All practice questions

A 68-year-old man with advanced idiopathic pulmonary fibrosis is admitted to an inpatient hospice unit. Over the next several days, his respiratory status declines, and he develops progressive, severe dyspnea that causes him significant distress. The medical team plans a stepwise approach to symptom management. Arrange the following interventions in the most appropriate sequential order for managing this patient's progressive terminal dyspnea, from the initial first-line approach to the final intervention of last resort for truly refractory symptoms.

A $73$-year-old man presents to the clinic for a routine health maintenance examination. He has no acute complaints and feels well. His medical history is significant for essential hypertension and mild benign prostatic hyperplasia. He is a former smoker who smoked $1$ pack of cigarettes daily for $40$ years before successfully quitting $16$ years ago at age $57$. He has been receiving annual low-dose chest CT scans for lung cancer screening for the past several years; his most recent scan was $13$ months ago and was normal. His last screening colonoscopy was performed exactly $10$ years ago at age $63$ and was completely normal with excellent bowel preparation. He also underwent a normal abdominal aortic ultrasound at age $66$. He is highly functional, exercises daily, and has a life expectancy of greater than $10$ years. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in this patient's preventive care?

A 52-year-old woman presents to the outpatient clinic to discuss severe vasomotor symptoms, including frequent hot flashes and night sweats, which have caused significant sleep disruption and daytime fatigue over the past three months. Her last menstrual period was 14 months ago. Her medical history is notable for an unprovoked deep vein thrombosis in her left lower extremity five years ago, for which she completed a six-month course of oral anticoagulation. She currently takes no medications. The patient states, "My older sister had terrible hot flashes and started oral estrogen and progesterone pills, which completely cured her. I want a prescription for the same pills today." Additionally, she requests a dual-energy x-ray absorptiometry scan because her mother recently suffered a hip fracture at age 78. Which of the following is the most appropriate next step in counseling this patient?

Match the following clinical safety scenarios to their most appropriate patient safety classification.

A neurologist is evaluating whether to incorporate a newly approved disease-modifying therapy into their clinical practice for patients with moderate-to-severe relapsing-remitting multiple sclerosis (RRMS). To make an evidence-based decision, the physician reviews a recent phase III trial published in a prominent medical journal. The study included $3,200$ adult patients with RRMS who were randomly assigned in a $1:1$ ratio to receive either the new therapy or a placebo over a $24$-month period.

During the study period, $64$ of the $1,600$ patients receiving the new therapy experienced a confirmed clinical relapse. In contrast, $112$ of the $1,600$ patients in the placebo group experienced a confirmed clinical relapse. The authors of the study report a relative risk of $0.57$ for clinical relapse ($95\%$ CI, $0.43$ to $0.76$; $p = 0.003$).

Based on the data provided, which of the following is the most accurate interpretation regarding the efficacy and clinical impact of this new therapy?

A 62-year-old man comes to the clinic for a routine follow-up regarding type 2 diabetes mellitus and heart failure with reduced ejection fraction (LVEF 35%). His current medications include metformin, empagliflozin, lisinopril, carvedilol, and rosuvastatin. Laboratory studies show a hemoglobin A1c of 10.4%, an increase from 8.9% six months ago. The physician explains that the patient's blood glucose remains severely elevated despite maximal oral therapy and recommends initiating once-daily basal insulin. The patient becomes visibly distressed, crosses his arms, and states, "I am not taking the needle. My uncle started insulin and he lost his leg a year later. It completely ruined his life. I will not let that happen to me." Which of the following is the most appropriate next step in management?

During a comprehensive health maintenance visit, a primary care physician evaluates a $45$-year-old male with a history of extensive ulcerative colitis. The patient was diagnosed with the condition $9$ years ago and is currently in clinical remission on maintenance adalimumab therapy. His social history reveals a $10$-pack-year smoking habit; he currently smokes $10$ cigarettes daily. He reports that his last lower gastrointestinal endoscopy was performed at the time of his diagnosis. He has received no immunizations over the past decade. The physician is planning his preventive care and cancer surveillance strategy. Based on current guidelines, which of the following is the most appropriate combination of screening and immunization interventions for this patient?

A surgical ward charge nurse observes that a newly hired physician assistant (PA) consistently alters patients' pain management regimens without notifying the primary nursing staff. This practice has resulted in several instances of delayed medication administration, as nurses are unaware of the new orders until they check the electronic health record hours later. The charge nurse decides to address this recurring workflow issue directly with the PA to improve interprofessional teamwork. Which of the following is the most appropriate communication strategy for the nurse to utilize in this situation?

Medical residents attending a journal club are analyzing the methodology sections of various epidemiological studies. For each analytical objective or study design feature listed below, identify the appropriate statistical metric used to report the findings.

A 72-year-old man is evaluated in the palliative care clinic for new-onset pain. He has a history of metastatic prostate cancer with diffuse osteoblastic bone metastases and symptomatic benign prostatic hyperplasia. He is currently maintained on an extended-release morphine regimen that adequately controls his baseline dull, aching bone pain. Over the past two weeks, he has developed severe, "shooting and burning" pain radiating down his right posterior thigh and calf. He rates this new pain as an 8 on a 10-point scale. Neurologic examination reveals decreased pinprick sensation over the lateral aspect of the right lower leg. His motor strength is 5/5 in all extremities. He has normal anal sphincter tone and reports no issues with bowel function or new urinary symptoms. He is alert, oriented, and demonstrates a clear understanding of his prognosis and treatment options.

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

Public health officials are investigating an unexpected cluster of cerebral venous sinus thrombosis (CVST) cases among young adult women. They structure an observational study wherein women diagnosed with CVST are identified from hospital records, and a comparison group of women without CVST is subsequently selected. To account for tobacco use—a potent known risk factor for CVST—the investigators ensure that for every patient with CVST who smokes, a corresponding smoker without CVST is enrolled. Non-smokers are similarly paired.

Which of the following is a direct methodological consequence of utilizing this specific design strategy?

Match each patient's clinical vignette with the most appropriate next step in preventive screening or disease surveillance based on current evidence-based guidelines.

A 32-year-old woman is evaluated in the preoperative clinic before an elective laparoscopic cholecystectomy. She has no history of abnormal bleeding after tooth extractions or minor cuts. Her only medication is an oral contraceptive pill. Vital signs are within normal limits. Physical examination is unremarkable.

Laboratory results are as follows:

Because of the isolated prolonged aPTT, a mixing study is performed using a 1:1 ratio of the patient's plasma and normal pooled plasma. The aPTT immediately after mixing is $64$ seconds, and after a 2-hour incubation at $37^\circ C$, it remains $66$ seconds.

Which of the following is the most likely explanation for these laboratory findings?

A 54-year-old man with a body mass index of 34 kg/m² comes to the clinic for a follow-up visit regarding his newly diagnosed type 2 diabetes mellitus. He reports struggling to adhere to his prescribed diet and exercise regimen. Laboratory studies show a fasting plasma glucose of 145 mg/dL and a hemoglobin A1c of 7.6%. The physician initiates metformin therapy and explains that the patient's condition is primarily driven by peripheral insulin resistance, which is characterized by a blunted intracellular response to endogenous insulin in target tissues. Place the following molecular events in the correct chronological sequence representing the normal cellular mechanism of insulin-mediated glucose uptake in skeletal muscle, from initial hormone binding to the final physiological effect.

A 32-year-old woman comes to the clinic for a routine follow-up. She feels well and has no specific complaints. She has a history of mild depression treated with sertraline for the past two years. Her family history is notable for a father who had "high calcium levels" but never required surgery. Her blood pressure is 118/76 mm Hg, and her pulse is 72/min. Physical examination is unremarkable.

Laboratory studies show:

Which of the following is the most appropriate next step in diagnostic evaluation?

A 41-year-old woman with systemic lupus erythematosus on chronic glucocorticoid therapy presents with progressively worsening right groin pain that is exacerbated by weight-bearing. Physical examination reveals limited internal rotation of the right hip. Suspecting avascular necrosis (osteonecrosis) of the femoral head, you review the natural history of this condition to guide your diagnostic imaging strategy and patient counseling. Arrange the following characteristic imaging findings of avascular necrosis in chronological order, from the earliest initial presentation to the most advanced end-stage of the disease.

A $45$-year-old woman comes to the clinic for follow-up of recently diagnosed hypertension. Her blood pressure was $162/98$ mm Hg at a health fair two months ago and $158/96$ mm Hg during a clinic visit two weeks ago. Today, she is entirely asymptomatic and reports no headaches, palpitations, diaphoresis, or muscle weakness. She takes no medications and has no significant past medical history. Her family history is unremarkable. Vital signs today show a blood pressure of $160/94$ mm Hg and a pulse of $76$/min. BMI is $24$ kg/m $^2$. Physical examination is normal, with no abdominal bruits, striae, or edema. Routine laboratory testing shows:

Sodium: $144$ mEq/L
Potassium: $2.9$ mEq/L
Chloride: $102$ mEq/L
Bicarbonate: $31$ mEq/L
Blood urea nitrogen: $12$ mg/dL
Creatinine: $0.8$ mg/dL

Which of the following is the most appropriate next step in laboratory evaluation?

An occupational medicine physician evaluates a 42-year-old warehouse worker who developed acute-onset, severe lower back pain after lifting a heavy crate the previous day. The pain radiates down the posterior aspect of the right thigh and calf to the lateral aspect of the foot. The patient denies any history of malignancy, recent weight loss, fever, or bowel and bladder incontinence. The physician suspects an acute lumbosacral disc herniation and wishes to use bedside maneuvers to clinically confirm the diagnosis, aiming to avoid immediate magnetic resonance imaging. Which of the following elicited physical examination findings, if present, demonstrates the highest specificity for confirming this patient's suspected diagnosis?

A 72-year-old man is evaluated in the neurology clinic for a 6-month history of progressive weakness in his legs, unsteadiness, and numbness in his hands and feet. He reports that his symptoms began gradually, but he now requires a cane to ambulate. His medical history is significant for hypertension, osteoarthritis, and severe periodontitis that resulted in full dental extractions 5 years ago. His current prescription medications include hydrochlorothiazide and acetaminophen. On neurological examination, he exhibits spasticity in the lower extremities, 4/5 strength bilaterally in hip flexion and ankle dorsiflexion, and hyperreflexia at the knees. Sensation to vibration and proprioception is markedly decreased at the toes and ankles. Romberg test is positive. Laboratory studies reveal a hemoglobin of 10.2 g/dL, mean corpuscular volume of 108 fL, absolute neutrophil count of 1,100/mm³, normal thyroid-stimulating hormone, normal serum vitamin B12, normal serum folate, and normal methylmalonic acid levels. Which of the following historical elements is most important to elicit to determine the underlying cause of this patient's presentation?

A $54$-year-old man presents to the emergency department with a $4$-day history of progressively worsening shortness of breath, right-sided pleuritic chest pain, and a nonproductive cough. His temperature is $38.2^{\circ}\text{C}$ ($100.8^{\circ}\text{F}$), blood pressure is $130/80\text{ mm Hg}$, heart rate is $108\text{ beats/min}$, and respiratory rate is $22\text{ breaths/min}$. On physical examination, the right hemithorax shows decreased excursion during inspiration. Palpation reveals decreased tactile fremitus over the right lower lung field. Percussion over this area produces a dull note. Auscultation reveals decreased vesicular breath sounds at the right base without wheezes or crackles. When the patient is asked to repeatedly say 'E', the sound heard over the affected area is muffled and indistinguishable. Which of the following best describes the underlying pathophysiologic mechanism responsible for this patient's localized physical examination findings?