All practice questions

A 72-year-old woman is admitted to the general medical ward with community-acquired pneumonia. She is prescribed intravenous levofloxacin. On hospital day 2, she develops acute respiratory distress, hypotension, and a diffuse urticarial rash shortly after the levofloxacin infusion is started. She is diagnosed with anaphylactic shock, promptly treated with intramuscular epinephrine, and transferred to the intensive care unit for stabilization. A subsequent investigation reveals that the patient had a documented severe allergy to fluoroquinolones in her electronic health record (EHR). The admitting physician had bypassed the EHR allergy alert. During the root cause analysis, the physician explains that the EHR generates dozens of pop-up alerts daily for minor drug-drug interactions and mild intolerances, leading them to habitually close all alerts without reading them in order to manage their workload. Which of the following is the most effective intervention to prevent this type of adverse event from recurring?

A 65-year-old woman comes to the physician for a routine health maintenance examination. She feels well and has no acute complaints. She went through menopause at age 51 and denies any postmenopausal vaginal bleeding. Her medical history is significant for well-controlled essential hypertension, for which she takes lisinopril. She smoked one pack of cigarettes daily for 25 years but quit 20 years ago. Her mother died of a myocardial infarction at age 75.

Review of her medical records shows:
- A normal screening colonoscopy at age 57.
- A normal screening mammogram 6 months ago.
- Negative cervical cytology and human papillomavirus cotesting at ages 55, 60, and 64.
- No history of fractures, and she has never had a bone density scan.

Vital signs are within normal limits. Physical examination shows no abnormalities.

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

A pediatrician is completing a well-child examination for a 4-year-old girl who will soon begin preschool. The patient was diagnosed with systemic juvenile idiopathic arthritis one year ago and is currently maintained on weekly methotrexate and a high-dose daily regimen of oral prednisone. Her growth parameters track along the 50th percentile, and her physical examination reveals no active joint inflammation or deformities. A review of her electronic immunization registry confirms she received all standard childhood vaccines appropriately up to her 18-month visit. According to current guidelines for clinical preventive services, which of the following is the most appropriate management plan for this patient today?

A 45-year-old woman presents to her primary care physician with fatigue, intermittent joint pain, and a faint facial rash. The physician suspects systemic lupus erythematosus (SLE) and orders an antinuclear antibody (ANA) test. The prevalence of SLE in patients presenting with these non-specific symptoms in a general primary care setting is approximately 2%. In a specialized rheumatology clinic where the assay was originally validated, the prevalence of SLE among tested patients is 30%. The ANA test has a reported sensitivity of 95% and a specificity of 80%. When comparing the performance of the ANA test in the general primary care setting to its performance in the rheumatology clinic, which of the following best describes the test characteristics in the primary care setting?

A 28-year-old man presents to an outpatient urgent care clinic with a 3-day history of high fever, cough, coryza, and conjunctivitis. Today, he developed a diffuse maculopapular rash that began on his face and is spreading to his trunk. He recently returned from a trip to a country with an ongoing measles outbreak and has never been vaccinated. The physician makes a clinical diagnosis of measles (rubeola) and places the patient in an isolation room. The patient works as a line cook in a popular, crowded local restaurant. When informed of the diagnosis and the need for strict airborne isolation, he becomes highly agitated and states, "I cannot afford to miss work. I am going to my shift tonight. You are not allowed to tell my boss or anyone else; that is a violation of my medical privacy." Which of the following entities is the physician ethically or legally permitted to notify regarding this patient's diagnosis and infectious risk without his explicit consent? (Select all that apply)

A hospital quality improvement committee is tasked with investigating a recent increase in medication administration delays on the surgical ward. They decide to conduct a formal Root Cause Analysis (RCA). Arrange the following steps of the RCA process in the correct chronological order, from first to last.

Physicians must constantly navigate the ethical and legal boundaries of patient confidentiality, distinguishing between situations that demand absolute privacy and those that require mandatory reporting. Match each complex clinical scenario with the most appropriate ethical or legal course of action regarding confidentiality.

A tertiary care center uses a quantitative enzyme-linked immunosorbent assay (ELISA) to diagnose a severe mosquito-borne viral infection in patients presenting with undifferentiated fever. For the past several years, the diagnostic threshold for a positive test has been set at an optical density of $0.50$. At this baseline threshold, the assay has a sensitivity of $80\%$ and a specificity of $85\%$.

Recently, climate changes have led to a massive surge in the vector population, causing the prevalence of the viral infection among febrile patients to increase from $10\%$ to $40\%$. Concurrently, because the standard treatment has severe nephrotoxic side effects, the hospital administration decides to raise the diagnostic threshold from $0.50$ to $0.80$ to minimize the inappropriate administration of therapy to uninfected patients.

Which of the following best describes the expected combined impact of these two changes on the assay's positive predictive value (PPV) and negative predictive value (NPV) compared to the original baseline?

A multicenter randomized controlled trial is initiated to evaluate the efficacy of a novel monoclonal antibody compared to standard care in patients with severe, refractory rheumatoid arthritis. The primary endpoint is the rate of achieving clinical remission at 12 months. The trial is originally designed to enroll 1,000 patients to achieve $80\%$ statistical power. However, due to slow recruitment, the trial is terminated early after enrolling only 350 patients. The final analysis reveals a relative risk (RR) for clinical remission of 1.35 in the novel therapy group compared to standard care, with a $95\%$ confidence interval (CI) of 0.92 to 1.98 ($p = 0.11$). The investigators conclude that there is no significant difference between the two treatments. Which of the following is the most accurate statistical critique of these findings?

A 48-year-old man establishes care at a new primary care clinic. He has not seen a healthcare provider in 15 years. He reports a history of intravenous drug use in his twenties but has been in recovery for 20 years. He is currently asymptomatic, and his physical examination is unremarkable. The physician discusses Hepatitis C virus (HCV) screening, which the patient agrees to undergo. Assuming each diagnostic step yields positive or abnormal results that necessitate further action, arrange the following clinical steps in the correct chronological sequence for this patient's screening and preventive care cascade.

A 22-year-old man is evaluated in the hospital for severe right leg pain. Ten hours ago, he underwent closed reduction and placement of a circumferential long-leg cast for a closed, displaced midshaft tibia fracture sustained during a soccer match. He states that the pain is agonizing, describes it as a deep 'burning' sensation, and reports that it has progressively worsened over the last three hours despite receiving scheduled doses of intravenous hydromorphone. On physical examination, the right foot is warm and pink. Capillary refill is 2 seconds, and the dorsalis pedis and posterior tibial pulses are palpable. He holds his ankle in slight plantar flexion. Passive dorsiflexion of the right toes elicits excruciating pain. Sensation to light touch is decreased over the first dorsal web space. Which of the following is the most appropriate initial step in the management of this patient?

Medical researchers at a specialized hepatobiliary center are investigating the etiology of cholangiocarcinoma, a malignancy with a very low population incidence. To explore potential risk factors, the researchers identify 120 patients who were diagnosed with cholangiocarcinoma at their center over the past decade. For a comparison group, they recruit 360 patients who were admitted to the same medical center for elective orthopedic procedures during the same time period. Investigators conduct detailed, structured interviews with all participants to gather information about their lifetime occupational histories and past dietary habits, specifically focusing on the consumption of raw, undercooked freshwater fish. Which of the following statements regarding the chosen epidemiological study design and its inherent characteristics are correct? (Select 2)

A team of rheumatology researchers is investigating a novel serum autoantibody as a potential predictor of systemic sclerosis. The researchers utilize an existing longitudinal health study that originally enrolled 80,000 healthy female teachers in 2005. At the time of enrollment, all participants provided comprehensive health surveys and baseline blood samples, which were frozen and stored. Between 2005 and 2025, 320 of these participants developed systemic sclerosis. To minimize expensive laboratory costs, the researchers retrieve the frozen 2005 blood samples of the 320 women who developed the disease. They also randomly select and retrieve the 2005 blood samples of 1,280 women from the same original cohort who did not develop the disease, matching them by age and smoking status. The researchers then analyze all selected samples to compare the presence of the autoantibody between the two groups. Which of the following best describes this epidemiologic study design?

A 52-year-old woman is evaluated in the emergency department for a 2-day history of severe left-sided flank pain, nausea, and chills. Her temperature is 39.4°C (102.9°F), pulse is 118/min, and blood pressure is 88/56 mm Hg. Physical examination reveals marked left costovertebral angle tenderness and voluntary guarding. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum creatinine of $1.9 \text{ mg/dL}$ (baseline $0.9 \text{ mg/dL}$). A non-contrast computed tomography scan of the abdomen and pelvis demonstrates an 8-mm calculus in the proximal left ureter with ipsilateral hydronephrosis and prominent perinephric fat stranding. Intravenous fluid resuscitation and empiric broad-spectrum antibiotics are immediately initiated. Which of the following is the most appropriate next step in management?

A 55-year-old man is admitted to the progressive care unit with a deep vein thrombosis and is receiving a continuous intravenous heparin infusion. The night shift nurse prepares to draw blood to check the patient's activated partial thromboplastin time (aPTT). While gathering supplies, the nurse is interrupted by an urgent call for assistance from an adjacent patient room. The nurse briefly leaves the supplies, returns 10 minutes later, and hurriedly draws the blood sample directly from the intravenous line through which the heparin is actively infusing. The laboratory reports a critically elevated aPTT of >150 seconds. The covering physician immediately halts the heparin infusion. However, a repeat phlebotomy performed one hour later reveals a subtherapeutic aPTT, indicating the initial sample was contaminated by the infusion line. The incident is reported in the hospital's incident reporting system. According to the principles of patient safety and quality improvement, which of the following is the most appropriate initial step in response to this event?

A 34-year-old man is brought to the emergency department directly from his workplace at a synthetic chemical and dye manufacturing plant. His coworkers report that he was transferring a vat of aniline-based chemicals when a spill occurred, soaking his clothing. Shortly after, he developed acute-onset shortness of breath, a severe headache, and confusion. His medical history is notable for major depressive disorder, for which he takes fluoxetine. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $110/70\text{ mmHg}$, pulse $118/\text{min}$, and respiratory rate $24/\text{min}$. Pulse oximetry shows an oxygen saturation of $85\%$ on room air. The patient is placed on $100\%$ oxygen via a non-rebreather mask, but his oxygen saturation remains at $85\%$. Physical examination reveals an agitated man with prominent bluish discoloration of the lips and fingertips. Lungs are clear to auscultation bilaterally. Cardiac examination reveals tachycardia with a regular rhythm. An arterial blood gas analysis obtained while the patient is on $100\%$ oxygen shows:

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

A 48-year-old woman comes to the clinic for a follow-up appointment. One month ago, she was diagnosed with Huntington disease after presenting with a 2-year history of progressive choreiform movements, irritability, and cognitive decline. Genetic testing confirmed a CAG trinucleotide repeat expansion. She is accompanied by her husband, who is aware of the diagnosis. The patient has a 26-year-old son from a previous marriage. Her son and his wife are currently expecting their first child. During the visit, the physician strongly encourages the patient to discuss her diagnosis with her son given the 50% risk of inheritance. The patient becomes visibly upset and states, "He is already under so much stress with the baby coming. Knowing about this disease will ruin his life right now. I forbid you from telling him or anyone else." The patient's examination shows clear capacity to understand her diagnosis and make medical decisions. Which of the following is the most appropriate next step by the physician?

Match each clinical presentation and physical examination finding to the most appropriate surgical vascular pathology.

Establish the most appropriate high-priority screening intervention for each presented patient scenario based on current USPSTF Grade A and B evidence-based guidelines.

A rural community health center introduces a new rapid point-of-care test for Lyme disease during the summer months. Based on epidemiological data, the pre-test probability of a patient having Lyme disease when presenting with non-specific flu-like symptoms in this region is $25\%$. The rapid test has a documented sensitivity of $84\%$ and a specificity of $92\%$. A 32-year-old forestry worker presents with malaise and myalgia and tests positive on this new assay. What is the positive predictive value of this test for this patient? Express your answer as a percentage rounded to one decimal place.