exacerbated by deep breathing, and feels distinct from his initial postoperative discomfort. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $22/\text{min}$. On physical examination, the sternal incision is erythematous with a small amount of cloudy, serosanguineous drainage. Firm palpation of the sternum elicits a clicking sensation and palpable movement of the bony edges when the patient coughs. The lungs are clear to auscultation bilaterally. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with $85\%$ neutrophils. A chest radiograph demonstrates a widened mediastinum and a new, small left-sided pleural effusion. Which of the following is the most appropriate next step in management?

Match each patient presentation to the most appropriate United States Preventive Services Task Force (USPSTF) screening recommendation.

An evaluation is requested in the emergency department for a 54-year-old woman reporting two days of severe, colicky abdominal pain accompanied by progressive swelling of her abdomen. She notes an inability to pass stool or flatus over the past 24 hours and has experienced three episodes of bilious emesis today. Her past surgical history is notable for an open total abdominal hysterectomy performed five years ago. On presentation, her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse is $98/\text{min}$, and blood pressure is $110/70\text{ mmHg}$. Abdominal examination demonstrates marked distension and tympany with hyperactive, high-pitched bowel sounds. Palpation reveals diffuse mild tenderness, but there is no guarding, rigidity, or rebound tenderness. Initial laboratory evaluations show:

Leukocyte count: $11,200/\text{mm}^3$
Serum sodium: $136\text{ mEq/L}$
Serum potassium: $3.2\text{ mEq/L}$
Serum chloride: $96\text{ mEq/L}$
Serum bicarbonate: $28\text{ mEq/L}$
Serum lactate: $1.1\text{ mmol/L}$ (normal: $0.5$-$2.2\text{ mmol/L}$)

Arrange the following management steps in the most appropriate chronological sequence for this patient.