A 79-year-old male presents to your office for his annual flu shot. On physical exam you note several linear bruises on his back. Upon further questioning he denies abuse from his daughter and son-in-law, who live in the same house. The patient states he does not want this information shared with anyone. What is the most appropriate next step, paired with its justification?

Breach patient confidentiality, as this patient is a potential victim of elder abuse and reporting is mandated in most states

Breach patient confidentiality, as this patient's care should be discussed with the daughter as she is his primary caregiver

See the patient back in 2 weeks and assess whether the patient's condition has improved, as his condition is not severe

Do not break patient confidentiality, as elder abuse reporting is not mandatory

Do not break patient confidentiality, as this would potentially worsen the situation

A 15-year-old female presents to her family physician for an annual school physical exam and check-up. She is accompanied by her mother to the visit and is present in the exam room. The patient has no complaints, and she does not have any past medical problems. She takes no medications. The patient reports that she remains active, exercising 5 times a week, and eats a healthy and varied diet. Which of the following would be the best way for the physician to obtain a more in-depth social history, including sexual history and use of alcohol, tobacco, or recreational drugs?

Ask the mother to step outside into the hall for a portion of the visit

Disallow the mother to be present in the examination room throughout the entirety of the visit

Give the patient a social history questionnaire to fill out in the exam room

Ask the patient the questions directly, with her mother still in the exam room

Speak softly to the patient so that the mother does not hear and the patient is not embarrassed

An otherwise healthy 67-year-old woman comes to your clinic after being admitted to the hospital for 2 weeks after breaking her hip. She has not regularly seen a physician for the past several years because she has been working hard at her long-time job as a schoolteacher. You wonder if she has not been taking adequate preventative measures to prevent osteoporosis and order the appropriate labs. Although she is recovering from surgery well, she is visibly upset because she is worried that her hospital bill will bankrupt her. Which of the following best describes her Medicare coverage?

Medicare Part A will cover the majority of her hospital fees, including inpatient drugs and lab tests.

Medicare Part C will cover the majority of drug costs during her inpatient treatment.

Medicare is unlikely to cover the cost of her admission because she has not been paying her premium.

Medicare Part B will cover the majority of her hospital fees, including inpatient drugs and lab tests.

Medicare Part D will cover the cost of drugs during her inpatient treatment.

A 25-year-old man comes to the physician for severe back pain. He describes the pain as shooting and stabbing. On a 10-point scale, he rates the pain as a 9 to 10. The pain started after he lifted a heavy box at work; he works at a supermarket and recently switched from being a cashier to a storekeeper. The patient appears to be in severe distress. Vital signs are within normal limits. On physical examination, the spine is nontender without paravertebral muscle spasms. Range of motion is normal. A straight-leg raise test is negative. After the physical examination has been completed, the patient asks for a letter to his employer attesting to his inability to work as a storekeeper. Which of the following is the most appropriate response?

I understand that you are uncomfortable, but the findings do not match the severity of your symptoms. Let's talk about the recent changes at your job.

“Yes. Since work may worsen your condition, I would prefer that you stay home a few days. I will write a letter to your employer to explain the situation.”

You say you are in severe pain. However, the physical examination findings do not suggest a physical problem that can be addressed with medications or surgery. I'd like to meet on a regular basis to see how you're doing.

The physical exam findings do not match your symptoms, which suggests a psychological problem. I would be happy to refer you to a mental health professional.

The physical exam findings suggest a psychological rather than a physical problem. But there is a good chance that we can address it with cognitive-behavioral therapy.

A trauma 'huddle' is called. Morphine is administered for pain. Low-flow oxygen is begun. A traumatic diaphragmatic rupture is suspected. Infusion of 0.9% saline is begun. Which of the following is the most appropriate next step in management?

CT of the chest, abdomen, and pelvis

A regional academic medical center has 10 cases of adenovirus in the span of a week among its ICU patients. A committee is formed to investigate this outbreak. They are tasked with identifying the patients and interviewing the care providers to understand how adenovirus could have been spread from patient to patient. This committee will review charts, talk to the care provider teams, and investigate current patient safety and sanitation measures in the ICU. The goal of the committee is to identify weaknesses in the current system and to put in place a plan to help prevent this sort of outbreak from reoccurring in the future. The committee is most likely using what type of analysis?

Failure mode and effects analysis

A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?

Computed tomography (CT) scan of cervical spine, hips, and lumbar area

AP and lateral radiographs of hips

Lateral radiograph (x-ray) of hips

Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area

Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area

Trauma quality improvement for USMLE Step 2 CK: High-Yield Surgery Lessons

QI Framework - Better Trauma Care

Plan-Do-Study-Act (PDSA) Cycle for Quality Improvement

Goal: Systematically analyze care to ↓ morbidity & mortality. Based on the continuous Plan-Do-Study-Act (PDSA) cycle.
Core Components:
- Structure: Resources, staffing, trauma center designation.
- Process: Trauma registry data collection, M&M conferences, clinical practice guideline adherence.
- Outcome: Functional recovery, mortality rates, complications.

⭐ The Trauma Registry is the cornerstone of QI, providing essential data for performance benchmarks and research. The National Trauma Data Bank (NTDB) is the largest U.S. trauma registry database.

QI Components - The Audit Toolkit

Key tools for systematically monitoring and improving trauma care quality. These components work together to identify areas for improvement, from system-wide processes to individual clinical performance.

Component	Purpose	Key Features
Trauma Registry	Systematic data collection	- Captures demographics, injury severity (ISS), processes, outcomes - Forms the data foundation for all QI activities
Audits	Process & standards review	- Retrospective analysis against established standards - Identifies system-level trends, deviations, and outliers
Peer Review	Individual case evaluation	- Confidential, multidisciplinary physician review of care - Focuses on clinical judgment; educational & non-punitive

QI in Action - Closing the Loop

Morbidity & Mortality (M&M) Conference: A confidential, peer-review forum to analyze adverse outcomes.
- Goal: Identify system-based errors & cognitive biases, not to assign individual blame.
- Drives targeted educational and procedural modifications.
PDSA Cycle (Plan-Do-Study-Act): The core engine for implementing change.
- Plan: Define the problem & a potential solution.
- Do: Test the change on a small scale.
- Study: Analyze the results of the test.
- Act: Implement the change widely or restart the cycle with a new plan.

⭐ Key Principle: M&M conference findings are typically peer-review protected and non-discoverable in legal proceedings to ensure honest evaluation of events for quality improvement.

High-Yield Points - ⚡ Biggest Takeaways

Trauma registries are foundational, tracking patient data to analyze outcomes and guide improvements.

Morbidity & Mortality (M&M) conferences provide structured peer review to identify preventable deaths and system errors.

The Performance Improvement and Patient Safety (PIPS) program drives the cycle of data analysis and intervention.

Focus on system-level issues over individual errors to create lasting, effective change.

Audit filters (e.g., unexpected death, delayed surgery) automatically flag cases for in-depth review.

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