Index int64 1 500 | id int64 1 500 | QA_Type stringclasses 10
values | question stringlengths 71 4.63k | answer stringlengths 1 515 | Scoring_Points listlengths 2 6 | reference stringlengths 184 1.41k |
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1 | 1 | Patient Information collection & Diagnostic Workup | A 50 years old male presented with frontal bossing, enlarged nasal bone, enlarged jaw and spade like fingers. Which of the following test will you do for diagnosis?
A. IGF1
B. ACTH
C. TSH
D. Serum coisol | A. IGF1 | [
"Frontal bossing, prognathism (enlarged jaw), and spade-like fingers are hallmark features of acromegaly from excess growth hormone in adults.",
"Insulin-like growth factor 1 (IGF-1) levels accurately reflect average growth hormone secretion and are the recommended initial diagnostic test for suspected acromegaly... | Answer: A. IGF1
Scoring points:
- Frontal bossing, prognathism (enlarged jaw), and spade-like fingers are hallmark features of acromegaly from excess growth hormone in adults.
- Insulin-like growth factor 1 (IGF-1) levels accurately reflect average growth hormone secretion and are the recommended initial diagnostic tes... |
2 | 2 | Patient Information collection & Diagnostic Workup | 45-year-old presents with persistent productive cough and clubbing. On auscultation, wheeze and crackles are present. Which is the most specific investigation to confirm the diagnosis?
A. HRCT
B. Bronchoscopy with bronchoalveolar lavage
C. Chest X-ray
D. MRI | A. HRCT | [
"Persistent productive cough and digital clubbing with wheezing and crackles suggest chronic suppurative airway disease, specifically bronchiectasis.",
"High-resolution CT scan directly visualizes bronchial dilation and wall thickening, making it the most specific investigation to confirm bronchiectasis."
] | Answer: A. HRCT
Scoring points:
- Persistent productive cough and digital clubbing with wheezing and crackles suggest chronic suppurative airway disease, specifically bronchiectasis.
- High-resolution CT scan directly visualizes bronchial dilation and wall thickening, making it the most specific investigation to confir... |
3 | 3 | Patient Information collection & Diagnostic Workup | Chronic alcoholic comes with pain epigastrium and recurrent vomiting. On examination guarding in upper epigastrium. Chest X-ray normal. What to do next?
A. UGI endoscopy
B. Serum lipase
C. CECT
D. Alcohol breath test | B. Serum lipase | [
"Epigastric pain with guarding in a chronic alcoholic strongly suggests acute pancreatitis.",
"Serum lipase measurement is the most sensitive and specific initial test for diagnosing acute pancreatitis."
] | Answer: B. Serum lipase
Scoring points:
- Epigastric pain with guarding in a chronic alcoholic strongly suggests acute pancreatitis.
- Serum lipase measurement is the most sensitive and specific initial test for diagnosing acute pancreatitis. |
4 | 4 | Patient Information collection & Diagnostic Workup | A 25-year-old man presents to his primary care physician for trouble with focus and concentration. He states that he lives at home with his parents his entire life and recently was able to get a job at a local factory. Ever since the patient started working, he has had trouble focusing on his job. He is unable to stay ... | A. Bright light therapy and decreased light at night | [
"His consistent inability to fall asleep until just two hours before his alarm despite an early bedtime indicates a delayed sleep-phase circadian rhythm disorder.",
"Daytime sleepiness and involuntary 'daydreaming' episodes reflect insufficient restorative sleep from circadian misalignment rather than primary sei... | Answer: A. Bright light therapy and decreased light at night
Scoring points:
- His consistent inability to fall asleep until just two hours before his alarm despite an early bedtime indicates a delayed sleep-phase circadian rhythm disorder.
- Daytime sleepiness and involuntary 'daydreaming' episodes reflect insufficien... |
5 | 5 | Patient Information collection & Diagnostic Workup | A 3-day-old boy is evaluated in the hospital nursery for the delayed passage of meconium. The patient is breastfed, has been feeding well every 2 hours, and is urinating over 8 times per day. He was born at 35 weeks gestation to a 27-year-old G4P4 mother. The patient is of Ashkenazi Jewish descent and the patient’s par... | B. Abdominal radiograph | [
"Delayed passage of meconium beyond 48 hours with abdominal distension and absent bowel sounds suggests neonatal intestinal obstruction with risk of perforation.",
"An abdominal radiograph is the fastest, lowest-radiation study to detect free air and exclude perforation before any contrast studies."
] | Answer: B. Abdominal radiograph
Scoring points:
- Delayed passage of meconium beyond 48 hours with abdominal distension and absent bowel sounds suggests neonatal intestinal obstruction with risk of perforation.
- An abdominal radiograph is the fastest, lowest-radiation study to detect free air and exclude perforation b... |
6 | 6 | Patient Information collection & Diagnostic Workup | A 38-year-old woman with a history of systemic lupus erythematosus, obesity, and hyperlipidemia presents to her primary care physician for evaluation of new bilateral blisters on her hands. She says that she first noticed these blisters shortly after returning from a weekend trip to the beach two weeks prior. She denie... | D. Urine porphyrin levels | [
"Flaccid blisters with hemorrhagic crusts on the dorsal hands in sun-exposed areas suggest a photosensitivity blistering disorder rather than an autoimmune bullous disease.",
"Hyperpigmentation and hypertrichosis on the malar cheeks further point toward porphyria cutanea tarda.",
"Porphyria cutanea tarda result... | Answer: D. Urine porphyrin levels
Scoring points:
- Flaccid blisters with hemorrhagic crusts on the dorsal hands in sun-exposed areas suggest a photosensitivity blistering disorder rather than an autoimmune bullous disease.
- Hyperpigmentation and hypertrichosis on the malar cheeks further point toward porphyria cutane... |
7 | 7 | Patient Information collection & Diagnostic Workup | A 14-year-old boy presents to the emergency department with hand pain after falling from his skateboard one day ago. He reports that he lost his balance while attempting a new trick and fell on his outstretched hands. He has been icing his hand and taking several tablets of ibuprofen every few hours, but the pain and s... | B. Radiograph of the wrist | [
"Fall on an outstretched hand with tenderness in the anatomical snuffbox strongly suggests a scaphoid fracture.",
"Scaphoid fractures carry a high risk of avascular necrosis and nonunion if not diagnosed and treated promptly.",
"Wrist radiographs are the initial diagnostic study to confirm a scaphoid fracture."... | Answer: B. Radiograph of the wrist
Scoring points:
- Fall on an outstretched hand with tenderness in the anatomical snuffbox strongly suggests a scaphoid fracture.
- Scaphoid fractures carry a high risk of avascular necrosis and nonunion if not diagnosed and treated promptly.
- Wrist radiographs are the initial diagnos... |
8 | 8 | Patient Information collection & Diagnostic Workup | A 20-year-old man has had frequent upper respiratory tract infections over the past 4 years. He has daily purulent sputum and has noted decreased exercise tolerance over the past 2 years. He and his wife have been unable to conceive because of his low sperm count. Scattered expiratory wheezing and rhonchi are heard thr... | D. Sweat chloride test | [
"Chronic daily purulent sputum production with frequent respiratory infections, hyperinflation on chest x-ray, and obstructive spirometry suggest cystic fibrosis–related lung disease.",
"Low sperm count in a young man with chronic pulmonary findings reflects congenital absence of the vas deferens from CFTR dysfun... | Answer: D. Sweat chloride test
Scoring points:
- Chronic daily purulent sputum production with frequent respiratory infections, hyperinflation on chest x-ray, and obstructive spirometry suggest cystic fibrosis–related lung disease.
- Low sperm count in a young man with chronic pulmonary findings reflects congenital abs... |
9 | 9 | Patient Information collection & Diagnostic Workup | A 19-year-old woman comes to the emergency department because, she says, "I'm burning up." Medical history is significant for intravenous drug use. Physical examination discloses a systolic heart murmur over the precordium. An expected physical finding will be which of the following?
A. Decreased intensity of the murmu... | H. Increased intensity of the murmur with deep inspiration | [
"Tricuspid regurgitation is the most common valvular lesion in IV drug users with endocarditis, producing a holosystolic murmur at the left lower sternal border.",
"Right-sided heart murmurs intensify with inspiration due to increased venous return to the right ventricle.",
"Deep inspiration augments right vent... | Answer: H. Increased intensity of the murmur with deep inspiration
Scoring points:
- Tricuspid regurgitation is the most common valvular lesion in IV drug users with endocarditis, producing a holosystolic murmur at the left lower sternal border.
- Right-sided heart murmurs intensify with inspiration due to increased ve... |
10 | 10 | Patient Information collection & Diagnostic Workup | A 65-year-old woman presents with mild shortness of breath and a chronic, nonproductive cough. She reports being in good health, has never smoked, and has completed all age-appropriate cancer screenings.
Her vital signs are normal, and her oxygen saturation is 95% on room air. A chest X-ray reveals a moderate left p... | G. Synovitis of the metacarpophalangeal joints and subcutaneous nodules | [
"Pleural fluid analysis with very high LDH, low pH, and very low glucose indicates an exudative effusion in the range of rheumatoid pleurisy, empyema, or malignancy.",
"Negative Gram stain and modest leukocyte count make empyema unlikely in this context.",
"Cytology showing slender, spindle-shaped cells can ref... | Answer: G. Synovitis of the metacarpophalangeal joints and subcutaneous nodules
Scoring points:
- Pleural fluid analysis with very high LDH, low pH, and very low glucose indicates an exudative effusion in the range of rheumatoid pleurisy, empyema, or malignancy.
- Negative Gram stain and modest leukocyte count make emp... |
11 | 11 | Patient Information collection & Diagnostic Workup | A 9-year-old female presents with shortness of breath and new-onset cyanosis. She has dextrocardia, a double inlet left ventricle with malposition of the great arteries and pulmonary atresia, an extracardiac fenestrated Fontan, and has had a left pulmonary artery patch augmentation. Her vital signs are significant for ... | G. An activated protein C resistance ratio of 0.3 | [
"Fontan palliation directs systemic venous blood to the pulmonary arteries without a pumping ventricle, creating a circuit prone to thrombosis.",
"New-onset cyanosis in a Fontan patient reflects decreased pulmonary blood flow from conduit obstruction or thrombus.",
"An activated protein C resistance ratio of 0.... | Answer: G. An activated protein C resistance ratio of 0.3
Scoring points:
- Fontan palliation directs systemic venous blood to the pulmonary arteries without a pumping ventricle, creating a circuit prone to thrombosis.
- New-onset cyanosis in a Fontan patient reflects decreased pulmonary blood flow from conduit obstruc... |
12 | 12 | Patient Information collection & Diagnostic Workup | A 19-year-old female athlete presents for sports clearance evaluation. She is currently asymptomatic but has a history of multiple spontaneous pneumothoraces. Physical examination reveals joint hypermobility, a chest wall deformity with depression of the sternum (pectus excavatum), and a decreased upper-to-lower body s... | G. Thoracolumbar scoliosis | [
"History of spontaneous pneumothoraces, joint hypermobility, pectus excavatum, and decreased upper-to-lower body segment ratio is consistent with Marfan syndrome.",
"Marfan syndrome causes connective tissue–mediated skeletal abnormalities, including spinal deformities.",
"Thoracolumbar scoliosis is a common mus... | Answer: G. Thoracolumbar scoliosis
Scoring points:
- History of spontaneous pneumothoraces, joint hypermobility, pectus excavatum, and decreased upper-to-lower body segment ratio is consistent with Marfan syndrome.
- Marfan syndrome causes connective tissue–mediated skeletal abnormalities, including spinal deformities.... |
13 | 13 | Patient Information collection & Diagnostic Workup | A 23-year-old female presents to the emergency department with episodic back pain radiating to her abdomen that began yesterday, rating it 10/10 during episodes. Her medical history includes asthma, anxiety, and previously treated chlamydia. She takes fluoxetine. Laboratory results show:
Hematologic:
- Hemoglobin: 14 ... | D. Renal ultrasound | [
"Episodic, severe back pain radiating to the abdomen in a pregnant patient is highly suggestive of ureteral colic from nephrolithiasis.",
"Microscopic hematuria supports a diagnosis of kidney stones rather than primarily biliary, gynecologic, or gastrointestinal causes.",
"In pregnancy, initial imaging should a... | Answer: D. Renal ultrasound
Scoring points:
- Episodic, severe back pain radiating to the abdomen in a pregnant patient is highly suggestive of ureteral colic from nephrolithiasis.
- Microscopic hematuria supports a diagnosis of kidney stones rather than primarily biliary, gynecologic, or gastrointestinal causes.
- In ... |
14 | 14 | Patient Information collection & Diagnostic Workup | A 68-year-old woman visits her primary care physician due to four months of persistent lower back pain. She states that the pain is not triggered by any specific activity and does not improve with over-the-counter medications. The pain disrupts her sleep at night. She also reports increasing fatigue and unintentional w... | A. Bone marrow biopsy | [
"Persistent lower back pain accompanied by anemia, hypercalcemia, renal insufficiency, and an elevated total protein suggests multiple myeloma (CRAB criteria).",
"A wide protein gap, total protein – albumin > 4 g/dL, indicates monoclonal immunoglobulin production characteristic of plasma cell dyscrasias.",
"Def... | Answer: A. Bone marrow biopsy
Scoring points:
- Persistent lower back pain accompanied by anemia, hypercalcemia, renal insufficiency, and an elevated total protein suggests multiple myeloma (CRAB criteria).
- A wide protein gap, total protein – albumin > 4 g/dL, indicates monoclonal immunoglobulin production characteri... |
15 | 15 | Patient Information collection & Diagnostic Workup | A 73-year-old male presents with an 8-month history of worsening bilateral lower extremity pain. The pain starts after walking one to two blocks and radiates down the buttocks with cramping and tingling. It is exacerbated by walking downhill and relieved by sitting and leaning forward. His medical history includes hype... | I. MRI scan of the spine | [
"Pain radiating to the buttocks with cramping and tingling triggered by walking suggests claudication of neurogenic rather than vascular origin.",
"Relief of symptoms by sitting and forward flexion ('shopping-cart sign') is characteristic of lumbar spinal canal stenosis.",
"Normal muscle strength, a negative st... | Answer: I. MRI scan of the spine
Scoring points:
- Pain radiating to the buttocks with cramping and tingling triggered by walking suggests claudication of neurogenic rather than vascular origin.
- Relief of symptoms by sitting and forward flexion ('shopping-cart sign') is characteristic of lumbar spinal canal stenosis.... |
16 | 16 | Patient Information collection & Diagnostic Workup | A 5-week-old infant girl is brought to the emergency department by her parents due to a 1-week history of yellowing of her skin. Over the past 4 days, her urine has become darker, and her stools have turned paler than normal. She has been exclusively breastfed since birth and was delivered at 39 weeks' gestation follow... | B. Cholangiography | [
"Conjugated hyperbilirubinemia persisting beyond 2 weeks of age with direct bilirubin predominance indicates neonatal cholestasis.",
"Dark urine and pale stools in a 5-week-old suggest an obstructive process in the biliary tree, most consistent with biliary atresia.",
"Cholangiography is the gold-standard test ... | Answer: B. Cholangiography
Scoring points:
- Conjugated hyperbilirubinemia persisting beyond 2 weeks of age with direct bilirubin predominance indicates neonatal cholestasis.
- Dark urine and pale stools in a 5-week-old suggest an obstructive process in the biliary tree, most consistent with biliary atresia.
- Cholangi... |
17 | 17 | Patient Information collection & Diagnostic Workup | An 8-year-old boy presents with a 6-week history of a wet cough that worsens in the morning and has not improved with treatments such as albuterol, prednisone, or cetirizine.
He reports no recent choking incidents, no fever, weight loss, or other upper respiratory symptoms, and no one else in his household is sympto... | B. Prescribe a course of oral amoxicillin-clavulanate | [
"Chronic wet cough >4 weeks in a child suggests prolonged bacterial infection rather than asthma or allergy.",
"Lack of response to albuterol, steroids, and antihistamines rules out asthma or allergic causes.",
"No systemic symptoms (fever, weight loss) make serious systemic infections or immunodeficiency less ... | Answer: B. Prescribe a course of oral amoxicillin-clavulanate
Scoring points:
- Chronic wet cough >4 weeks in a child suggests prolonged bacterial infection rather than asthma or allergy.
- Lack of response to albuterol, steroids, and antihistamines rules out asthma or allergic causes.
- No systemic symptoms (fever, we... |
18 | 18 | Patient Information collection & Diagnostic Workup | A 42-year-old male comes to the emergency department with a one-week history of cough with blood-tinged sputum and dyspnea. He reports fever, chills, and arthralgias. His vital signs show:
- Temperature: 102°F (38.9°C)
- Blood pressure: 159/98 mmHg
- Pulse: 80/min
- Respirations: 14/min
- O2 saturation: 98% on room air... | J. Type 4 collagen antibody levels | [
"Hemoptysis with renal involvement suggests pulmonary-renal syndrome, classic for anti–Type IV collagen disease.",
"Urinalysis shows RBCs and protein, indicating glomerulonephritis, not infection or simple pneumonia.",
"Negative blood cultures and chest CT rule out infection or endocarditis, pointing to autoimm... | Answer: J. Type 4 collagen antibody levels
Scoring points:
- Hemoptysis with renal involvement suggests pulmonary-renal syndrome, classic for anti–Type IV collagen disease.
- Urinalysis shows RBCs and protein, indicating glomerulonephritis, not infection or simple pneumonia.
- Negative blood cultures and chest CT rule ... |
19 | 19 | Patient Information collection & Diagnostic Workup | A 76-year-old woman is brought to the emergency department by her son due to a 1-day history of upper abdominal pain, nausea, and shortness of breath. She was treated with coronary stent placement 3 days ago following an inferior wall myocardial infarction. Her medical history includes type 2 diabetes mellitus and rece... | C. Serial measurement of serum troponin concentration | [
"Recent inferior MI with stent placement raises concern for reinfarction or stent thrombosis.",
"Upper abdominal pain, nausea, and dyspnea in this context may represent atypical ischemic symptoms.",
"Bradycardia on a beta-blocker can mask ischemic ECG changes, necessitating biomarker evaluation.",
"Troponin i... | Answer: C. Serial measurement of serum troponin concentration
Scoring points:
- Recent inferior MI with stent placement raises concern for reinfarction or stent thrombosis.
- Upper abdominal pain, nausea, and dyspnea in this context may represent atypical ischemic symptoms.
- Bradycardia on a beta-blocker can mask isch... |
20 | 20 | Patient Information collection & Diagnostic Workup | A 6-week-old male infant is evaluated for weight concerns. His birth at 38 weeks and 3 days was uncomplicated, with normal spontaneous vaginal delivery to healthy parents. During the newborn period, he had mild abdominal distention with patent anus, and imaging showed slightly dilated small bowel loops and borderline s... | A. Perform sweat testing | [
"Failure to thrive is demonstrated by a drop in weight percentile from the 50th at birth to the 3rd at six weeks.",
"Normal feeding volume, vigorous feeds, and adequate stooling rule out intake or vomiting as the cause of weight loss.",
"Resolved mild bowel dilation on initial imaging makes significant structur... | Answer: A. Perform sweat testing
Scoring points:
- Failure to thrive is demonstrated by a drop in weight percentile from the 50th at birth to the 3rd at six weeks.
- Normal feeding volume, vigorous feeds, and adequate stooling rule out intake or vomiting as the cause of weight loss.
- Resolved mild bowel dilation on in... |
21 | 21 | Patient Information collection & Diagnostic Workup | A 10-year-old female patient comes for a follow-up evaluation after multiple elevated blood pressure readings. Her initial reading during a routine visit was 136/86 mm Hg, followed by a school nurse measurement of 134/82 mm Hg. The patient reports experiencing intermittent headaches, with a current headache intensity o... | H. Refer to the emergency department | [
"Persistent blood pressure readings in the Stage 2 range, >95th percentile +12 mm Hg, on multiple occasions confirm significant pediatric hypertension.",
"Intermittent headaches are a symptom of possible end-organ involvement, raising concern for hypertensive urgency or emergency.",
"A normal physical exam and ... | Answer: H. Refer to the emergency department
Scoring points:
- Persistent blood pressure readings in the Stage 2 range, >95th percentile +12 mm Hg, on multiple occasions confirm significant pediatric hypertension.
- Intermittent headaches are a symptom of possible end-organ involvement, raising concern for hypertensive... |
22 | 22 | Patient Information collection & Diagnostic Workup | A 50-year-old female with a history of chronic alcohol use disorder presents with severe abdominal pain. Her medical history includes peptic ulcer disease. Physical examination is challenging as the patient refuses abdominal palpation due to the intensity of the pain. The provider suspects spontaneous bacterial periton... | J. Forced cough elicits abdominal pain | [
"Chronic alcohol use disorder predisposes to cirrhosis and ascites, which is the substrate for spontaneous bacterial peritonitis (SBP).",
"SBP is an infection of the ascitic fluid causing peritoneal inflammation.",
"A positive cough sign (pain elicited by forced cough) is a sensitive indicator of peritoneal irr... | Answer: J. Forced cough elicits abdominal pain
Scoring points:
- Chronic alcohol use disorder predisposes to cirrhosis and ascites, which is the substrate for spontaneous bacterial peritonitis (SBP).
- SBP is an infection of the ascitic fluid causing peritoneal inflammation.
- A positive cough sign (pain elicited by fo... |
23 | 23 | Patient Information collection & Diagnostic Workup | A 65-year-old male presents to the clinic with a three-month history of left leg discomfort. He describes a persistent cramping sensation in his left calf that begins after walking two blocks and resolves with rest. His medical history includes type II diabetes mellitus and hypertension. His mother had a pulmonary embo... | E. Toe-brachial index | [
"Persistent calf cramping with exertion that resolves with rest is characteristic of intermittent claudication from peripheral arterial disease.",
"Diabetes causes medial arterial calcification, leading to noncompressible vessels and a falsely elevated ankle–brachial index (ABI >1.3).",
"A resting ABI >1.3 indi... | Answer: E. Toe-brachial index
Scoring points:
- Persistent calf cramping with exertion that resolves with rest is characteristic of intermittent claudication from peripheral arterial disease.
- Diabetes causes medial arterial calcification, leading to noncompressible vessels and a falsely elevated ankle–brachial index ... |
24 | 24 | Patient Information collection & Diagnostic Workup | A 43-year-old man with a history of diabetes and hypertension presents with a 6-month history of progressive cough and exertional dyspnea. The cough occasionally produces clear sputum and is associated with intermittent wheezing. Despite treatment for presumed asthma with a medium-dose inhaled glucocorticoid, an oral l... | C. Bronchoscopy | [
"Asymmetric wheezing localized to the right side with normal chest imaging and CT suggests a focal endobronchial lesion rather than diffuse airway disease.",
"Normal pulmonary function tests and lack of response to asthma treatments argue against asthma and point toward structural airway obstruction.",
"Broncho... | Answer: C. Bronchoscopy
Scoring points:
- Asymmetric wheezing localized to the right side with normal chest imaging and CT suggests a focal endobronchial lesion rather than diffuse airway disease.
- Normal pulmonary function tests and lack of response to asthma treatments argue against asthma and point toward structura... |
25 | 25 | Patient Information collection & Diagnostic Workup | A 56-year-old man arrives at the emergency department with sudden right scrotal pain, accompanied by swelling and nausea, which began three hours earlier after lifting a heavy object. He reports that the swelling has been intermittently present for years, worsening with physical strain or coughing, but it had never bee... | C. No further tests are needed | [
"Non-reducible, tender, erythematous scrotal swelling in the setting of sudden pain after lifting is diagnostic of an incarcerated inguinal hernia.",
"A history of intermittent groin or scrotal bulge that worsens with straining supports the clinical diagnosis of an inguinal hernia.",
"Incarcerated hernias are c... | Answer: C. No further tests are needed
Scoring points:
- Non-reducible, tender, erythematous scrotal swelling in the setting of sudden pain after lifting is diagnostic of an incarcerated inguinal hernia.
- A history of intermittent groin or scrotal bulge that worsens with straining supports the clinical diagnosis of an... |
26 | 26 | Patient Information collection & Diagnostic Workup | A 28-year-old woman comes to the clinic with a three-month history of joint pain, fatigue, and a facial rash that worsens upon sun exposure. Over the past two weeks, she has developed ankle swelling and frothy urine. Her medical history is unremarkable. Vital signs include a temperature of 37.1°C (98.8°F), heart rate o... | G. Renal biopsy | [
"The combination of malar rash, symmetric inflammatory arthritis, and new-onset proteinuria and microscopic hematuria in a young woman strongly suggests systemic lupus erythematosus with renal involvement, lupus nephritis.",
"Renal biopsy is required to confirm the diagnosis of lupus nephritis and to determine th... | Answer: G. Renal biopsy
Scoring points:
- The combination of malar rash, symmetric inflammatory arthritis, and new-onset proteinuria and microscopic hematuria in a young woman strongly suggests systemic lupus erythematosus with renal involvement, lupus nephritis.
- Renal biopsy is required to confirm the diagnosis of l... |
27 | 27 | Patient Information collection & Diagnostic Workup | A 61-year-old male presents for medical evaluation with complaints of excessive fatigue, shortness of breath, and unintentional weight loss of 12-lb (5.4 kg) over two months. He denies experiencing abdominal pain, melena, or changes in bowel habits. The patient has not sought medical care for many years but was encoura... | E. Colonoscopy | [
"Microcytic anemia in an adult suggests iron deficiency.",
"Unintentional weight loss in a 61-year-old with iron deficiency anemia raises concern for gastrointestinal malignancy.",
"New-onset iron deficiency anemia in men over 50 requires evaluation for colorectal cancer.",
"Colonoscopy is the definitive test... | Answer: E. Colonoscopy
Scoring points:
- Microcytic anemia in an adult suggests iron deficiency.
- Unintentional weight loss in a 61-year-old with iron deficiency anemia raises concern for gastrointestinal malignancy.
- New-onset iron deficiency anemia in men over 50 requires evaluation for colorectal cancer.
- Colonos... |
28 | 28 | Patient Information collection & Diagnostic Workup | A 6-year-old girl is brought to the pediatrician due to recurrent sinusitis and pulmonary infections, which have caused frequent absences from school. Her parents are also concerned about her history of chronic constipation and large, floating stools. She is in the 14th percentile for height and the 4th percentile for ... | I. Repeat sweat chloride test | [
"An initial sweat chloride of 68 mmol/L exceeds the diagnostic threshold,>60 mmol/L) for cystic fibrosis.",
"Current guidelines require two positive sweat chloride measurements on separate occasions to confirm the diagnosis.",
"Repeating the sweat test ensures the accuracy and reproducibility of the result.",
... | Answer: I. Repeat sweat chloride test
Scoring points:
- An initial sweat chloride of 68 mmol/L exceeds the diagnostic threshold,>60 mmol/L) for cystic fibrosis.
- Current guidelines require two positive sweat chloride measurements on separate occasions to confirm the diagnosis.
- Repeating the sweat test ensures the ac... |
29 | 29 | Patient Information collection & Diagnostic Workup | A 31-year-old male seeks medical attention for dyspnea that developed following a "cold" two weeks ago, accompanied by a persistent cough. He reports no fever, chills, chest pain, sore throat, or rhinorrhea. His history includes seasonal allergies treated with fluticasone nasal spray and a tonsillectomy at age 8. Famil... | H. Alpha-1 antitrypsin level | [
"Hyperlucent lungs and hyperinflation in a 31-year-old suggest genetic emphysema.",
"Family history of liver disease: Cirrhosis in mother and maternal grandfather indicates possible alpha-1 antitrypsin deficiency inheritance.",
"Mildly elevated liver enzymes: AST and ALT elevations point to liver involvement fr... | Answer: H. Alpha-1 antitrypsin level
Scoring points:
- Hyperlucent lungs and hyperinflation in a 31-year-old suggest genetic emphysema.
- Family history of liver disease: Cirrhosis in mother and maternal grandfather indicates possible alpha-1 antitrypsin deficiency inheritance.
- Mildly elevated liver enzymes: AST and... |
30 | 30 | Patient Information collection & Diagnostic Workup | A 65-year-old male smoker with a history of diabetes, hypertension, and chronic kidney disease presents to the emergency department with acute-onset, severe chest pain radiating to his back that began while sitting at work. He is non-adherent to his prescribed amlodipine and metformin. His vital signs show a temperatur... | E. Transesophageal echocardiogram | [
"Combination of acute-onset chest pain radiating to the back, interarm blood pressure differential, and a diastolic decrescendo murmur indicates aortic dissection with associated aortic regurgitation.",
"In a patient with chronic kidney disease, iodinated contrast used for CT Angiography carries a significant ris... | Answer: E. Transesophageal echocardiogram
Scoring points:
- Combination of acute-onset chest pain radiating to the back, interarm blood pressure differential, and a diastolic decrescendo murmur indicates aortic dissection with associated aortic regurgitation.
- In a patient with chronic kidney disease, iodinated contra... |
31 | 31 | Patient Information collection & Diagnostic Workup | A 25-year-old male seeks medical attention for chronic symptoms including fatigue, abdominal discomfort, diarrhea, and weight loss. His abdominal pain improves after defecation, and he produces large, malodorous stools. His medical history includes an ACL injury and a previous transfusion reaction requiring epinephrine... | B. Bowel wall biopsy | [
"Chronic diarrhea with large, malodorous stools indicates fat malabsorption consistent with celiac disease.",
"Ataxia and anemia reflect micronutrient deficiencies from intestinal villous damage.",
"Small‐intestinal biopsy demonstrating villous atrophy is the diagnostic gold standard."
] | Answer: B. Bowel wall biopsy
Scoring points:
- Chronic diarrhea with large, malodorous stools indicates fat malabsorption consistent with celiac disease.
- Ataxia and anemia reflect micronutrient deficiencies from intestinal villous damage.
- Small‐intestinal biopsy demonstrating villous atrophy is the diagnostic gold ... |
32 | 32 | Patient Information collection & Diagnostic Workup | A 65-year-old woman presents with an 8-month history of progressive difficulty swallowing food and retrosternal chest discomfort. She describes a sensation of “food getting stuck” in her throat and occasionally hears a “gurgling sound” while eating. She has also experienced episodes of coughing up undigested food, alon... | B. Barium esophagram | [
"Regurgitation of undigested food, halitosis, and a gurgling sound during eating strongly suggest a Zenker diverticulum.",
"The sensation of food getting stuck in the throat localizes the problem to the proximal esophagus.",
"Barium esophagram is the diagnostic test of choice to visualize a Zenker diverticulum ... | Answer: B. Barium esophagram
Scoring points:
- Regurgitation of undigested food, halitosis, and a gurgling sound during eating strongly suggest a Zenker diverticulum.
- The sensation of food getting stuck in the throat localizes the problem to the proximal esophagus.
- Barium esophagram is the diagnostic test of choice... |
33 | 33 | Patient Information collection & Diagnostic Workup | A 60-year-old male patient reports progressive fatigue over several weeks. His medical history includes chronic kidney disease due to previous regular NSAID use for back pain. He has no history of hypertension, diabetes, cardiac or pulmonary conditions. He denies gastrointestinal or urinary symptoms and has stopped all... | A. Serum protein immunoelectrophoresis | [
"Normocytic anemia, new-onset proteinuria, hypercalcemia, low‐normal PTH and worsening renal function raise suspicion for multiple myeloma.",
"Serum protein immunoelectrophoresis screens for monoclonal protein characteristic of multiple myeloma."
] | Answer: A. Serum protein immunoelectrophoresis
Scoring points:
- Normocytic anemia, new-onset proteinuria, hypercalcemia, low‐normal PTH and worsening renal function raise suspicion for multiple myeloma.
- Serum protein immunoelectrophoresis screens for monoclonal protein characteristic of multiple myeloma. |
34 | 34 | Patient Information collection & Diagnostic Workup | A 42-year-old female with rheumatoid arthritis spanning 20 years seeks emergency care for gnawing, sharp, intermittent pain in her epigastrium and left upper quadrant, without radiation. While antacids provided some relief, her symptoms have intensified over two weeks. This morning at a mall, she experienced acute symp... | C. Cardiac stress testing | [
"Patient’s gnawing epigastric and LUQ pain with nausea and diaphoresis could stem from gastrointestinal or cardiac ischemia.",
"Long-standing rheumatoid arthritis with chronic corticosteroid use increases cardiovascular risk despite normal vital signs.",
"Normal ECG and cardiac enzymes at rest do not exclude in... | Answer: C. Cardiac stress testing
Scoring points:
- Patient’s gnawing epigastric and LUQ pain with nausea and diaphoresis could stem from gastrointestinal or cardiac ischemia.
- Long-standing rheumatoid arthritis with chronic corticosteroid use increases cardiovascular risk despite normal vital signs.
- Normal ECG and ... |
35 | 35 | Patient Information collection & Diagnostic Workup | A 35-year-old woman arrives at the emergency department with complaints of fatigue, shortness of breath, and palpitations. She underwent an uncomplicated laparoscopic appendectomy a week ago, during which she received a prophylactic dose of cefotetan. Her past medical history is unremarkable, and she denies any family ... | I. Direct Coombs test | [
"Hemolysis occurring one week after cefotetan exposure suggests drug-induced immune hemolytic anemia.",
"Reticulocytosis, elevated LDH, indirect bilirubin, and low haptoglobin confirm active hemolysis.",
"Microspherocytes on peripheral smear indicate antibody-mediated red cell destruction.",
"The Direct Coomb... | Answer: I. Direct Coombs test
Scoring points:
- Hemolysis occurring one week after cefotetan exposure suggests drug-induced immune hemolytic anemia.
- Reticulocytosis, elevated LDH, indirect bilirubin, and low haptoglobin confirm active hemolysis.
- Microspherocytes on peripheral smear indicate antibody-mediated red ce... |
36 | 36 | Patient Information collection & Diagnostic Workup | A 67-year-old male presents with sudden-onset pleuritic chest pain and shortness of breath. He denies fever, chills, cough, or lower-extremity swelling. His medical history includes prostate cancer, type 2 diabetes, chronic renal insufficiency (baseline serum creatinine: 2.6 mg/dL), an estimated glomerular filtration r... | F. Ventilation-perfusion imaging | [
"Acute pleuritic chest pain and dyspnea in a patient with recent surgery and malignancy are highly suggestive of pulmonary embolism.",
"Renal insufficiency, serum creatinine 2.8 mg/dL, eGFR 24 mL/min/1.73 m², contraindicates iodinated contrast for CT angiography.",
"Ventilation-perfusion scanning evaluates pulm... | Answer: F. Ventilation-perfusion imaging
Scoring points:
- Acute pleuritic chest pain and dyspnea in a patient with recent surgery and malignancy are highly suggestive of pulmonary embolism.
- Renal insufficiency, serum creatinine 2.8 mg/dL, eGFR 24 mL/min/1.73 m², contraindicates iodinated contrast for CT angiography.... |
37 | 37 | Patient Information collection & Diagnostic Workup | A 27-year-old male patient is admitted to the hospital with acute, unremitting left-flank pain of 6 hours' duration. He has a recent diagnosis of idiopathic membranous nephropathy and takes lisinopril 40 mg daily. He reports no fever, chills, nausea, vomiting, or dysuria. His previous serum creatinine was 1.1 mg/dL two... | A. CT angiography | [
"Idiopathic membranous nephropathy with nephrotic-range proteinuria, protein-to-creatinine ratio 8.1 mg/mg, and hypoalbuminemia, 1.8 g/dL, creates a hypercoagulable state.",
"Acute, unremitting left-flank pain in a nephrotic patient is highly suggestive of renal vein thrombosis.",
"An increase in serum creatini... | Answer: A. CT angiography
Scoring points:
- Idiopathic membranous nephropathy with nephrotic-range proteinuria, protein-to-creatinine ratio 8.1 mg/mg, and hypoalbuminemia, 1.8 g/dL, creates a hypercoagulable state.
- Acute, unremitting left-flank pain in a nephrotic patient is highly suggestive of renal vein thrombosis... |
38 | 38 | Patient Information collection & Diagnostic Workup | A 28-year-old man experiencing homelessness, with a history of asthma, presents to clinic with a persistent rash on his scalp and feet that has been present for approximately one year. He describes the rash as dry and flaky, and reports severe nocturnal pruritus that interferes with sleep. Over-the-counter dandruff sha... | C. Culture in Sabouraud liquid medium | [
"A chronic, scaly, alopecic scalp patch with cervical lymphadenopathy strongly suggests tinea capitis (dermatophyte infection).",
"Sabouraud culture is the gold-standard diagnostic test for dermatophyte infections, accurately identifying the fungal organism."
] | Answer: C. Culture in Sabouraud liquid medium
Scoring points:
- A chronic, scaly, alopecic scalp patch with cervical lymphadenopathy strongly suggests tinea capitis (dermatophyte infection).
- Sabouraud culture is the gold-standard diagnostic test for dermatophyte infections, accurately identifying the fungal organism. |
39 | 39 | Patient Information collection & Diagnostic Workup | A 2-year-old female patient presents with persistent cough and nasal congestion since birth that has not improved with treatment using albuterol, fluticasone, or loratadine. Her history includes one episode of pneumonia, though she maintains appropriate weight gain. Which diagnostic test would be most suitable to estab... | I. Genetic testing | [
"Persistent cough and nasal congestion since birth, plus recurrent pneumonia and no response to asthma/allergy treatments, indicate a non‐atopic etiology and raise suspicion for cystic fibrosis.",
"Genetic testing provides a conclusive diagnosis by detecting disease-causing CFTR variants."
] | Answer: I. Genetic testing
Scoring points:
- Persistent cough and nasal congestion since birth, plus recurrent pneumonia and no response to asthma/allergy treatments, indicate a non‐atopic etiology and raise suspicion for cystic fibrosis.
- Genetic testing provides a conclusive diagnosis by detecting disease-causing CF... |
40 | 40 | Patient Information collection & Diagnostic Workup | A 24-year-old female patient visits her PCP reporting chronic diarrhea characterized by malodorous, loose stools and significant weight loss (35 pounds) over three years. She mentions a recent episode of a pruritic, papular rash on her elbows and forearms that spontaneously resolved after two months. She has no history... | G. Small bowel endoscopy and biopsy | [
"Chronic malodorous, loose stools and significant weight loss indicate a malabsorptive process.",
"Pruritic, papular rash on extensor surfaces, dermatitis herpetiformis, is highly specific for celiac disease.",
"Small intestinal biopsy demonstrating villous atrophy and crypt hyperplasia is the diagnostic gold s... | Answer: G. Small bowel endoscopy and biopsy
Scoring points:
- Chronic malodorous, loose stools and significant weight loss indicate a malabsorptive process.
- Pruritic, papular rash on extensor surfaces, dermatitis herpetiformis, is highly specific for celiac disease.
- Small intestinal biopsy demonstrating villous atr... |
41 | 41 | Patient Information collection & Diagnostic Workup | A 37-year-old man seeks medical attention at your clinic for neck pain on the left side that radiates down his arm to his hand. The pain began following an intense workout three days ago and has progressively worsened. X-rays show mild spondylitic changes without spondylolisthesis. A cervical spine MRI reveals a left-s... | E. Weakness with wrist flexion | [
"MRI showing a left C6–7 foraminal disc herniation localizes compression to the C7 nerve root.",
"The C7 nerve root innervates wrist flexor muscles, so C7 compression leads to weakness in wrist flexion."
] | Answer: E. Weakness with wrist flexion
Scoring points:
- MRI showing a left C6–7 foraminal disc herniation localizes compression to the C7 nerve root.
- The C7 nerve root innervates wrist flexor muscles, so C7 compression leads to weakness in wrist flexion. |
42 | 42 | Patient Information collection & Diagnostic Workup | For the detection of left-to-right intracardiac shunts, which of the following contrast medium administration protocols would likely yield the best results?
Answer Choices: (A) Biphasic (contrast medium, followed by contrast medium / saline mix) (B) Triphasic (contrast medium, followed by contrast medium / saline mix, ... | I. Biphasic (contrast medium, followed by saline) | [
"Contrast followed by saline flush pushes contrast into the right heart, maximizing opacification of both ventricles.",
"Saline flush after contrast ensures even distribution and clear delineation between chambers, improving shunt visualization.",
"This biphasic approach is the standard method for echocardiogra... | Answer: I. Biphasic (contrast medium, followed by saline)
Scoring points:
- Contrast followed by saline flush pushes contrast into the right heart, maximizing opacification of both ventricles.
- Saline flush after contrast ensures even distribution and clear delineation between chambers, improving shunt visualization.
... |
43 | 43 | Patient Information collection & Diagnostic Workup | A 32-year-old man comes to his primary care physician for an annual physical examination. He mentions experiencing neck pain since waking up this morning, which he attributes to "sleeping in an awkward position." He denies any other symptoms. His medical history is unremarkable, and he only takes a daily multivitamin. ... | B. Pressing on the anterolateral aspect of the right posterior tubercle of the transverse process of the associated vertebra | [
"The patient has an anterior C4 tender point, which corresponds to the anterolateral aspect of C4 posterior tubercle.",
"This site overlies the scalenes, commonly involved in acute neck strain from awkward sleeping positions.",
"Direct pressure on the anterolateral posterior tubercle reproduces tenderness, conf... | Answer: B. Pressing on the anterolateral aspect of the right posterior tubercle of the transverse process of the associated vertebra
Scoring points:
- The patient has an anterior C4 tender point, which corresponds to the anterolateral aspect of C4 posterior tubercle.
- This site overlies the scalenes, commonly involved... |
44 | 44 | Patient Information collection & Diagnostic Workup | A 70-year-old male presents to the emergency department with a 3-day history of shortness of breath, orthopnea, and lower extremity edema. His medical history includes a myocardial infarction 6 years ago requiring revascularization and hypertension. Current medications include simvastatin and lisinopril. Upon arrival, ... | J. Fractional excretion of urea (FEUrea) | [
"Furosemide can increase urinary sodium excretion, making FENa and urine sodium unreliable.",
"FEUrea is not affected by diuretics and accurately distinguishes prerenal azotemia, low FEUrea from intrinsic renal injury, higher FEUrea.",
"In a hypotensive, diuretic‐treated patient with rising creatinine, a low FE... | Answer: J. Fractional excretion of urea (FEUrea)
Scoring points:
- Furosemide can increase urinary sodium excretion, making FENa and urine sodium unreliable.
- FEUrea is not affected by diuretics and accurately distinguishes prerenal azotemia, low FEUrea from intrinsic renal injury, higher FEUrea.
- In a hypotensive, d... |
45 | 45 | Patient Information collection & Diagnostic Workup | A 62-year-old woman presents with a 2-month history of fatigue and shortness of breath during exertion. She also reports episodes of waking up at night coughing and gasping for air. Cardiac examination reveals a grade 3/6 holosystolic murmur that is loudest at the apex. Which of the following physical examination findi... | B. Early diastolic extra heart sound | [
"Exertional dyspnea and paroxysmal nocturnal dyspnea signal left‐sided heart failure.",
"A holosystolic murmur at the apex is characteristic of mitral regurgitation, which causes volume overload of the left ventricle.",
"An early diastolic extra heart sound (S3) reflects rapid filling of a dilated, volume‐overl... | Answer: B. Early diastolic extra heart sound
Scoring points:
- Exertional dyspnea and paroxysmal nocturnal dyspnea signal left‐sided heart failure.
- A holosystolic murmur at the apex is characteristic of mitral regurgitation, which causes volume overload of the left ventricle.
- An early diastolic extra heart sound (S... |
46 | 46 | Patient Information collection & Diagnostic Workup | A 50-year-old female with a history of alcoholic cirrhosis, portal hypertension, esophageal varices, and hepatic encephalopathy is brought in with new-onset confusion. Her husband, though unfamiliar with her chronic conditions, confirms she regularly takes spironolactone, labetalol, lactulose, and furosemide. Her vital... | G. Diagnostic abdominal paracentesis | [
"Cirrhotic patient with tense ascites, fever, hypotension, leukocytosis, and worsening encephalopathy raises high suspicion for spontaneous bacterial peritonitis.",
"Ascitic fluid analysis via paracentesis is required to confirm SBP by PMNs > 250 cells/mm³."
] | Answer: G. Diagnostic abdominal paracentesis
Scoring points:
- Cirrhotic patient with tense ascites, fever, hypotension, leukocytosis, and worsening encephalopathy raises high suspicion for spontaneous bacterial peritonitis.
- Ascitic fluid analysis via paracentesis is required to confirm SBP by PMNs > 250 cells/mm³. |
47 | 47 | Patient Information collection & Diagnostic Workup | A 22-year-old female presents to the emergency department with acute onset of severe head and neck pain that developed over 8 hours. Her vital signs show a temperature of 39.0°C, heart rate of 125 beats per minute, and blood pressure of 120/70 mm Hg. While in the emergency department, she experiences a brief 10-second ... | E. Perform CT of the head | [
"Acute onset of severe headache, fever, and a new generalized seizure raises concern for CNS infection with possible increased intracranial pressure or mass effect.",
"Head CT is required before lumbar puncture to exclude contraindications (e.g., elevated intracranial pressure) and guide safe evaluation."
] | Answer: E. Perform CT of the head
Scoring points:
- Acute onset of severe headache, fever, and a new generalized seizure raises concern for CNS infection with possible increased intracranial pressure or mass effect.
- Head CT is required before lumbar puncture to exclude contraindications (e.g., elevated intracranial p... |
48 | 48 | Patient Information collection & Diagnostic Workup | A 28-year-old female patient presents with a 6-month history of menstrual irregularity and virilization. Previously, she had regular menses since menarche at age 13. Recent symptoms include a 5 kg weight gain, menstrual cycles extending to 30-50 days, facial acne, and increased hair growth on her face, abdomen, and arm... | J. Imaging of the adrenal glands and the pelvis | [
"Markedly elevated testosterone with virilization (clitoral enlargement) and moderately elevated DHEA-S point toward an androgen‐secreting tumor.",
"Cross‐sectional imaging of the adrenal glands and the pelvis can localize a neoplasm and definitively establish the diagnosis."
] | Answer: J. Imaging of the adrenal glands and the pelvis
Scoring points:
- Markedly elevated testosterone with virilization (clitoral enlargement) and moderately elevated DHEA-S point toward an androgen‐secreting tumor.
- Cross‐sectional imaging of the adrenal glands and the pelvis can localize a neoplasm and definitive... |
49 | 49 | Patient Information collection & Diagnostic Workup | A 5-year-old female presents to the emergency department with a 6-day history of fever, irritability, vomiting, and headache. Her only significant recent history is dental work for multiple cavity fillings. Physical examination reveals temperature of 40.2°C, heart rate of 160/min, and blood pressure of 90/50 mm Hg. The... | B. CT of the brain | [
"Recent dental work with a new systolic murmur, fever, lethargy, vomiting, headache, and focal left arm weakness suggest intracranial abscess or infarct from embolic spread.",
"Noncontrast head CT is the fastest way to detect mass lesions or hemorrhage and guide further management."
] | Answer: B. CT of the brain
Scoring points:
- Recent dental work with a new systolic murmur, fever, lethargy, vomiting, headache, and focal left arm weakness suggest intracranial abscess or infarct from embolic spread.
- Noncontrast head CT is the fastest way to detect mass lesions or hemorrhage and guide further manage... |
50 | 50 | Patient Information collection & Diagnostic Workup | A 70-year-old woman presents with a 6-month history of bladder pain and dysuria. Her medical history includes a 50-pack year smoking history and excessive consumption of caffeine and alcohol. Previous treatment with intravesical instillations for bladder pain syndrome, diagnosed by her gynecologist, has been unsuccessf... | G. Urinalysis with microscopy | [
"A elderly smoker with persistent bladder pain and dysuria despite negative cultures warrants evaluation for hematuria or other signs of malignancy.",
"Urinalysis with microscopy is the initial, noninvasive test to detect microscopic hematuria or abnormal cells, guiding further workup."
] | Answer: G. Urinalysis with microscopy
Scoring points:
- A elderly smoker with persistent bladder pain and dysuria despite negative cultures warrants evaluation for hematuria or other signs of malignancy.
- Urinalysis with microscopy is the initial, noninvasive test to detect microscopic hematuria or abnormal cells, gui... |
51 | 51 | Treatment | A patient presented to emergency with overdose some drug. There were increased salivation and increased bronchial secretions. On examination, blood pressure was 88/60 mmHg. RBC esterase level is 50. What should be the treatment of this person?
A. Neostigmine
B. Atropine
C. Flumazenil
D. Physostigmine | B. Atropine | [
"Increased salivation, bronchial secretions, and hypotension (88/60) are hallmark signs of cholinergic toxicity.",
"Organophosphate and carbamate poisoning cause cholinergic excess by inhibiting acetylcholinesterase and RBC esterase level of 50 (low) supports acetylcholinesterase inhibition.",
"Atropine is a mu... | Answer: B. Atropine
Scoring points:
- Increased salivation, bronchial secretions, and hypotension (88/60) are hallmark signs of cholinergic toxicity.
- Organophosphate and carbamate poisoning cause cholinergic excess by inhibiting acetylcholinesterase and RBC esterase level of 50 (low) supports acetylcholinesterase inh... |
52 | 52 | Treatment | In a 40 years old patient with head injury, which of the following is the best strategy to decrease the intracerebral pressure?
A. Limiting pCO, of the patient
B. Administer sedatives
C. Oxygen supplementation by mechanical ventilation
D. Administer nimodipine | A. Limiting pCO, of the patient | [
"pCO₂ directly affects cerebral blood flow through vasodilation and vasoconstriction ",
"Lowering pCO₂ causes cerebral vasoconstriction, which reduces cerebral blood volume and thus ICP."
] | Answer: A. Limiting pCO, of the patient
Scoring points:
- pCO₂ directly affects cerebral blood flow through vasodilation and vasoconstriction
- Lowering pCO₂ causes cerebral vasoconstriction, which reduces cerebral blood volume and thus ICP. |
53 | 53 | Treatment | A 10 years old boy came to emergency with complains of severe pain in right scrotum that is not relieved for the past 1 hour. On examination, testicular torsion of the right side is suspected. The surgical intervention should be:
A. Immediate scrotal exploration of the affected side and operate opposite side if symptom... | C. Immediate exploration of the affected side and operate opposite side even if asymptomatic | [
"Immediate surgical exploration is the standard of care to salvage the affected testis.",
"Even if the opposite testis is asymptomatic, contralateral orchidopexy is recommended due to risk of bilateral anatomic predisposition (bell-clapper deformity)."
] | Answer: C. Immediate exploration of the affected side and operate opposite side even if asymptomatic
Scoring points:
- Immediate surgical exploration is the standard of care to salvage the affected testis.
- Even if the opposite testis is asymptomatic, contralateral orchidopexy is recommended due to risk of bilateral a... |
54 | 54 | Treatment | A neonate presented with jaundice on first day of life. His mother's blood group is `0' positive. How will you manage this patient?
A. Observe only as it is mostly physiological jaundice
B. Exchange transfusion
C. Liver function tests and liver biopsy as it is mostly due to cholestasis
D. Phototherapy | D. Phototherapy | [
"Jaundice on the first day of life is pathological and requires urgent evaluation and treatment.",
"A mother with blood group O positive can have ABO incompatibility with the neonate, leading to hemolytic disease of the newborn.",
"Hemolysis causes rapid rise in unconjugated bilirubin, increasing risk of kernic... | Answer: D. Phototherapy
Scoring points:
- Jaundice on the first day of life is pathological and requires urgent evaluation and treatment.
- A mother with blood group O positive can have ABO incompatibility with the neonate, leading to hemolytic disease of the newborn.
- Hemolysis causes rapid rise in unconjugated bilir... |
55 | 55 | Treatment | A 29-year-old, 4 months pregnant primigravida has history of juvenile myoclonic epilepsy. She has been regularly taking sodium valproate and now presents requesting for an opinion for a change in her anti-epileptic treatment. What would you sugeets her?
A. Immediately taper off valproate and sta lamotrigine
B. Switch t... | C. Continue valproate and serial drug monitoring in blood | [
"Sodium valproate is known to have teratogenic effects, particularly neural tube defects, when used during pregnancy, making it a concern for pregnant women.",
"However, abrupt discontinuation of sodium valproate can lead to seizure exacerbation, which poses a significant risk to both the mother and the fetus.",
... | Answer: C. Continue valproate and serial drug monitoring in blood
Scoring points:
- Sodium valproate is known to have teratogenic effects, particularly neural tube defects, when used during pregnancy, making it a concern for pregnant women.
- However, abrupt discontinuation of sodium valproate can lead to seizure exace... |
56 | 56 | Treatment | A 12 years old boy came with complaints of 4 hypopigmented patches on back and on left arm. The patches had loss of sensation. Which of the following is the treatment for this case?
A. Rifampicin (450 mg) + Dapsone (50 mg) + Clofazimine (150 mg) monthly and 50 mg daily
B. Rifampicin (600 mg) + Dapsone (150 mg) only
C. ... | C. Rifampicin (450 mg) + Dapsone (50 mg) + Clofazimine (150 mg) monthly and 50 mg alternate days | [
"Hypopigmented patches with loss of sensation are classic signs of tuberculoid leprosy.",
"Presence of more than 1 patch but less than 5 patches with sensory loss is diagnostic of paucibacillary leprosy in children.",
"WHO recommends multidrug therapy (MDT) for paucibacillary leprosy to prevent resistance and e... | Answer: C. Rifampicin (450 mg) + Dapsone (50 mg) + Clofazimine (150 mg) monthly and 50 mg alternate days
Scoring points:
- Hypopigmented patches with loss of sensation are classic signs of tuberculoid leprosy.
- Presence of more than 1 patch but less than 5 patches with sensory loss is diagnostic of paucibacillary lepr... |
57 | 57 | Treatment | A 32-year-old man presents to the emergency department with pain upon defecation. His symptoms started a few weeks ago but have been worsening. Sometimes he notes blood on the toilet paper. He has to strain to have bowel movements and has trouble defecating secondary to pain. He is generally healthy and does not smoke.... | A. Testing for HIV, fecal occult blood, and sexually transmitted diseases | [
"The patient has an anal fissure that is lateral to the midline, which is atypical in location.",
"Atypical anal fissures warrant evaluation for secondary causes, including infections, malignancy, or systemic disease.",
"HIV and STDs (e.g., syphilis, herpes) can cause atypical or recurrent anal ulcers and fissu... | Answer: A. Testing for HIV, fecal occult blood, and sexually transmitted diseases
Scoring points:
- The patient has an anal fissure that is lateral to the midline, which is atypical in location.
- Atypical anal fissures warrant evaluation for secondary causes, including infections, malignancy, or systemic disease.
- HI... |
58 | 58 | Treatment | A 57-year-old man is brought to the emergency department by his wife with confusion. He was seen in the emergency department 2 days ago for profuse epistaxis. His primary care provider was concerned and had advised him to go to the hospital, as the patient is on warfarin for atrial fibrillation. However, his bleeding r... | D. Clindamycin | [
"The patient presents with confusion, hypotension, tachycardia, tachypnea, and a purpuric rash, which are indicative of septic shock, likely due to disseminated intravascular coagulation (DIC) from a bacterial infection.",
"The patient's recent history of epistaxis and warfarin use suggests a possible bleeding di... | Answer: D. Clindamycin
Scoring points:
- The patient presents with confusion, hypotension, tachycardia, tachypnea, and a purpuric rash, which are indicative of septic shock, likely due to disseminated intravascular coagulation (DIC) from a bacterial infection.
- The patient's recent history of epistaxis and warfarin us... |
59 | 59 | Treatment | A 13-day-old boy is brought by his mother for eye redness and ocular discharge. The mother reports that the patient has developed a cough and nasal discharge. Pregnancy and delivery were uncomplicated but the mother had limited prenatal care during the third trimester. Immediately after delivery, the baby was given sil... | B. Oral erythromycin | [
"The neonate is 13 days old with mucoid eye discharge, eyelid swelling, and respiratory symptoms, suggesting a systemic infectious process and Chlamydia trachomatis is a common cause of neonatal conjunctivitis developing 5–14 days after birth, often accompanied by pneumonia.",
"Chest radiograph findings of hyperi... | Answer: B. Oral erythromycin
Scoring points:
- The neonate is 13 days old with mucoid eye discharge, eyelid swelling, and respiratory symptoms, suggesting a systemic infectious process and Chlamydia trachomatis is a common cause of neonatal conjunctivitis developing 5–14 days after birth, often accompanied by pneumonia... |
60 | 60 | Treatment | A 31-year-old man presents to the emergency department for fever, malaise, and cough. For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum. He denies any recent travel or sick contacts and infrequently smokes cigarettes. Approximately 5 weeks ago, he presented with... | A. Continue current anti-retroviral treatment, antimicrobial, and anti-tuberculoid therapies | [
"The patient has advanced HIV with a previously documented CD4 count of 40/mm³, placing him at high risk for opportunistic infections, including tuberculosis (TB).",
"Recent improvement in CD4 count and viral suppression indicates successful initiation of antiretroviral therapy (ART).",
"Worsening symptoms with... | Answer: A. Continue current anti-retroviral treatment, antimicrobial, and anti-tuberculoid therapies
Scoring points:
- The patient has advanced HIV with a previously documented CD4 count of 40/mm³, placing him at high risk for opportunistic infections, including tuberculosis (TB).
- Recent improvement in CD4 count and ... |
61 | 61 | Treatment | A 55-year-old man presents to his primary care physician with persistent symptoms of depression. He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce. Since then, he notes that his symptoms are roughly unchanged. His other medications include albuterol. His tempe... | E. Maintain dose of current medication | [
"Fluoxetine, an SSRI, typically requires at least 4–6 weeks to show full therapeutic effect in major depressive disorder.",
"The patient has been on fluoxetine for only 3 weeks, which is within the expected latency period for symptom improvement.",
"Prematurely increasing the dose or switching medications befor... | Answer: E. Maintain dose of current medication
Scoring points:
- Fluoxetine, an SSRI, typically requires at least 4–6 weeks to show full therapeutic effect in major depressive disorder.
- The patient has been on fluoxetine for only 3 weeks, which is within the expected latency period for symptom improvement.
- Prematur... |
62 | 62 | Treatment | A 48-year-old man presents to the emergency room with a 2-hour history of severe abdominal pain, nausea, and vomiting. He states that he has not passed gas or had a bowel movement in 4 days and his pain has worsened and become constant over the past 2 hours. His only medical history includes an appendectomy that he und... | B. Urgent surgical intervention | [
"The patient's presentation is consistent with acute abdominal pathology, likely bowel obstruction or perforation, given the severe abdominal pain, distension, guarding, rebound tenderness, and absence of bowel movements or gas passage.",
"The patient's vital signs indicate hemodynamic instability with hypotensio... | Answer: B. Urgent surgical intervention
Scoring points:
- The patient's presentation is consistent with acute abdominal pathology, likely bowel obstruction or perforation, given the severe abdominal pain, distension, guarding, rebound tenderness, and absence of bowel movements or gas passage.
- The patient's vital sign... |
63 | 63 | Treatment | A 56-year-old woman presents to the emergency department with muscle weakness. Her symptoms have progressively worsened over the course of 2 weeks and are most significant in her lower extremities. She also notices increased urinary frequency. Approximately 1 month ago, she was diagnosed with calcium phosphate nephroli... | C. Administer intravenous sodium bicarbonate | [
"The patient has hypokalemia (K⁺ 2.9 mEq/L) and metabolic acidosis (HCO₃⁻ 18 mEq/L), consistent with distal (type 1) renal tubular acidosis (RTA). Calcium phosphate kidney stones and low urine pH support a diagnosis of distal RTA, which leads to acid retention and potassium loss.",
"Progressive muscle weakness is... | Answer: C. Administer intravenous sodium bicarbonate
Scoring points:
- The patient has hypokalemia (K⁺ 2.9 mEq/L) and metabolic acidosis (HCO₃⁻ 18 mEq/L), consistent with distal (type 1) renal tubular acidosis (RTA). Calcium phosphate kidney stones and low urine pH support a diagnosis of distal RTA, which leads to acid... |
64 | 64 | Treatment | A 67-year-old man presents to the emergency room with a 2 day history of progressively worsening fatigue and shortness of breath. His past medical history is significant for previous myocardial infarction, a 30-pack-year smoking history, gastroesophageal reflux disease, and poorly controlled hypertension. The patient’s... | B. Furosemide | [
"The patient presents with symptoms of heart failure, including progressively worsening fatigue, shortness of breath, elevated jugular venous pressure, S3 heart sound, bibasilar crackles, and pitting edema.",
"The arterial blood gas analysis shows a primary respiratory alkalosis with metabolic compensation, indic... | Answer: B. Furosemide
Scoring points:
- The patient presents with symptoms of heart failure, including progressively worsening fatigue, shortness of breath, elevated jugular venous pressure, S3 heart sound, bibasilar crackles, and pitting edema.
- The arterial blood gas analysis shows a primary respiratory alkalosis wi... |
65 | 65 | Treatment | A 23-year-old man presents to the emergency department for altered mental status after a finishing a marathon. He has a medical history of obesity and anxiety and is not currently taking any medications. His temperature is 104°F (40°C), blood pressure is 147/88 mmHg, pulse is 200/min, respirations are 33/min, and oxyge... | C. Lactated ringer | [
"The patient is presenting with symptoms consistent with exertional heat stroke, indicated by altered mental status, high body temperature (104°F), tachycardia, tachypnea, and hot flushed skin after a marathon.",
"The laboratory findings show hypernatremia (Na+ 165 mEq/L) and signs of dehydration (elevated BUN an... | Answer: C. Lactated ringer
Scoring points:
- The patient is presenting with symptoms consistent with exertional heat stroke, indicated by altered mental status, high body temperature (104°F), tachycardia, tachypnea, and hot flushed skin after a marathon.
- The laboratory findings show hypernatremia (Na+ 165 mEq/L) and ... |
66 | 66 | Treatment | A 22-year-old man presents to the emergency department with difficulty breathing. He has experienced similar symptoms before. Today, he was hit in the face with a football, followed by significant swelling of his lips and tongue. The patient speaks with a muffled voice. His temperature is 98.1°F (36.7°C), blood pressur... | D. Fresh frozen plasma | [
"The patient presents with difficulty breathing, significant swelling of the lips and tongue, and a history of similar symptoms, suggesting hereditary angioedema.",
"Hereditary angioedema is characterized by episodes of severe swelling, often triggered by trauma or stress, and is not associated with urticaria or ... | Answer: D. Fresh frozen plasma
Scoring points:
- The patient presents with difficulty breathing, significant swelling of the lips and tongue, and a history of similar symptoms, suggesting hereditary angioedema.
- Hereditary angioedema is characterized by episodes of severe swelling, often triggered by trauma or stress,... |
67 | 67 | Treatment | A 59-year-old woman comes to the clinic due to a 3-month history of “always feeling the urge to urinate” as well as vaginal pruritis. She states that she has had involuntary loss of urine about 4 times each day over the past 3 months. It is not associated with coughing or sneezing. Menopause occurred at age 52. She has... | E. Vaginal moisturizers | [
"The patient's symptoms and physical examination findings are consistent with genitourinary syndrome of menopause (GSM), which includes symptoms such as vaginal pruritis, urinary urgency, and dyspareunia due to estrogen deficiency.",
"The physical examination reveals pale and atrophic vulvar skin, reduced elastic... | Answer: E. Vaginal moisturizers
Scoring points:
- The patient's symptoms and physical examination findings are consistent with genitourinary syndrome of menopause (GSM), which includes symptoms such as vaginal pruritis, urinary urgency, and dyspareunia due to estrogen deficiency.
- The physical examination reveals pale... |
68 | 68 | Treatment | A 60-year-old man presents to his primary care physician with weight gain. He states that ever since his wife died 4 months ago, he has been eating and sleeping more and no longer engages in any activities he once enjoyed such as hiking or fishing. He feels guilty for not spending more time with his wife before she die... | E. Venlafaxine | [
"The patient exhibits symptoms of major depressive disorder (anhedonia, guilt, hypersomnia, impaired concentration, functional impairment), requiring antidepressant therapy.",
"He has diabetic peripheral neuropathy (burning, electric pain, reduced sensation), which requires treatment targeting neuropathic pain.",... | Answer: E. Venlafaxine
Scoring points:
- The patient exhibits symptoms of major depressive disorder (anhedonia, guilt, hypersomnia, impaired concentration, functional impairment), requiring antidepressant therapy.
- He has diabetic peripheral neuropathy (burning, electric pain, reduced sensation), which requires treatm... |
69 | 69 | Treatment | A 26-year-old medical student presents to occupational health after sustaining a needlestick injury. She was drawing blood from an HIV-positive patient when she stuck herself percutaneously while capping the needle. She immediately washed the puncture wound with saline. The medical student has had a negative HIV serolo... | D. Repeat HIV serology and initiate triple antiretroviral therapy immediately | [
"The exposure was a percutaneous needlestick injury, which is a high-risk route for HIV transmission.",
"The source patient has a very high viral load (1.8 million copies/mL), significantly increasing transmission risk.",
"Post-exposure prophylaxis (PEP) with triple antiretroviral therapy should be started imme... | Answer: D. Repeat HIV serology and initiate triple antiretroviral therapy immediately
Scoring points:
- The exposure was a percutaneous needlestick injury, which is a high-risk route for HIV transmission.
- The source patient has a very high viral load (1.8 million copies/mL), significantly increasing transmission risk... |
70 | 70 | Treatment | A 26-year-old woman presents to the emergency department with 1 day of vaginal bleeding and lower abdominal pain. The pain is most pronounced in the lower abdomen and has gotten worse over the past day. Her last menstrual period was 7 weeks ago. She denies any recent abdominal or vaginal trauma. She has no other past m... | B. Laparoscopy | [
"The patient has positive beta-hCG (2,700 IU/L) with vaginal bleeding and abdominal pain, raising strong suspicion for ectopic pregnancy.",
"Hemodynamic instability (BP 79/50 mmHg, HR 135/min) with abdominal tenderness suggests ruptured ectopic pregnancy, a surgical emergency.",
"Use of a copper IUD significant... | Answer: B. Laparoscopy
Scoring points:
- The patient has positive beta-hCG (2,700 IU/L) with vaginal bleeding and abdominal pain, raising strong suspicion for ectopic pregnancy.
- Hemodynamic instability (BP 79/50 mmHg, HR 135/min) with abdominal tenderness suggests ruptured ectopic pregnancy, a surgical emergency.
- U... |
71 | 71 | Treatment | A 25-year-old man is brought to the emergency department by paramedics for altered mental status. He was found lying down at a bus stop unresponsive. On arrival, the patient has slurred speech and is somnolent. Further is unable to be elicited. His temperature is 98.0°F (36.7°C), blood pressure is 130/80 mmHg, pulse is... | C. Observation | [
"The patient's presentation is consistent with opioid intoxication, indicated by altered mental status, somnolence, slurred speech, miotic pupils, and decreased bowel sounds.",
"The patient's vital signs are stable, with normal temperature, blood pressure, pulse, and oxygen saturation, suggesting no immediate lif... | Answer: C. Observation
Scoring points:
- The patient's presentation is consistent with opioid intoxication, indicated by altered mental status, somnolence, slurred speech, miotic pupils, and decreased bowel sounds.
- The patient's vital signs are stable, with normal temperature, blood pressure, pulse, and oxygen satura... |
72 | 72 | Treatment | A 71-year-old man arrives to the emergency room appearing cyanotic and having weak, shallow respirations. He is brought in by his home care nurse, who reports that the patient has a history of myasthenia gravis and frequent urinary tract infections. The patient was in his normal state of health until 5 days ago when he... | B. Plasmapheresis | [
"The patient has myasthenia gravis and presents with respiratory failure (PO₂ 55 mmHg, PCO₂ 60 mmHg, pH 7.30), indicating a myasthenic crisis.",
"Aminoglycosides (e.g., gentamicin) can worsen neuromuscular transmission and are known triggers for myasthenic crisis.",
"Clinical signs of bulbar and respiratory mus... | Answer: B. Plasmapheresis
Scoring points:
- The patient has myasthenia gravis and presents with respiratory failure (PO₂ 55 mmHg, PCO₂ 60 mmHg, pH 7.30), indicating a myasthenic crisis.
- Aminoglycosides (e.g., gentamicin) can worsen neuromuscular transmission and are known triggers for myasthenic crisis.
- Clinical si... |
73 | 73 | Treatment | A 27-year-old man presents to the emergency department. He was brought in by staff from the homeless shelter when they found him unresponsive. The patient is a known IV drug abuser but otherwise has an unknown past medical history. He currently attends a methadone clinic. His temperature is 99.5°F (37.5°C), blood press... | B. Insulin, potassium, IV fluids, and glucose | [
"The patient presents with hyperglycemia (glucose: 589 mg/dL), metabolic acidosis (HCO3-: 17 mEq/L), and hyperkalemia (K+: 6.3 mEq/L), which are indicative of diabetic ketoacidosis (DKA).",
"The initial treatment for DKA includes insulin to reduce blood glucose levels, IV fluids to address dehydration, and potass... | Answer: B. Insulin, potassium, IV fluids, and glucose
Scoring points:
- The patient presents with hyperglycemia (glucose: 589 mg/dL), metabolic acidosis (HCO3-: 17 mEq/L), and hyperkalemia (K+: 6.3 mEq/L), which are indicative of diabetic ketoacidosis (DKA).
- The initial treatment for DKA includes insulin to reduce bl... |
74 | 74 | Treatment | A 65-year-old man with a history of hypertension, obesity, and alcoholic cirrhosis is seen in clinic for follow-up. He feels well and currently drinks 5 glasses of wine each night. Medications include atenolol and lisinopril. On physical exam, temperature is 98.1 deg F (36.7 deg C), blood pressure is 151/82 mmHg, pulse... | A. Proceed with liver biopsy | [
"The patient has cirrhosis (alcoholic liver disease, spider angiomata), placing him at high risk for hepatocellular carcinoma (HCC).",
"A 2 cm hepatic lesion with arterial phase enhancement but no venous or delayed phase washout is not diagnostic of HCC based on imaging criteria alone.",
"Definitive diagnosis o... | Answer: A. Proceed with liver biopsy
Scoring points:
- The patient has cirrhosis (alcoholic liver disease, spider angiomata), placing him at high risk for hepatocellular carcinoma (HCC).
- A 2 cm hepatic lesion with arterial phase enhancement but no venous or delayed phase washout is not diagnostic of HCC based on imag... |
75 | 75 | Treatment | A 61-year-old man was started on rosuvastatin 40 mg 8 weeks ago and presents today for a follow-up. He complains of pain in his legs and general weakness. On physical exam, he has full range of motion of his extremities but complains of pain. His blood pressure is 126/84 mm Hg and heart rate is 74/min. The decision is... | A. Restart rosuvastatin at a lower dose | [
"The patient experienced statin-associated muscle symptoms (SAMS) that resolved upon discontinuation, confirming the statin as the likely cause.",
"Rosuvastatin is a high-potency statin, and muscle symptoms are dose-dependent, making dose reduction an effective strategy to maintain therapy and reduce side effects... | Answer: A. Restart rosuvastatin at a lower dose
Scoring points:
- The patient experienced statin-associated muscle symptoms (SAMS) that resolved upon discontinuation, confirming the statin as the likely cause.
- Rosuvastatin is a high-potency statin, and muscle symptoms are dose-dependent, making dose reduction an effe... |
76 | 76 | Treatment | A 42-year-old man with AIDS comes to the physician for intermittent fever, nonproductive cough, malaise, decreased appetite, abdominal pain, and a 3.6-kg (8-lb) weight loss over the past month. He has not seen a doctor since he became uninsured 2 years ago. His temperature is 38.3°C (100.9°F). Abdominal examination sho... | D. Azithromycin and ethambutol | [
"The patient has advanced AIDS (CD4 count <50/mm³) with systemic symptoms and acid-fast bacilli in blood cultures, suggesting disseminated Mycobacterium avium complex (MAC) infection which presents with fever, weight loss, hepatosplenomegaly, and abdominal symptoms.",
"Azithromycin plus ethambutol is the first-li... | Answer: D. Azithromycin and ethambutol
Scoring points:
- The patient has advanced AIDS (CD4 count <50/mm³) with systemic symptoms and acid-fast bacilli in blood cultures, suggesting disseminated Mycobacterium avium complex (MAC) infection which presents with fever, weight loss, hepatosplenomegaly, and abdominal symptom... |
77 | 77 | Treatment | A 59-year-old man presents to general medical clinic for his yearly checkup. He has no complaints except for a dry cough. He has a past medical history of type II diabetes, hypertension, hyperlipidemia, asthma, and depression. His home medications are sitagliptin/metformin, lisinopril, atorvastatin, albuterol inhaler, ... | E. Change lisinopril to losartan | [
"The patient has a dry, persistent cough and is taking lisinopril, an ACE inhibitor, which is a known cause of ACE inhibitor-induced cough.",
"Losartan, an angiotensin receptor blocker (ARB), does not affect bradykinin metabolism, and is the preferred alternative when ACE inhibitor–induced cough occurs."
] | Answer: E. Change lisinopril to losartan
Scoring points:
- The patient has a dry, persistent cough and is taking lisinopril, an ACE inhibitor, which is a known cause of ACE inhibitor-induced cough.
- Losartan, an angiotensin receptor blocker (ARB), does not affect bradykinin metabolism, and is the preferred alternative... |
78 | 78 | Treatment | A 35-year-old man visits your office for his annual health checkup. He was diagnosed with generalized anxiety disorder 6 months ago, which is being treated with citalopram. He comments that his symptoms have improved since initiating the prescribed therapy; however, in the past 2 months, he has been unable to have sexu... | A. Lowering citalopram dose | [
"The patient reports improved anxiety symptoms but has developed sexual side effects (erectile dysfunction, low libido) after starting citalopram.",
"Selective serotonin reuptake inhibitors (SSRIs) like citalopram commonly cause sexual dysfunction, which is dose-dependent.",
"Dose reduction is a recognized firs... | Answer: A. Lowering citalopram dose
Scoring points:
- The patient reports improved anxiety symptoms but has developed sexual side effects (erectile dysfunction, low libido) after starting citalopram.
- Selective serotonin reuptake inhibitors (SSRIs) like citalopram commonly cause sexual dysfunction, which is dose-depen... |
79 | 79 | Treatment | A 36-year-old woman comes to the physician because of difficulty discarding items in her home. She says that the accumulation of things in her kitchen and dining room makes regular use of these spaces incredibly difficult. Her behavior started when she was in high school. She feels anxious when she tries to discard her... | B. Fluoxetine | [
"The patient meets diagnostic criteria for hoarding disorder, evidenced by difficulty discarding possessions, clutter interfering with living space, and significant distress.",
"Cognitive behavioral therapy (CBT) is first-line treatment for hoarding disorder, but pharmacotherapy is recommended if there is insuffi... | Answer: B. Fluoxetine
Scoring points:
- The patient meets diagnostic criteria for hoarding disorder, evidenced by difficulty discarding possessions, clutter interfering with living space, and significant distress.
- Cognitive behavioral therapy (CBT) is first-line treatment for hoarding disorder, but pharmacotherapy is... |
80 | 80 | Treatment | A 43-year-old male is brought to the emergency department after his son found him vomiting bright red blood. He is visibly intoxicated, and hospital records indicate a long history of alcohol substance abuse treated with antabuse (disulfiram). Vital signs include T 98.4, HR 89, BP 154/92, and RR 20. EGD is notable for ... | B. Conservative management with IV fluid hydration and observation | [
"The patient has a longitudinal tear at the gastroesophageal junction consistent with Mallory-Weiss syndrome, a common cause of upper GI bleeding after forceful vomiting.",
"Mallory-Weiss tears typically result in self-limited bleeding and often do not require endoscopic intervention if there is no active bleedin... | Answer: B. Conservative management with IV fluid hydration and observation
Scoring points:
- The patient has a longitudinal tear at the gastroesophageal junction consistent with Mallory-Weiss syndrome, a common cause of upper GI bleeding after forceful vomiting.
- Mallory-Weiss tears typically result in self-limited bl... |
81 | 81 | Treatment | A 33-year-old man presents to the infectious diseases clinic for follow-up. He was recently admitted to the hospital with fever, shortness of breath, and cough, and was found to have Pneumocystic jirovecii pneumonia and a new diagnosis of HIV. His CD4 count is 175, viral load is pending. As part of routine laboratory s... | C. Treat with three weekly injections of penicillin, obtain titers in 6 months | [
"The patient has a positive RPR with a titer of 1:64 and a positive FTA-ABS, indicating a diagnosis of syphilis.",
"Given the patient's CD4 count of 175, he is considered to have late latent syphilis or syphilis of unknown duration, which requires treatment with three weekly injections of penicillin G benzathine.... | Answer: C. Treat with three weekly injections of penicillin, obtain titers in 6 months
Scoring points:
- The patient has a positive RPR with a titer of 1:64 and a positive FTA-ABS, indicating a diagnosis of syphilis.
- Given the patient's CD4 count of 175, he is considered to have late latent syphilis or syphilis of un... |
82 | 82 | Treatment | A 38-year-old woman presents to her physician’s clinic for recurrent episodes of chest pain that wakes her from her sleep. While usually occurring late at night, she has also had similar pains during the day at random times, most recently while sitting at her desk in her office and at other times while doing the dishes... | C. Isosorbide dinitrate | [
"The patient’s recurrent chest pain at rest, often nocturnal and unrelated to exertion, is characteristic of vasospastic (Prinzmetal) angina.",
"Isosorbide dinitrate, a long-acting nitrate, is effective in preventing coronary vasospasm and relieving chest pain in patients with vasospastic angina."
] | Answer: C. Isosorbide dinitrate
Scoring points:
- The patient’s recurrent chest pain at rest, often nocturnal and unrelated to exertion, is characteristic of vasospastic (Prinzmetal) angina.
- Isosorbide dinitrate, a long-acting nitrate, is effective in preventing coronary vasospasm and relieving chest pain in patients... |
83 | 83 | Treatment | A 32-year-old man presents to the emergency department with fever, nausea, and vomiting. The patient states that his symptoms started last night and have persisted to this morning. He has a past medical history of asthma, and his current medications include albuterol and fluticasone. His temperature is 102°F (38.9°C), ... | E. IV fluids and monitoring | [
"The patient presents with fever, photophobia, neck stiffness, and nausea, and CSF findings show mild pleocytosis with normal glucose and protein, consistent with viral (aseptic) meningitis, which is typically self-limited.",
"Viral meningitis in immunocompetent adults is usually managed with supportive care, inc... | Answer: E. IV fluids and monitoring
Scoring points:
- The patient presents with fever, photophobia, neck stiffness, and nausea, and CSF findings show mild pleocytosis with normal glucose and protein, consistent with viral (aseptic) meningitis, which is typically self-limited.
- Viral meningitis in immunocompetent adult... |
84 | 84 | Treatment | A 5-year-old Syrian immigrant and her family present for an immigration physical. Her mother describes photophobia, bilateral lacrimation, eye itching, and eyelid swelling for the last week. She is known to have an allergy to cephalosporins. She was born at 39 weeks gestation via spontaneous vaginal delivery. She has m... | D. The child should be administered a single dose of oral azithromycin. | [
"The child's symptoms of photophobia, bilateral lacrimation, eye itching, and eyelid swelling are indicative of trachoma, a condition caused by Chlamydia trachomatis.",
"Trachoma is a common infectious cause of blindness in areas with poor sanitation and is prevalent in certain regions, including parts of the Mid... | Answer: D. The child should be administered a single dose of oral azithromycin.
Scoring points:
- The child's symptoms of photophobia, bilateral lacrimation, eye itching, and eyelid swelling are indicative of trachoma, a condition caused by Chlamydia trachomatis.
- Trachoma is a common infectious cause of blindness in ... |
85 | 85 | Treatment | A 45-year-old homeless man comes to the emergency department because of progressive neck pain for 3 days. He also reports headaches and numbness in both hands. Over the past 4 months, he has had intermittent lower back pain after waking up. The back pain improves with movement. He also has recurrent episodes of gout in... | B. Intravenous ciprofloxacin and vancomycin therapy | [
"The patient presents with fever, neck pain, neurologic symptoms, and MRI-confirmed spinal inflammation, consistent with vertebral osteomyelitis, a serious infection often seen in IV drug users.",
"Empiric treatment for vertebral osteomyelitis should include vancomycin (for MRSA coverage) and ciprofloxacin (for g... | Answer: B. Intravenous ciprofloxacin and vancomycin therapy
Scoring points:
- The patient presents with fever, neck pain, neurologic symptoms, and MRI-confirmed spinal inflammation, consistent with vertebral osteomyelitis, a serious infection often seen in IV drug users.
- Empiric treatment for vertebral osteomyelitis ... |
86 | 86 | Treatment | A 39-year-old woman comes to the physician because of fever, generalized fatigue, and chills for 1 week. She has been having dull right-side abdominal pain during this period. She has nausea. She has no history of travel outside the United States. She has type 1 diabetes mellitus. Current medications include insulin an... | E. Perform percutaneous drainage | [
"The patient presents with fever, right upper quadrant pain, leukocytosis, and a tender, enlarged liver, with ultrasound findings consistent with a hepatic abscess, requiring drainage.",
"Percutaneous drainage is the standard initial management for pyogenic liver abscess, allowing source control and microbial ide... | Answer: E. Perform percutaneous drainage
Scoring points:
- The patient presents with fever, right upper quadrant pain, leukocytosis, and a tender, enlarged liver, with ultrasound findings consistent with a hepatic abscess, requiring drainage.
- Percutaneous drainage is the standard initial management for pyogenic liver... |
87 | 87 | Treatment | A 25-year-old man presents to his primary care provider complaining of several weeks of intense itching, particularly localized around his anus. Of note, the patient denies any recent travel, sexual contacts, fever, dysuria, or diarrhea. His temperature is 98.1°F (36.7°C), blood pressure is 110/70 mmHg, pulse is 65/min... | E. Pyrantel pamoate | [
"The patient presents with intense itching localized around the anus and a positive scotch tape test, which are indicative of enterobiasis (pinworm infection) caused by Enterobius vermicularis.",
"The patient has a documented allergy to albendazole, which is a common treatment for pinworm infection, necessitating... | Answer: E. Pyrantel pamoate
Scoring points:
- The patient presents with intense itching localized around the anus and a positive scotch tape test, which are indicative of enterobiasis (pinworm infection) caused by Enterobius vermicularis.
- The patient has a documented allergy to albendazole, which is a common treatmen... |
88 | 88 | Treatment | A 45-year-old man presents to the emergency department with severe dyspnea, wheezing, and palpitations. His symptoms began approx. 20 minutes after being stung by a bee on the left arm. Past medical history is significant for hypertension for which he takes labetalol. While being questioned, the patient becomes obtunde... | B. Administer glucagon | [
"The patient is in anaphylactic shock with persistent hypotension despite IM epinephrine and fluids, indicating refractory anaphylaxis.",
"The patient is on labetalol (a beta-blocker), which can impair the response to epinephrine; glucagon acts independently of beta-adrenergic receptors and is effective in restor... | Answer: B. Administer glucagon
Scoring points:
- The patient is in anaphylactic shock with persistent hypotension despite IM epinephrine and fluids, indicating refractory anaphylaxis.
- The patient is on labetalol (a beta-blocker), which can impair the response to epinephrine; glucagon acts independently of beta-adrene... |
89 | 89 | Treatment | A 67-year-old man presents to his primary care physician for a follow up appointment. He was released from the hospital 1 week ago for an appropriately managed ST-elevation myocardial infarction (STEMI); however, he has not filled any of his prescriptions and did not attend his follow up appointment as scheduled. The p... | D. Metoprolol succinate | [
"The patient is post-STEMI and shows signs of congestive symptoms (JVD, peripheral edema), despite a preserved ejection fraction, indicating high cardiovascular risk and the need for cardioprotective therapy.",
"Metoprolol succinate, a beta-1 selective blocker, has proven mortality benefit in patients post-myocar... | Answer: D. Metoprolol succinate
Scoring points:
- The patient is post-STEMI and shows signs of congestive symptoms (JVD, peripheral edema), despite a preserved ejection fraction, indicating high cardiovascular risk and the need for cardioprotective therapy.
- Metoprolol succinate, a beta-1 selective blocker, has proven... |
90 | 90 | Treatment | A hospitalized 34-year-old man with severe diarrhea and bloating for 1 month is diagnosed with celiac disease based on serology and duodenal biopsy. He has no history of any serious illnesses and takes no medications. He has no history of recent travel. His vital signs are within normal limits. Physical examination is ... | A. Avoiding all dairy products | [
"The patient has newly diagnosed celiac disease with severe diarrhea and bloating, which are commonly worsened by secondary lactose intolerance due to damaged intestinal villi.",
"lactase deficiency is a common, temporary complication of untreated celiac disease, and avoiding dairy can significantly reduce gastro... | Answer: A. Avoiding all dairy products
Scoring points:
- The patient has newly diagnosed celiac disease with severe diarrhea and bloating, which are commonly worsened by secondary lactose intolerance due to damaged intestinal villi.
- lactase deficiency is a common, temporary complication of untreated celiac disease, a... |
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