All practice questions

A 72-year-old resident of a long-term care facility is rushed to the acute care bay because of sudden unresponsiveness and an elevated temperature. The transporting crew reports that the patient was found in bed, difficult to rouse, and exhibiting shallow breathing. On assessment, the patient's temperature is 39.6°C (103.3°F), blood pressure is 68/34 mmHg, heart rate is 132/min, and respirations are 26/min. The skin displays a reticular, purplish discoloration over the lower extremities, and capillary refill is substantially delayed. Which of the following are the most appropriate simultaneous initial stabilization steps for this patient? (Select exactly 2 options)

A 48-year-old woman comes to the clinic for evaluation of a newly noticed lump in her anterior neck, which she discovered while applying lotion two weeks ago. Over the past two months, she has experienced a $3\text{-kg}$ ($6.6\text{-lb}$) unintentional weight loss, increased sweating, and intermittent palpitations. She denies dysphagia, hoarseness, or dyspnea. Vital signs show a blood pressure of $132/78 \text{ mm Hg}$, a heart rate of $104\text{/min}$, and a respiratory rate of $16\text{/min}$. Physical examination reveals a $2.5\text{-cm}$, firm, mobile, non-tender nodule in the right lobe of the thyroid gland. No cervical lymphadenopathy is appreciated.

Initial laboratory and imaging studies are obtained. The serum thyroid-stimulating hormone (TSH) level is $0.05 \text{ mU/L}$ (normal: $0.4-4.0 \text{ mU/L}$). A targeted neck ultrasound confirms a $2.5\text{-cm}$ solid, primarily hypoechoic nodule in the right thyroid lobe with regular margins and no suspicious microcalcifications.

Which of the following is the most appropriate next step in the diagnostic workup of this patient's nodule?

A 65-year-old woman presents to the clinic for a routine wellness visit. She has a history of primary hypertension and osteoarthritis, for which she takes amlodipine and acetaminophen. She does not smoke or consume alcohol. Her family history is notable for a mother who experienced a hip fracture at age 75. Her vital signs and physical examination are unremarkable. A review of her medical records reveals the following preventive care history:

- Mammography: Normal results 3 years ago
- Colonoscopy: Normal results 11 years ago
- Pap smear with human papillomavirus (HPV) co-testing: Negative 4 years ago. She has a documented history of two additional consecutive negative co-tests over the prior decade, with no history of cervical intraepithelial neoplasia.
- Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine: Administered 6 years ago

Which of the following combinations of screening tests is most appropriate to order for this patient today?

Review the clinical scenarios of the following four patients presenting to the emergency department. Match each patient with their most appropriate initial disposition and care setting based on validated clinical risk stratification tools.

A 28-year-old woman is brought to the emergency department by paramedics due to continuous generalized shaking of her arms and legs. Her roommate states she found her seizing 20 minutes ago. The patient has a history of epilepsy but has not taken her medications recently due to insurance issues. On arrival, she is unresponsive to verbal commands and has continuous, rhythmic, bilateral extremity jerking. Her blood pressure is 142/88 mm Hg, heart rate is 118/min, respiratory rate is 22/min, and oxygen saturation is 96% on a non-rebreather mask. Fingerstick blood glucose is 98 mg/dL. Two large-bore intravenous lines are established.

Arrange the following pharmacologic interventions in the most appropriate chronological sequence for managing this patient's condition, assuming she continues to seize despite each successive therapy.

A 68-year-old man presents to the emergency department complaining of sudden, severe pain in his right leg that began 2 hours ago. He describes the leg as feeling "numb and heavy." His medical history is significant for hypertension, type 2 diabetes mellitus, and atrial fibrillation. He states he ran out of his prescribed apixaban two weeks ago. His vital signs are temperature 37.1°C (98.8°F), blood pressure 156/92 mm Hg, pulse 118/min and irregularly irregular, and respirations 16/min. Physical examination of the right lower extremity reveals pallor and coolness to the touch from the mid-calf down. The right dorsalis pedis and posterior tibial pulses are absent on both palpation and continuous-wave Doppler ultrasound. He has decreased sensation to light touch over the dorsum of the right foot and exhibits mild weakness when asked to dorsiflex his toes. The left lower extremity is warm with normal pulses. Which of the following is the most appropriate next step in the management of this patient?

A $41$-year-old woman is brought to the emergency department by her husband due to a two-day history of progressively worsening right-sided abdominal pain, fevers, and confusion. Her past medical history is significant for morbid obesity, for which she underwent a laparoscopic Roux-en-Y gastric bypass and a cholecystectomy four years ago. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $128/\text{min}$, blood pressure is $78/48\text{ mm Hg}$, and respirations are $26/\text{min}$. Physical examination reveals scleral icterus and significant tenderness to palpation in the right upper quadrant with involuntary guarding. The patient is oriented only to her own name. Laboratory studies show a leukocyte count of $21,000/\text{mm}^3$, a total bilirubin of $7.2\text{ mg/dL}$, a direct bilirubin of $5.5\text{ mg/dL}$, and an alkaline phosphatase of $510\text{ U/L}$. Aspartate aminotransferase (AST) is $180\text{ U/L}$ and alanine aminotransferase (ALT) is $210\text{ U/L}$. A bedside right upper quadrant ultrasound reveals a dilated common bile duct measuring $1.5\text{ cm}$ with internal echogenic foci and posterior acoustic shadowing. The patient receives $3\text{ L}$ of intravenous crystalloids and broad-spectrum antibiotics. Despite these measures, her blood pressure remains $80/50\text{ mm Hg}$, and a continuous norepinephrine infusion is initiated. Which of the following is the most appropriate next step in the management of this patient?

Investigators at an academic medical center are designing a randomized, double-blind, placebo-controlled trial to evaluate a novel Janus kinase (JAK) inhibitor for the treatment of moderate-to-severe plaque psoriasis. The primary endpoint is the absolute change in the Psoriasis Area and Severity Index (PASI) score from baseline to 16 weeks. Preliminary power calculations indicate that the current study design only yields 65% statistical power ($\beta = 0.35$), which is below the conventional 80% threshold. The research team meets to discuss protocol revisions to improve the study's ability to detect a true difference between the treatment and placebo groups.

Which of the following modifications would increase the statistical power of this trial? (Select all that apply)

An outpatient clinic physician is preparing to disclose a diagnosis of Alzheimer disease to a 64-year-old former mechanic and his wife, following a recent comprehensive neurocognitive evaluation and brain MRI. The physician intends to follow the SPIKES protocol for delivering difficult medical news. Arrange the following physician actions in the correct chronological sequence according to this communication framework.

A consortium of hepatology researchers initiates a long-term observational project to evaluate the impact of ultra-processed food consumption on the development of incident non-alcoholic fatty liver disease (NAFLD). They enroll $24,500$ healthy adults aged 35 to 55 years who have normal baseline hepatic ultrasound findings and normal liver enzyme levels. Participants complete validated dietary assessments at enrollment and every two years thereafter. The research team tracks these individuals over a 12-year period, performing periodic hepatic imaging and laboratory tests to identify new cases of NAFLD. Which of the following statements regarding this investigation are correct? (Select all that apply)

A 78-year-old woman with advanced Alzheimer dementia is admitted to the medical intensive care unit with aspiration pneumonia and septic shock. She requires vasopressor support and noninvasive positive pressure ventilation. Despite broad-spectrum antibiotics and fluid resuscitation, her respiratory status continues to decline, and the care team considers endotracheal intubation. The patient is profoundly encephalopathic and lacks decision-making capacity. She does not have a designated healthcare proxy or an advance directive. The patient's family includes her 80-year-old husband and two adult daughters. The husband has a documented history of mild cognitive impairment. However, upon evaluation by the intensive care physician, the husband demonstrates a clear understanding of his wife's prognosis and the risks and benefits of intubation. He consistently expresses his rationale for choosing comfort-focused measures, citing his wife's previously expressed wishes to avoid mechanical ventilation. The two adult daughters strongly disagree with the husband and demand that their mother be intubated and fully resuscitated, arguing that their father's cognitive impairment invalidates his decision. Which of the following is the most appropriate next step in the management of this patient?

An institutional review board is evaluating several new clinical research proposals. Match each proposed research objective and methodology with the most appropriate epidemiological study design.

A pharmaceutical company sponsors a phase III, randomized, double-blind clinical trial to compare a newly developed oral targeted therapy against standard methotrexate for the treatment of moderate-to-severe rheumatoid arthritis. The study protocol pre-specifies an alpha level of $0.05$ and a power of $80\%$ to detect a $15\%$ absolute difference in the rate of clinical remission at $24$ weeks. Based on these parameters, the required sample size is calculated to be $800$ patients. Due to strict inclusion criteria and recruitment challenges, the enrollment period is closed early after only $400$ patients have been randomized.

At the $24$-week follow-up, the clinical remission rate is $45\%$ in the new therapy group and $33\%$ in the methotrexate group. The statistical analysis yields a p-value of $0.09$. The investigators publish their findings, concluding that the new oral therapy is not superior to standard methotrexate.

Which of the following is the most accurate statistical critique of this trial's conclusion?

A 66-year-old man with a history of progressive glioblastoma is evaluated during a routine home hospice visit. He has been bedbound for the past month and became entirely unresponsive 24 hours ago. His daughter, who is his primary caregiver, is highly distressed. She reports that her father has developed very noisy, gurgling breathing over the past several hours. She states, 'It sounds like he is choking on his own fluid. Please suction it out so he can breathe.'

Vital signs are temperature 37.1°C (98.8°F), pulse 98/min, and respirations 18/min. Physical examination reveals an unresponsive patient. There is prominent gurgling heard during both inspiration and expiration. The patient's face is relaxed, and he shows no signs of grimacing, accessory muscle use, or restlessness. Lung auscultation reveals transmitted upper airway sounds bilaterally without focal crackles or wheezes. Which of the following is the most appropriate next step in management?

Review the following patient clinical profiles encountered during primary care wellness visits. For each patient, identify the single most appropriate, guideline-concordant preventive screening intervention and interval based on current evidence-based recommendations.

A 54-year-old man presents to the clinic for a routine health maintenance examination. He has no significant past medical history and takes no medications. He has a 35-pack-year smoking history and continues to smoke one pack of cigarettes daily. During the visit, the physician recommends an annual low-dose chest CT for lung cancer screening. The patient immediately crosses his arms and says, "I don't see the point of doing that. If I have lung cancer, it's a death sentence anyway, so I would rather just live my life without knowing."

Which of the following is the most appropriate initial response by the physician?

An epidemiologist at a global health organization is investigating the relationship between sedentary behavior and cardiovascular mortality. The investigator analyzes data from 40 different industrialized nations, plotting the average daily hours of television viewing per capita against the national incidence of myocardial infarction per 100,000 population. A strong positive correlation is identified ($r = +0.82$, $p < 0.01$). Based on these findings, the investigator publishes a report concluding that a person who watches more than four hours of television daily has a significantly increased individual risk of experiencing a myocardial infarction. Which of the following best describes the fundamental methodological error in the investigator's conclusion?

A medical director at a rural community health center is planning a randomized controlled trial to evaluate a novel text-message adherence protocol for patients with hypertension. Initially, statistical modeling determined that 300 patients are needed to achieve $80\%$ power at a two-tailed significance level of $\alpha = 0.05$. This calculation assumed a minimum clinically important difference in mean systolic blood pressure of $5\text{ mmHg}$ and a population standard deviation of $8\text{ mmHg}$.

A week before enrollment begins, a comprehensive regional health survey is published, revealing that the true population standard deviation for systolic blood pressure in this demographic is actually $14\text{ mmHg}$. If the investigator proceeds with the originally planned sample size of 300 patients and an alpha of $0.05$, which of the following is the most accurate statement regarding the study's design and statistical parameters?

A 48-year-old man presents to the clinic to establish primary care. The physician intends to implement a structured, evidence-based behavioral intervention for smoking cessation during the visit. Arrange the following physician actions in the correct chronological sequence according to standard clinical guidelines for tobacco cessation (the 5 A's model).

An academic research group is designing a prospective cohort study to investigate the association between daily ultra-processed food consumption and the incidence of non-alcoholic fatty liver disease (NAFLD) in young adults. To ensure the study yields reliable conclusions, the principal investigator specifies an acceptable false-positive rate of $5\%$. Through a pilot analysis and sample size estimation, the research team determines there is an $18\%$ probability that the study will fail to detect a true $1.5$-fold increased risk of NAFLD, should one actually exist. Based on these specified parameters, what is the statistical power of this cohort study to detect the true association, expressed as a percentage?