All practice questions

Match each clinical vignette describing a mechanism of injury, physical exam finding, and radiographic pattern with the correct upper extremity orthopedic diagnosis.

A $76$-year-old man presents to the emergency department with the sudden onset of agonizing, diffuse abdominal pain that began $2\text{ hours}$ ago. He has a history of paroxysmal atrial fibrillation and recently stopped taking his apixaban. On physical examination, his temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $145/88\text{ mm Hg}$, pulse is $120/\text{min}$ and irregularly irregular, and respirations are $22/\text{min}$. His abdomen is soft, non-distended, and remarkably exhibits only mild tenderness to deep palpation, without guarding, rebound, or rigidity. Bowel sounds are hypoactive. Laboratory studies show a leukocyte count of $19,000/\text{mm}^3$ and a serum lactate level of $4.2\text{ mmol/L}$. Arrange the following steps in the most appropriate chronological sequence for the optimal diagnosis and management of this patient's condition.

A 28-year-old woman with a history of a ventriculoperitoneal (VP) shunt placed for communicating hydrocephalus presents to the emergency department with a severe headache, nausea, and projectile vomiting. Over the last hour, she has become increasingly lethargic. Her temperature is 37.1°C (98.8°F), heart rate is 52/min, respiratory rate is 10/min, and blood pressure is 165/95 mmHg. Physical examination shows bilateral papilledema and sluggishly reactive pupils. The emergency physician suspects an acute shunt malfunction leading to critically elevated intracranial pressure.

Arrange the following steps in the most appropriate sequential order for the evaluation and definitive management of this patient's condition.

A 45-year-old woman is referred to the surgery clinic for evaluation of an enlarging anterior neck mass. Over the past 6 months, she has noticed a lump in her lower neck. During this time, she has also experienced worsening fatigue, constipation, cold intolerance, and a 4.5-kg (10-lb) weight gain. She has not had any difficulty swallowing or breathing. Her menstrual periods ceased one year ago. Physical examination reveals a non-tender, 3.5-cm, firm, mobile nodule in the right lobe of the thyroid gland. No cervical lymphadenopathy is present.

Laboratory studies show:

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

A 68-year-old woman is brought to the emergency department due to the sudden onset of severe right leg pain that began 2 hours ago. She has a history of permanent atrial fibrillation and was instructed to stop her apixaban three weeks ago prior to a dental extraction, but she never resumed the medication. On physical examination, the right leg is pale and cool to the touch below the knee. The right femoral pulse is palpable, but the popliteal, dorsalis pedis, and posterior tibial pulses are not palpable. She has intact sensation to light touch in her foot and normal toe movement. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A hospital's quality improvement committee wants to proactively reduce the risk of wrong-site surgeries in the ambulatory surgical center before any adverse events occur. They decide to conduct a Failure Mode and Effects Analysis (FMEA). Arrange the following steps of the FMEA process in the correct chronological order from first to last.

An obstetrician is counseling a 28-year-old nulliparous woman at 10 weeks gestation regarding noninvasive prenatal testing (NIPT) utilizing cell-free DNA. The clinic has recently updated its screening protocol. Previously, NIPT was offered exclusively to pregnant women aged 35 and older, a demographic known to have a higher baseline incidence of fetal aneuploidy. Under the newly implemented protocol, the exact same NIPT assay is offered universally to all pregnant women, significantly lowering the overall prevalence of aneuploidy in the clinic's total screened population. Assuming the intrinsic properties of the cell-free DNA assay remain identical, which of the following best describes the expected changes in the positive predictive value (PPV) and negative predictive value (NPV) of this diagnostic test when applied to the universal screening group compared to the advanced maternal age group?

A 48-year-old woman is evaluated for right-sided flank pain and nausea on postoperative day 2 following a total abdominal hysterectomy for symptomatic uterine leiomyomata. She reports the pain is constant and severe. Her temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), blood pressure is $128/78\text{ mm Hg}$, and pulse is $86/\text{min}$. Physical examination reveals exquisite right costovertebral angle tenderness. The surgical incision is clean, dry, and intact without erythema or induration. Laboratory results are as follows:

Blood urea nitrogen: $28\text{ mg/dL}$
Serum creatinine: $1.8\text{ mg/dL}$ (baseline: $0.8\text{ mg/dL}$)

Urinalysis:
Leukocyte esterase: negative
Nitrites: negative
WBC: $1-2/\text{hpf}$
RBC: $10-15/\text{hpf}$

Renal ultrasonography demonstrates moderate right-sided hydronephrosis. The left kidney appears normal. Which of the following is the most appropriate next step in management?

An observational study investigates the association between the regular use of a newly approved prescription sleep medication and the incidence of daytime motor vehicle collisions. Unadjusted analysis reveals a significant positive association (RR = 2.4, 95% CI 1.7-3.1). During peer review, a reviewer expresses concern that underlying obstructive sleep apnea (OSA) is distorting the results. OSA independently increases the risk of motor vehicle collisions and is strongly associated with a higher likelihood of being prescribed sleep medications. Which of the following epidemiological methods are appropriate to control for the influence of OSA in this study? (Select all that apply)

Match each patient's clinical presentation with the most appropriate definitive surgical intervention or management step.

An $82$-year-old woman residing in an assisted living facility is brought to the emergency center after developing bilious emesis and progressive abdominal bloating over the past two days. Her medical history includes an open cholecystectomy and atrial fibrillation. For the last $12\text{ hours}$, her previously colicky cramping has transitioned into a constant, severe ache. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $102/60\text{ mm Hg}$, and pulse is $115/\text{min}$ and irregularly irregular. Physical evaluation shows marked abdominal distension. Bowel sounds are absent. Light palpation produces significant guarding and rigidity localized to the periumbilical region. Laboratory values show a leukocyte count of $16,500/\text{mm}^3$ with $12\%$ bands, a hemoglobin of $13.2\text{ g/dL}$, and a venous lactate of $4.2\text{ mmol/L}$. An acute abdominal series reveals dilated central bowel loops, prominent mucosal folds extending entirely across the lumen, and multiple air-fluid levels. There is no free intraperitoneal air. Which of the following is the most appropriate management for this patient's current condition?

A regional occupational health board is evaluating the impact of night-shift work on metabolic health among healthcare workers. Demographic data indicate that $40\%$ of the nursing workforce in this region is assigned to permanent night shifts. A comprehensive longitudinal study demonstrates that the relative risk of developing type 2 diabetes mellitus over a 10-year period for night-shift nurses, compared to their day-shift counterparts, is $2.5$. Assuming the association is causal, what percentage of the incident type 2 diabetes cases in this entire nursing population can be attributed to night-shift work? (Enter your answer as a percentage.)

A $68$-year-old man presents to the clinic complaining of progressive shortness of breath on exertion and a dry cough that has slowly worsened over the past year. He denies any fever, chills, chest pain, or productive sputum. The patient worked as a pipefitter in a naval shipyard for $30$ years before retiring. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $130/80\text{ mm Hg}$, pulse is $78/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals clubbing of the fingers and fine, dry end-inspiratory crackles at both lung bases. There is no jugular venous distension, and heart sounds are normal without murmurs. Laboratory studies show a normal complete blood count and a serum thyroid-stimulating hormone (TSH) level of $1.8\text{ }\mu\text{U/mL}$ (normal: $0.4-4.0\text{ }\mu\text{U/mL}$). A chest radiograph demonstrates bilateral reticulonodular interstitial opacities most prominent in the lower lobes, along with distinct calcified plaques on the diaphragmatic pleura. Which of the following is the most likely diagnosis?

A 9-year-old boy is brought to the pediatric clinic for a pre-travel consultation. His family is planning a trip to a developing nation in two months. The boy was diagnosed with severe Crohn disease one year ago and is currently receiving maintenance therapy with infliximab and daily high-dose prednisone. A review of his immunization record indicates he never received the Hepatitis A, MMR, or Varicella vaccines due to a previous lapse in medical care. The parents are inquiring about updating his immunizations before the trip. Which of the following vaccines is safe and appropriate to administer to this patient today?

For each of the following patients presenting for a routine health maintenance visit, identify the most strongly indicated clinical intervention or screening modality according to current clinical guidelines.

A 54-year-old woman comes to the clinic for a periodic health maintenance examination. She has a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia. Her current medications include metformin, lisinopril, amlodipine, and rosuvastatin. She underwent menopause at age 51 and has had no vaginal bleeding since that time. She does not use tobacco or alcohol. Her family history is unremarkable, with no known malignancies. Her last screening colonoscopy was performed at age 50 and was normal. Her last screening mammogram was performed at age 52 and was normal. Her last cervical cytology with human papillomavirus (HPV) co-testing was performed at age 50 and was normal. She received an intramuscular inactivated influenza vaccine 2 months ago and a Tdap booster 4 years ago. Vital signs show a blood pressure of 132/82 mm Hg, pulse of 76/min, and BMI of 34 kg/m². Which of the following is the most appropriate next step in this patient's preventive care?

A 46-year-old male with a history of an uncorrected right-to-left cardiac shunt is evaluated in the neurology unit for a progressively worsening, severe global headache over the past week. This morning, he developed new-onset weakness in his left arm and leg. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $145/90\text{ mm Hg}$, and heart rate is $88\text{/min}$. Neurologic examination reveals $3/5$ motor strength in the left upper and lower extremities and a left homonymous hemianopia. Fundoscopic examination shows bilateral optic disc swelling with blurred margins. A contrast-enhanced MRI of the brain demonstrates a $3.8\text{-cm}$ solitary ring-enhancing lesion with a necrotic core in the right frontoparietal lobe, surrounded by substantial vasogenic edema and a $7\text{-mm}$ midline shift. Which of the following is the most appropriate next step in management?

A local health department receives reports of several individuals developing severe watery diarrhea, abdominal cramps, and vomiting after attending a community picnic. An epidemiologist is immediately tasked with investigating this potential outbreak.

Arrange the following initial steps of the outbreak investigation in the standard chronological sequence recommended by the Centers for Disease Control and Prevention (CDC).

A surgical service is evaluating multiple patients with suspected vascular or cardiothoracic conditions. Match each patient's clinical presentation with the underlying pathophysiologic mechanism or anatomic lesion most likely responsible for their symptoms.

A series of patients present to the general surgery clinic with various complications following prior gastric resections and bariatric procedures. Match each clinical presentation with the most accurate underlying pathophysiologic mechanism.