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First Aid for the

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2025- 2026
The Ultimate Resource for the i
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First Aid for the USMLE
Step 2ck & 3
2025-2026

The Ultimate Resource for the Medical Exam Preparation,

featuring Updated Content, Practice Tests, CCS Mastery,
and a Premium E-Learning Course + Workbook (2 Book In
1)

NewGrade Publication
Copyright©2025 NewGrade Publication
All Rights Reserved.
All rights reserved. No part of this book may be reproduced, stored in a
retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior
written permission of the copyright holder.
Disclaimer
Note: While we've made every effort to ensure the accuracy of this study guide, it's
important to remember that it's a supplementary resource. Always consult your nursing
program or official exam resources for the most up-to-date and comprehensive
information.
This study guide is designed to help you enhance your understanding of the USMLE Step
1 exam and improve your chances of success. It provides practice questions,
explanations, and strategies to aid in your preparation. However, it's not a substitute for
professional guidance or official exam materials.
We recommend using this guide in conjunction with your nursing coursework and other
study resources. If you have any questions or concerns, please consult with your
instructors or a qualified healthcare professional.
By using this study guide, you agree to use it at your own discretion and acknowledge
that the authors and publishers are not responsible for any potential inaccuracies or any
consequences that may arise from your use of the guide.
CONTENTS
INTRODUCTION
Book 1: USMLE Step 2ck
Chapter 1: Exam Overview and Preparation Strategies
Understanding the USMLE Step 2 CK format and content
Creating an effective study schedule
Best practices for using review materials and question banks

Chapter 2: Internal Medicine

High-yield topics in cardiology, pulmonology, and gastroenterology
Key concepts in endocrinology, nephrology, and hematology
Key concepts in nephrology
Key concepts in hematology
Critical care and emergency medicine essentials
Chapter 2 Summary and Workbook

Chapter 3: Surgery and Surgical Subspecialties

General surgery principles and common procedures
Orthopedics, urology, and otolaryngology highlights
Neurosurgery and ophthalmology fundamentals
Chapter 3 Summary and Workbook

Chapter 4: Pediatrics
Growth and development milestones
Common pediatric illnesses and management
Neonatal and adolescent medicine
Neonatal and adolescent medicine (continued)
Chapter 4 Summary and Workbook

Chapter 5: Obstetrics and Gynecology

Normal and complicated pregnancy
Gynecological disorders and treatments
Reproductive endocrinology and infertility
Chapter 5 Summary and Workbook
Chapter 6: Psychiatry
Major psychiatric disorders and their management
Psychopharmacology essentials
Child and adolescent psychiatry
Chapter 6 Summary and Workbook

Chapter 7: Preventive Medicine and Ethics

Screening guidelines and immunizations
Occupational and environmental health
Medical ethics and patient safety
Chapter 7 Summary and Workbook

Book 2: USMLE Step 3

Chapter 8: Step 3 Exam Format and Strategies
Understanding the two-day exam structure
Mastering computer-based case simulations (CCS)
Time management techniques for multiple-choice questions (MCQs)

Chapter 9: Advanced Clinical Medicine

Complex patient presentations and management
Multisystem disorders and their approach
Evidence-based medicine application
Chapter 9 Summary and Workbook

Chapter 10: Emergency Medicine and Critical Care

Acute care scenarios and interventions
Advanced cardiac life support (ACLS) principles
Trauma management and triage
Chapter 10 Summary and Workbook

Chapter 11: Public Health and Patient Safety

Quality improvement and patient safety measures
Healthcare systems and policy
Chapter 11 Summary and Workbook

Chapter 12: Clinical Reasoning and Decision Making

Diagnostic algorithms and clinical problem-solving
Interpreting laboratory and imaging studies
Risk assessment and prognosis determination
Chapter 12 Summary and Workbook

Chapter 13: Exam Day Preparation and Anxiety

Management
Final week study tips and review strategies
Strategies for managing exam anxiety
Practical relaxation techniques and mindfulness exercises
Nutrition and sleep optimization for peak performance

Practice Tests Sections

Book 1 USMLE Step 1 Questions Banks
Book 2 USMLE Step 2ck Questions Banks

Conclusion
Success stories and anecdotes from recent test-takers
Practical mnemonic techniques for last-minute review
Words of encouragement and motivation for exam day

Bonus
Access the E-learning Course Below
HOW TO USE THIS
BOOK?
To make the most of "First Aid for the USMLE Step 2 CK & 3 2025-2026," follow this detailed guide:

1. Start Early: Begin your preparation at least 3-6 months before your exam date. This book is
comprehensive, so allow ample time to cover all material thoroughly.
2. Review the Table of Contents: Familiarize yourself with the book's structure and content
areas. This will help you create a study schedule and prioritize topics.
3. Take the Initial Self-Assessment: Use the practice questions provided to gauge your baseline
knowledge and identify weak areas that need more focus.
4. Create a Study Schedule: Develop a realistic study plan that covers all topics, allocating
more time to challenging areas. Include regular breaks to prevent burnout.
5. Use Active Learning Techniques: As you read each chapter, take notes, create flashcards,
and draw diagrams to reinforce key concepts.
6. Utilize the E-Learning Course: Incorporate the premium e-learning course into your study
routine. This interactive resource can help reinforce difficult concepts and provide
additional practice.
7. Practice CCS Cases: Dedicate time to mastering Computer-based Case Simulations (CCS).
Use the CCS strategies provided in the book and practice with the sample cases.
8. Complete Practice Tests: Regularly take the practice tests included in the book to assess your
progress and familiarize yourself with the exam format.
9. Use the Workbook: Complete the exercises in the accompanying workbook to reinforce your
learning and identify areas that need further review.
10. Review High-Yield Information: Pay special attention to the high-yield
facts, mnemonics, and clinical pearls highlighted throughout the book.
11. Focus on Weak Areas: Use your practice test results to identify and
focus on improving your weak areas.
12. Simulate Exam Conditions: As your exam date approaches, take full-
length practice tests under timed conditions to build stamina and improve time management.
13. Review Strategies for Managing Exam Anxiety: Implement the stress-
reduction techniques provided in the book, such as deep breathing and positive self-talk.
14. Final Review: In the week before the exam, focus on reviewing high-
yield topics and your personal weak areas. Avoid cramming new information.
Remember, consistent study and active engagement with the material are key to success. Trust in your
preparation and approach the exam with confidence..
Who's This Book For? Let's Find Out!
This book, "First Aid for the USMLE Step 2 CK & 3 2025-2026," is designed to serve as the ultimate
resource for a broad range of medical professionals and students preparing for these critical exams.
Below is a detailed explanation of whom this book is intended for:
Medical Students Preparing for the USMLE Step 2 CK
This book is tailored for medical students in their clinical years who are preparing to take the USMLE
Step 2 CK. It provides:

Comprehensive Coverage: High-yield topics across all major disciplines, including

internal medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry, and preventive
medicine.
Clinical Reasoning Focus: Emphasis on clinical decision-making skills required for patient
management scenarios.
Practice Questions: Over 1,000 practice questions to reinforce learning and simulate exam
conditions.
Study Strategies: Guidance on how to effectively prepare for the exam with structured
schedules and targeted review.
Residents Preparing for the USMLE Step 3
For residents in their first or second year of postgraduate training, this book is an essential tool for
preparing for the USMLE Step 3. It includes:

CCS Mastery: A dedicated section on mastering Computer-based Case Simulations (CCS),

a unique component of the Step 3 exam.
Advanced Clinical Topics: Detailed explanations of multisystem disorders, risk assessment,
and evidence-based medicine.
Time Management Techniques: Strategies to handle the two-day exam format efficiently.
International Medical Graduates (IMGs)
International Medical Graduates aiming to pass the USMLE exams and secure residency positions in the
United States will find this book invaluable. It offers:

Updated Content: Current guidelines and evidence-based practices relevant to U.S.

healthcare.
Cultural Competency Tips: Insights into U.S. clinical practice norms and patient
communication strategies.
E-Learning Support: A premium e-learning course to supplement self-study efforts.
Physicians Seeking Licensure or Recertification
For practicing physicians who need to pass the USMLE exams as part of licensure or recertification
requirements, this book provides:
Concise Summaries: High-yield information presented in an easy-to-digest format.
Clinical Algorithms: Flowcharts and decision trees to streamline diagnostic and therapeutic
approaches.
Students Struggling with Test Anxiety
This book also addresses the needs of students who experience test anxiety or struggle with standardized
exams by offering:

Anxiety Management Strategies: Practical tips and exercises to reduce stress and improve
focus.
Mindfulness Techniques: Relaxation exercises integrated into study routines.
Those Looking for a Comprehensive “All-in-One” Resource
Whether you are a first-time test-taker or retaking the exam, this book combines everything you need into
one resource:

Two Books in One: Covers both Step 2 CK and Step 3 preparation in a single volume.
Workbook Integration: Practice exercises and self-assessment tools to reinforce learning.
Premium Features: Access to an interactive e-learning course that complements the written
material.
This book is designed with flexibility in mind, making it suitable for diverse learners at different stages of
their medical journey. Whether you are studying independently or as part of a group, this resource equips
you with all the tools needed to excel on these high-stakes exams.
INTRODUCTION
Have you ever wondered why some medical students breeze through the USMLE Step 2 CK and Step 3
exams while others struggle? The answer lies not just in knowledge, but in preparation strategy and exam
technique. Every year, thousands of aspiring physicians face these crucial exams, with approximately
45% failing to pass on their first attempt. This statistic isn't just a number—it represents countless hours
of study, significant financial investment, and dreams temporarily put on hold.
Dr. Michael Chen remembers vividly the day he received his Step 2 CK score. Despite months of
dedicated study, he had fallen short by just a few points. "I felt like the ground had disappeared beneath
my feet," he recalls. "All those nights of studying, all those sacrifices—and I was back at square one."
Michael's story is not unique. Many students find themselves overwhelmed by the vast amount of material
to cover, struggling to identify high-yield topics, or grappling with the unique challenges of computer-
based case simulations (CCS).
But there's hope. With the right resources and strategies, success is within reach. This is where "First Aid
for the USMLE Step 2 CK & 3 2025-2026" comes in. This comprehensive guide is designed to address
the major pitfalls students encounter, from content gaps to time management issues. By combining updated,
high-yield content with proven study techniques, practice questions, and a focus on CCS mastery, this
book aims to significantly improve your chances of success.
Whether you're a first-time test-taker or seeking to improve your score, this guide offers a structured
approach to exam preparation. From mnemonics that make complex concepts stick, to strategies for
tackling the most challenging question types, to workbook , and to a premium e-learning course that
reinforces key principles, "First Aid for the USMLE Step 2 CK & 3" is your ultimate companion on the
journey to becoming a licensed physician.
As you embark on this challenging yet rewarding path, remember Dr. Chen's words: "Success isn't about
never failing. It's about learning, adapting, and persevering." Let this book be your roadmap to success,
guiding you through the intricacies of the USMLE Step 2 CK and Step 3 exams, and bringing you one step
closer to achieving your medical career goals.!
Book 1: USMLE Step 2ck

Chapter 1: Exam Overview and Preparation

Strategies
The USMLE Step 2 Clinical Knowledge (CK) exam is a crucial milestone in your medical education
journey. This chapter provides a comprehensive overview of the exam format, content, and effective
preparation strategies to help you succeed. The Step 2 CK assesses your ability to apply medical
knowledge, skills, and understanding of clinical science essential for providing patient care under
supervision. It emphasizes health promotion and disease prevention and incorporates principles of
clinical sciences and basic patient-centered skills.
The exam is a computer-based test administered in a single day, lasting approximately 9 hours. It consists
of multiple-choice questions divided into eight 60-minute blocks, with a total of about 318 items. The
content is integrated, meaning questions may cover multiple disciplines within a single vignette. Major
subject areas tested include internal medicine, obstetrics and gynecology, pediatrics, preventive
medicine, psychiatry, surgery, and other areas relevant to providing care under supervision.
To excel on the Step 2 CK, you need a well-structured study plan, high-yield review materials, and
effective practice strategies. This chapter will guide you through understanding the exam format and
content, creating an optimal study schedule, and utilizing review resources and question banks effectively.
By following these strategies, you'll be well-prepared to tackle the challenges of the Step 2 CK and
demonstrate your clinical knowledge and skills.

Understanding the USMLE Step 2 CK format and content

The USMLE Step 2 CK exam is designed to assess a medical student's ability to apply clinical knowledge
and skills in patient care scenarios. It's crucial to have a thorough understanding of the exam format and
content to prepare effectively and perform well on test day.
The exam is administered as a computer-based test and consists of approximately 318 multiple-choice
questions divided into eight 60-minute blocks. Each block contains about 40 questions, and you'll have a
total of 9 hours to complete the entire exam, including break time. The questions are presented in a single-
best-answer format, where you must choose the most appropriate answer from the options provided.
Content-wise, the Step 2 CK covers a broad range of clinical sciences, with an emphasis on patient care
and health promotion. The exam integrates basic and clinical sciences, testing your ability to apply
knowledge across multiple disciplines. The major subject areas covered include:

1. Internal Medicine
2. Obstetrics and Gynecology
3. Pediatrics
4. Preventive Medicine
5. Psychiatry
6. Surgery
7. Other areas relevant to providing care under supervision
These subjects are not tested in isolation but are integrated throughout the exam. You may encounter
questions that require knowledge from multiple disciplines to arrive at the correct answer.
The exam also focuses on specific physician tasks and competencies, including:

1. Making a diagnosis
2. Understanding mechanisms of disease
3. Applying principles of management
4. Health maintenance and disease prevention
5. Interpretation of medical literature and biostatistics
Questions on the Step 2 CK are often presented as clinical vignettes, describing a patient's symptoms,
medical history, physical examination findings, and sometimes laboratory or imaging results. You'll need
to analyze this information to determine the most likely diagnosis, appropriate next step in management, or
best preventive measure.
The exam also includes questions on patient safety, quality improvement, interprofessional teamwork, and
professionalism. These topics reflect the increasing emphasis on these areas in modern medical practice.
To succeed on the Step 2 CK, you should be familiar with common and important disease presentations,
their diagnosis, and management. You should also be comfortable interpreting laboratory values, imaging
studies, and other diagnostic tests. Additionally, knowledge of evidence-based medicine principles and
the ability to apply them to clinical scenarios is crucial.
It's important to note that the Step 2 CK is not just about memorizing facts. The exam is designed to test
your ability to apply knowledge in clinical contexts, make sound decisions, and provide patient-centered
care. This means you need to develop strong clinical reasoning skills and the ability to synthesize
information from various sources to arrive at the best answer.
Time management is another critical aspect of the exam. With about 1.5 minutes per question on average,
you need to be efficient in reading and analyzing the vignettes and selecting your answers. Practice with
timed question blocks is essential to develop this skill.
Understanding the scoring system is also helpful. The Step 2 CK is scored on a three-digit scale, with the
passing score set at 209. However, aiming for a score well above the passing threshold is advisable,
especially if you're applying to competitive residency programs.
Lastly, keep in mind that the USMLE periodically updates the content and format of its exams. Stay
informed about any changes by regularly checking the official USMLE website and adjusting your
preparation accordingly.
By thoroughly understanding the format and content of the Step 2 CK, you can tailor your study approach
to match the exam's requirements, focus on high-yield topics, and develop the necessary skills to excel on
test day.
Creating an effective study schedule
Developing a well-structured and realistic study schedule is crucial for success on the USMLE Step 2
CK. An effective study plan helps you cover all necessary material, allows for regular review, and
prevents last-minute cramming. Here's how to create and maintain a productive study schedule:
Start Early: Begin your Step 2 CK preparation well in advance, ideally 3-6 months before your exam
date. This gives you ample time to cover all topics thoroughly and allows for multiple rounds of review.
Assess Your Knowledge: Begin by taking a diagnostic test or reviewing your performance in clinical
rotations to identify your strengths and weaknesses. This will help you allocate more time to subjects that
need improvement.
Set Realistic Goals: Break down your study plan into weekly and daily goals. Be specific about what
topics you'll cover each day. Make sure your goals are achievable to avoid feeling overwhelmed.
Prioritize High-Yield Topics: Focus on subjects that are frequently tested and have a significant impact on
your score. Use review books and question banks to identify these high-yield areas.
Create a Balanced Schedule: Divide your study time among different subjects. Don't spend too much time
on one area at the expense of others. Rotate through subjects to maintain interest and prevent burnout.
Incorporate Active Learning: Include a mix of reading, note-taking, flashcard review, and question
practice in your daily schedule. Active learning techniques help reinforce concepts and improve retention.
Use Spaced Repetition: Review topics at increasing intervals. This technique helps move information
from short-term to long-term memory.
Schedule Regular Breaks: Include short breaks every 50-60 minutes and longer breaks every few hours.
This helps maintain focus and prevents mental fatigue.
Allocate Time for Question Banks: Dedicate a significant portion of your study time to practicing
questions. Start with untimed blocks to focus on learning, then progress to timed blocks to simulate exam
conditions.
Plan for Full-Length Practice Tests: Schedule at least 2-3 full-length practice exams spread throughout
your study period. These help build stamina and familiarize you with the exam format.
Be Flexible: Allow some flexibility in your schedule for unexpected events or topics that require more
time than anticipated. Build in some buffer days for review or catch-up.
Review and Adjust Regularly: Evaluate your progress weekly. If you're consistently falling behind
schedule or finding certain study methods ineffective, be willing to adjust your plan.
Maintain a Healthy Lifestyle: Include time for exercise, proper meals, and adequate sleep in your
schedule. Physical and mental well-being are crucial for effective studying.
Use Technology: Utilize study apps or digital calendars to track your progress and set reminders for study
sessions.
Create a Conducive Study Environment: Designate a quiet, comfortable space for studying. Minimize
distractions by turning off notifications on your devices during study sessions.
Collaborate with Study Partners: If it suits your learning style, schedule regular study sessions with
classmates. This can help with motivation and allow for discussion of difficult concepts.
Incorporate Clinical Experiences: If possible, relate your studies to patients you've seen during rotations.
This real-world application can enhance understanding and retention.
Plan for Final Review: In the last few weeks before the exam, schedule time to review high-yield topics
and your personal weak areas.
Taper Studying Before the Exam: In the final days leading up to the exam, reduce your study intensity to
prevent burnout. Focus on review and confidence-building activities.
Prepare for Exam Day: Include time in your schedule to plan logistics for the exam day, such as
transportation and what to bring.
By creating and following a well-structured study schedule, you can ensure comprehensive coverage of
the Step 2 CK material, reduce stress, and maximize your chances of success on exam day. Remember,
consistency is key – stick to your schedule as much as possible, but also be kind to yourself and allow for
adjustments as needed.

Best practices for using review materials and question banks

Effectively utilizing review materials and question banks is crucial for success on the USMLE Step 2 CK.
These resources help consolidate your knowledge, identify weak areas, and familiarize you with the exam
format. Here are best practices for making the most of these study tools:
Choose High-Quality Resources: Select review books and question banks that are up-to-date and align
with the current Step 2 CK content outline. Look for resources that provide clear explanations and cover
high-yield topics.
Start with a Comprehensive Review: Begin your preparation by reading through a comprehensive review
book or set of review materials. This helps refresh your knowledge and provides a foundation for more
focused study later.
Use Multiple Resources: Don't rely on a single review book or question bank. Different resources may
explain concepts in ways that resonate better with your learning style. They also help ensure you're
covering all necessary topics.
Read Actively: When using review materials, engage with the content actively. Take notes, create
summaries, or draw diagrams to reinforce your understanding. This active engagement helps with
retention and recall.
Focus on Understanding, Not Memorization: While some memorization is necessary, focus on
understanding concepts and their clinical applications. This approach aligns better with the Step 2 CK's
emphasis on clinical reasoning.
Utilize Flashcards: Create or use pre-made flashcards for quick reviews of key concepts, diagnostic
criteria, and treatment algorithms. Digital flashcard apps with spaced repetition features can be
particularly effective.
Incorporate Multimedia Resources: Use video lectures, podcasts, or interactive online modules to
supplement your reading. These can provide alternative explanations and cater to different learning styles.
Start Question Banks Early: Begin using question banks early in your preparation, not just in the final
weeks. This helps identify knowledge gaps and guides your study focus.
Use Untimed Mode Initially: When starting with question banks, use untimed mode to focus on learning
from each question without the pressure of time constraints.
Read All Answer Explanations: Whether you answer a question correctly or incorrectly, always read the
full explanation. This reinforces correct knowledge and helps correct misunderstandings.
Track Your Performance: Keep a log of your question bank performance, noting areas where you
consistently struggle. Use this information to guide your review and focus on weak areas.
Simulate Exam Conditions: As you progress in your preparation, start doing timed blocks of questions to
simulate exam conditions. This helps improve your pacing and builds mental stamina.
Review Missed Questions: Regularly review questions you've answered incorrectly. Create a "mistake
journal" to analyze why you missed these questions and how to avoid similar errors in the future.
Use Question Banks for Active Recall: After studying a topic, use targeted questions from your question
bank to reinforce your learning through active recall.
Practice Clinical Reasoning: Focus on questions that present clinical vignettes and require you to apply
knowledge to patient scenarios. This aligns with the Step 2 CK's emphasis on clinical application.
Utilize Self-Assessment Tools: Many question banks offer self-assessment exams. Use these to gauge your
readiness and identify areas needing further review.
Balance Breadth and Depth: While it's important to cover all topics, allocate more time to high-yield
areas and your personal weak spots.
Integrate Information Across Disciplines: Look for connections between different subjects. The Step 2
CK often requires synthesizing information from multiple disciplines.
Use Images and Diagrams: Pay special attention to questions involving image interpretation, as these are
common on the Step 2 CK. Practice describing and interpreting X-rays, CT scans, and other diagnostic
images.
Focus on Patient Safety and Quality Improvement: These topics are increasingly important on the Step 2
CK. Ensure your review materials and question banks adequately cover these areas.
Review Ethics and Professionalism: Don't neglect questions on medical ethics and professionalism.
These topics are integral to the Step 2 CK and can be challenging if not adequately prepared for.
Practice Time Management: As you work through question banks, develop strategies for managing your
time effectively. Learn when to move on from difficult questions to ensure you complete all questions in a
block.
Analyze Answer Choices: When reviewing questions, understand why each incorrect answer choice is
wrong. This helps sharpen your ability to eliminate distractors on the actual exam.
Use Question Banks for Final Review: In the weeks leading up to your exam, use question banks for
comprehensive review, focusing on your weakest areas and high-yield topics.
Stay Updated: Medical knowledge evolves rapidly. Ensure you're using the most current editions of
review materials and updated question banks to align with the latest guidelines and practices.
By following these best practices, you can maximize the effectiveness of your review materials and
question banks, leading to a more thorough and efficient preparation for the USMLE Step 2 CK.
Remember, consistent and deliberate practice with these resources is key to improving your clinical
knowledge and test-taking skills.
Chapter 2: Internal Medicine
Internal medicine encompasses a broad range of medical knowledge and skills essential for diagnosing
and treating adult patients. This chapter covers high-yield topics across major organ systems, key
concepts in various subspecialties, and critical care and emergency medicine essentials. The content aims
to provide a comprehensive review of the most important and frequently tested areas on the USMLE Step
2 CK exam.
The chapter is organized into three main sections, each focusing on different aspects of internal medicine.
The first section covers high-yield topics in cardiology, pulmonology, and gastroenterology - three core
areas that feature prominently in clinical practice and on board exams. The second section explain the key
concepts in endocrinology, nephrology, and hematology, which are crucial for understanding hormonal
disorders, kidney diseases, and blood-related conditions. The final section addresses critical care and
emergency medicine essentials, preparing students for managing acutely ill patients and handling medical
emergencies.
Throughout this chapter, the emphasis is on clinical presentation, diagnostic approaches, and evidence-
based management strategies. The content integrates pathophysiology with clinical decision-making,
helping students develop a solid foundation for patient care. By mastering these topics, medical students
and residents will be well-equipped to handle a wide range of internal medicine cases and excel on their
board exams.

High-yield topics in cardiology, pulmonology, and

gastroenterology
Cardiology
Cardiology is a cornerstone of internal medicine, focusing on the diagnosis and treatment of heart and
blood vessel disorders. This section covers essential topics that are frequently encountered in clinical
practice and tested on board exams.
Coronary Artery Disease (CAD) remains the leading cause of morbidity and mortality worldwide.
Understanding its pathophysiology, risk factors, and management is crucial. CAD results from
atherosclerotic plaque buildup in coronary arteries, leading to reduced blood flow to the heart muscle.
Key risk factors include hypertension, diabetes, smoking, hyperlipidemia, obesity, and family history.
Diagnosis often involves a combination of clinical presentation, electrocardiogram (ECG) changes,
cardiac biomarkers, and imaging studies such as stress tests or coronary angiography. Treatment strategies
range from lifestyle modifications and medical therapy to revascularization procedures like percutaneous
coronary intervention (PCI) or coronary artery bypass grafting (CABG).
Acute Coronary Syndrome (ACS) encompasses a spectrum of conditions including unstable angina, non-
ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). Rapid
recognition and management of ACS is critical. STEMI, characterized by ST-segment elevation on ECG,
requires immediate reperfusion therapy, preferably primary PCI if available within 90 minutes, or
fibrinolytic therapy if PCI is not readily accessible. NSTEMI and unstable angina are managed with
antiplatelet therapy, anticoagulation, and early invasive strategy in high-risk patients.
Heart Failure is a complex clinical syndrome resulting from structural or functional cardiac
abnormalities. It's classified based on ejection fraction as reduced (HFrEF) or preserved (HFpEF).
Diagnosis relies on clinical symptoms, physical examination findings, natriuretic peptide levels, and
echocardiography. Treatment of HFrEF includes ACE inhibitors or ARBs, beta-blockers,
mineralocorticoid receptor antagonists, and in select cases, SGLT2 inhibitors. Device therapy such as
implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization therapy (CRT) may be
indicated in certain patients.
Arrhythmias are common in clinical practice. Atrial fibrillation, the most prevalent sustained arrhythmia,
requires a thorough understanding of stroke risk assessment (CHA2DS2-VASc score) and anticoagulation
strategies. Other important arrhythmias include supraventricular tachycardias, ventricular tachycardia,
and bradyarrhythmias. Management may involve rate control, rhythm control, anticoagulation,
antiarrhythmic drugs, or device therapy.
Valvular Heart Disease is another crucial area in cardiology. Aortic stenosis, mitral regurgitation, and
mitral stenosis are particularly high-yield. Understanding the pathophysiology, clinical presentation, and
indications for intervention (surgical or transcatheter) is essential. Echocardiography plays a central role
in diagnosis and follow-up of valvular diseases.
Hypertension, a major risk factor for cardiovascular disease, requires a nuanced approach to diagnosis
and management. The latest guidelines emphasize the importance of out-of-office blood pressure
measurements and risk-based treatment thresholds. First-line pharmacological options include ACE
inhibitors, ARBs, calcium channel blockers, and thiazide diuretics.
Preventive Cardiology focuses on primary and secondary prevention of cardiovascular disease. This
includes risk assessment tools like the Pooled Cohort Equations, lipid management strategies, and
appropriate use of aspirin for primary prevention. Understanding the latest guidelines on statin therapy
and target LDL levels is crucial.
Lastly, a solid grasp of ECG interpretation is indispensable in cardiology. This includes recognizing
common arrhythmias, ischemic changes, conduction abnormalities, and electrolyte disturbances on ECG.

Pulmonology
Pulmonology, the study of respiratory system diseases, is a vital component of internal medicine. This
section covers key topics that are essential for clinical practice and board exams.
Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality
worldwide. It's characterized by persistent airflow limitation due to airway and/or alveolar
abnormalities. Risk factors include smoking, occupational exposures, and alpha-1 antitrypsin deficiency.
Diagnosis is based on spirometry showing a post-bronchodilator FEV1/FVC ratio < 0.7. Management
involves smoking cessation, bronchodilators (short-acting and long-acting beta-2 agonists and
anticholinergics), inhaled corticosteroids in select patients, pulmonary rehabilitation, and oxygen therapy
when indicated. Exacerbations are treated with systemic corticosteroids, antibiotics, and intensified
bronchodilator therapy.
Asthma is a chronic inflammatory airway disease characterized by variable expiratory airflow limitation
and respiratory symptoms. Diagnosis is based on typical symptoms and demonstration of variable airflow
limitation. Management follows a step-wise approach, with inhaled corticosteroids as the cornerstone of
treatment for persistent asthma. Short-acting beta-2 agonists are used for quick relief. Severe asthma may
require biologics targeting specific inflammatory pathways.
Pneumonia remains a significant cause of morbidity and mortality. Community-acquired pneumonia (CAP)
is distinguished from hospital-acquired and ventilator-associated pneumonia. For CAP, risk stratification
using tools like the CURB-65 or Pneumonia Severity Index guides decisions on outpatient versus inpatient
management. Empiric antibiotic choices depend on severity and risk factors for drug-resistant pathogens.
Healthcare-associated pneumonia requires broader antibiotic coverage.
Pulmonary Embolism (PE) is a potentially life-threatening condition requiring prompt diagnosis and
treatment. Risk factors include immobility, surgery, malignancy, and inherited thrombophilias. Diagnosis
often involves D-dimer testing and CT pulmonary angiography. Risk stratification guides management
decisions, including outpatient treatment for low-risk PE and consideration of thrombolysis for high-risk
PE.
Interstitial Lung Diseases (ILDs) encompass a heterogeneous group of disorders affecting the lung
parenchyma. High-yield topics include idiopathic pulmonary fibrosis, sarcoidosis, and hypersensitivity
pneumonitis. Diagnosis often requires integration of clinical, radiological (high-resolution CT), and
sometimes histopathological findings. Treatment varies depending on the specific ILD but may include
antifibrotic agents, immunosuppression, or management of underlying causes.
Obstructive Sleep Apnea (OSA) is increasingly recognized as a significant health problem. Risk factors
include obesity, male gender, and certain craniofacial abnormalities. Diagnosis is confirmed by
polysomnography. Treatment options include continuous positive airway pressure (CPAP), oral
appliances, and in some cases, surgery.
Lung Cancer screening with low-dose CT is recommended for high-risk individuals. Understanding the
approach to solitary pulmonary nodules is crucial. For diagnosed lung cancer, staging and knowledge of
current treatment modalities, including targeted therapies and immunotherapy, are important.
Pleural Diseases, including pleural effusions and pneumothorax, are common. Understanding the approach
to diagnosing the etiology of pleural effusions (Light's criteria for distinguishing transudates from
exudates) and management of pneumothorax is essential.
Tuberculosis remains a global health concern. Knowledge of screening, diagnosis (including interferon-
gamma release assays), and treatment of both latent and active TB is important. Understanding the
approach to multidrug-resistant TB is also crucial.
Lastly, interpretation of Pulmonary Function Tests (PFTs) is a key skill in pulmonology. This includes
understanding spirometry patterns in obstructive and restrictive lung diseases, lung volumes, and diffusing
capacity.

Gastroenterology
Gastroenterology focuses on the digestive system and its disorders. This section covers high-yield topics
crucial for clinical practice and board exams.
Gastroesophageal Reflux Disease (GERD) is a common condition characterized by symptoms or
complications resulting from the reflux of gastric contents into the esophagus. Diagnosis is often based on
typical symptoms and response to empiric therapy. Endoscopy is indicated for alarm symptoms or
persistent symptoms despite therapy. Management includes lifestyle modifications, proton pump inhibitors
(PPIs), and in refractory cases, surgical options like fundoplication.
Peptic Ulcer Disease (PUD) can affect the stomach or duodenum. The two main causes are Helicobacter
pylori infection and NSAIDs. Diagnosis is confirmed by endoscopy. Management involves treating the
underlying cause (H. pylori eradication or discontinuation of NSAIDs) and acid suppression with PPIs.
Complications like bleeding or perforation require urgent intervention.
Inflammatory Bowel Disease (IBD) includes Crohn's disease and ulcerative colitis. Understanding the
differences in clinical presentation, disease distribution, and extraintestinal manifestations is crucial.
Diagnosis involves a combination of clinical, laboratory, endoscopic, and histological findings.
Treatment options include 5-ASA compounds, corticosteroids, immunomodulators, and biologics, with
the choice depending on disease severity and location.
Colorectal Cancer screening is a key aspect of preventive medicine. Current guidelines recommend
screening starting at age 45 for average-risk individuals. Options include colonoscopy, fecal
immunochemical testing, and stool DNA testing. Understanding the approach to positive screening tests
and surveillance intervals is important.
Liver Diseases form a significant part of gastroenterology. Viral hepatitis (particularly hepatitis B and C)
requires knowledge of screening, diagnosis, and current treatment options. Alcoholic and non-alcoholic
fatty liver diseases are increasingly common. Cirrhosis and its complications (portal hypertension,
ascites, hepatic encephalopathy, hepatocellular carcinoma) are high-yield topics. Understanding the
Model for End-Stage Liver Disease (MELD) score for prognostication is crucial.
Pancreatitis, both acute and chronic, is an important topic. For acute pancreatitis, understanding the
etiology (gallstones and alcohol being the most common), severity assessment, and management
principles is key. Chronic pancreatitis requires knowledge of diagnosis (including pancreatic function
tests and imaging) and management of pain and exocrine insufficiency.
Gastrointestinal Bleeding, both upper and lower, requires a systematic approach. For upper GI bleeding,
understanding the management of variceal versus non-variceal bleeding is crucial. Lower GI bleeding
necessitates knowledge of common causes and appropriate diagnostic and therapeutic interventions.
Functional Gastrointestinal Disorders, particularly irritable bowel syndrome (IBS), are common.
Understanding the Rome criteria for diagnosis and management options is important.
Celiac Disease is an immune-mediated enteropathy triggered by gluten ingestion in genetically susceptible
individuals. Diagnosis involves serological testing and duodenal biopsy. Management centers on a strict
gluten-free diet.
Diverticular Disease is common in Western populations. Understanding the spectrum from asymptomatic
diverticulosis to acute diverticulitis is important. Management of acute diverticulitis and indications for
surgery should be known.
Lastly, a solid understanding of common GI procedures is crucial. This includes indications and
contraindications for endoscopy, colonoscopy, ERCP, and liver biopsy.

Key concepts in endocrinology, nephrology, and hematology

Endocrinology
Endocrinology deals with disorders of the endocrine system and its specific secretions called hormones.
This section covers key concepts that are essential for clinical practice and board exams.
Diabetes Mellitus is a cornerstone of endocrinology. Type 1 diabetes, characterized by autoimmune
destruction of pancreatic beta cells, requires lifelong insulin therapy. Type 2 diabetes, marked by insulin
resistance and relative insulin deficiency, is managed with a combination of lifestyle modifications and
medications. Understanding the diagnostic criteria (fasting plasma glucose ≥126 mg/dL, 2-hour plasma
glucose ≥200 mg/dL during an OGTT, HbA1c ≥6.5%, or random plasma glucose ≥200 mg/dL with
symptoms) is crucial. Management of type 2 diabetes typically starts with metformin, with additional
agents added based on patient characteristics and comorbidities. These may include sulfonylureas,
thiazolidinediones, DPP-4 inhibitors, GLP-1 receptor agonists, SGLT2 inhibitors, and insulin.
Recognizing and managing acute complications (diabetic ketoacidosis, hyperosmolar hyperglycemic
state) and chronic complications (microvascular and macrovascular) is essential.
Thyroid Disorders are common endocrine problems. Hypothyroidism, most often caused by autoimmune
thyroiditis (Hashimoto's disease), is diagnosed by elevated TSH and low free T4. Treatment involves
levothyroxine replacement. Hyperthyroidism, commonly due to Graves' disease, is characterized by low
TSH and elevated free T4 and/or T3. Management options include antithyroid drugs, radioactive iodine
ablation, and surgery. Thyroid nodules require evaluation with ultrasound and possibly fine-needle
aspiration based on sonographic features.
Adrenal Disorders include Cushing's syndrome, Addison's disease, and pheochromocytoma. Cushing's
syndrome, characterized by cortisol excess, requires understanding of the diagnostic approach (24-hour
urinary free cortisol, overnight dexamethasone suppression test) and differentiating ACTH-dependent
from ACTH-independent causes. Addison's disease, or primary adrenal insufficiency, presents with
fatigue, hyperpigmentation, and electrolyte abnormalities. Diagnosis is confirmed with the ACTH
stimulation test. Pheochromocytoma, a catecholamine-secreting tumor, requires a high index of suspicion
and is diagnosed with plasma or urinary metanephrines.
Pituitary Disorders encompass a range of conditions affecting the "master gland." Prolactinomas, the most
common functioning pituitary adenomas, are diagnosed with elevated prolactin levels and pituitary
imaging. Treatment typically involves dopamine agonists. Acromegaly, caused by growth hormone excess,
requires understanding of the diagnostic approach (IGF-1 levels, growth hormone suppression test) and
treatment options (surgery, medical therapy, radiation). Hypopituitarism necessitates a systematic
approach to evaluating each pituitary hormone axis.
Calcium Disorders are important endocrine topics. Primary hyperparathyroidism, characterized by
elevated calcium and inappropriately normal or elevated PTH, is most often caused by a parathyroid
adenoma. Surgical removal is the definitive treatment. Hypoparathyroidism leads to hypocalcemia and
requires careful management with calcium and vitamin D supplementation.
Osteoporosis, while not strictly an endocrine disorder, is often managed by endocrinologists.
Understanding risk factors, indications for screening with dual-energy X-ray absorptiometry (DEXA), and
treatment options (bisphosphonates, denosumab, teriparatide) is crucial.
Male Hypogonadism requires careful diagnosis based on low morning testosterone levels and appropriate
clinical features. Treatment with testosterone replacement should be considered in symptomatic men with
consistently low testosterone levels.
Obesity is increasingly recognized as an endocrine disorder. Understanding the pathophysiology,
complications, and management options (lifestyle interventions, pharmacotherapy, bariatric surgery) is
important.
Lipid Disorders, while often managed by cardiologists, have a significant endocrine component.
Understanding the latest guidelines for lipid management is crucial. The American College of Cardiology
and American Heart Association guidelines focus on risk assessment and appropriate statin therapy. For
primary prevention in patients without clinical atherosclerotic cardiovascular disease (ASCVD), the
guidelines recommend using the Pooled Cohort Equations to estimate 10-year ASCVD risk. High-intensity
statin therapy is recommended for patients with LDL cholesterol ≥190 mg/dL, diabetes mellitus with age
40-75 years and LDL ≥70 mg/dL, or 10-year ASCVD risk ≥7.5%. Moderate-intensity statin therapy is
recommended for patients with 10-year risk of 5% to 7.5%. The guidelines emphasize shared decision-
making between clinicians and patients regarding the potential benefits, adverse effects, and patient
preferences for treatment.
For patients with clinical ASCVD, high-intensity statin therapy is recommended to achieve at least a 50%
reduction in LDL cholesterol. If high-intensity statin therapy is not tolerated, moderate-intensity statin
therapy should be used with the goal of achieving at least a 30-50% reduction in LDL cholesterol. Non-
statin therapies may be considered to further lower LDL cholesterol in high-risk patients who have a less-
than-anticipated response to statins, are unable to tolerate a less-than-recommended intensity of a statin,
or are completely statin intolerant.
The management of hypertriglyceridemia is another important aspect of lipid disorders. Elevated
triglycerides are associated with increased cardiovascular risk and can lead to pancreatitis when
severely elevated. Lifestyle modifications, including weight loss, dietary changes, and increased physical
activity, are the cornerstone of treatment for mild to moderate hypertriglyceridemia. For patients with
triglycerides >500 mg/dL, pharmacologic therapy with fibrates, niacin, or high-dose omega-3 fatty acids
should be considered to reduce the risk of pancreatitis.
Familial hypercholesterolemia (FH) is a genetic disorder characterized by very high LDL cholesterol
levels and premature cardiovascular disease. Diagnosis is based on LDL cholesterol levels, family
history, and physical findings such as tendon xanthomas. Treatment of FH typically requires high-intensity
statin therapy, often in combination with other lipid-lowering agents such as ezetimibe or PCSK9
inhibitors.
The role of lipoprotein(a) [Lp(a)] in cardiovascular risk assessment has gained attention in recent years.
Elevated Lp(a) levels are associated with increased risk of ASCVD and aortic valve stenosis. While
there are currently no specific therapies targeting Lp(a), its measurement may be useful in refining risk
assessment in certain patient populations.
Metabolic syndrome, characterized by a cluster of risk factors including abdominal obesity, hypertension,
dyslipidemia, and insulin resistance, is an important endocrine concept with significant implications for
cardiovascular health. Management of metabolic syndrome focuses on lifestyle modifications and
treatment of individual components to reduce overall cardiovascular risk.
The interplay between diabetes mellitus and lipid disorders is complex. Diabetic dyslipidemia,
characterized by elevated triglycerides, low HDL cholesterol, and small, dense LDL particles, contributes
significantly to the increased cardiovascular risk in patients with diabetes. Management of lipids in
diabetic patients often requires a multifaceted approach, including glycemic control, statin therapy, and
treatment of other cardiovascular risk factors.
Thyroid dysfunction can have significant effects on lipid metabolism. Hypothyroidism is associated with
elevated total and LDL cholesterol levels, while hyperthyroidism can lead to decreased LDL cholesterol
and increased triglycerides. Screening for thyroid dysfunction is important in patients with unexplained
dyslipidemia, and treatment of the underlying thyroid disorder often leads to improvement in lipid
profiles.
The role of diet and nutrition in lipid management cannot be overstated. The Mediterranean diet,
characterized by high intake of fruits, vegetables, whole grains, and healthy fats, has been shown to have
beneficial effects on lipid profiles and cardiovascular risk. Plant sterols and stanols, found in certain
foods and supplements, can help lower LDL cholesterol by reducing intestinal absorption of cholesterol.
Emerging therapies for lipid disorders include PCSK9 inhibitors, which have shown significant LDL-
lowering effects and reduction in cardiovascular events in high-risk patients. Bempedoic acid, a novel
ATP citrate lyase inhibitor, offers an additional option for LDL lowering in patients who are statin-
intolerant or require additional therapy. Gene therapy approaches for familial hypercholesterolemia are
also under investigation and may offer new treatment options for this challenging disorder in the future.

Key concepts in nephrology

Nephrology focuses on disorders of the kidney and their impact on overall health. A key concept in
nephrology is understanding glomerular filtration rate (GFR), which measures how well the kidneys filter
waste from the blood. Normal GFR is around 120 mL/min/1.73m2, with values below 60 indicating
chronic kidney disease. Creatinine is commonly used to estimate GFR, though it has limitations. Cystatin
C provides a more accurate GFR estimate, especially in patients with reduced muscle mass.
Acute kidney injury (AKI) refers to a rapid decline in kidney function over hours to days. Common causes
include decreased renal perfusion, nephrotoxic medications, and urinary obstruction. Management focuses
on treating the underlying cause, optimizing fluid status, and avoiding further kidney damage. Severe AKI
may require temporary dialysis support.
Chronic kidney disease (CKD) involves a gradual loss of kidney function over months to years. Diabetes
and hypertension are leading causes. CKD is staged based on GFR and albuminuria levels. Early stages
are often asymptomatic, so screening high-risk patients is crucial. Treatment aims to slow progression
through blood pressure control, glycemic control in diabetics, and lifestyle modifications. As CKD
advances, complications like anemia, bone disease, and metabolic acidosis require management.
Glomerulonephritis encompasses inflammatory conditions affecting the glomeruli. It can be primary or
secondary to systemic diseases like lupus. Presentation may include hematuria, proteinuria, edema, and
hypertension. Kidney biopsy is often needed for definitive diagnosis. Treatment depends on the specific
type but may include immunosuppression.
Nephrotic syndrome is characterized by heavy proteinuria, hypoalbuminemia, edema, and hyperlipidemia.
Common causes are minimal change disease, focal segmental glomerulosclerosis, and membranous
nephropathy. Management includes diuretics, ACE inhibitors or ARBs to reduce proteinuria, and treating
the underlying cause.
Renal tubular acidosis involves impaired acid-base regulation by the kidneys. There are several types
based on the specific tubular defect. Symptoms may include fatigue, muscle weakness, and kidney stones.
Treatment focuses on alkali supplementation.
Polycystic kidney disease is an inherited disorder causing multiple cysts to form in the kidneys. It can
lead to kidney enlargement, hypertension, and progressive CKD. Management includes blood pressure
control and pain management for cyst complications.
Renal artery stenosis can cause secondary hypertension and ischemic nephropathy. Atherosclerosis is the
most common cause in older adults, while fibromuscular dysplasia is more common in younger patients.
Diagnosis often involves imaging studies. Treatment may include medication, angioplasty with stenting, or
surgery in severe cases.
Kidney stones affect about 10% of people during their lifetime. Common types include calcium oxalate,
uric acid, and struvite stones. Prevention focuses on increased fluid intake and dietary modifications
based on stone composition. Medical therapy may include thiazide diuretics, citrate supplementation, or
allopurinol. Larger stones may require lithotripsy or surgical removal.
Renal replacement therapy becomes necessary in end-stage renal disease. Options include hemodialysis,
peritoneal dialysis, and kidney transplantation. The choice depends on patient factors and preferences.
Transplantation offers the best outcomes but requires lifelong immunosuppression.

Key concepts in hematology

Hematology deals with disorders of the blood and blood-forming organs. A fundamental concept is
hematopoiesis - the process by which blood cells are produced in the bone marrow. Understanding the
stages of blood cell development and regulation is crucial for diagnosing and treating hematologic
disorders.
Anemia is a common hematologic problem characterized by decreased red blood cell mass or
hemoglobin concentration. Classification is based on red cell size (microcytic, normocytic, macrocytic)
and underlying mechanism (decreased production, increased destruction, blood loss). Iron deficiency is
the most common cause worldwide. Evaluation includes a complete blood count, reticulocyte count, and
iron studies. Treatment depends on the specific cause but may involve iron supplementation, vitamin B12
or folate replacement, or addressing chronic diseases.
Hemoglobinopathies are inherited disorders affecting hemoglobin structure or production. Sickle cell
disease results from a mutation causing abnormal hemoglobin S, leading to red cell sickling and vaso-
occlusion. Management includes pain control, hydration, and prevention of complications. Thalassemias
involve reduced or absent production of globin chains. Severity varies widely, with transfusion
dependence in severe cases.
Hemostasis involves the delicate balance between clotting and bleeding. Primary hemostasis refers to
platelet adhesion and aggregation, while secondary hemostasis involves the coagulation cascade.
Disorders can lead to excessive bleeding or thrombosis. Common tests include platelet count,
prothrombin time (PT), and activated partial thromboplastin time (aPTT).
Thrombocytopenia, or low platelet count, can result from decreased production, increased destruction, or
splenic sequestration. Immune thrombocytopenia is an important acquired cause. Management may
include corticosteroids, intravenous immunoglobulin, or other immunosuppressants. Severe cases may
require platelet transfusions.
Venous thromboembolism encompasses deep vein thrombosis and pulmonary embolism. Risk factors
include immobility, surgery, cancer, and inherited thrombophilias. Anticoagulation is the mainstay of
treatment, with options including heparin, low molecular weight heparin, direct oral anticoagulants, and
warfarin.
Leukemias are malignancies of white blood cells. Acute leukemias involve immature blast cells and
require urgent treatment. Chronic leukemias involve more mature cells and often have a more indolent
course. Classification is based on cell lineage (myeloid vs lymphoid) and clinical features. Treatment
may include chemotherapy, targeted therapies, and stem cell transplantation.
Lymphomas are cancers of lymphoid tissue. Hodgkin lymphoma is characterized by Reed-Sternberg cells
and has a bimodal age distribution. Non-Hodgkin lymphomas comprise a diverse group of malignancies
with varying clinical behaviors. Staging and histologic subtype guide treatment approaches.
Multiple myeloma is a plasma cell malignancy characterized by monoclonal protein production. It can
lead to bone lesions, hypercalcemia, renal dysfunction, and anemia. Treatment has evolved significantly
with the advent of proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies.
Myeloproliferative neoplasms involve excessive production of mature blood cells. They include
polycythemia vera, essential thrombocythemia, and primary myelofibrosis. JAK2 mutations are common.
Management aims to prevent thrombotic and hemorrhagic complications.
Transfusion medicine is an important aspect of hematology. Blood component therapy includes packed red
blood cells, platelets, fresh frozen plasma, and cryoprecipitate. Understanding indications, risks, and
alternatives is crucial. Transfusion reactions can range from mild febrile reactions to life-threatening
hemolysis or TRALI (transfusion-related acute lung injury).

Critical care and emergency medicine essentials

Critical care
Critical care medicine focuses on managing patients with life-threatening conditions. A key principle is
the ABCs - Airway, Breathing, Circulation. Securing the airway is paramount in critically ill patients.
Endotracheal intubation may be necessary for airway protection or mechanical ventilation. Rapid
sequence intubation involves administering a sedative and paralytic to facilitate quick, safe intubation.
Mechanical ventilation supports patients unable to breathe adequately on their own. Understanding
ventilator modes, settings, and potential complications is crucial. Lung-protective ventilation strategies
aim to minimize ventilator-induced lung injury. Weaning protocols help liberate patients from mechanical
ventilation when appropriate.
Shock is a state of inadequate tissue perfusion. Types include hypovolemic, cardiogenic, distributive
(e.g., septic), and obstructive. Early recognition and treatment are vital. Management principles include
addressing the underlying cause, fluid resuscitation, and vasopressor support if needed. Septic shock
requires prompt antibiotic administration and source control.
Acute respiratory distress syndrome (ARDS) involves diffuse alveolar damage leading to hypoxemia.
Management includes lung-protective ventilation, prone positioning in severe cases, and consideration of
neuromuscular blockade. Extracorporeal membrane oxygenation (ECMO) may be used in refractory
cases.
Hemodynamic monitoring guides management of critically ill patients. Tools include arterial lines for
continuous blood pressure monitoring, central venous catheters for fluid management and medication
administration, and pulmonary artery catheters for advanced hemodynamic assessment. Echocardiography
provides valuable information about cardiac function and volume status.
Acute kidney injury is common in ICU patients. Continuous renal replacement therapy may be necessary
for severe cases, especially in hemodynamically unstable patients. Indications include refractory
acidosis, hyperkalemia, and volume overload.
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Early
recognition using tools like the qSOFA score is crucial. The Surviving Sepsis Campaign guidelines
emphasize early antibiotics, fluid resuscitation, and source control.
Acute liver failure can lead to coagulopathy, encephalopathy, and multiorgan dysfunction. Management
includes supportive care, treating the underlying cause, and monitoring for complications like cerebral
edema. Liver transplantation may be lifesaving in select cases.
Neurological emergencies in the ICU include status epilepticus, acute ischemic stroke, and increased
intracranial pressure. Rapid assessment and intervention are essential. Monitoring tools like intracranial
pressure monitors and continuous EEG may guide management.
Nutrition support is vital in critically ill patients. Enteral nutrition is preferred when feasible. Parenteral
nutrition may be necessary in some cases. Careful attention to electrolyte and micronutrient replacement is
important.
Sedation and analgesia management aims to keep patients comfortable while avoiding oversedation.
Daily sedation interruptions and spontaneous breathing trials facilitate earlier liberation from mechanical
ventilation. Delirium is a common complication that requires active prevention and management.
End-of-life care is an important aspect of critical care. This involves clear communication with patients
and families, addressing goals of care, and providing comfort measures when appropriate. Understanding
concepts of medical futility and ethical principles in withdrawing or withholding life-sustaining
treatments is crucial.
Emergency medicine essentials
Emergency medicine requires rapid assessment and management of acute conditions. The initial approach
to any patient involves the primary survey: Airway, Breathing, Circulation, Disability (neurological
status), and Exposure. This systematic approach helps identify and address life-threatening conditions
quickly.
Triage is a crucial concept in emergency medicine, allowing prioritization of patients based on acuity.
Common triage systems include the Emergency Severity Index (ESI) and the Canadian Triage and Acuity
Scale (CTAS).
Chest pain is a common presenting complaint. The differential diagnosis is broad, including life-
threatening conditions like acute coronary syndrome, pulmonary embolism, and aortic dissection. Initial
evaluation includes ECG, cardiac enzymes, and chest x-ray. Risk stratification tools help guide
management decisions.
Shortness of breath can result from cardiac, pulmonary, or other systemic causes. Assessment includes
vital signs, oxygen saturation, and work of breathing. Point-of-care ultrasound can provide valuable
information about cardiac function and lung pathology.
Altered mental status requires a systematic approach. The mnemonic AEIOU TIPS helps remember
common causes: Alcohol, Electrolytes, Insulin, Opiates, Uremia, Trauma, Infection, Psychogenic, and
Stroke. Rapid glucose check and naloxone administration for suspected opioid overdose are early
interventions.
Trauma management follows ATLS principles. The primary survey identifies immediate life threats.
Secondary survey involves a head-to-toe examination. Damage control resuscitation emphasizes early
blood product administration in massive hemorrhage.
Stroke care emphasizes rapid assessment and early intervention. The FAST (Face, Arms, Speech, Time)
mnemonic aids in recognition. CT imaging distinguishes ischemic from hemorrhagic stroke. Thrombolysis
with tPA is indicated in select patients with acute ischemic stroke.
Sepsis recognition and early management are crucial. The qSOFA score (altered mental status, respiratory
rate ≥22, systolic blood pressure ≤100 mmHg) helps identify high-risk patients. Early antibiotics and
fluid resuscitation are key interventions.
Toxicologic emergencies require knowledge of common toxidromes and antidotes. Activated charcoal
may be used for some ingestions. Specific antidotes include naloxone for opioids, N-acetylcysteine for
acetaminophen toxicity, and fomepizole for toxic alcohols.
Pediatric emergencies require consideration of age-specific conditions and medication dosing. The
Broselow tape aids in rapid weight estimation and equipment sizing. Common pediatric emergencies
include respiratory distress (e.g., croup, bronchiolitis) and fever in young infants.
Procedural skills are essential in emergency medicine. These include airway management, central line
placement, lumbar puncture, and wound care. Ultrasound guidance improves safety for many procedures.
Disaster preparedness is an important aspect of emergency medicine. This involves understanding
hospital disaster plans, triage in mass casualty incidents, and decontamination procedures for chemical
exposures.
Emergency physicians must be adept at breaking bad news and discussing goals of care. Clear
communication with patients, families, and other healthcare providers is crucial. Understanding legal and
ethical issues, such as consent for treatment and capacity assessment, is also important in emergency
practice.

Chapter 2 Summary and Workbook

This chapter provides a comprehensive overview of key topics in internal medicine, focusing on
cardiology, pulmonology, gastroenterology, endocrinology, nephrology, and hematology. It also covers
critical care and emergency medicine essentials.
In cardiology, the chapter discusses coronary artery disease, acute coronary syndrome, heart failure,
arrhythmias, valvular heart disease, hypertension, and preventive cardiology. It emphasizes the
importance of understanding pathophysiology, risk factors, diagnostic approaches, and management
strategies for these conditions.
The pulmonology section covers chronic obstructive pulmonary disease, asthma, pneumonia, pulmonary
embolism, interstitial lung diseases, obstructive sleep apnea, lung cancer, and pleural diseases. It
highlights the significance of proper diagnosis, management, and interpretation of pulmonary function
tests.
Gastroenterology topics include gastroesophageal reflux disease, peptic ulcer disease, inflammatory
bowel disease, colorectal cancer screening, liver diseases, pancreatitis, gastrointestinal bleeding, and
functional gastrointestinal disorders.
The endocrinology section focuses on diabetes mellitus, thyroid disorders, adrenal disorders, pituitary
disorders, calcium disorders, osteoporosis, and lipid disorders. It emphasizes the importance of
understanding diagnostic criteria, treatment options, and management of complications.
Nephrology covers acute kidney injury, chronic kidney disease, glomerulonephritis, nephrotic syndrome,
renal tubular acidosis, polycystic kidney disease, renal artery stenosis, and kidney stones.
The hematology section discusses anemia, hemoglobinopathies, hemostasis disorders, thrombocytopenia,
venous thromboembolism, leukemias, lymphomas, multiple myeloma, and transfusion medicine.
Lastly, the chapter covers critical care and emergency medicine essentials, including mechanical
ventilation, shock management, sepsis, acute respiratory distress syndrome, and various emergency
presentations
Grab Your Pen & Let’s Do Some Quick Tests
1. How would you approach a patient presenting with chest pain to differentiate between
cardiac and non-cardiac causes?
2. What are the key differences in management between heart failure with reduced ejection
fraction and preserved ejection fraction?
3. How would you determine the appropriate anticoagulation strategy for a patient with atrial
fibrillation?
4. What factors would you consider when deciding between medical management and surgical
intervention for a patient with valvular heart disease?
5. How would you approach the diagnosis and management of a patient with suspected
interstitial lung disease?
6. What are the potential complications of inflammatory bowel disease, and how would you
monitor for them?
7. How would you determine the appropriate treatment regimen for a newly diagnosed type 2
diabetic patient?
8. What factors would you consider when evaluating a patient for potential renal replacement
therapy?
9. How would you approach the diagnosis and management of a patient with suspected
hematologic malignancy?
10. What are the key considerations in managing a patient with septic
shock in the intensive care unit?

.
Chapter 3: Surgery and Surgical Subspecialties
Surgery and its subspecialties form a critical component of medical practice, encompassing a wide range
of procedures and techniques aimed at diagnosing, treating, and managing various conditions. This
chapter provides an overview of key principles and practices across general surgery and important
surgical subspecialties.
General surgery serves as the foundation, covering core concepts like preoperative evaluation,
intraoperative management, and postoperative care that apply broadly across surgical fields. Common
general surgical procedures like appendectomy and cholecystectomy are explored. The chapter then
examines major surgical subspecialties including orthopedics, urology, otolaryngology, neurosurgery and
ophthalmology. For each, we highlight important conditions, diagnostic approaches, and surgical
interventions.
Orthopedics focuses on the musculoskeletal system, addressing fractures, joint disorders, and spine
conditions through both operative and non-operative means. Urology covers diseases of the urinary tract
and male reproductive system, with procedures ranging from kidney stone removal to prostate surgery.
Otolaryngology deals with ear, nose, and throat disorders, encompassing hearing loss, sinus disease, and
head and neck cancers. Neurosurgery involves complex procedures on the brain, spine, and peripheral
nerves to treat tumors, vascular abnormalities, and trauma. Finally, ophthalmology addresses disorders of
the eye and visual system through both medical and surgical approaches.
By providing an integrated overview of these surgical fields, this chapter aims to equip medical students
and clinicians with essential knowledge to understand surgical management across a range of common
and critical conditions. The focus is on high-yield concepts most relevant for clinical practice and board
examinations.

General surgery principles and common procedures

General surgery encompasses a broad range of procedures and serves as the foundation for many surgical
subspecialties. A thorough understanding of general surgical principles is essential for all physicians,
regardless of their ultimate specialty. This section covers key concepts in preoperative evaluation,
intraoperative management, and postoperative care, as well as common general surgical procedures.
Preoperative evaluation is a critical step in ensuring optimal surgical outcomes. A comprehensive history
and physical examination should be performed, with particular attention to factors that may increase
perioperative risk. This includes assessing the patient's overall health status, identifying any
comorbidities, and evaluating functional capacity. Routine preoperative testing should be tailored to the
individual patient and planned procedure. For healthy patients undergoing low-risk procedures, extensive
testing is often unnecessary. However, patients with significant medical problems or those undergoing
major surgery may require more extensive workup, including laboratory studies, electrocardiogram, chest
radiograph, and possibly further cardiac or pulmonary evaluation.
Proper preoperative fasting is important to reduce the risk of aspiration during anesthesia. For elective
procedures, patients should fast from solid food for at least 8 hours and clear liquids for at least 2 hours
prior to surgery. Medications should be reviewed, with particular attention to anticoagulants, antiplatelet
agents, and drugs that may interact with anesthetics. Many medications should be continued up to the day
of surgery, while others may need to be held or adjusted. Antibiotic prophylaxis is indicated for many
surgical procedures to reduce the risk of surgical site infections. The choice of antibiotic and timing of
administration should be based on the specific procedure and patient factors.
Intraoperative management focuses on maintaining homeostasis and optimizing conditions for successful
surgery. Proper positioning of the patient is crucial to prevent nerve injuries and pressure ulcers. Careful
attention to fluid management, temperature regulation, and pain control is essential. Monitoring of vital
signs, urine output, and blood loss helps guide fluid and blood product administration. The surgical team
must adhere to strict sterile technique and follow established protocols to minimize the risk of surgical
site infections.
Postoperative care begins in the recovery room and continues throughout the hospital stay and follow-up
period. Early recognition and management of common postoperative complications is crucial. Pain
control is a key aspect of postoperative care, typically involving a multimodal approach with opioid and
non-opioid analgesics. Early mobilization and respiratory care help prevent complications like deep vein
thrombosis and pneumonia. Proper wound care and incision management promote healing and reduce
infection risk. Nutrition should be optimized, with early feeding encouraged when appropriate. Discharge
planning should begin early, addressing the patient's needs for follow-up care, medication management,
and activity restrictions.
Appendectomy is one of the most common emergency general surgical procedures. The classic
presentation of acute appendicitis includes periumbilical pain migrating to the right lower quadrant,
accompanied by anorexia, nausea, and low-grade fever. However, atypical presentations are common,
particularly in children, elderly patients, and pregnant women. Diagnosis is typically made based on
clinical presentation, supported by laboratory findings (leukocytosis) and imaging studies (ultrasound or
CT scan). Laparoscopic appendectomy has largely replaced open appendectomy as the preferred surgical
approach in most cases, offering advantages of smaller incisions, less postoperative pain, and faster
recovery.
Cholecystectomy is another frequently performed general surgical procedure, most commonly for
symptomatic cholelithiasis or acute cholecystitis. Patients typically present with right upper quadrant
pain, often associated with fatty food intake. Diagnosis is confirmed by ultrasound demonstration of
gallstones and, in cases of acute cholecystitis, gallbladder wall thickening and pericholecystic fluid.
Laparoscopic cholecystectomy is the gold standard treatment for most patients, although open
cholecystectomy may be necessary in certain situations, such as severe inflammation or extensive
adhesions.
Hernia repair is a common elective general surgical procedure. Inguinal hernias are the most frequent
type, presenting as a bulge in the groin area that may be reducible. Surgical repair can be performed using
either an open or laparoscopic approach, with the choice depending on factors such as hernia type, patient
characteristics, and surgeon preference. Mesh repair has become standard for most adult hernia repairs,
significantly reducing recurrence rates compared to primary tissue repair.
Bowel resection may be necessary for various conditions, including colon cancer, inflammatory bowel
disease, and diverticulitis. The extent of resection depends on the underlying pathology and location. For
colon cancer, adequate lymph node sampling is crucial for accurate staging. Anastomotic technique is
critical to minimize the risk of leak, which can be a devastating complication. In some cases, a temporary
or permanent ostomy may be necessary.
Breast surgery is an important component of general surgery, encompassing both benign and malignant
conditions. Breast-conserving surgery followed by radiation therapy has largely replaced mastectomy as
the standard of care for early-stage breast cancer, offering equivalent survival with improved cosmetic
outcomes. Sentinel lymph node biopsy has reduced the need for full axillary lymph node dissection in
many cases, decreasing the risk of lymphedema.
Thyroidectomy is performed for both benign and malignant thyroid conditions. Key considerations include
preservation of the recurrent laryngeal nerves and parathyroid glands to avoid complications of voice
changes and hypocalcemia. Intraoperative nerve monitoring is increasingly used to help identify and
preserve the recurrent laryngeal nerves.
Trauma surgery is a critical aspect of general surgery, requiring rapid assessment and decision-making.
The initial evaluation follows the ABCDE approach: Airway, Breathing, Circulation, Disability, and
Exposure. Damage control surgery principles may be employed in severely injured patients, focusing on
controlling hemorrhage and contamination, with definitive repair delayed until the patient is more stable.
Minimally invasive surgery techniques, including laparoscopy and robotic surgery, have revolutionized
many areas of general surgery. These approaches offer benefits of smaller incisions, less postoperative
pain, and faster recovery for many procedures. However, they also require specialized training and
equipment, and may not be appropriate for all patients or conditions.
Understanding and applying these general surgery principles and common procedures forms the
foundation for safe and effective surgical care across a wide range of conditions. As medical knowledge
and technology continue to advance, surgeons must stay current with evolving techniques and best
practices to provide optimal care for their patients.

Orthopedics, urology, and otolaryngology highlights

Orthopedics, urology, and otolaryngology are distinct surgical subspecialties that address a wide range of
conditions affecting the musculoskeletal system, urinary tract, and ear, nose, and throat regions,
respectively. Each field has its own unique set of diagnostic approaches, surgical techniques, and
treatment modalities.
Orthopedics focuses on the diagnosis, treatment, rehabilitation, and prevention of disorders of the bones,
joints, ligaments, tendons, muscles, and nerves. A fundamental concept in orthopedics is fractures
management. Fractures are classified based on their location, pattern, and whether they are open or
closed. Treatment options range from conservative management with casting or splinting to surgical
fixation using plates, screws, nails, or external fixators. The choice of treatment depends on factors such
as fracture type, location, patient age, and functional demands.
Joint replacement surgery is a major area of orthopedics, with hip and knee arthroplasty being among the
most common procedures. These surgeries aim to relieve pain and improve function in patients with
severe osteoarthritis or other joint disorders. Advances in implant materials and surgical techniques have
led to improved longevity and outcomes for joint replacements. However, complications such as
infection, dislocation, and implant loosening remain important considerations.
Spine surgery is another key component of orthopedics, addressing conditions such as herniated discs,
spinal stenosis, and scoliosis. Minimally invasive techniques have become increasingly popular for many
spine procedures, offering potential benefits of smaller incisions, less muscle damage, and faster
recovery. However, complex spinal deformities or extensive degenerative changes may still require
traditional open approaches.
Sports medicine is a growing subspecialty within orthopedics, focusing on the treatment and prevention of
athletic injuries. Common procedures include arthroscopic repair of meniscal tears, ligament
reconstructions (such as anterior cruciate ligament repair), and rotator cuff repairs. Rehabilitation plays a
crucial role in sports medicine, with physical therapy being an integral part of treatment for many
conditions.
Pediatric orthopedics deals with musculoskeletal issues specific to children, including developmental
disorders like developmental dysplasia of the hip, clubfoot, and scoliosis. Treatment approaches must
consider the child's growth potential and aim to maximize long-term function.
Urology encompasses the medical and surgical management of disorders of the male and female urinary
tract, as well as the male reproductive system. Urolithiasis, or kidney stones, is a common urological
condition. Management options include medical expulsive therapy for small stones, extracorporeal shock
wave lithotripsy (ESWL) for intermediate-sized stones, and surgical interventions like ureteroscopy or
percutaneous nephrolithotomy for larger stones or those resistant to other treatments.
Prostate disorders are a major focus in urology. Benign prostatic hyperplasia (BPH) can be managed
medically with alpha-blockers and 5-alpha reductase inhibitors, or surgically with procedures like
transurethral resection of the prostate (TURP) or newer minimally invasive techniques. Prostate cancer
screening remains controversial, but when diagnosed, treatment options range from active surveillance for
low-risk disease to radical prostatectomy or radiation therapy for more aggressive cancers.
Bladder cancer is another important urological malignancy. Non-muscle invasive bladder cancer is
typically managed with transurethral resection followed by intravesical therapy, while muscle-invasive
disease often requires radical cystectomy with urinary diversion. Advances in reconstructive techniques
have improved quality of life for patients requiring urinary diversion.
Male infertility falls within the realm of urology, with interventions ranging from medical management to
surgical procedures like varicocelectomy or microsurgical sperm retrieval. Erectile dysfunction is also
addressed by urologists, with treatment options including oral medications, intracavernosal injections,
and penile implants.
Urologic trauma, including injuries to the kidneys, ureters, bladder, and urethra, requires specialized
management. The trend has been towards more conservative management when possible, but severe
injuries may still require surgical intervention.
Otolaryngology, also known as ear, nose, and throat (ENT) surgery, covers a diverse range of conditions
affecting the head and neck region. Otology focuses on disorders of the ear, including hearing loss,
vertigo, and chronic otitis media. Surgical interventions in this area include tympanoplasty for tympanic
membrane perforation, mastoidectomy for chronic mastoiditis, and cochlear implantation for severe
sensorineural hearing loss.
Rhinology deals with disorders of the nose and sinuses. Functional endoscopic sinus surgery (FESS) has
revolutionized the treatment of chronic rhinosinusitis, allowing for more targeted and less invasive
interventions. Septoplasty and rhinoplasty address structural and functional issues of the nose.
Laryngology encompasses disorders of the larynx and voice. Procedures in this area range from office-
based interventions like vocal fold injection for vocal cord paralysis to more extensive surgeries for
laryngeal cancer.
Head and neck oncology is a significant component of otolaryngology, dealing with cancers of the oral
cavity, pharynx, larynx, and neck. Treatment often involves a multidisciplinary approach, combining
surgery with radiation therapy and chemotherapy. Advances in reconstructive techniques, including free
tissue transfer, have improved functional and aesthetic outcomes following extensive resections.
Pediatric otolaryngology addresses conditions specific to children, such as recurrent otitis media, which
may require tympanostomy tube insertion, and obstructive sleep apnea, often treated with
adenotonsillectomy.
Facial plastic and reconstructive surgery is another important aspect of otolaryngology, encompassing
both cosmetic procedures and reconstruction following trauma or cancer resection.
In all these subspecialties, minimally invasive and endoscopic techniques have gained prominence,
offering potential benefits of reduced morbidity and faster recovery. However, open surgical approaches
remain important for many conditions and may be preferable in certain situations.
Advances in technology, including improved imaging modalities, computer-assisted navigation, and
robotic surgery, continue to shape the practice of these surgical subspecialties. These innovations offer
the potential for more precise and less invasive interventions, but also require ongoing education and
training for surgeons to maintain proficiency.
Interdisciplinary collaboration is increasingly important in these fields. For example, a patient with a
complex pelvic floor disorder might require input from urology, gynecology, and colorectal surgery.
Similarly, management of head and neck cancer often involves close cooperation between otolaryngology,
radiation oncology, medical oncology, and plastic surgery.
As with all surgical specialties, a thorough understanding of anatomy, meticulous surgical technique, and
careful attention to perioperative management are crucial for achieving optimal outcomes in orthopedics,
urology, and otolaryngology. Ongoing research continues to refine our understanding of disease processes
and treatment approaches in these fields, emphasizing the need for surgeons to stay current with evolving
evidence and best practices.

Neurosurgery and ophthalmology fundamentals

Neurosurgery and ophthalmology are highly specialized surgical fields that deal with some of the most
complex and delicate structures in the human body. Neurosurgery focuses on the diagnosis and treatment
of disorders affecting the central and peripheral nervous systems, including the brain, spinal cord, and
peripheral nerves. Ophthalmology, on the other hand, is concerned with diseases and surgery of the visual
pathways, including the eye and related structures. Both specialties require a deep understanding of
intricate anatomy and physiology, as well as advanced surgical techniques.
In neurosurgery, one of the most critical areas is the management of traumatic brain injury (TBI). TBI can
range from mild concussions to severe injuries requiring immediate surgical intervention. The initial
management follows the principles of Advanced Trauma Life Support, with particular emphasis on
maintaining adequate cerebral perfusion pressure. Severe TBI often requires intracranial pressure
monitoring and may necessitate decompressive craniectomy in cases of refractory intracranial
hypertension. Neurosurgeons must be adept at quickly assessing the need for surgical intervention based
on clinical presentation and neuroimaging findings.
Brain tumors represent another major focus of neurosurgery. These can be broadly categorized as primary
(arising from brain tissue or its coverings) or metastatic. Gliomas, meningiomas, and pituitary adenomas
are among the most common primary brain tumors. The surgical approach to brain tumors has been
revolutionized by advances in neuroimaging, intraoperative navigation systems, and functional mapping
techniques. These tools allow for more precise tumor localization and resection while minimizing damage
to eloquent brain areas. However, the infiltrative nature of many brain tumors, particularly high-grade
gliomas, often precludes complete resection, necessitating adjuvant therapies like radiation and
chemotherapy.
Cerebrovascular neurosurgery deals with conditions affecting the blood vessels of the brain and spinal
cord. Aneurysms, arteriovenous malformations (AVMs), and cavernous malformations are key pathologies
in this area. The management of cerebral aneurysms has evolved significantly with the development of
endovascular techniques like coil embolization, which can often provide a less invasive alternative to
open surgical clipping. However, complex aneurysms may still require open surgery. The choice between
endovascular and open surgical approaches depends on factors such as aneurysm location, size, and
morphology, as well as patient characteristics.
AVMs present a unique challenge, with treatment options including microsurgical resection, endovascular
embolization, stereotactic radiosurgery, or a combination of these modalities. The decision-making
process must carefully weigh the risk of intervention against the natural history of the lesion, particularly
in unruptured AVMs. The ARUBA trial has sparked significant debate in this area, suggesting that medical
management alone may be superior to intervention for unruptured AVMs in terms of stroke prevention and
functional outcomes1
.
Cavernous malformations, while less prone to catastrophic hemorrhage than AVMs, can cause significant
morbidity through recurrent bleeding and seizures. Surgical resection is often considered for symptomatic
lesions, especially those in accessible locations.
Acute ischemic stroke has become an important focus of neurosurgical intervention. Mechanical
thrombectomy has revolutionized the treatment of large vessel occlusion strokes, significantly expanding
the time window for intervention and improving outcomes for many patients
This has necessitated close collaboration between neurosurgeons, neurologists, and
neurointerventionalists in comprehensive stroke centers.
Spinal vascular malformations, though less common than their intracranial counterparts, represent another
important area of cerebrovascular neurosurgery. These lesions can cause significant neurological deficits
and require careful evaluation and treatment planning.
In pediatric neurosurgery, conditions such as moyamoya disease and vein of Galen malformations present
unique challenges. Revascularization procedures for moyamoya, including direct and indirect bypass
techniques, aim to reduce stroke risk and improve cerebral blood flow. Endovascular management of vein
of Galen malformations has significantly improved outcomes for these complex congenital lesions.
Advances in neuroimaging, including high-resolution MRI, functional MRI, and advanced angiographic
techniques, have greatly enhanced the ability to diagnose and plan treatment for cerebrovascular
disorders. Intraoperative imaging and neuronavigation systems have improved the precision and safety of
neurosurgical procedures.
The field of cerebrovascular neurosurgery continues to evolve rapidly, with ongoing research into novel
endovascular devices, improved microsurgical techniques, and a better understanding of the molecular
and genetic basis of vascular malformations. This progress promises to further refine treatment strategies
and improve outcomes for patients with cerebrovascular disorders.

Chapter 3 Summary and Workbook

This chapter provides a detailed overview of surgery and its subspecialties, emphasizing the principles,
diagnostic approaches, and treatment techniques critical for managing a wide range of conditions.
General Surgery Principles and Common Procedures
General surgery forms the foundation for many surgical subspecialties. Key principles include
preoperative evaluation, intraoperative management, and postoperative care. Preoperative assessment
focuses on identifying comorbidities and optimizing patient health before surgery. Intraoperative
management involves maintaining homeostasis, fluid balance, and sterile technique. Postoperative care
emphasizes early mobilization, pain control, wound care, and prevention of complications such as
infections or deep vein thrombosis. Common procedures like appendectomy, cholecystectomy, hernia
repair, bowel resection, breast surgery, and thyroidectomy are discussed with a focus on indications,
techniques, and outcomes. Minimally invasive techniques such as laparoscopy and robotic surgery are
highlighted for their benefits in reducing recovery time and complications.
Orthopedics, Urology, and Otolaryngology Highlights
Orthopedics addresses musculoskeletal disorders through both surgical and non-surgical means. Topics
include fracture management, joint replacement surgeries (e.g., hip and knee arthroplasty), spine surgeries
for conditions like herniated discs or scoliosis, and sports medicine procedures. Pediatric orthopedics
focuses on developmental disorders such as scoliosis or clubfoot.
Urology covers conditions of the urinary tract and male reproductive system. Key topics include kidney
stone management (e.g., lithotripsy or ureteroscopy), prostate disorders (e.g., BPH or prostate cancer),
bladder cancer treatments, male infertility interventions, erectile dysfunction therapies, and urologic
trauma management.
Otolaryngology (ENT) focuses on head and neck conditions. Topics include hearing loss treatments (e.g.,
cochlear implants), sinus disease management (e.g., functional endoscopic sinus surgery), laryngeal
disorders (e.g., vocal fold injections or laryngeal cancer surgeries), pediatric ENT conditions like
recurrent otitis media or obstructive sleep apnea, and head and neck oncology.
Neurosurgery and Ophthalmology Fundamentals
Neurosurgery deals with complex conditions affecting the brain, spine, and peripheral nerves. Topics
include traumatic brain injury management (e.g., intracranial pressure monitoring), brain tumor resections
using advanced imaging techniques, cerebrovascular interventions for aneurysms or arteriovenous
malformations (AVMs), and spinal surgeries for vascular malformations or degenerative diseases.
Pediatric neurosurgery covers congenital conditions like moyamoya disease or vein of Galen
malformations. Advances in neuroimaging have significantly improved diagnostic accuracy and surgical
precision in neurosurgery.
Ophthalmology focuses on diseases of the eye and visual system through both medical treatments and
surgical interventions.
The chapter emphasizes interdisciplinary collaboration across specialties to optimize patient outcomes
while highlighting the importance of staying current with evolving surgical techniques and best practices.
Grab Your Pen & Let’s Do Some Quick Tests
1. How would you approach the preoperative evaluation of a patient with multiple
comorbidities undergoing elective surgery?
2. What are the key differences between laparoscopic and open surgical approaches for
common procedures such as appendectomy or cholecystectomy?
3. How would you decide between conservative management versus surgical intervention for a
patient with a complex fracture?
4. What factors influence the choice of treatment modality for patients with kidney stones? How
do size and location affect management decisions?
5. How would you counsel a patient regarding treatment options for benign prostatic
hyperplasia (BPH) versus prostate cancer?
6. What are the benefits of functional endoscopic sinus surgery (FESS) compared to traditional
approaches in managing chronic rhinosinusitis?
7. How do advances in neuroimaging improve surgical outcomes for patients with brain tumors
or cerebrovascular disorders?
8. What considerations are important when performing joint replacement surgeries in elderly
patients with severe osteoarthritis?
9. How would you prioritize treatment goals in a patient presenting with multiple traumatic
injuries requiring damage control surgery?
10. What role does interdisciplinary collaboration play in managing
complex head and neck cancers involving otolaryngology, oncology, radiation therapy, and
reconstructive surgery?
Chapter 4: Pediatrics
Pediatrics is a vital medical specialty focused on the health and well-being of infants, children, and
adolescents. This chapter covers key aspects of pediatric care, including growth and development
milestones, common pediatric illnesses and their management, and specific considerations for neonatal
and adolescent medicine.
Understanding normal childhood development is crucial for identifying potential delays or abnormalities
early. Pediatricians must be well-versed in the expected physical, cognitive, and social milestones at
different ages to provide appropriate guidance to parents and intervene when necessary. This knowledge
forms the foundation for assessing a child's overall health and progress.
Pediatric practice involves managing a wide range of common childhood illnesses, from acute infections
to chronic conditions. Proper diagnosis and treatment of these illnesses require an understanding of age-
specific presentations, appropriate diagnostic workups, and evidence-based management strategies.
Pediatricians must also be adept at providing preventive care through immunizations, nutritional
counseling, and anticipatory guidance.
The field of pediatrics spans from birth through adolescence, with neonatal and adolescent medicine
representing important subspecialties. Neonatal care focuses on the unique needs and potential
complications of newborns, particularly those born prematurely or with congenital conditions. Adolescent
medicine addresses the physical and psychosocial changes of puberty and the transition to adulthood,
including reproductive health, mental health, and risky behaviors.
By mastering these core areas of pediatrics, healthcare providers can effectively promote the health and
well-being of children throughout their developmental journey. The following sections will explore each
of these crucial aspects of pediatric care in greater detail.

Growth and development milestones

Growth and development milestones are essential markers that help pediatricians and parents track a
child's progress across various domains. These milestones encompass physical growth, motor skills,
language acquisition, cognitive development, and social-emotional growth. Understanding these
milestones allows for early identification of potential delays or disorders, enabling timely intervention
and support.
Physical growth is typically assessed through measurements of height, weight, and head circumference.
These measurements are plotted on growth charts, which provide percentile rankings based on age and
gender. It's important to note that while individual growth patterns may vary, consistent growth along a
particular percentile curve is generally considered normal. Significant deviations from established
growth patterns may warrant further investigation.
Gross motor skills develop in a predictable sequence, starting with head control and progressing to
rolling over, sitting, crawling, and walking. By 2 months, infants should be able to lift their heads briefly
when lying on their stomachs. Rolling over typically occurs around 4 months, while sitting without
support is expected around 6 months. Most children begin crawling between 7-10 months and take their
first steps between 9-15 months. By 18 months, most toddlers can walk independently and begin to run.
Fine motor skills also follow a developmental progression. Newborns have a grasp reflex, which evolves
into voluntary grasping around 3-4 months. By 6 months, infants can typically transfer objects from one
hand to another. Pincer grasp, using the thumb and forefinger to pick up small objects, usually develops
around 9 months. As children grow, their fine motor skills become more refined, allowing for activities
such as drawing, using utensils, and eventually writing.
Language development is another crucial aspect of childhood milestones. Newborns communicate through
crying, while cooing and babbling emerge around 2-3 months. First words typically appear between 10-
14 months, with a rapid expansion of vocabulary occurring in the second year of life. By age 2, most
children can use two-word phrases. Language skills continue to develop rapidly, with most 4-year-olds
able to speak in complete sentences and engage in conversations.
Cognitive development encompasses a child's ability to think, reason, and problem-solve. Piaget's stages
of cognitive development provide a framework for understanding this progression. The sensorimotor
stage (birth to 2 years) involves learning through sensory experiences and motor actions. The
preoperational stage (2-7 years) is characterized by symbolic thinking and egocentrism. Concrete
operational thinking (7-11 years) allows for logical reasoning about concrete situations, while formal
operational thinking (11 years and older) involves abstract reasoning and hypothetical scenarios.
Social-emotional development involves a child's ability to form relationships, regulate emotions, and
develop self-awareness. Infants begin to smile socially around 2 months and develop stranger anxiety
around 6-8 months. Separation anxiety typically peaks around 10-18 months. Toddlers begin to assert
independence and may experience tantrums as they learn to regulate emotions. By preschool age, children
engage in cooperative play and begin to understand others' perspectives.
It's crucial to remember that while these milestones provide general guidelines, there is a range of normal
development. Some children may reach milestones earlier or later than average without cause for
concern. However, significant delays or regressions in skills should prompt further evaluation.
Red flags that may indicate developmental concerns include:

1. Failure to respond to sounds or visual stimuli by 3 months

2. Inability to hold head up by 4 months
3. Not babbling by 7 months
4. No words by 16 months
5. Not walking by 18 months
6. Loss of previously acquired skills at any age
When concerns arise, developmental screening tools such as the Ages and Stages Questionnaire (ASQ) or
the Denver Developmental Screening Test can be used to assess a child's progress more formally. If
delays are identified, referral to appropriate specialists (e.g., speech therapists, occupational therapists,
developmental pediatricians) may be necessary for further evaluation and intervention.
Early intervention is key in addressing developmental delays. Services may include speech therapy,
physical therapy, occupational therapy, or special education support. The earlier these interventions
begin, the better the outcomes tend to be, as young brains have greater plasticity and capacity for change.
Pediatricians play a crucial role in monitoring development by conducting regular well-child visits.
These visits allow for ongoing assessment of growth and development, as well as providing anticipatory
guidance to parents about what to expect in the coming months. Educating parents about normal
developmental progression and encouraging activities that promote development (e.g., reading to
children, providing opportunities for play and exploration) is an important aspect of pediatric care.
Understanding growth and development milestones is fundamental to pediatric practice. By closely
monitoring these milestones and addressing any concerns promptly, healthcare providers can help ensure
that children reach their full developmental potential.

Common pediatric illnesses and management

Pediatric practice involves managing a wide array of illnesses that commonly affect children. These range
from acute infections to chronic conditions, each requiring a tailored approach to diagnosis and treatment.
Understanding the unique presentations and management strategies for these illnesses is crucial for
providing effective pediatric care.
Respiratory infections are among the most frequent reasons for pediatric visits. Upper respiratory
infections (URIs), including the common cold, are typically viral in nature and managed symptomatically.
However, it's important to differentiate these from more serious conditions like streptococcal pharyngitis,
which requires antibiotic treatment. Rapid strep tests and throat cultures are useful diagnostic tools. Otitis
media, another common condition, may be managed with watchful waiting in many cases, but antibiotics
are indicated for severe cases or in younger children.
Lower respiratory tract infections, such as bronchiolitis and pneumonia, can be more serious.
Bronchiolitis, often caused by respiratory syncytial virus (RSV), typically affects infants and young
children. Management focuses on supportive care, including hydration and respiratory support if needed.
Pneumonia may be viral or bacterial; chest x-rays and laboratory tests can guide treatment decisions.
Bacterial pneumonia often requires antibiotic therapy, while viral pneumonia is managed supportively.
Gastrointestinal illnesses are also prevalent in pediatric populations. Acute gastroenteritis, characterized
by vomiting and diarrhea, is usually viral and self-limiting. The main concern is dehydration, particularly
in young children. Oral rehydration therapy is the cornerstone of treatment, with intravenous fluids
reserved for severe cases. Probiotics may be beneficial in reducing the duration of diarrhea.
Constipation is another common pediatric complaint. Management typically involves dietary
modifications, increased fluid intake, and sometimes the use of stool softeners or laxatives. It's important
to rule out more serious causes of constipation, such as Hirschsprung's disease, especially in infants with
delayed passage of meconium.
Skin conditions frequently encountered in pediatric practice include atopic dermatitis (eczema), impetigo,
and various viral exanthems. Eczema management involves identifying and avoiding triggers, maintaining
skin hydration, and using topical corticosteroids for flare-ups. Impetigo, a bacterial skin infection, is
treated with topical or oral antibiotics depending on the extent of involvement. Viral exanthems like
roseola, fifth disease, and hand-foot-mouth disease are generally self-limiting but may require
symptomatic management.
Asthma is a chronic condition that often begins in childhood. Management involves identifying and
avoiding triggers, using controller medications (typically inhaled corticosteroids), and having a clear
action plan for acute exacerbations. Proper inhaler technique and adherence to medication regimens are
crucial for effective management.
Allergic conditions, including allergic rhinitis and food allergies, are increasingly prevalent. Treatment of
allergic rhinitis may involve antihistamines, nasal corticosteroids, and allergen avoidance. Food allergies
require strict avoidance of the offending food and emergency preparedness with epinephrine auto-
injectors for severe reactions.
Attention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder. Diagnosis
involves comprehensive evaluation of symptoms across different settings. Treatment may include
behavioral interventions, educational accommodations, and medication (typically stimulants) when
indicated.
Obesity has become a significant pediatric health concern. Management involves a multifaceted approach
including dietary modifications, increased physical activity, and addressing any underlying psychological
factors. Regular monitoring of BMI and screening for associated complications (e.g., diabetes,
hypertension) is important.
Infectious diseases specific to childhood include measles, mumps, rubella, and varicella. While
vaccination has significantly reduced their incidence, outbreaks can still occur. Recognition of these
diseases and appropriate public health measures are crucial. Kawasaki disease, an acute vasculitis
primarily affecting young children, requires prompt recognition and treatment with intravenous
immunoglobulin to prevent coronary artery complications.
Pediatric oncology encompasses a range of childhood cancers, with leukemia being the most common.
Early recognition of warning signs (e.g., persistent fever, unexplained weight loss, easy bruising) is
crucial. Treatment typically involves a multidisciplinary approach including chemotherapy, radiation, and
sometimes surgery.
Congenital heart defects vary in severity and presentation. Some may be detected prenatally or soon after
birth, while others may not become apparent until later in childhood. Management depends on the specific
defect and may range from watchful waiting to medical management or surgical intervention.
Diabetes mellitus in children is predominantly type 1, although type 2 diabetes is increasing due to rising
obesity rates. Management involves insulin therapy, blood glucose monitoring, dietary management, and
education on disease management. Proper management is crucial to prevent both acute complications
(e.g., diabetic ketoacidosis) and long-term complications.
Epilepsy is a common neurological disorder in children. Accurate classification of seizure types guides
treatment decisions. Antiepileptic medications are the mainstay of treatment, with some cases requiring
surgical intervention. Education about seizure safety and management is crucial for patients and families.
Developmental and behavioral disorders, such as autism spectrum disorder, require early identification
and intervention. Management typically involves a multidisciplinary approach including behavioral
therapies, educational interventions, and sometimes medication for specific symptoms.
Pediatric rheumatological conditions, such as juvenile idiopathic arthritis, require a high index of
suspicion for diagnosis. Treatment often involves a combination of anti-inflammatory medications and
disease-modifying antirheumatic drugs.
In all these conditions, patient and family education plays a crucial role in management. Empowering
families with knowledge about the condition, its management, and when to seek medical attention is an
essential aspect of pediatric care. Additionally, consideration of the psychosocial impact of chronic
illnesses on children and their families is important, with referral to mental health professionals when
needed.
Preventive care, including immunizations and anticipatory guidance, remains a cornerstone of pediatric
practice. Staying updated on the latest vaccination schedules and screening recommendations is crucial
for providing comprehensive care.
Managing common pediatric illnesses requires a broad knowledge base, attention to age-specific
considerations, and a holistic approach that considers the child's overall well-being and family context.
Continuous learning and staying abreast of the latest evidence-based guidelines are essential for
providing optimal care in the ever-evolving field of pediatrics.

Neonatal and adolescent medicine

Neonatal and adolescent medicine represent two crucial subspecialties within pediatrics, each focusing
on unique developmental stages with specific health considerations and challenges.
Neonatal medicine deals with the medical care of newborn infants, especially those born prematurely or
with complications. The neonatal period, defined as the first 28 days of life, is a critical time of transition
from intrauterine to extrauterine life. During this period, rapid physiological changes occur, and various
congenital and acquired conditions may manifest.
Prematurity is a significant focus in neonatal medicine. Infants born before 37 weeks gestation are
considered premature, with those born before 32 weeks being at highest risk for complications. Common
issues in premature infants include respiratory distress syndrome (RDS), bronchopulmonary dysplasia
(BPD), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and retinopathy of
prematurity (ROP).
Management of premature infants often involves respiratory support, ranging from supplemental oxygen to
mechanical ventilation. Surfactant replacement therapy has significantly improved outcomes for infants
with RDS. Careful nutritional management, often including parenteral nutrition, is crucial for growth and
development. Regular screening for complications such as IVH and ROP is standard practice in neonatal
intensive care units (NICUs).
Term infants may also require NICU care for various reasons. Perinatal asphyxia can lead to hypoxic-
ischemic encephalopathy, requiring therapeutic hypothermia to minimize neurological damage. Congenital
anomalies, such as heart defects or gastrointestinal malformations, may necessitate immediate surgical
intervention.
Neonatal infections pose a significant risk due to the immature immune system of newborns. Group B
Streptococcus and Escherichia coli are common pathogens. Early-onset sepsis (within the first 72 hours
of life) is typically related to maternal factors, while late-onset sepsis is often associated with hospital-
acquired infections. Prompt recognition and treatment with appropriate antibiotics are crucial.
Jaundice is a common neonatal condition, usually benign but occasionally requiring treatment to prevent
kernicterus. Management may include phototherapy or, in severe cases, exchange transfusion. Careful
monitoring of bilirubin levels and risk factors is essential.
Neonatal abstinence syndrome (NAS), resulting from in utero exposure to drugs, particularly opioids, is
an increasing concern. Management involves supportive care and, when necessary, medication-assisted
treatment to manage withdrawal symptoms.
Long-term follow-up of high-risk infants is an important aspect of neonatal care, monitoring for
developmental delays and providing early intervention when needed.
Transitioning to adolescent medicine, this subspecialty focuses on the unique health needs of individuals
aged approximately 11 to 21 years. Adolescence is characterized by significant physical, cognitive, and
psychosocial changes, presenting both opportunities and challenges for healthcare providers.
Puberty and sexual development are central themes in adolescent medicine. Understanding normal
pubertal progression and addressing concerns about delayed or precocious puberty is crucial. Menstrual
disorders, such as dysmenorrhea and abnormal uterine bleeding, are common concerns in adolescent
females.
Reproductive health is a key focus, including contraception counseling, sexually transmitted infection
(STI) screening and treatment, and pregnancy care for adolescent mothers. Confidentiality is particularly
important in this area, balanced with appropriate parental involvement as required by law.
Mental health issues often emerge or intensify during adolescence. Depression, anxiety disorders, eating
disorders, and substance use disorders require careful screening, diagnosis, and management. Suicide
prevention is a critical aspect of adolescent care, necessitating regular screening and appropriate
intervention.
Risky behaviors, including substance use and unsafe sexual practices, are common in adolescence.
Anticipatory guidance and motivational interviewing techniques can be effective in promoting healthy
choices.
Chronic diseases may present unique challenges in adolescence. Conditions like type 1 diabetes, cystic
fibrosis, and inflammatory bowel disease require careful management during this period of transition.
Supporting adherence to treatment regimens and preparing for transition to adult care are important
considerations.
Sports medicine is another significant area in adolescent health. Managing sports-related injuries,
providing guidance on proper training techniques, and addressing issues like female athlete triad are
common tasks.
Eating disorders, including anorexia nervosa and bulimia nervosa, often emerge in adolescence. Early
recognition and multidisciplinary management, including medical, nutritional, and psychological support,
are crucial in addressing these complex conditions. Pediatricians and healthcare providers must be
vigilant in screening for signs of eating disorders, as early intervention can significantly improve
outcomes.
Anorexia nervosa is characterized by an intense fear of gaining weight and a distorted body image leading
to self-imposed starvation and excessive weight loss. Patients may present with significant weight loss,
amenorrhea, bradycardia, hypotension, and electrolyte imbalances. The treatment approach typically
involves a combination of medical stabilization, nutritional rehabilitation, and psychotherapy. Cognitive-
behavioral therapy (CBT) is the most effective psychotherapeutic approach for treating anorexia.
Bulimia nervosa involves episodes of binge eating followed by compensatory behaviors such as
vomiting, excessive exercise, or fasting. Patients may maintain a normal weight or be slightly overweight.
Similar to anorexia, the management of bulimia includes medical monitoring for complications such as
electrolyte imbalances and esophageal injury from vomiting. Psychotherapy, particularly CBT and
interpersonal therapy (IPT), is effective in addressing the underlying psychological issues associated with
bulimia.
In both conditions, family involvement can play a vital role in recovery. Family-based therapy (FBT) is
particularly effective for adolescents with anorexia, focusing on empowering parents to take an active
role in their child's recovery process. Regular follow-up is essential to monitor progress and prevent
relapse.
Other mental health conditions often co-occur with eating disorders, including anxiety disorders and
depression. A comprehensive treatment plan should address these comorbidities to optimize recovery
outcomes.
Transitioning to adolescent medicine requires understanding the unique challenges faced by teenagers.
This includes navigating the physical changes of puberty, mental health issues, and the social pressures
that can impact health behaviors. Adolescents may engage in risky behaviors such as substance use or
unprotected sex, necessitating appropriate counseling and education.
Immunizations remain crucial during adolescence to prevent diseases such as human papillomavirus
(HPV), meningococcal disease, and pertussis. The HPV vaccine is particularly important for preventing
cervical cancer and other HPV-related diseases.
Adolescent health visits should include discussions about mental health, sexual health, nutrition, and
physical activity. Confidentiality is essential to encourage open communication about sensitive topics.
Recognizing and managing eating disorders in adolescents requires a multidisciplinary approach that
includes medical care, nutritional support, psychotherapy, and family involvement. Understanding the
unique needs of adolescents is essential for providing comprehensive care during this critical
developmental stage.

Neonatal and adolescent medicine (continued)

Neonatal medicine focuses on the care of newborns during their first month of life. This period is critical
due to the rapid physiological changes that occur as infants transition from intrauterine to extrauterine life.
Neonates are at risk for various complications that can arise from prematurity or congenital conditions.
Premature infants are particularly vulnerable due to their underdeveloped organs and systems. Common
complications include respiratory distress syndrome (RDS), caused by surfactant deficiency;
intraventricular hemorrhage (IVH), which can lead to long-term neurological issues; and necrotizing
enterocolitis (NEC), a serious gastrointestinal condition affecting premature infants. Management
strategies often involve supportive care in a neonatal intensive care unit (NICU), including respiratory
support, temperature regulation, nutritional support via parenteral or enteral feeding, and careful
monitoring for complications.
Term infants may also require specialized care for various reasons such as birth asphyxia or congenital
anomalies. Conditions like congenital heart defects necessitate early intervention to prevent
complications such as heart failure or cyanosis. Pediatricians must be skilled at recognizing signs of
distress in newborns to initiate timely management.
Jaundice is another common condition in neonates that usually resolves without intervention but requires
monitoring to prevent kernicterus. Phototherapy is often used when bilirubin levels exceed safe
thresholds.
Neonatal abstinence syndrome (NAS) has gained attention due to increased substance use among pregnant
women. Infants born with NAS exhibit withdrawal symptoms requiring supportive care and sometimes
medication-assisted treatment.
Transitioning from neonatal care to adolescent medicine involves understanding the unique challenges
faced during this developmental stage. Adolescence is marked by significant physical growth and
psychosocial changes as individuals move toward adulthood.
Adolescent medicine addresses a wide range of issues including reproductive health, mental health
concerns, substance use disorders, and chronic illness management. Healthcare providers must be
prepared to discuss sensitive topics such as sexual health openly while maintaining confidentiality to
foster trust with adolescent patients.
Puberty brings about physical changes that can lead to body image concerns and self-esteem issues among
adolescents. Healthcare providers should guide adolescents through these changes while promoting
healthy lifestyle choices regarding nutrition and physical activity.
Mental health issues often emerge or become more pronounced during adolescence. Depression and
anxiety are common concerns that require careful assessment and intervention. Screening tools like the
PHQ-9 for depression can help identify at-risk youth who may benefit from further evaluation or
treatment.
Substance use remains a significant concern among adolescents. Screening for alcohol and drug use
should be routine during health visits using validated tools like the CRAFFT screening tool for substance
use disorders. Effective counseling strategies should be employed to address risky behaviors while
providing education on harm reduction techniques.
Sexual health education is vital during adolescence due to increased engagement in sexual activity among
teenagers. Discussions should include contraception options, STI prevention strategies including
vaccination against HPV, and the importance of regular check-ups with healthcare providers.
Chronic illnesses like asthma or diabetes require ongoing management during adolescence as patients
transition from pediatric to adult care models. Educating adolescents about self-management skills
empowers them to take responsibility for their health as they prepare for independence.
Adolescent healthcare visits should also address preventive measures such as immunizations against
diseases like meningitis and HPV. Ensuring that adolescents receive appropriate vaccinations helps
protect them from preventable diseases during this critical time in their lives.
Neonatal medicine focuses on the immediate care needs of newborns while adolescent medicine
addresses the complex physical, emotional, and social challenges faced by teenagers transitioning into
adulthood. By providing comprehensive care tailored to each developmental stage, healthcare providers
can promote optimal health outcomes across the lifespan

Chapter 4 Summary and Workbook

This chapter provides a comprehensive overview of pediatric care, covering three main areas: growth
and development milestones, common pediatric illnesses and their management, and neonatal and
adolescent medicine.
Growth and development milestones are crucial markers for tracking a child's progress across physical,
motor, language, cognitive, and social-emotional domains. The chapter emphasizes the importance of
understanding normal developmental patterns to identify potential delays or abnormalities early. It details
specific milestones for different age groups and highlights the use of growth charts and developmental
screening tools.
The section on common pediatric illnesses covers a wide range of conditions, from respiratory and
gastrointestinal infections to chronic diseases like asthma and diabetes. It emphasizes age-specific
presentations, appropriate diagnostic approaches, and evidence-based management strategies. The
importance of preventive care, including immunizations and anticipatory guidance, is also stressed.
Neonatal and adolescent medicine are presented as important subspecialties. Neonatal care focuses on the
unique needs of newborns, particularly those born prematurely or with complications. It covers common
neonatal issues such as respiratory distress syndrome, jaundice, and infections. Adolescent medicine
addresses the physical and psychosocial changes of puberty, including reproductive health, mental health
issues, and risky behaviors. The chapter emphasizes the importance of confidentiality and appropriate
counseling for adolescents.
Grab Your Pen & Let’s Do Some Quick Tests
1. How might your approach to assessing developmental milestones differ for a child with a
chronic illness compared to a typically developing child?
2. What strategies would you employ to differentiate between normal adolescent mood changes
and clinical depression in a teenage patient?
3. How would you balance the need for confidentiality with the importance of parental
involvement when treating an adolescent with a sexually transmitted infection?
4. In what ways might cultural differences impact your interpretation and communication of
growth and development milestones to parents?
5. How would you approach counseling parents who are hesitant about vaccinations for their
child?
6. What ethical considerations come into play when managing an eating disorder in an
adolescent who refuses treatment?
7. How might advances in neonatal care impact long-term outcomes for extremely premature
infants, and what are the ethical implications of these advances?
8. In what ways could the rising prevalence of childhood obesity influence your approach to
routine pediatric care?
9. How would you adapt your communication style when explaining a complex chronic
condition to a child versus an adolescent?
10. What strategies would you employ to promote medication adherence in
adolescents with chronic conditions as they transition to adult care?
Chapter 5: Obstetrics and Gynecology
Obstetrics and gynecology encompass the medical and surgical care of the female reproductive system
and associated disorders. This chapter covers key topics in women's health across the lifespan, from
pregnancy and childbirth to gynecologic conditions and reproductive endocrinology.
The first section focuses on normal and complicated pregnancy, exploring the physiological changes of
pregnancy, prenatal care, common pregnancy complications, and management of labor and delivery.
Understanding normal pregnancy progression and being able to identify and address potential
complications is crucial for ensuring the health and wellbeing of both mother and fetus.
The second section examines gynecological disorders and their treatments. This includes common
conditions like abnormal uterine bleeding, pelvic pain, sexually transmitted infections, and gynecologic
cancers. Proper diagnosis and management of these disorders is essential for maintaining women's
reproductive and overall health.
The third section covers reproductive endocrinology and infertility. Topics include the normal menstrual
cycle, disorders of the hypothalamic-pituitary-ovarian axis, evaluation and treatment of infertility, and
assisted reproductive technologies. This area highlights the complex interplay between hormones and
reproduction and the medical interventions available to address fertility issues.
By providing an integrated overview of obstetrics and gynecology, this chapter aims to equip medical
students and clinicians with essential knowledge to provide comprehensive care for female patients
across all stages of life. The focus is on high-yield concepts most relevant for clinical practice and board
examinations in this field.

Normal and complicated pregnancy

Pregnancy is a dynamic physiological state that involves significant changes to nearly every organ system
in a woman's body. A thorough understanding of normal pregnancy progression and potential
complications is essential for providing optimal care.
In a normal pregnancy, fertilization occurs when sperm meets egg, typically in the fallopian tube. The
fertilized egg then implants in the uterus around 6-10 days after ovulation. Human chorionic gonadotropin
(hCG) produced by the developing embryo maintains the corpus luteum, which produces progesterone to
support the pregnancy until the placenta takes over this function around 7-9 weeks gestation.
The first trimester (weeks 0-13) is marked by rapid fetal development. Major organ systems form during
this time. Common symptoms include nausea, vomiting, fatigue, and breast tenderness. The second
trimester (weeks 14-26) is often considered the most comfortable, as many first trimester symptoms
subside. Fetal movements become noticeable. The third trimester (weeks 27-40) involves continued fetal
growth and maternal body changes in preparation for labor and delivery.
Prenatal care typically begins in the first trimester and involves regular check-ups to monitor maternal
and fetal health. Key components include:

Confirmation of pregnancy and establishing due date

Review of medical history and risk assessment
Physical exam and baseline labs
Screening tests for genetic disorders and other conditions
Nutritional counseling and vitamin supplementation
Education on pregnancy progression and warning signs
While most pregnancies progress normally, various complications can arise. Some common pregnancy
complications include:
Gestational hypertension and preeclampsia: Elevated blood pressure that develops after 20 weeks
gestation. Preeclampsia also involves proteinuria and can progress to eclampsia (seizures) if untreated.
Management depends on severity and gestational age but may require early delivery.
Gestational diabetes: Glucose intolerance that develops during pregnancy. Managed with diet, exercise,
and sometimes insulin. Increases risks of macrosomia and neonatal hypoglycemia.
Placenta previa: Placenta covers or is near the cervical os. Can cause painless vaginal bleeding. May
require cesarean delivery if persistent.
Placental abruption: Premature separation of the placenta from the uterine wall. Presents with vaginal
bleeding and abdominal pain. Can compromise fetal oxygenation and cause maternal hemorrhage.
Preterm labor: Contractions and cervical changes before 37 weeks. Management aims to delay delivery
when possible and includes tocolytics and corticosteroids for fetal lung maturity.
Premature rupture of membranes (PROM): Rupture of amniotic sac before onset of labor. Increases risk
of infection. Management depends on gestational age.
Intrauterine growth restriction (IUGR): Fetal growth less than expected for gestational age. Can be due to
various maternal, placental, or fetal factors. Requires close monitoring and may necessitate early
delivery.
Multiple gestation: Increased risks of preterm labor, preeclampsia, and other complications. Requires
more intensive monitoring.
Rh incompatibility: Can occur when mother is Rh-negative and fetus is Rh-positive. Prevented with
RhoGAM administration.
Labor and delivery mark the culmination of pregnancy. Normal labor progresses through three stages:
First stage: Begins with onset of regular contractions and cervical dilation. Divided into latent and active
phases.
Second stage: From full cervical dilation to delivery of the infant.
Third stage: Delivery of the placenta.
Monitoring during labor includes assessment of maternal vital signs, fetal heart rate, and contraction
pattern. Abnormalities may indicate fetal distress and need for intervention.
Methods of delivery include:

Spontaneous vaginal delivery: Most common and preferred when possible.

Assisted vaginal delivery: Use of forceps or vacuum for extraction when needed.
Cesarean section: Surgical delivery through abdominal incision. May be planned or
emergent.
Complications during labor and delivery can include:
Prolonged labor: Arrest of dilation or descent. May require augmentation or cesarean.
Shoulder dystocia: Impaction of fetal shoulders after head delivery. Requires specific
maneuvers to resolve.
Postpartum hemorrhage: Excessive bleeding after delivery. Common causes include uterine
atony, retained placenta, and lacerations.
The postpartum period involves significant physiological changes as the body returns to pre-pregnancy
state. Key aspects of postpartum care include:

Monitoring for complications like infection or hemorrhage

Breastfeeding support
Contraception counseling
Screening for postpartum depression
Understanding the intricacies of normal pregnancy progression and being able to recognize and manage
complications is crucial for ensuring positive outcomes for both mother and infant. Obstetric care
requires vigilance, clinical acumen, and the ability to respond quickly to changing situations.

Gynecological disorders and treatments

Gynecological disorders encompass a wide range of conditions affecting the female reproductive system.
Proper diagnosis and management of these disorders is essential for maintaining women's health and
quality of life.
Abnormal uterine bleeding (AUB) is a common gynecological complaint. Causes can be categorized using
the PALM-COEIN system:

1. Polyp
2. Adenomyosis
3. Leiomyoma (fibroids)
4. Malignancy and hyperplasia
5. Coagulopathy
6. Ovulatory dysfunction
7. Endometrial
8. Iatrogenic
9. Not otherwise classified
Evaluation of AUB includes a thorough history, physical exam, and often imaging studies like ultrasound.
Endometrial biopsy may be indicated to rule out hyperplasia or cancer, especially in women over 35 or
with risk factors. Treatment depends on the underlying cause but may include hormonal therapies,
NSAIDs, antifibrinolytics like tranexamic acid, or surgical interventions
Pelvic pain is another frequent gynecologic complaint. Acute pelvic pain may be caused by ectopic
pregnancy, ovarian torsion, pelvic inflammatory disease (PID), or ovarian cysts. Chronic pelvic pain can
result from endometriosis, adenomyosis, pelvic congestion syndrome, or musculoskeletal issues.
Diagnosis often requires a combination of history, physical exam, laboratory tests, and imaging studies.
Treatment is directed at the underlying cause and may include analgesics, hormonal therapies, or surgical
intervention.
Endometriosis, the presence of endometrial-like tissue outside the uterus, affects approximately 10% of
reproductive-age women. It can cause chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility.
Diagnosis is ultimately made by visualization of lesions, typically via laparoscopy. Treatment options
include NSAIDs, hormonal suppression (e.g., combined oral contraceptives, progestins, GnRH agonists),
and surgical excision or ablation of lesions.
Uterine fibroids (leiomyomas) are benign smooth muscle tumors that can cause AUB, pelvic pain, and
bulk symptoms. Management depends on symptom severity, fibroid size and location, and patient's
reproductive plans. Options include expectant management, medical therapy (e.g., NSAIDs, tranexamic
acid, GnRH agonists), uterine artery embolization, and surgical approaches like myomectomy or
hysterectomy.
Pelvic organ prolapse occurs when pelvic floor muscles and ligaments become weakened or damaged,
allowing pelvic organs to descend. This can result in a sensation of pelvic pressure, urinary or fecal
incontinence, and sexual dysfunction. Treatment may involve pelvic floor physical therapy, pessaries, or
surgical repair.
Sexually transmitted infections (STIs) are a significant public health concern. Common STIs include:
Chlamydia and gonorrhea: Often asymptomatic but can cause cervicitis, PID, and long-term sequelae like
infertility. Diagnosed by nucleic acid amplification tests (NAATs) and treated with antibiotics.
Trichomonas: Causes vaginal discharge and irritation. Diagnosed by microscopy or NAAT and treated
with metronidazole.
Human Papillomavirus (HPV): Can cause genital warts and cervical dysplasia/cancer. Prevention through
vaccination is key.
Herpes Simplex Virus (HSV): Causes painful genital ulcers. Treated with antiviral medications.
HIV: Diagnosed by serologic testing. Early detection and treatment with antiretroviral therapy is crucial.
Proper screening, diagnosis, and treatment of STIs is essential for individual and public health.
Gynecologic cancers include:
Cervical cancer: Primarily caused by HPV. Screening with Pap smears and HPV testing has significantly
reduced incidence. Early-stage disease may be treated surgically, while advanced disease requires
chemoradiation.
Endometrial cancer: Most common gynecologic cancer in developed countries. Typically presents with
postmenopausal bleeding. Diagnosed by endometrial biopsy and treated primarily with surgery.
Ovarian cancer: O ft en diagnosed at advanced stages due to vague symptoms. CA-125 and transvaginal
ultrasound may aid in diagnosis, but definitive diagnosis requires surgery. Treatment involves
cytoreductive surgery and chemotherapy.
Vulvar cancer: Less common but incidence is rising. May present as a vulvar mass or ulcer. Diagnosed by
biopsy and treated with surgery and sometimes radiation.
Other important gynecologic conditions include:
Polycystic ovary syndrome (PCOS): Endocrine disorder characterized by irregular menses,
hyperandrogenism, and polycystic ovaries. Management focuses on addressing individual symptoms and
long-term health risks.
Vulvovaginal disorders: Includes conditions like bacterial vaginosis, vulvovaginal candidiasis, and
lichen sclerosus. Proper diagnosis and treatment is important for symptom relief and prevention of
complications.
Menopause: Natural cessation of menses, typically occurring around age 51. Management may involve
addressing vasomotor symptoms, vaginal atrophy, and long-term health risks associated with estrogen
deficiency.
Gynecologic care requires a comprehensive approach, considering not just the immediate presenting
problem but also screening for other conditions, addressing preventive care needs, and considering the
patient's overall health and well-being. Effective communication and shared decision-making are crucial
in providing patient-centered gynecologic care.

Reproductive endocrinology and infertility

Reproductive endocrinology and infertility (REI) is a subspecialty of obstetrics and gynecology that
focuses on hormonal functioning as it pertains to reproduction and the diagnosis and treatment of
infertility. A solid understanding of normal reproductive physiology is crucial for comprehending
disorders in this field.
The menstrual cycle is regulated by the hypothalamic-pituitary-ovarian (HPO) axis. Gonadotropin-
releasing hormone (GnRH) from the hypothalamus stimulates the anterior pituitary to release follicle-
stimulating hormone (FSH) and luteinizing hormone (LH). These gonadotropins act on the ovaries to
stimulate follicular development and ovulation.
The typical menstrual cycle consists of three phases:
Follicular phase: FSH stimulates follicular development. Estrogen levels rise as follicles grow,
eventually triggering the LH surge.
Ovulatory phase: The LH surge causes final oocyte maturation and ovulation.
Luteal phase: The corpus luteum produces progesterone, preparing the endometrium for potential
implantation.
If pregnancy doesn't occur, the corpus luteum degenerates, hormone levels fall, and menstruation occurs.
Disorders of the HPO axis can lead to various reproductive issues:
Hypothalamic amenorrhea: Can be caused by stress, excessive exercise, or low body weight. Results in
low GnRH pulsatility and subsequent low gonadotropins and estradiol.
Hyperprolactinemia: Elevated prolactin levels can suppress GnRH pulsatility, leading to oligomenorrhea
or amenorrhea. Common causes include prolactinomas, medications, and hypothyroidism.
Polycystic ovary syndrome (PCOS): Characterized by hyperandrogenism, oligo/anovulation, and
polycystic ovaries is often associated with insulin resistance.
Premature ovarian insufficiency: Loss of ovarian function before age 40. Can be idiopathic, genetic, or
due to iatrogenic causes like chemotherapy.
Infertility, defined as the inability to conceive after 12 months of regular unprotected intercourse (or 6
months if female partner is ≥35 years old), affects approximately 15% of couples. Causes can be
attributed to female factors (1/3), male factors (1/3), or a combination of both (1/3).
Evaluation of infertility includes:
Ovulatory function assessment: Can be done through menstrual history, basal body temperature charting,
urinary LH kits, or serum progesterone levels.
Tubal patency evaluation: Typically assessed via hysterosalpingogram (HSG) or laparoscopy with
chromotubation.
Uterine cavity assessment: Can be done with saline infusion sonohysterography or hysteroscopy.
Semen analysis: Evaluates sperm count, motility, and morphology.
Ovarian reserve testing: Includes antral follicle count on ultrasound and serum anti-Müllerian hormone
(AMH) levels.
Treatment of infertility depends on the underlying cause:
Ovulatory dysfunction: May be treated with medications like clomiphene citrate, letrozole, or
gonadotropins.
Tubal factor: May require surgical repair or in vitro fertilization (IVF).
Male factor: Can be addressed with intrauterine insemination (IUI) or intracytoplasmic sperm injection
(ICSI) during IVF.
Unexplained infertility: often managed with a stepwise approach from timed intercourse to IUI to IVF.
Assisted reproductive technologies (ART) have revolutionized the treatment of infertility. IVF involves
ovarian stimulation, oocyte retrieval, fertilization in the laboratory, and embryo transfer. Variations
include ICSI for severe male factor infertility and preimplantation genetic testing for chromosomal or
genetic disorders.
Other important topics in REI include:
Recurrent pregnancy loss: Defined as two or more failed clinical pregnancies. Evaluation may include
karyotyping, antiphospholipid antibody testing, and uterine cavity assessment.
Fertility preservation: Options like oocyte or embryo cryopreservation for patients facing gonadotoxic
treatments or desiring to delay childbearing.
Third-party reproduction: Use of donor gametes or gestational carriers when needed.
Disorders of sexual development: Conditions affecting chromosomal, gonadal, or anatomic sex
development.
Pediatric and adolescent gynecology: Management of reproductive issues in young patients, including
disorders of puberty.
The field of REI continues to advance rapidly, with ongoing research into new diagnostic tools and
treatment modalities. Ethical considerations are paramount, particularly regarding the creation and
disposition of embryos, genetic testing, and access to care.
Effective REI care requires not just medical expertise but also sensitivity to the emotional aspects of
infertility and family building. Patient education, counseling, and support are integral components of
comprehensive care in this field.

Chapter 5 Summary and Workbook

This chapter provides a comprehensive overview of obstetrics and gynecology, covering three main
areas: normal and complicated pregnancy, gynecological disorders and treatments, and reproductive
endocrinology and infertility.
The section on normal and complicated pregnancy discusses the physiological changes during pregnancy,
prenatal care, and common complications. It covers the stages of pregnancy, labor, and delivery, as well
as potential issues like gestational hypertension, gestational diabetes, and preterm labor. The importance
of monitoring both maternal and fetal health throughout pregnancy is emphasized.
The gynecological disorders section explores a wide range of conditions affecting women's reproductive
health. It covers abnormal uterine bleeding, pelvic pain, endometriosis, uterine fibroids, pelvic organ
prolapse, and sexually transmitted infections. The chapter also discusses gynecologic cancers and their
management. The importance of a comprehensive approach to gynecologic care, including preventive
measures and patient education, is highlighted.
The reproductive endocrinology and infertility section give more explanation into the complexities of the
menstrual cycle, disorders of the hypothalamic-pituitary-ovarian axis, and the evaluation and treatment of
infertility. It covers assisted reproductive technologies, recurrent pregnancy loss, and fertility
preservation. The chapter emphasizes the importance of understanding both the medical and emotional
aspects of infertility treatment.
Grab Your Pen & Let’s Do Some Quick Tests
1. How might your approach to managing a high-risk pregnancy differ from a low-risk
pregnancy, and what factors would you consider most critical?
2. In what ways could advances in prenatal genetic testing impact your counseling for expectant
parents?
3. How would you balance the benefits and risks of hormonal therapies in treating
gynecological disorders, particularly in patients with complex medical histories?
4. What ethical considerations would you face when counseling a patient about fertility
preservation options?
5. How might societal and cultural factors influence a woman's experience of menopause, and
how would you address these in your care?
6. In what ways could improving access to comprehensive sex education impact the prevalence
and management of sexually transmitted infections?
7. How would you approach the topic of fertility with a patient undergoing cancer treatment,
considering both immediate and long-term implications?
8. What strategies would you employ to improve early detection rates for ovarian cancer, given
its often vague initial symptoms?
9. How might emerging technologies in assisted reproduction change your approach to treating
infertility in the coming years?
10. In what ways could integrating mental health support into obstetric and
gynecologic care improve overall patient outcomes?
Chapter 6: Psychiatry
Psychiatry is a branch of medicine that focuses on the diagnosis, treatment, and prevention of mental,
emotional, and behavioral disorders. This chapter provides an overview of major psychiatric disorders,
essential psychopharmacology, and the unique aspects of child and adolescent psychiatry. Understanding
these areas is crucial for effective patient care and management in psychiatric practice.
The first section discusses major psychiatric disorders, including mood disorders, anxiety disorders,
psychotic disorders, personality disorders, and substance use disorders. Each disorder is characterized
by specific symptoms and diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5). The management strategies for these disorders vary widely and may include
psychotherapy, pharmacotherapy, or a combination of both. Recognizing the nuances of each disorder is
essential for providing appropriate treatment and support to patients.
The second section focuses on psychopharmacology essentials. This includes an understanding of various
classes of psychiatric medications such as antidepressants, antipsychotics, mood stabilizers, anxiolytics,
and stimulants. Knowledge of pharmacodynamics, pharmacokinetics, side effects, and drug interactions is
critical for safe prescribing practices. Additionally, understanding the role of medication in conjunction
with psychotherapy can enhance treatment outcomes.
The third section addresses child and adolescent psychiatry. This area emphasizes the unique
developmental considerations in diagnosing and treating mental health conditions in younger populations.
It covers common disorders such as attention-deficit/hyperactivity disorder (ADHD), autism spectrum
disorders (ASD), anxiety disorders, and mood disorders. Early identification and intervention are key
components in managing these conditions effectively.
By integrating knowledge from these three subchapters, healthcare providers can develop a
comprehensive understanding of psychiatric care across different populations. This chapter aims to equip
medical students and clinicians with the essential knowledge needed for effective assessment and
management of psychiatric conditions.

Major psychiatric disorders and their management

Psychiatric disorders represent a wide spectrum of conditions that affect mental health and overall
functioning. Understanding the diagnostic criteria, clinical features, and management options for these
disorders is essential for providing quality care.
Mood disorders are characterized by significant disturbances in mood that impact daily functioning.
Major depressive disorder (MDD) is one of the most common mood disorders. It presents with symptoms
such as persistent sadness or low mood, loss of interest or pleasure in activities (anhedonia), changes in
appetite or weight, sleep disturbances, fatigue, feelings of worthlessness or excessive guilt, difficulty
concentrating, and recurrent thoughts of death or suicide. Diagnosis is based on DSM-5 criteria which
require the presence of five or more symptoms during the same two-week period.
Management of MDD typically involves a combination of psychotherapy and pharmacotherapy.
Cognitive-behavioral therapy (CBT) has shown efficacy in treating depression by addressing negative
thought patterns and behaviors. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs)
are often first-line pharmacologic treatments due to their favorable side effect profile. Other options
include serotonin-norepinephrine reuptake inhibitors (SNRIs), atypical antidepressants, and tricyclic
antidepressants (TCAs). In severe cases or when there is a risk of self-harm or suicide, electroconvulsive
therapy (ECT) may be considered.
Bipolar disorder involves episodes of depression alternating with episodes of mania or hypomania. The
manic phase is characterized by elevated mood, increased energy or activity levels, decreased need for
sleep, grandiosity, racing thoughts, distractibility, increased talkativeness, and impulsive behaviors.
Management includes mood stabilizers such as lithium or valproate during manic episodes along with
atypical antipsychotics when necessary. Antidepressants may be used cautiously during depressive
episodes but can trigger manic episodes if not combined with a mood stabilizer.
Anxiety disorders encompass several conditions characterized by excessive fear or worry that interferes
with daily life. Generalized anxiety disorder (GAD) involves persistent worry about various aspects of
life such as work or health. Panic disorder is characterized by recurrent unexpected panic attacks
accompanied by physical symptoms like palpitations and shortness of breath. Social anxiety disorder
involves intense fear of social situations leading to avoidance behavior.
Management strategies for anxiety disorders often include psychotherapy such as CBT or exposure
therapy alongside pharmacotherapy options like SSRIs or benzodiazepines for short-term relief during
acute episodes. It is important to assess each patient's individual needs when determining treatment
approaches.
Psychotic disorders are marked by distortions in thinking and perception. Schizophrenia is the most well-
known psychotic disorder characterized by symptoms such as hallucinations (often auditory), delusions
(fixed false beliefs), disorganized thinking or speech, and negative symptoms like flat affect or avolition.
Diagnosis requires at least two active-phase symptoms lasting for a significant portion of one month with
some signs present for at least six months.
Management primarily involves antipsychotic medications which can help reduce positive symptoms but
may have side effects ranging from metabolic syndrome to extrapyramidal symptoms depending on
whether they are typical or atypical antipsychotics. Psychosocial interventions including supportive
therapy can also play an important role in managing schizophrenia.
Personality disorders are characterized by enduring patterns of behavior that deviate from cultural
expectations and lead to distress or impairment in functioning. Borderline personality disorder (BPD)
exemplifies this category with symptoms including emotional instability, intense interpersonal
relationships marked by idealization and devaluation, impulsivity, self-harming behaviors, and chronic
feelings of emptiness.
Management often involves dialectical behavior therapy (DBT), which focuses on skills training in
emotional regulation and interpersonal effectiveness while also addressing self-harming behaviors
through validation techniques. Medications may be used to target specific symptoms but are not
considered primary treatment modalities.
Substance use disorders involve the harmful use of psychoactive substances leading to significant
impairment or distress. The diagnosis is based on criteria outlined in DSM-5 that assess patterns related
to substance use including cravings, tolerance development, withdrawal symptoms upon cessation,
unsuccessful attempts to cut down use despite desire to do so, social issues stemming from use among
others.
Management strategies encompass behavioral therapies such as motivational interviewing combined with
pharmacotherapy options like methadone or buprenorphine for opioid use disorder; naltrexone for alcohol
use disorder; and disulfiram as an aversive agent against alcohol consumption.
Understanding major psychiatric disorders requires familiarity with their diagnostic criteria along with
effective management strategies tailored to individual patient needs. Ongoing assessment throughout
treatment is crucial for optimizing outcomes while minimizing potential risks associated with
medications.

Psychopharmacology essentials
Psychopharmacology is a critical component of psychiatric practice, involving the use of medications to
treat mental health disorders. A thorough understanding of the major classes of psychiatric medications,
their mechanisms of action, indications, and side effects is essential for effective patient care.
Antidepressants are among the most commonly prescribed psychiatric medications. Selective serotonin
reuptake inhibitors (SSRIs) like fluoxetine, sertraline, and escitalopram are typically first-line agents for
depression and anxiety disorders. They work by blocking the reuptake of serotonin in the synaptic cleft,
increasing its availability. SSRIs are generally well-tolerated, with common side effects including
nausea, headache, and sexual dysfunction. It's important to counsel patients that these medications may
take 4-6 weeks to reach full therapeutic effect.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine inhibit the
reuptake of both serotonin and norepinephrine. They are often used for depression, anxiety, and chronic
pain conditions. Side effects are similar to SSRIs, but they may also cause increased blood pressure and
heart rate.
Bupropion is a unique antidepressant that primarily affects dopamine and norepinephrine. It's often used
for depression, especially in patients concerned about sexual side effects or weight gain. Bupropion can
also help with smoking cessation. However, it lowers the seizure threshold and should be avoided in
patients with seizure disorders.
Tricyclic antidepressants (TCAs) like amitriptyline and nortriptyline are older medications that are still
used, particularly for chronic pain and refractory depression. They have a broader range of side effects
including anticholinergic effects, weight gain, and cardiac conduction changes. TCAs can be lethal in
overdose, so caution is needed when prescribing to patients at risk for suicide.
Monoamine oxidase inhibitors (MAOIs) like phenelzine are rarely used as first-line agents due to dietary
restrictions and drug interactions, but can be effective for treatment-resistant depression.
Antipsychotics are another crucial class of medications in psychiatry. First-generation or typical
antipsychotics like haloperidol primarily block dopamine D2 receptors. They are effective for positive
symptoms of schizophrenia but can cause significant extrapyramidal side effects (EPS) including
akathisia, dystonia, and tardive dyskinesia.
Second-generation or atypical antipsychotics like risperidone, olanzapine, and quetiapine have a more
diverse receptor profile, affecting serotonin receptors in addition to dopamine. They generally have a
lower risk of EPS but can cause significant metabolic side effects including weight gain, diabetes, and
hyperlipidemia. Regular monitoring of weight, blood glucose, and lipids is essential.
Clozapine is a unique atypical antipsychotic reserved for treatment-resistant schizophrenia due to its risk
of agranulocytosis. It requires regular blood monitoring but can be highly effective in refractory cases.
Mood stabilizers are crucial for treating bipolar disorder. Lithium, the oldest mood stabilizer, is effective
for both manic and depressive episodes and has anti-suicidal properties. However, it has a narrow
therapeutic window and requires regular monitoring of blood levels and renal and thyroid function.
Anticonvulsants like valproic acid, carbamazepine, and lamotrigine are also used as mood stabilizers.
Valproic acid and carbamazepine are particularly effective for manic episodes, while lamotrigine is more
often used for bipolar depression. These medications require monitoring of liver function and blood
counts.
Benzodiazepines like lorazepam and clonazepam are commonly used for short-term management of
anxiety and insomnia. They work by enhancing the effect of GABA, the brain's primary inhibitory
neurotransmitter. While effective, they carry risks of dependence and cognitive impairment, especially in
older adults. Long-term use should generally be avoided.
Stimulants such as methylphenidate and amphetamines are the mainstay of treatment for attention-
deficit/hyperactivity disorder (ADHD). They work by increasing dopamine and norepinephrine in the
prefrontal cortex, improving attention and impulse control. Side effects can include decreased appetite,
insomnia, and rarely, cardiac issues. Regular monitoring of blood pressure and heart rate is important.
When prescribing any psychotropic medication, it's crucial to consider potential drug interactions. Many
psychiatric medications are metabolized by the cytochrome P450 system in the liver, leading to numerous
potential interactions. For example, fluoxetine and paroxetine are potent inhibitors of CYP2D6 and can
increase levels of medications metabolized by this enzyme.
It's also important to consider the impact of medical comorbidities on medication choice. For instance,
bupropion should be avoided in patients with seizure disorders, and TCAs should be used cautiously in
patients with cardiac conduction abnormalities.
Special populations require particular attention in psychopharmacology. In pregnancy, the risks and
benefits of medication must be carefully weighed. SSRIs are generally considered relatively safe, but
paroxetine should be avoided due to a potential increased risk of cardiac defects. Mood stabilizers like
valproic acid are teratogenic and should be avoided if possible.
In older adults, the principle of "start low, go slow" is crucial. Older adults are more sensitive to side
effects and may have altered drug metabolism. Medications with anticholinergic effects should be used
cautiously due to the risk of cognitive impairment and falls.
Finally, it's important to remember that psychopharmacology is just one component of psychiatric
treatment. Combining medication with psychotherapy often leads to better outcomes than either treatment
alone. Patient education about medications, including expected benefits and potential side effects, is
crucial for promoting adherence and achieving optimal outcomes.

Child and adolescent psychiatry

Child and adolescent psychiatry is a specialized field that focuses on the diagnosis and treatment of
mental health disorders in young people. This area of practice requires a deep understanding of
developmental processes, family dynamics, and the unique ways in which psychiatric disorders may
manifest in children and adolescents.
Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most common conditions seen in child
psychiatry. It's characterized by persistent inattention and/or hyperactivity-impulsivity that interferes with
functioning or development. Diagnosis requires symptoms to be present in multiple settings (e.g., home
and school) for at least six months. Treatment typically involves a combination of behavioral
interventions and medication. Stimulants like methylphenidate and amphetamines are first-line
pharmacological treatments, with non-stimulants like atomoxetine as alternatives.
Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits
in social communication and interaction, along with restricted, repetitive patterns of behavior, interests,
or activities. Symptoms must be present from early childhood, even if they're not recognized until later.
Early intervention is crucial and typically involves intensive behavioral therapies. While there's no
medication that treats the core symptoms of ASD, medications may be used to manage associated
symptoms like irritability or attention problems.
Anxiety disorders are common in children and adolescents. These include Generalized Anxiety Disorder,
Social Anxiety Disorder, and Specific Phobias. Cognitive-Behavioral Therapy (CBT) is the first-line
treatment for most childhood anxiety disorders. SSRIs may be used in more severe cases or when therapy
alone is insufficient. It's important to monitor for potential side effects, including increased suicidal
ideation, especially when starting SSRIs in adolescents.
Depression in children and adolescents can present differently than in adults. Children may show more
irritability than sadness, and may have somatic complaints or social withdrawal. Treatment typically
involves psychotherapy, with CBT and Interpersonal Therapy (IPT) showing good evidence. In moderate
to severe cases, or when therapy alone is insufficient, SSRIs may be used. Fluoxetine is FDA-approved
for children age 8 and older, while escitalopram is approved for age 12 and up.
Bipolar Disorder in youth is a controversial diagnosis. While some children do experience clear manic
episodes, many present with severe irritability and mood swings without distinct manic episodes. This
presentation has led to the introduction of Disruptive Mood Dysregulation Disorder (DMDD) in DSM-5.
Treatment of pediatric bipolar disorder typically involves mood stabilizers like lithium or valproic acid,
sometimes in combination with atypical antipsychotics.
Eating disorders, including Anorexia Nervosa and Bulimia Nervosa, often emerge in adolescence. These
disorders have the highest mortality rate of any psychiatric condition, making early intervention crucial.
Treatment typically involves a multidisciplinary approach including medical management, nutritional
rehabilitation, and psychotherapy. Family-Based Treatment (FBT) has shown good evidence for
adolescents with anorexia.
Substance use disorders in adolescents require special attention. The developing brain is particularly
vulnerable to the effects of substances, and early use increases the risk of addiction later in life. Treatment
typically involves a combination of individual and family therapy, with approaches like Motivational
Interviewing and Contingency Management showing good evidence.
Trauma-related disorders, including Post-Traumatic Stress Disorder (PTSD) and Adjustment Disorders,
are unfortunately common in children and adolescents. Trauma-Focused CBT is an evidence-based
treatment for children with PTSD. In cases of ongoing trauma or unstable home environments, addressing
safety and providing support are the first priorities.
Disruptive behavior disorders, including Oppositional Defiant Disorder and Conduct Disorder, can be
challenging to treat. Parent management training and other family-based interventions are typically first-
line treatments. In severe cases, especially with aggression, atypical antipsychotics may be used, but the
metabolic side effects require careful consideration and monitoring.
Psychotic disorders, while less common in children, can emerge in adolescence. Early-onset
schizophrenia is associated with poorer outcomes, making early intervention crucial. Atypical
antipsychotics are the mainstay of pharmacological treatment, but require careful monitoring due to their
significant side effect profile.
Tic disorders, including Tourette's Syndrome, often first appear in childhood. Education and behavioral
interventions are first-line treatments for mild to moderate tics. For more severe cases, alpha-2 agonists
like guanfacine or antipsychotics may be used.
In all areas of child and adolescent psychiatry, involving the family in treatment is crucial. Parents are
often the primary agents of change, particularly for younger children. Family therapy can be beneficial in
many conditions, helping to address family dynamics that may be contributing to or maintaining the child's
symptoms.
It's also important to consider the child's environment beyond the family. Coordinating with schools is
often necessary, whether to implement accommodations for conditions like ADHD or ASD, or to address
bullying that may be contributing to anxiety or depression.
Child and adolescent psychiatrists must also be aware of child protection issues. They are mandated
reporters and must know when and how to report suspected abuse or neglect.
Finally, it's crucial to remember that children and adolescents are not just small adults. Their brains are
still developing, and this impacts both the presentation of psychiatric disorders and their treatment.
Medications may have different effects or side effect profiles in children compared to adults. Long-term
effects on development must always be considered when prescribing medications to young people.
As our understanding of neurodevelopment and the early origins of mental illness grows, child and
adolescent psychiatry continues to evolve. Early intervention and prevention are increasingly recognized
as key strategies for promoting lifelong mental health. By addressing mental health concerns early in life,
we have the opportunity to significantly impact the trajectory of a young person's life and potentially
prevent more severe or chronic difficulties in adulthood.

Chapter 6 Summary and Workbook

This chapter provides a comprehensive overview of psychiatry, focusing on three main areas: major
psychiatric disorders and their management, psychopharmacology essentials, and child and adolescent
psychiatry.
The section on major psychiatric disorders covers mood disorders (including major depressive disorder
and bipolar disorder), anxiety disorders, psychotic disorders (particularly schizophrenia), personality
disorders, and substance use disorders. For each disorder, the chapter discusses diagnostic criteria,
clinical features, and management strategies, emphasizing the importance of combining psychotherapy and
pharmacotherapy when appropriate.
The psychopharmacology section details various classes of psychiatric medications, including
antidepressants (SSRIs, SNRIs, TCAs), antipsychotics, mood stabilizers, benzodiazepines, and
stimulants. It emphasizes the importance of understanding drug mechanisms, side effects, interactions, and
special considerations for different populations.
The child and adolescent psychiatry section highlights the unique aspects of mental health in younger
populations. It covers common disorders such as ADHD, autism spectrum disorder, anxiety disorders,
depression, and eating disorders in children and adolescents. The chapter stresses the importance of early
intervention, family involvement, and considering developmental factors in diagnosis and treatment.
Grab Your Pen & Let’s Do Some Quick Tests
1. How might your approach to treating depression differ in an adolescent compared to an
adult, considering both pharmacological and psychotherapeutic interventions?
2. In what ways could cultural factors influence the presentation and treatment of anxiety
disorders, and how would you address these in your practice?
3. How would you balance the potential benefits and risks when considering antipsychotic
medication for a child with severe behavioral issues?
4. What ethical considerations come into play when treating a teenager with a substance use
disorder who wishes to keep their treatment confidential from their parents?
5. How might advances in neuroscience change our understanding and treatment of personality
disorders in the coming years?
6. In what ways could improving mental health literacy in schools impact the early
identification and treatment of psychiatric disorders in children?
7. How would you approach the challenge of medication adherence in a patient with
schizophrenia who lacks insight into their condition?
8. What strategies would you employ to reduce the stigma associated with seeking psychiatric
help, particularly in communities where mental health is not openly discussed?
9. How might the increasing use of telemedicine in psychiatry affect the therapeutic relationship
and treatment outcomes?
10. In light of the ongoing debate about the diagnosis of bipolar disorder
in children, how would you approach a case where the distinction between bipolar disorder
and severe ADHD is unclear?
Chapter 7: Preventive Medicine and Ethics
Preventive medicine and ethics form the cornerstone of modern medical practice, encompassing a wide
range of topics crucial for providing comprehensive patient care. This chapter explores key aspects of
preventive medicine, including screening guidelines, immunizations, occupational and environmental
health, as well as the ethical considerations that guide medical decision-making and ensure patient safety.
Preventive medicine focuses on promoting health and preventing disease before it occurs. This involves
regular health screenings, vaccinations, and lifestyle modifications to reduce the risk of illness. Screening
guidelines provide evidence-based recommendations for detecting diseases early when they are most
treatable. Immunizations play a vital role in preventing infectious diseases and protecting both individuals
and communities.
Occupational and environmental health addresses the impact of work and environmental factors on human
health. This field aims to identify, evaluate, and control workplace hazards, as well as assess and mitigate
environmental risks that may affect public health. Understanding these factors is essential for healthcare
providers to effectively counsel patients and implement preventive strategies.
Medical ethics and patient safety are fundamental to maintaining trust in the healthcare system and
ensuring optimal patient outcomes. Ethical principles guide decision-making in complex medical
situations, while patient safety initiatives aim to reduce medical errors and improve the quality of care.
Together, these elements create a framework for delivering high-quality, patient-centered healthcare that
prioritizes prevention and upholds ethical standards.

Screening guidelines and immunizations

Screening guidelines and immunizations are essential components of preventive medicine, aimed at
detecting diseases early and preventing infectious illnesses. These guidelines are developed based on
extensive research and are regularly updated to reflect the latest evidence-based recommendations.
Cancer screening is a critical aspect of preventive care. Colorectal cancer screening should begin at age
50 for average-risk individuals, with options including colonoscopy every 10 years, annual fecal occult
blood testing, or sigmoidoscopy with barium enema every 5 years. For those with a family history of
colorectal cancer, screening may need to start earlier. Breast cancer screening recommendations suggest
mammograms every 1-2 years for women aged 50 and older, with some organizations recommending
starting at age 40. Cervical cancer screening should begin at age 21 with Pap smears every 3 years until
age 65. For women aged 30-65, co-testing with Pap and HPV every 5 years is an alternative option. Lung
cancer screening with low-dose CT is recommended annually for adults aged 55-80 with a 30 pack-year
smoking history who currently smoke or have quit within the past 15 years.
Cardiovascular disease screening is another crucial area. Blood pressure should be checked at least
every 2 years in adults 18 and older, with more frequent monitoring for those at higher risk. Lipid
screening should begin at age 20 and be repeated every 5 years if normal. Diabetes screening is
recommended for adults over 45 or earlier for those with risk factors such as obesity or family history.
Osteoporosis screening with bone densitometry is recommended for all women aged 65 and older, and for
younger postmenopausal women with risk factors. Men should be screened starting at age 70.
Immunizations play a vital role in preventing infectious diseases. The influenza vaccine is recommended
annually for all adults, with particular emphasis on high-risk groups such as those with chronic medical
conditions, pregnant women, and adults over 65. The pneumococcal vaccine is recommended for adults
65 and older, as well as younger adults with certain medical conditions. There are two types: the
pneumococcal conjugate vaccine (PCV13) and the pneumococcal polysaccharide vaccine (PPSV23). The
specific recommendation depends on the individual's age and risk factors.
The tetanus, diphtheria, and pertussis (Tdap) vaccine should be given once to adults, followed by a Td
booster every 10 years. The shingles vaccine is recommended for adults 50 and older to prevent herpes
zoster and its complications. The human papillomavirus (HPV) vaccine is recommended for adolescents
and young adults up to age 26 to prevent cervical cancer and genital warts.
For adults traveling to certain areas, additional vaccines may be necessary. These can include hepatitis A
and B, typhoid, yellow fever, and meningococcal vaccines, depending on the destination and the traveler's
health status.
It's important to note that screening and immunization recommendations can vary based on individual risk
factors, family history, and personal preferences. Healthcare providers should engage in shared decision-
making with patients, discussing the potential benefits and risks of each screening test and vaccine.
Implementing these guidelines effectively requires a systematic approach. Electronic health records can
be used to track patients' screening and immunization status, generating reminders for both providers and
patients. Patient education is crucial to ensure understanding of the importance of preventive care and to
address any concerns or misconceptions.
While these guidelines provide a framework for preventive care, they should be applied judiciously.
Over-screening can lead to false positives, unnecessary procedures, and increased anxiety. Conversely,
under-screening may miss opportunities for early intervention. Balancing these considerations requires
clinical judgment and ongoing communication with patients.
As medical knowledge advances, screening and immunization guidelines continue to evolve. Healthcare
providers must stay informed about the latest recommendations and be prepared to adjust their practices
accordingly. This dynamic nature of preventive medicine underscores the importance of lifelong learning
in the medical profession.

Occupational and environmental health

Occupational and environmental health focuses on the interplay between work, environment, and human
health. This field is crucial for identifying, evaluating, and controlling workplace hazards, as well as
assessing and mitigating environmental risks that may affect public health.
In the workplace, various hazards can impact employee health. Physical hazards include noise, radiation,
extreme temperatures, and ergonomic issues. Chemical hazards encompass exposure to toxic substances,
solvents, and heavy metals. Biological hazards involve infectious agents, while psychosocial hazards
include stress, bullying, and shift work. Occupational health professionals work to identify these hazards
and implement control measures to protect workers.
Occupational diseases are conditions that arise from workplace exposures. These can include respiratory
diseases like asbestosis and silicosis from inhaling particulate matter, skin conditions from chemical
exposures, and musculoskeletal disorders from repetitive motions or poor ergonomics. Occupational
cancers, such as mesothelioma from asbestos exposure or leukemia from benzene exposure, are
particularly concerning due to their long latency periods.
Prevention is key in occupational health. This involves implementing the hierarchy of controls:
elimination, substitution, engineering controls, administrative controls, and personal protective
equipment. For example, a noisy machine might be replaced with a quieter model (substitution), enclosed
in a sound-proof booth (engineering control), or workers might be required to wear hearing protection
(personal protective equipment).
Occupational health also involves health surveillance programs to detect early signs of work-related
health effects. These can include regular hearing tests for workers exposed to noise, lung function tests for
those exposed to respiratory hazards, or blood tests for workers handling certain chemicals.
Environmental health addresses broader issues that affect community health. Air pollution is a significant
concern, with both outdoor and indoor air quality impacting respiratory and cardiovascular health. Water
quality is another crucial area, with contamination from industrial waste, agricultural runoff, and
inadequate sanitation systems posing serious health risks.
Climate change is an emerging environmental health issue with far-reaching consequences. It can lead to
increased frequency and severity of natural disasters, changes in disease patterns, and food and water
insecurity. Public health professionals play a key role in developing adaptation strategies and promoting
mitigation efforts.
Environmental toxins are another area of focus. Lead exposure, particularly in children, can cause
developmental delays and cognitive impairment. Mercury contamination in fish can affect neurological
development. Endocrine disruptors in plastics and other consumer products have been linked to various
health effects.
The built environment also impacts health. Urban planning decisions affect air quality, physical activity
levels, and access to healthy food. Housing conditions can influence exposure to allergens, pests, and
toxic substances like lead paint or asbestos.
Environmental justice is an important concept in this field, recognizing that certain populations, often
low-income and minority communities, bear a disproportionate burden of environmental health risks.
Addressing these disparities requires a combination of policy changes, community engagement, and
targeted interventions.
Risk assessment and management are key tools in both occupational and environmental health. This
involves identifying hazards, assessing exposure levels, characterizing risks, and implementing control
measures. Communication of these risks to workers, communities, and policymakers is crucial for
effective action.
Legislation plays a significant role in occupational and environmental health. In the United States, the
Occupational Safety and Health Administration (OSHA) sets and enforces standards for workplace safety.
The Environmental Protection Agency (EPA) regulates environmental pollutants and oversees cleanup of
contaminated sites. Understanding these regulatory frameworks is essential for healthcare providers
advising patients on occupational and environmental health issues.
Healthcare providers play a crucial role in recognizing and managing occupational and environmental
health issues. Taking a thorough occupational and environmental history is important for identifying
potential exposures. This includes asking about current and past jobs, hobbies, and living conditions.
Recognizing the signs and symptoms of occupational and environmental diseases allows for early
intervention and prevention of further exposure.
Collaboration between healthcare providers, occupational health professionals, and public health experts
is essential for addressing complex occupational and environmental health issues. This interdisciplinary
approach allows for comprehensive assessment and management of health risks at both individual and
population levels.
As our understanding of the complex interactions between work, environment, and health continues to
grow, the field of occupational and environmental health will remain dynamic and crucial for promoting
public health and preventing disease.

Medical ethics and patient safety

Medical ethics and patient safety are fundamental aspects of healthcare that guide decision-making and
ensure the delivery of high-quality, patient-centered care. These interrelated fields form the backbone of
modern medical practice, emphasizing the importance of moral principles and systematic approaches to
reduce harm and improve outcomes.
Medical ethics is grounded in four primary principles: autonomy, beneficence, non-maleficence, and
justice. Autonomy refers to the patient's right to make informed decisions about their own healthcare. This
principle underlies the concept of informed consent, where patients must be given adequate information
about their condition, treatment options, and potential risks and benefits before making decisions.
Beneficence is the obligation to act in the best interest of the patient, while non-maleficence is the duty to
avoid harm. These principles often come into tension, particularly in end-of-life care decisions where the
benefits of treatment must be weighed against potential suffering. Justice relates to the fair distribution of
healthcare resources and equal treatment of patients.
Ethical dilemmas in medicine often arise when these principles conflict. For example, a patient's
autonomous decision to refuse life-saving treatment may conflict with the physician's duty of beneficence.
Resolving such conflicts requires careful consideration of the specific circumstances, open
communication with patients and families, and sometimes consultation with ethics committees.
Confidentiality is another crucial ethical principle in healthcare. Patients have a right to privacy regarding
their medical information, and healthcare providers have a duty to protect this information. However,
there are situations where confidentiality may need to be breached, such as when there is a risk of harm to
the patient or others. Understanding the legal and ethical frameworks surrounding confidentiality is
essential for healthcare providers.
End-of-life care presents numerous ethical challenges. Decisions about withholding or withdrawing life-
sustaining treatment, palliative care, and physician-assisted death are complex and emotionally charged.
Advance directives and discussions about goals of care can help guide these decisions, but healthcare
providers must be prepared to navigate difficult conversations and conflicting family opinions.
Research ethics is another important area, ensuring that human subjects are protected in medical studies.
The principles of respect for persons, beneficence, and justice guide research ethics. Informed consent,
minimization of risks, and fair selection of research subjects are key considerations. Institutional Review
Boards (IRBs) play a crucial role in overseeing research to ensure ethical standards are met.
Patient safety, closely tied to medical ethics, focuses on preventing harm to patients during the course of
their healthcare. It is a systems-based approach that recognizes that most medical errors result from flaws
in healthcare delivery systems rather than individual negligence.
A culture of safety is essential for improving patient outcomes. This involves creating an environment
where staff feel comfortable reporting errors and near-misses without fear of punishment. Root cause
analysis is used to investigate adverse events, identifying systemic issues that contributed to the error and
developing strategies to prevent future occurrences.
Medication safety is a critical aspect of patient safety. Strategies to reduce medication errors include
computerized physician order entry systems, barcode medication administration, and medication
reconciliation processes. Clear communication about medications, including proper labeling and patient
education, is also crucial.
Preventing healthcare-associated infections is another key focus of patient safety efforts. Hand hygiene,
proper sterilization of equipment, and appropriate use of antibiotics are essential practices. Catheter-
associated urinary tract infections and central line-associated bloodstream infections are particular areas
of concern, with specific bundles of interventions developed to reduce their occurrence.
Surgical safety has been significantly improved through the implementation of checklists. The World
Health Organization Surgical Safety Checklist, which includes verification of patient identity, surgical
site, and equipment availability, has been shown to reduce surgical complications and mortality.
Communication failures are a common source of medical errors. Structured communication tools like
SBAR (Situation, Background, Assessment, Recommendation) have been developed to improve handoffs
between healthcare providers. Patient engagement in their own safety, through initiatives like "Speak Up"
campaigns, is also encouraged.
Quality improvement methodologies, such as Plan-Do-Study-Act (PDSA) cycles, are widely used in
healthcare to systematically test and implement changes to improve patient safety and outcomes. These
approaches emphasize continuous learning and adaptation based on data and feedback.
The intersection of ethics and patient safety is particularly evident in the disclosure of medical errors.
Ethically, healthcare providers have a duty to be honest with patients about errors that have occurred in
their care. This transparency is also crucial for improving patient safety, as it allows for learning from
mistakes and implementing preventive measures.
As healthcare becomes increasingly complex and technology-driven, new ethical and safety
considerations continue to emerge. Issues surrounding artificial intelligence in healthcare decision-
making, genetic testing and personalized medicine, and the use of big data all present novel challenges
that require ongoing ethical reflection and safety considerations.
Medical ethics and patient safety are integral to the practice of medicine, ensuring that care is delivered
in a manner that respects patient autonomy, promotes wellbeing, and minimizes harm. By integrating
ethical principles with systematic approaches to safety, healthcare providers can work towards the goal
of high-quality, patient-centered care.

Chapter 7 Summary and Workbook

This chapter covers three main areas: screening guidelines and immunizations, occupational and
environmental health, and medical ethics and patient safety.
The section on screening guidelines and immunizations emphasizes the importance of early disease
detection and prevention. It details recommendations for cancer screenings (colorectal, breast, cervical,
and lung), cardiovascular disease screening, and osteoporosis screening. The chapter also covers
essential immunizations for adults, including influenza, pneumococcal, tetanus, shingles, and HPV
vaccines.
Occupational and environmental health focuses on identifying and mitigating health risks in workplaces
and communities. It covers occupational hazards, diseases, and prevention strategies, as well as broader
environmental health issues like air and water quality, climate change impacts, and environmental toxins.
The importance of risk assessment, management, and communication is emphasized.
The medical ethics and patient safety section discusses the four primary ethical principles in healthcare:
autonomy, beneficence, non-maleficence, and justice. It explores ethical dilemmas, confidentiality issues,
and end-of-life care decisions. Patient safety is addressed through a systems-based approach, covering
strategies to prevent medical errors, improve communication, and create a culture of safety in healthcare
settings
Grab Your Pen & Let’s Do Some Quick Tests
1. How would you balance the benefits of early disease detection through screening with the
potential harms of over-diagnosis and unnecessary interventions?
2. In what ways might socioeconomic factors influence adherence to recommended screening
and immunization guidelines, and how would you address these disparities?
3. How would you approach counseling a patient who refuses vaccinations based on personal
beliefs, considering both individual autonomy and public health concerns?
4. What ethical considerations arise when implementing occupational health measures that
might conflict with workers' personal freedoms or cultural practices?
5. How might advances in genetic testing and personalized medicine change our approach to
preventive care and screening recommendations?
6. What strategies would you employ to improve environmental health in disadvantaged
communities facing disproportionate environmental risks?
7. How would you navigate the ethical tension between a patient's autonomous decision to
refuse life-saving treatment and your duty of beneficence as a healthcare provider?
8. In what ways could the increasing use of artificial intelligence in healthcare decision-making
impact patient safety and medical ethics?
9. How would you approach the disclosure of a medical error to a patient, considering both
ethical obligations and potential legal implications?
10. What role should healthcare providers play in addressing climate
change as an emerging public health threat?
Book 2: USMLE Step 3
Chapter 8: Step 3 Exam Format and Strategies
The USMLE Step 3 exam is the final assessment in the United States Medical Licensing Examination
sequence. This two-day exam evaluates a physician's ability to apply medical knowledge and
understanding of biomedical and clinical science essential for the unsupervised practice of medicine. The
exam focuses on patient management in ambulatory settings and emphasizes clinical decision-making
skills.
The Step 3 exam incorporates two testing formats: multiple-choice questions (MCQs) and computer-
based case simulations (CCS). Day 1 consists of 232 MCQs divided into 6 blocks of 38-39 questions
each. Day 2 includes 180 MCQs in 6 blocks, followed by 13 case simulations. This structure allows for a
comprehensive assessment of clinical knowledge and decision-making abilities.
Understanding the exam's format and developing effective strategies for both MCQs and CCS is crucial
for success. The following subchapters will explore the two-day exam structure in detail, provide
guidance on mastering CCS, and offer time management techniques for MCQs. By thoroughly preparing
for each component of the exam, test-takers can approach Step 3 with confidence and maximize their
performance.

Understanding the two-day exam structure

The USMLE Step 3 exam is a comprehensive assessment spread over two days, designed to evaluate a
physician's readiness for unsupervised medical practice. This extended format allows for a thorough
examination of clinical knowledge, decision-making skills, and patient management abilities. Let's break
down the structure of each day to gain a clear understanding of what to expect.
Day 1 of the Step 3 exam is dedicated entirely to multiple-choice questions (MCQs). This portion of the
exam consists of 232 questions divided into six blocks. Each block contains between 38 and 39 questions
and has a time limit of 60 minutes. The total testing time for Day 1 is 7 hours, which includes a 45-minute
break for lunch and optional breaks between blocks.
The MCQs on Day 1 cover a wide range of medical topics, including internal medicine, pediatrics,
obstetrics and gynecology, surgery, psychiatry, and epidemiology/biostatistics. These questions are
designed to test your ability to apply basic science concepts to clinical scenarios, interpret laboratory and
diagnostic studies, and make appropriate management decisions.
Day 2 of the exam is split into two distinct parts. The first part mirrors the format of Day 1, with 180
MCQs divided into six blocks of 30 questions each. Each block has a 45-minute time limit. This portion
of Day 2 takes approximately 5 hours and 15 minutes to complete, including break time.
The second part of Day 2 introduces the computer-based case simulations (CCS). This section consists of
13 case simulations, each representing a unique patient scenario. You'll have a maximum of 10 or 20
minutes per case, depending on its complexity. The total time allotted for the CCS portion is 3 hours.
The CCS component is a critical part of the Step 3 exam, as it assesses your ability to manage a patient
over time. These simulations require you to take a focused history, perform a targeted physical exam,
order appropriate diagnostic tests, and implement treatment plans. The cases unfold in real-time, allowing
you to see the results of your interventions and adjust your management accordingly.
It's important to note that the exam days are long and mentally demanding. Day 1 typically runs from 8 am
to 4:45 pm, while Day 2 can last from 8 am to 5:15 pm. These times include orientation and break
periods. The extended duration of the exam tests not only your medical knowledge but also your stamina
and ability to maintain focus over prolonged periods.
To succeed in this two-day format, it's crucial to develop a strategy that addresses both the MCQ and
CCS components. For the MCQs, focus on efficient time management and quick, accurate decision-
making. Practice answering questions under timed conditions to improve your speed and accuracy.
For the CCS portion, familiarize yourself with the software interface and practice managing simulated
cases. Develop a systematic approach to patient care that you can apply consistently across various
scenarios. This might include a standard method for taking a history, ordering initial tests, and formulating
differential diagnoses.
The two-day structure of the Step 3 exam also requires careful preparation in terms of physical and
mental endurance. In the weeks leading up to the exam, try to simulate exam conditions by studying for
extended periods. Ensure you're well-rested before each exam day and bring nutritious snacks to maintain
your energy levels throughout the testing sessions.
Remember that the exam is designed to be challenging, but it's also meant to be a fair assessment of your
abilities as a physician. The two-day format allows for a comprehensive evaluation of your skills across
various medical disciplines and in different testing formats. By understanding the structure of the exam
and preparing accordingly, you can approach Step 3 with confidence and demonstrate your readiness for
independent medical practice.

Mastering computer-based case simulations (CCS)

Computer-based case simulations (CCS) form a crucial component of the USMLE Step 3 exam, designed
to assess a physician's ability to manage patient care over time. This innovative testing format presents
unique challenges and opportunities for examinees. Mastering CCS requires a combination of clinical
knowledge, strategic thinking, and familiarity with the software interface.
The CCS portion of Step 3 consists of 13 cases, each representing a different patient scenario. These
cases vary in complexity and duration, with some lasting up to 20 minutes and others as short as 10
minutes. The software simulates real-time patient care, allowing you to order tests, prescribe treatments,
and observe the results of your interventions as the case progresses.
One of the key aspects of mastering CCS is understanding the software interface. Familiarize yourself
with the various tabs and functions available, including the patient chart, order entry system, and results
reporting. Practice navigating between these sections efficiently to maximize your time management
during the exam.
When approaching a CCS case, start by carefully reading the initial patient presentation. This information
provides crucial details about the patient's chief complaint, vital signs, and relevant history. Based on this
initial data, formulate a preliminary differential diagnosis and develop an initial management plan.
As you progress through the case, maintain a systematic approach to patient care. This should include:

1. Taking a focused history

2. Performing a targeted physical examination
3. Ordering appropriate diagnostic tests
4. Implementing initial treatment measures
5. Reassessing the patient and adjusting management as needed
Remember that CCS cases unfold in real-time, meaning that patient conditions can change rapidly. Stay
vigilant for new symptoms, abnormal test results, or unexpected complications. Be prepared to modify
your management plan based on these evolving factors.
Time management is critical in CCS. While you have a maximum of 10 or 20 minutes per case, aim to
complete each simulation efficiently without sacrificing thoroughness. Prioritize your actions based on the
urgency of the patient's condition. For example, in a case of suspected myocardial infarction, ordering an
ECG and administering aspirin should take precedence over obtaining a detailed family history.
One common pitfall in CCS is over-ordering tests or treatments. While it's important to be thorough,
unnecessary orders can waste valuable time and may even harm the simulated patient. Focus on high-yield
diagnostic tests and evidence-based treatments that directly address your working diagnosis.
Conversely, don't hesitate to order essential tests or treatments out of fear of over-ordering. Failure to
diagnose or treat a serious condition can result in a poor score, even if you've been conservative with
your orders overall.
Practice interpreting lab results and imaging studies quickly and accurately. The CCS software provides
these results in a format similar to what you'd encounter in clinical practice. Develop a systematic
approach to reviewing these results to ensure you don't miss critical information.
Pay attention to the passage of time within each case. The software typically allows you to advance time
when appropriate, such as waiting for test results or observing a patient's response to treatment. Use this
feature judiciously to manage your cases efficiently.
Documentation is another crucial aspect of CCS. The software may prompt you to write brief notes or
summaries at various points in the case. These notes should be concise yet comprehensive, reflecting your
clinical reasoning and justifying your management decisions.
To improve your CCS performance, consider the following strategies:

1. Practice with sample cases: Utilize available CCS practice software to familiarize yourself
with the interface and improve your case management skills.
2. Review common presentations: Focus on high-yield clinical scenarios that frequently appear
in CCS, such as chest pain, shortness of breath, abdominal pain, and altered mental status.
3. Develop a structured approach: Create a mental checklist for each major presenting
complaint to ensure you cover all essential aspects of patient care.
4. Study guidelines: Familiarize yourself with current clinical practice guidelines for common
conditions, as these often inform the optimal management strategies in CCS cases.
5. Improve your clinical decision-making: Practice analyzing clinical scenarios and making
rapid, evidence-based decisions.
6. Learn from your mistakes: After completing practice cases, thoroughly review your
performance, identifying areas for improvement.
Remember that CCS is designed to assess your ability to provide comprehensive, patient-centered care.
Approach each case as if you were managing a real patient, balancing the need for thorough evaluation
with efficient and timely interventions.
By mastering the CCS format, you'll not only improve your performance on the Step 3 exam but also
enhance your skills as a clinician. The problem-solving and patient management abilities honed through
CCS practice will serve you well throughout your medical career.
Time management techniques for multiple-choice questions
(MCQs)
Effective time management is crucial for success on the multiple-choice question (MCQ) portions of the
USMLE Step 3 exam. With hundreds of questions to answer over two days, developing strategies to
maximize your efficiency is essential. This section will explore various techniques to help you manage
your time effectively during the MCQ sections of the exam.
First and foremost, it's important to understand the structure of the MCQ portions. On Day 1, you'll face
232 questions divided into six blocks of 38-39 questions each. Day 2 begins with 180 questions in six
blocks of 30 questions each. Each block has a time limit of 60 minutes on Day 1 and 45 minutes on Day 2.
This translates to an average of about 90 seconds per question on Day 1 and 90 seconds per question on
Day 2.
One of the most effective time management techniques is to maintain a consistent pace throughout each
block. Avoid spending too much time on any single question, as this can leave you rushed and stressed
towards the end of the block. If you find yourself struggling with a particularly difficult question, make
your best guess, flag it for review, and move on. You can always return to it if time permits at the end of
the block.
To help maintain this pace, consider using a simple mental math technique. For a 60-minute block with 40
questions, you should aim to complete 10 questions every 15 minutes. Quickly check your progress at
these 15-minute intervals. If you're falling behind, you'll know to pick up the pace slightly.
Another useful strategy is to read the last line of the question stem first. This Often contains the actual
question being asked and can help you focus your attention on the relevant information as you read through
the rest of the stem. This technique can save valuable seconds on each question, which adds up
significantly over the course of the exam.
When approaching each question, try to formulate your own answer before looking at the options
provided. This can help prevent you from being swayed by plausible-sounding but incorrect choices. If
your answer matches one of the options, it's likely to be correct. If not, you can quickly eliminate options
that don't align with your thinking.
Elimination is a powerful tool for managing time on MCQs. Even if you're not immediately sure of the
correct answer, you can rule out one or more options based on your medical knowledge. This increases
your chances of selecting the correct answer, even if you need to make an educated guess.
Be wary of changing your answers unless you're absolutely certain you've made a mistake. Research has
shown that first instincts are correct, and changing answers can sometimes lead to errors. If you have
time at the end of a block to review flagged questions, only change an answer if you have a specific
reason for doing so.
It's also important to read each question carefully, but efficiently. Look for key words or phrases that
might point you towards the correct answer. Be particularly attentive to words like "most likely," "least
likely," "first step," or "best initial treatment," as these can significantly influence the correct choice.
Practice active reading to improve your speed and comprehension. This involves engaging with the text,
mentally summarizing key points, and anticipating where the question is leading. With practice, this
technique can help you process information more quickly and accurately.
Time management also extends to your use of break periods. The Step 3 exam allows for a 45-minute
lunch break on each day, as well as optional breaks between blocks. Use these breaks wisely to rest,
refuel, and refocus. However, be careful not to take excessive breaks, as this can disrupt your rhythm and
concentration.
Consider developing a personalized approach to difficult questions. Some test-takers prefer to tackle the
hardest questions first while their minds are fresh, while others find it more effective to build momentum
with easier questions before addressing more challenging ones. Experiment with different approaches
during your practice sessions to find what works best for you.
Remember that the USMLE Step 3 is a test of clinical judgment as much as it is a test of medical
knowledge. Many questions will present complex clinical scenarios that require careful analysis. While
it's important to work efficiently, don't sacrifice accuracy for speed. It's better to answer fewer questions
correctly than to rush through and make preventable errors.
As you practice for the exam, gradually increase your speed over time. Start by giving yourself ample
time to answer practice questions, focusing on accuracy. As you become more comfortable with the
question format and content, start imposing stricter time limits on yourself until you can consistently
complete blocks within the allotted time.
Finally, maintain perspective throughout the exam. If you find yourself falling behind or struggling with a
particular block, don't panic. Take a deep breath, refocus, and do your best with the remaining questions.
Remember that the exam is designed to be challenging, and it's likely that other test-takers are facing
similar difficulties.
By implementing these time management techniques and practicing them regularly, you can approach the
MCQ portions of the USMLE Step 3 with confidence. Effective time management will allow you to
showcase your medical knowledge and clinical reasoning skills to the fullest extent, maximizing your
chances of success on this important exam.
Chapter 9: Advanced Clinical Medicine
Advanced clinical medicine requires physicians to synthesize complex medical knowledge and apply it to
challenging patient scenarios. This chapter focuses on three key areas that are essential for providing
high-quality patient care at an advanced level: managing complex patient presentations, approaching
multisystem disorders, and applying evidence-based medicine principles.
Complex patient presentations often involve multiple interacting medical problems, atypical disease
manifestations, or diagnostic dilemmas that require careful clinical reasoning. Physicians must be adept at
prioritizing issues, considering broad differential diagnoses, and developing comprehensive management
plans that address all of a patient's medical needs. This section will explore strategies for tackling
complicated cases and making sound clinical decisions when faced with ambiguity or conflicting
information.
Multisystem disorders present unique challenges, as they can affect multiple organ systems simultaneously
and have wide-ranging impacts on a patient's health. A systematic approach is crucial for accurately
diagnosing and managing these conditions. This section will examine frameworks for evaluating patients
with suspected multisystem disease, interpreting patterns of organ involvement, and coordinating care
across medical specialties.
Evidence-based medicine forms the foundation of modern clinical practice. Physicians must be skilled at
critically appraising medical literature, interpreting study results, and appropriately applying research
findings to individual patients. This section will review key concepts in evidence-based medicine,
including study design, statistical analysis, and clinical decision-making based on the best available
evidence. Practical examples will illustrate how to integrate evidence-based principles into daily patient
care.
By mastering these advanced clinical skills, physicians can provide optimal care for patients with
complex medical needs and stay at the forefront of medical knowledge and practice.

Complex patient presentations and management

Complex patient presentations challenge even experienced clinicians and require a thoughtful, systematic
approach. These cases often involve multiple medical problems, atypical disease manifestations, or
diagnostic uncertainty. Successfully managing complex patients demands strong clinical reasoning skills,
attention to detail, and the ability to synthesize large amounts of information.
One common scenario is the patient with multiple chronic conditions. For example, consider a 65-year-
old man with longstanding hypertension, type 2 diabetes, and chronic kidney disease who presents with
new-onset chest pain. Each of his underlying conditions increases his cardiovascular risk and complicates
the diagnostic workup. The clinician must consider how these comorbidities interact and affect the
presentation and management of potential acute coronary syndrome.
When approaching such cases, start by gathering a thorough history and performing a careful physical
exam. Pay close attention to the timeline and progression of symptoms, as this can provide valuable clues.
Review all available medical records, including prior test results and medication lists. Develop a
prioritized problem list to organize your thoughts and ensure no issues are overlooked.
Generate a broad differential diagnosis that accounts for common and uncommon causes of the patient's
presentation. Consider how the patient's known medical problems could be contributing, but also maintain
a high index of suspicion for new pathology. Atypical presentations of common diseases are more likely
than rare diseases, but both possibilities should be entertained.
Diagnostic testing should be targeted and judicious. While a "shotgun" approach of ordering every
possible test may seem tempting, it often leads to false positive results and unnecessary follow-up.
Instead, use a stepwise approach, starting with high-yield, non-invasive tests and proceeding to more
specialized studies as needed. Always consider the pre-test probability of disease and how test results
will change management.
Interpretation of test results requires careful consideration of the patient's clinical context. Normal
reference ranges may not apply to patients with certain chronic conditions. For example, troponin levels
may be chronically elevated in patients with end-stage renal disease, complicating the diagnosis of acute
myocardial infarction. Similarly, inflammatory markers like erythrocyte sedimentation rate can be
elevated due to numerous conditions, limiting their specificity.
Management plans for complex patients should be comprehensive and address all active medical issues.
Prioritize interventions based on acuity and potential impact on outcomes. Consider how treatments for
one condition may affect others - for instance, NSAIDs given for pain could worsen renal function in a
patient with chronic kidney disease. Medication reconciliation is crucial to avoid interactions and
optimize adherence.
Coordination of care across multiple providers and specialties is often necessary. Clearly communicate
your assessment and plan to consultants, and integrate their recommendations into the overall management
strategy. Designate a primary point person (often the general internist or hospitalist) to oversee the big
picture and ensure all aspects of care are addressed.
Patient education and shared decision-making take on added importance in complex cases. Explain
diagnoses and treatment options in understandable terms, and involve the patient in setting goals of care.
Address any barriers to adherence or follow-up. Consider the patient's values and preferences when
weighing the risks and benefits of different management options.
Close follow-up is essential for complex patients. Develop a clear plan for outpatient management,
including specific follow-up appointments, monitoring parameters, and criteria for seeking urgent medical
attention. Provide detailed discharge instructions and ensure a smooth transition of care to outpatient
providers.
Diagnostic uncertainty is common in complex cases, and physicians must be comfortable managing this
ambiguity. When a definitive diagnosis cannot be reached, focus on treating symptoms, monitoring for
disease progression, and ruling out dangerous conditions. Be willing to revisit the diagnosis if the clinical
picture changes or fails to improve as expected.
Finally, maintain a humble and open-minded approach. Complex cases often have twists and turns that can
challenge our initial impressions. Be willing to reconsider diagnoses, seek second opinions when
appropriate, and learn from unexpected outcomes. Cultivate intellectual curiosity and use challenging
cases as opportunities for continued learning and improvement.
By applying these principles, clinicians can navigate the complexities of difficult patient presentations
and provide high-quality, patient-centered care. The ability to manage complex patients effectively is a
hallmark of advanced clinical medicine and a valuable skill for any physician to develop.
Multisystem disorders and their approach
Multisystem disorders present unique challenges in diagnosis and management due to their wide-ranging
effects on multiple organ systems. These conditions require a comprehensive and systematic approach to
ensure all aspects of the disease are addressed. Common examples of multisystem disorders include
systemic lupus erythematosus, sarcoidosis, vasculitides, and various inherited metabolic disorders.
When approaching a patient with a suspected multisystem disorder, begin with a thorough history and
physical examination. Pay close attention to the chronology and progression of symptoms across different
organ systems. Look for patterns or clusters of symptoms that might suggest a unifying diagnosis. A
detailed review of systems is crucial, as patients may not volunteer symptoms they don't realize are
related to their condition.
Consider the patient's demographics, as many multisystem disorders have characteristic age, gender, or
ethnic distributions. For example, systemic lupus erythematosus is more common in young women,
particularly those of African or Asian descent. Familial Mediterranean fever is more prevalent in
individuals of Mediterranean or Middle Eastern ancestry.
Physical examination should be comprehensive, looking for subtle signs of systemic involvement. Skin
findings can be particularly informative in many multisystem disorders. For instance, the malar rash of
lupus, the nodules of rheumatoid arthritis, or the purpuric rash of vasculitis can provide valuable
diagnostic clues. Careful examination of the eyes, oral mucosa, joints, and peripheral nervous system is
also essential.
Laboratory testing in multisystem disorders often begins with a broad panel of screening tests to assess
organ function and identify areas of involvement. This typically includes a complete blood count,
comprehensive metabolic panel, urinalysis, and inflammatory markers such as erythrocyte sedimentation
rate and C-reactive protein. More specific tests can then be ordered based on the clinical picture and
suspected diagnosis.
Autoantibody testing plays a crucial role in the diagnosis of many multisystem disorders, particularly
autoimmune diseases. However, interpretation of these tests requires caution, as false positives can occur,
and the presence of autoantibodies does not always indicate active disease. Consider the pre-test
probability and use autoantibody testing to confirm clinical suspicions rather than as a screening tool.
Imaging studies can help assess the extent of organ involvement and identify subclinical disease. Chest
radiographs and high-resolution CT scans can reveal pulmonary involvement in conditions like
sarcoidosis or interstitial lung disease associated with connective tissue disorders. Echocardiography
may be necessary to evaluate cardiac involvement in systemic diseases.
Tissue biopsy often plays a crucial role in confirming the diagnosis of multisystem disorders. The choice
of biopsy site depends on the suspected diagnosis and the accessibility of affected tissues. For example,
temporal artery biopsy is essential in the diagnosis of giant cell arteritis, while renal biopsy may be
necessary to confirm lupus nephritis.
Once a diagnosis is established, develop a comprehensive management plan that addresses all affected
organ systems. Prioritize treatment of life-threatening or organ-threatening manifestations. Many
multisystem disorders require immunosuppressive therapy, which carries its own risks and requires
careful monitoring.
Coordinate care with relevant specialists to ensure all aspects of the disease are properly managed. This
may involve rheumatologists, nephrologists, pulmonologists, dermatologists, and others depending on the
specific organ systems involved. Designate a primary coordinating physician to oversee the overall care
plan and ensure effective communication between providers.
Patient education is crucial in managing multisystem disorders. Explain the nature of the disease, its
potential complications, and the importance of adherence to treatment and follow-up. Provide resources
for patient support groups and reliable information about their condition.
Regular follow-up and monitoring are essential to track disease activity, assess treatment response, and
detect complications early. Develop a monitoring plan that includes regular clinical assessments,
laboratory tests, and imaging studies as appropriate for the specific disorder.
Be prepared to adjust the treatment plan as needed based on the patient's response and any new
developments. Many multisystem disorders have a relapsing-remitting course, requiring periodic
intensification of therapy during flares and careful tapering during remissions.
Consider the long-term complications and comorbidities associated with both the disease itself and its
treatments. For example, patients with systemic lupus erythematosus have an increased risk of
cardiovascular disease and osteoporosis, which should be addressed in their overall care plan.
Multisystem disorders often have a significant impact on a patient's quality of life and psychosocial well-
being. Address these aspects of care by providing appropriate psychological support, occupational
therapy, and social services as needed.
Finally, stay up-to-date with the latest research and treatment guidelines for multisystem disorders. Many
of these conditions are areas of active research, with new diagnostic criteria and treatment options
emerging regularly.
By applying a systematic and comprehensive approach to multisystem disorders, clinicians can improve
diagnostic accuracy, optimize treatment outcomes, and enhance the overall quality of care for these
complex patients.

Evidence-based medicine application

Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence
in making decisions about the care of individual patients. It integrates clinical expertise, patient values,
and the best available research evidence. Applying EBM principles is crucial for providing high-quality,
up-to-date patient care.
The first step in applying EBM is formulating a clear clinical question. Use the PICO format:
Patient/Problem, Intervention, Comparison, and Outcome. For example, "In adults with type 2 diabetes
(P), does metformin (I) compared to sulfonylureas (C) reduce the risk of cardiovascular events (O)?" A
well-formulated question guides the literature search and helps focus on relevant evidence.
Conduct a thorough literature search using reputable databases such as PubMed, Cochrane Library, or
EMBASE. Use appropriate search terms and filters to narrow down results. Consider consulting a
medical librarian for complex searches. Be aware of publication bias - negative studies are less likely to
be published, potentially skewing the available evidence.
When evaluating studies, consider the hierarchy of evidence. Systematic reviews and meta-analyses of
randomized controlled trials (RCTs) provide the highest level of evidence for questions about therapy.
For questions about prognosis, cohort studies may be most appropriate. Case-control studies can be
valuable for rare conditions or outcomes.
Critically appraise the methodology of studies you review. For RCTs, assess randomization methods,
blinding, intention-to-treat analysis, and loss to follow-up. For observational studies, consider potential
confounding factors and how they were addressed. Evaluate the validity of the study's conclusions based
on the methods used.
Pay close attention to the study population and setting. Consider whether the results are generalizable to
your patient population. Studies conducted in tertiary care centers may not be directly applicable to
primary care settings. Be cautious about extrapolating results to populations that were excluded or
underrepresented in the study.
Understand key statistical concepts to interpret study results accurately. Distinguish between statistical
significance (p-values) and clinical significance (effect size). Consider absolute risk reduction and
number needed to treat (NNT) rather than relying solely on relative risk reduction, which can be
misleading.
Be aware of common biases in medical research. Selection bias can occur if study participants are not
representative of the target population. Information bias may result from inaccurate data collection or
recall bias in retrospective studies. Confounding occurs when an unmeasured variable influences both the
exposure and outcome of interest.
When multiple studies address the same question, look for consistency in results. If studies show
conflicting results, consider potential reasons for the discrepancies, such as differences in study
populations, interventions, or outcome measures.
Apply the evidence to your individual patient. Consider how closely your patient matches the study
population. Take into account the patient's preferences, values, and specific circumstances. The best
external evidence may be inapplicable or inappropriate for an individual patient.
Use clinical practice guidelines as a starting point, but remember that they may not account for all clinical
scenarios. Guidelines are based on available evidence and expert consensus at the time of publication,
but may not reflect the most recent research. Always consider the strength of recommendations and the
quality of evidence behind them.
Be prepared to explain your evidence-based decisions to patients in understandable terms. Discuss the
potential benefits and risks of different treatment options, using absolute numbers rather than percentages
when possible. Involve patients in shared decision-making, considering their values and preferences.
Recognize the limitations of EBM. Not all clinical questions have been or can be answered by high-
quality studies. In these cases, rely on pathophysiological reasoning, clinical experience, and patient
preferences while clearly acknowledging the uncertainty.
Stay up-to-date with the latest evidence in your field. Regularly read key journals, attend conferences, and
participate in continuing medical education activities. Consider using evidence-based medicine resources
like UpToDate or DynaMed for point-of-care information.
Implement systems to incorporate new evidence into practice. This might include regular journal clubs,
clinical pathways, or decision support tools integrated into electronic health records. Be willing to
change practice when new evidence contradicts previous beliefs or standards of care.
Contribute to the body of evidence when possible. Participate in clinical research, quality improvement
projects, or case reports. Share your clinical experiences and insights to help advance medical
knowledge.
Finally, cultivate a culture of inquiry and continuous learning. Encourage questioning of established
practices and be open to new ideas supported by evidence. Model evidence-based practice for trainees
and colleagues, fostering an environment where clinical decisions are based on the best available
evidence rather than tradition or anecdote.
By consistently applying these principles of evidence-based medicine, clinicians can provide the highest
quality care to their patients, staying current with medical advances and making informed decisions based
on the best available evidence.

Chapter 9 Summary and Workbook

This chapter focuses on three key areas of advanced clinical medicine: managing complex patient
presentations, approaching multisystem disorders, and applying evidence-based medicine principles.
Complex patient presentations often involve multiple interacting medical problems or atypical disease
manifestations. The chapter emphasizes the importance of thorough history-taking, physical examination,
and developing a prioritized problem list. It stresses the need for generating broad differential diagnoses,
judicious use of diagnostic tests, and careful interpretation of results in the context of the patient's overall
clinical picture. The importance of comprehensive management plans, care coordination, patient
education, and close follow-up is highlighted.
The section on multisystem disorders discusses the challenges of diagnosing and managing conditions that
affect multiple organ systems simultaneously. It emphasizes the importance of recognizing patterns of
symptoms, considering patient demographics, and using a combination of laboratory tests, imaging
studies, and sometimes tissue biopsies to reach a diagnosis. The chapter stresses the need for coordinated
care among specialists and regular monitoring of disease activity and treatment response.
The evidence-based medicine (EBM) section outlines the process of applying research evidence to
clinical practice. It covers formulating clinical questions, conducting literature searches, critically
appraising studies, and applying findings to individual patients. The chapter emphasizes the importance of
understanding statistical concepts, recognizing research biases, and considering patient preferences in
clinical decision-making.
Grab Your Pen & Let’s Do Some Quick Tests
1. How would you approach prioritizing multiple medical issues in a complex patient with
limited healthcare resources?
2. In what ways might cognitive biases affect your clinical reasoning when dealing with
atypical disease presentations?
3. How would you balance the need for comprehensive diagnostic testing with the risks of
over-testing in a patient with a suspected multisystem disorder?
4. What strategies would you employ to improve care coordination for a patient with a complex
multisystem disorder being managed by multiple specialists?
5. How might the increasing availability of genetic testing influence your approach to
diagnosing and managing multisystem disorders?
6. In what ways could artificial intelligence and machine learning impact the application of
evidence-based medicine in clinical practice?
7. How would you approach a clinical scenario where the best available evidence conflicts
with established clinical guidelines?
8. What ethical considerations arise when applying population-based research findings to
individual patients with unique circumstances?
9. How might the principles of evidence-based medicine be applied to improve the
management of rare diseases with limited research data?
10. In what ways could improving health literacy among patients impact
the practice of evidence-based, shared decision-making?
Chapter 10: Emergency Medicine and Critical
Care
Emergency medicine and critical care are vital fields that deal with the assessment and management of
acute, life-threatening conditions. This chapter covers key aspects of emergency and critical care
medicine that are essential for providing optimal care to critically ill and injured patients.
The first section focuses on acute care scenarios and interventions. It explores common emergency
presentations such as chest pain, shortness of breath, altered mental status, and shock. For each scenario,
the emphasis is on rapid assessment, differential diagnosis, and initial stabilization measures. Key
interventions like airway management, fluid resuscitation, and emergency medications are discussed in
detail. This section aims to develop the clinical reasoning and decision-making skills needed to manage
acutely ill patients.
The second section covers advanced cardiac life support (ACLS) principles. It reviews the latest
guidelines for managing cardiac arrest and peri-arrest conditions. Topics include basic and advanced
airway management, high-quality CPR, defibrillation, post-cardiac arrest care, and management of acute
coronary syndromes. The focus is on the systematic ACLS algorithms and the evidence behind current
resuscitation practices. This knowledge is crucial for any physician involved in code situations.
The third section addresses trauma management and triage. It covers the initial approach to the trauma
patient, including the primary and secondary surveys. Key concepts in trauma resuscitation are discussed,
such as damage control surgery and massive transfusion protocols. The section also reviews triage
principles for mass casualty incidents. Understanding these concepts is essential for effectively managing
traumatic injuries and optimizing outcomes in resource-limited situations.
By mastering the knowledge and skills presented in this chapter, physicians will be better prepared to
handle a wide range of emergency and critical care scenarios. The goal is to develop a systematic
approach to critically ill patients that can be applied across various clinical settings.

Acute care scenarios and interventions

Acute care scenarios require rapid assessment and intervention to prevent further deterioration and
optimize patient outcomes. This section will cover several common emergency presentations and the key
interventions required.
Chest pain is a frequent complaint in the emergency department that requires careful evaluation. The
initial approach involves quickly ruling out life-threatening causes like acute coronary syndrome, aortic
dissection, pulmonary embolism, and tension pneumothorax. A focused history should assess the quality,
onset, location, radiation, associated symptoms, and risk factors. The physical exam should evaluate vital
signs, heart and lung sounds, and signs of heart failure or shock.
An ECG should be obtained within 10 minutes of arrival for all patients with concerning chest pain.
Cardiac biomarkers like troponin should be measured, though a single negative result does not rule out
myocardial infarction. Chest x-ray can identify alternative diagnoses like pneumonia or pneumothorax.
For suspected acute coronary syndrome, aspirin should be given immediately unless contraindicated.
Nitroglycerin can provide symptomatic relief if blood pressure allows. Anticoagulation and early
cardiology consultation for possible cardiac catheterization are indicated for ST-elevation myocardial
infarction or high-risk non-ST elevation acute coronary syndrome.
Shortness of breath is another common emergency presentation with a broad differential. Initial
assessment should focus on work of breathing, use of accessory muscles, ability to speak, and oxygen
saturation. Lung exam may reveal wheezes, crackles, or decreased breath sounds. Cardiac exam should
assess for signs of heart failure. Chest x-ray can identify pulmonary edema, pneumonia, pneumothorax, or
pleural effusions. Arterial blood gas helps assess the severity of respiratory compromise and acid-base
status.
For patients with severe respiratory distress, supplemental oxygen should be provided immediately.
Nebulized bronchodilators like albuterol are indicated for wheezing. Non-invasive positive pressure
ventilation can be beneficial for COPD exacerbations or cardiogenic pulmonary edema. Intubation and
mechanical ventilation may be required for patients with respiratory failure or altered mental status.
Antibiotics should be given promptly for suspected pneumonia. Diuretics are indicated for
decompensated heart failure.
Altered mental status requires a systematic approach to identify and address the underlying cause. The
initial survey should assess for immediate threats to airway, breathing, and circulation. Finger-stick
glucose should be checked immediately to rule out hypoglycemia. A focused neurologic exam including
Glasgow Coma Scale should be performed. CT head may be indicated to evaluate for intracranial
hemorrhage or mass lesion. Lumbar puncture should be considered if meningitis is suspected.
Empiric treatment with thiamine, glucose, and naloxone (the "coma cocktail") can be given while the
workup is ongoing. Intubation for airway protection may be required for patients with significantly
depressed mental status. Antibiotics and acyclovir should be started promptly if CNS infection is
suspected. Status epilepticus requires aggressive treatment with benzodiazepines followed by anti-
epileptic medications.
Shock is a state of inadequate tissue perfusion that requires rapid recognition and intervention. The initial
approach involves assessing for signs of shock including tachycardia, hypotension, altered mental status,
oliguria, and poor peripheral perfusion. Point-of-care ultrasound can help differentiate between
cardiogenic, hypovolemic, and obstructive shock. Large-bore IV access should be obtained immediately.
Fluid resuscitation with crystalloids is the first-line treatment for most types of shock. Vasopressors like
norepinephrine are indicated for persistent hypotension despite adequate volume resuscitation.
Mechanical ventilation may be required to decrease work of breathing. Broad-spectrum antibiotics should
be given within one hour for suspected septic shock. Emergent echocardiography and pericardiocentesis
may be life-saving for cardiac tamponade. Thrombolytics should be considered for massive pulmonary
embolism with hemodynamic compromise.
Airway management is a critical skill in emergency medicine. Indications for intubation include
respiratory failure, airway protection, and anticipated clinical course. Proper positioning and
preoxygenation are key steps before attempting intubation. Rapid sequence intubation involves
administering a sedative and paralytic in rapid succession to facilitate intubation. Common sedatives
include etomidate, ketamine, and propofol. Succinylcholine and rocuronium are frequently used
paralytics.
Video laryngoscopy can improve first-pass success rates compared to direct laryngoscopy. Rescue
devices like laryngeal mask airways and bougie introducers should be readily available. A surgical
airway via cricothyrotomy is the last resort for can't intubate, can't ventilate scenarios. Confirmation of
proper tube placement is crucial and involves assessing for bilateral breath sounds, chest rise, and end-
tidal CO2.
Procedural sedation is frequently required in the emergency department for painful procedures. Common
indications include fracture/dislocation reduction, cardioversion, and abscess drainage. Preprocedural
assessment should evaluate for high-risk features and difficult airway. Proper monitoring including
continuous pulse oximetry, blood pressure, and cardiac monitoring is essential.
Commonly used agents include propofol, ketamine, etomidate, and midazolam. Fentanyl or other opioids
can be added for additional analgesia. The provider performing the sedation should be skilled in airway
management and prepared to manage potential complications like respiratory depression or hemodynamic
instability. Careful titration and close patient monitoring are key to safe and effective procedural sedation.
Point-of-care ultrasound has become an invaluable tool in emergency medicine. Common applications
include evaluation for pneumothorax, pericardial effusion, abdominal aortic aneurysm, and deep vein
thrombosis. The FAST exam (Focused Assessment with Sonography in Trauma) can rapidly identify
intraperitoneal free fluid in trauma. Ultrasound-guided peripheral and central line placement improves
success rates and reduces complications. Cardiac ultrasound can assess for wall motion abnormalities,
valvular disease, and volume status.
Effective communication and teamwork are crucial in managing acute care scenarios. Clear role
designation and closed-loop communication help ensure critical tasks are completed. Regular team
training and simulation can improve performance during actual resuscitations. Proper documentation of
interventions, patient response, and medical decision-making is important from both medical and
medicolegal perspectives.
Lastly, it's important to address the psychological impact of critical illness on patients and families. Clear
communication about the patient's condition and treatment plan is essential. Palliative care consultation
can be beneficial for patients with poor prognosis or complex symptom management needs. Proper self-
care and debriefing are also important for emergency providers to maintain their own mental health and
prevent burnout.

Advanced cardiac life support (ACLS) principles

Advanced Cardiac Life Support (ACLS) encompasses a set of clinical interventions for the urgent
treatment of cardiac arrest, stroke, and other life-threatening medical emergencies. It builds on the
foundation of basic life support (BLS) by adding advanced airway management, monitoring, and
pharmacological interventions. Understanding and applying ACLS principles is crucial for any healthcare
provider involved in emergency care.
The cornerstone of ACLS is high-quality cardiopulmonary resuscitation (CPR). This involves chest
compressions at a rate of 100-120 per minute, allowing full chest recoil between compressions,
minimizing interruptions, and ensuring adequate depth (at least 2 inches or 5 cm). Proper hand placement
is on the lower half of the sternum. Compressions should be initiated immediately upon recognition of
cardiac arrest and continued with minimal interruptions.
Rotating compressors every 2 minutes helps maintain high-quality compressions. The importance of
effective chest compressions cannot be overstated - they are the primary driver of forward blood flow
during resuscitation. Even brief pauses in chest compressions can significantly decrease coronary and
cerebral perfusion pressures, reducing the likelihood of successful resuscitation.
Airway management in ACLS begins with basic techniques like head tilt-chin lift or jaw thrust maneuvers
to open the airway. Bag-mask ventilation is often the initial method of oxygenation and ventilation.
However, advanced airway devices such as endotracheal tubes or supraglottic airways are frequently
employed in prolonged resuscitations. The emphasis in current guidelines is on minimizing interruptions
to chest compressions during airway management.
Continuous waveform capnography is recommended to confirm and monitor correct endotracheal tube
placement. It's important to note that while securing the airway is important, it should not cause significant
delays in chest compressions or defibrillation for shockable rhythms.
Early defibrillation is critical for patients in ventricular fibrillation (VF) or pulseless ventricular
tachycardia (VT). These "shockable" rhythms have the best prognosis if treated promptly with
defibrillation. For witnessed arrests where a defibrillator is immediately available, defibrillation should
be performed as soon as possible. In unwitnessed arrests or when the defibrillator is not immediately
available, a short period of CPR (about 2 minutes) before the first shock may be beneficial.
Subsequent shocks should be delivered with minimal delay after each 2-minute cycle of CPR. Energy
levels depend on the type of defibrillator - for biphasic defibrillators, the initial dose is typically 120-
200 J, while for monophasic defibrillators, 360 J is used. The shock should be delivered as quickly as
possible after the rhythm check to minimize the pre-shock pause.
Pharmacological interventions play a significant role in ACLS. Epinephrine is the primary vasopressor
used in cardiac arrest. It's recommended to give 1 mg every 3-5 minutes for both shockable and non-
shockable rhythms. The alpha-adrenergic effects of epinephrine increase coronary and cerebral perfusion
pressures, which is thought to be its primary mechanism of benefit in cardiac arrest.
Amiodarone or lidocaine can be considered for shock-refractory VF/VT. Amiodarone is typically given
as a 300 mg bolus, followed by a 150 mg dose if needed. Lidocaine is dosed at 1-1.5 mg/kg initially, with
subsequent doses of 0.5-0.75 mg/kg. It's important to note that while these antiarrhythmic medications may
increase the likelihood of successful defibrillation, they have not been shown to improve long-term
survival.
The ACLS algorithms provide a systematic approach to managing cardiac arrest and peri-arrest
conditions. For cardiac arrest, the algorithm branches based on whether the rhythm is shockable (VF/VT)
or non-shockable (asystole/pulseless electrical activity). Key steps include immediate initiation of CPR,
rhythm analysis every 2 minutes, defibrillation for shockable rhythms, and administration of epinephrine.
Throughout the resuscitation, it's crucial to consider and treat potential reversible causes, often
remembered as the "Hs and Ts" (Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia,
Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis (pulmonary), Thrombosis
(coronary)).
Post-cardiac arrest care is an integral part of the ACLS approach. This includes optimizing oxygenation
and ventilation, maintaining adequate blood pressure (often requiring vasopressors), and considering
targeted temperature management for comatose patients. Early coronary angiography should be
considered for patients with suspected cardiac etiology, particularly those with ST-elevation on ECG.
ACLS also covers the management of acute coronary syndromes (ACS). This includes rapid recognition
of ST-elevation myocardial infarction (STEMI) and high-risk non-ST elevation ACS. Key interventions
include administration of aspirin, consideration of other antiplatelet agents and anticoagulants, and timely
reperfusion therapy (primary percutaneous coronary intervention or fibrinolysis) for STEMI.
Tachyarrhythmias are another important component of ACLS. The approach depends on whether the
patient is stable or unstable. For unstable patients with tachycardia (those with signs of shock, altered
mental status, ischemic chest pain, or acute heart failure), immediate synchronized cardioversion is
indicated. For stable patients, the specific treatment depends on whether the rhythm is regular or irregular
and whether the QRS complex is narrow or wide.
Bradyarrhythmias are managed based on the presence or absence of symptoms. Symptomatic bradycardia
may be treated with atropine, transcutaneous pacing, or infusion of chronotropic agents like dopamine or
epinephrine. Permanent pacemaker placement may be necessary for some patients with persistent
symptomatic bradycardia.
Stroke management is another crucial aspect of ACLS. This involves rapid recognition using tools like the
Cincinnati Prehospital Stroke Scale or the Los Angeles Prehospital Stroke Screen. Time is critical in
stroke management, and the goal is to minimize the time from symptom onset to definitive treatment. This
may involve intravenous thrombolysis with tPA for eligible patients or endovascular therapy for large
vessel occlusions.
Effective ACLS requires not just knowledge of algorithms and pharmacology, but also strong teamwork
and communication skills. Clear role designation, closed-loop communication, and regular team training
can significantly improve performance during actual resuscitations. It's also important to address ethical
considerations in resuscitation, including when to start and when to stop resuscitative efforts.
Regular training and updating of ACLS skills is crucial for all providers involved in emergency care.
Guidelines are regularly updated based on the latest evidence, and staying current with these changes is
essential for providing optimal care. Simulation-based training can be particularly effective in improving
both technical and non-technical skills required for successful resuscitation.

Trauma management and triage

Trauma management is a critical aspect of emergency medicine that requires a systematic approach to
rapidly assess and treat life-threatening injuries. The principles of trauma care are designed to identify
and address the most serious threats to life first, following the ABCDE approach: Airway, Breathing,
Circulation, Disability, and Exposure.
The initial assessment of a trauma patient begins with the primary survey. This rapid evaluation aims to
identify and treat immediate life-threatening conditions. Airway assessment is the first priority. Look for
signs of airway obstruction, such as stridor or gurgling. In trauma patients, always assume cervical spine
injury until proven otherwise. Maintain cervical spine immobilization while managing the airway. If the
airway is compromised or the patient has a decreased level of consciousness, consider early intubation.
Breathing is assessed next. Look for signs of respiratory distress, such as tachypnea, use of accessory
muscles, or cyanosis. Auscultate the chest and assess for symmetry of breath sounds. Tension
pneumothorax, a life-threatening condition, may present with absent breath sounds on the affected side,
tracheal deviation, and hemodynamic instability. Immediate needle decompression is indicated if
suspected.
Circulation assessment focuses on identifying and controlling hemorrhage. Look for external bleeding and
control it with direct pressure. Assess for signs of shock, including tachycardia, hypotension, and poor
peripheral perfusion.
Intravenous access should be established, typically with two large-bore IVs. Fluid resuscitation with
isotonic crystalloids is initiated for patients with signs of hypovolemic shock. The goal is to maintain
systolic blood pressure around 90 mmHg (permissive hypotension) to avoid exacerbating bleeding while
maintaining organ perfusion.
Disability assessment evaluates neurological status using the Glasgow Coma Scale (GCS). This assesses
eye opening, verbal response, and motor response. A GCS score of 8 or less indicates severe head injury
and the need for airway protection.
Exposure involves completely undressing the patient to thoroughly examine for injuries, while being
careful to prevent hypothermia. Log roll the patient to examine the back.
Following the primary survey, a more detailed secondary survey is performed. This involves a head-to-
toe examination to identify all injuries. Relevant imaging studies are obtained based on the mechanism of
injury and physical exam findings.
Key early interventions in trauma management include:

Control of external hemorrhage

Airway management and cervical spine immobilization
Oxygen administration
IV fluid resuscitation for shock
Pain control
Tetanus prophylaxis
Antibiotics for open fractures
Damage control surgery may be needed for patients with severe injuries and physiological derangement.
This involves an abbreviated initial operation to control hemorrhage and contamination, followed by ICU
resuscitation and later definitive repair.
Trauma systems and protocols have significantly improved outcomes for severely injured patients. Key
aspects include rapid transport to appropriate trauma centers, organized trauma teams, and evidence-
based management algorithms. Ongoing reassessment and vigilance for deterioration is crucial in trauma
care.

Chapter 10 Summary and Workbook

This chapter covers three key areas of emergency medicine and critical care: acute care scenarios and
interventions, advanced cardiac life support (ACLS) principles, and trauma management and triage.
The acute care scenarios section discusses common emergency presentations like chest pain, shortness of
breath, altered mental status, and shock. It emphasizes rapid assessment, differential diagnosis, and initial
stabilization measures. Key interventions such as airway management, fluid resuscitation, and emergency
medications are detailed. The importance of effective communication, teamwork, and addressing the
psychological impact on patients and families is highlighted.
The ACLS section reviews current guidelines for managing cardiac arrest and peri-arrest conditions. It
covers high-quality CPR, early defibrillation, airway management, and pharmacological interventions.
The ACLS algorithms for shockable and non-shockable rhythms are explained, along with post-cardiac
arrest care. Management of acute coronary syndromes, tachyarrhythmias, bradyarrhythmias, and stroke is
also discussed.
The trauma management section outlines the systematic ABCDE approach to assessing and treating trauma
patients. It covers the primary and secondary surveys, key early interventions, and the concept of damage
control surgery. The importance of trauma systems and protocols in improving patient outcomes is
emphasized.

Grab Your Pen & Let’s Do Some Quick Tests

1. How would you prioritize interventions in a patient presenting with multiple life-threatening
conditions simultaneously?
2. In what ways might cognitive biases affect clinical decision-making in high-stress emergency
situations, and how can these be mitigated?
3. How would you balance the need for rapid intervention with the importance of obtaining a
thorough patient history in an emergency setting?
4. What ethical considerations arise when deciding to terminate resuscitation efforts in a
cardiac arrest patient?
5. How might advances in technology, such as artificial intelligence, impact the future of
emergency triage and initial patient assessment?
6. In what ways could improving public education on basic life support and early recognition
of emergencies impact patient outcomes?
7. How would you approach the challenge of maintaining up-to-date skills in rarely performed
but critical procedures like cricothyrotomy?
8. What strategies could be employed to improve communication and coordination between
pre-hospital and in-hospital emergency care providers?
9. How might the principles of trauma management be adapted for mass casualty incidents with
limited resources?
10. In what ways could simulation-based training be optimized to improve
both technical and non-technical skills in emergency medicine?
Chapter 11: Public Health and Patient Safety
Public health and patient safety are critical components of modern healthcare systems, focusing on
preventing disease, promoting health, and ensuring safe, high-quality care for populations and individuals.
This chapter explores key aspects of public health and patient safety that are essential for physicians to
understand and apply in their practice.
The first section covers epidemiology and biostatistics, which provide the foundation for evidence-based
medicine and public health interventions. Epidemiology examines the distribution and determinants of
health-related events in populations, while biostatistics offers the tools to analyze and interpret health
data. Together, these disciplines enable healthcare professionals to identify health trends, assess risk
factors, and evaluate the effectiveness of interventions.
The second section addresses quality improvement and patient safety measures. As healthcare becomes
increasingly complex, systematic approaches to enhancing care quality and reducing medical errors have
become paramount. This section explores strategies for identifying and mitigating risks, implementing
safety protocols, and fostering a culture of continuous improvement in healthcare settings.
The third section examines healthcare systems and policy, providing an overview of how healthcare is
organized, financed, and delivered. Understanding the structure and function of healthcare systems is
crucial for physicians, as it impacts patient care, resource allocation, and health outcomes. This section
also covers key health policies and their implications for clinical practice and population health.
By mastering these topics, physicians can contribute more effectively to improving public health and
ensuring patient safety, ultimately leading to better health outcomes for individuals and communities.
Epidemiology and biostatistics
Epidemiology and biostatistics form the cornerstone of public health and evidence-based medicine. These
disciplines provide the tools and methods necessary to study health patterns in populations, identify risk
factors for diseases, and evaluate the effectiveness of interventions. Understanding these concepts is
crucial for physicians to interpret medical literature critically and make informed decisions in clinical
practice.
Epidemiology is the study of the distribution and determinants of health-related states or events in
specified populations. It goes beyond simply counting cases of disease to examining patterns, causes, and
effects of health conditions. Key concepts in epidemiology include incidence, prevalence, and mortality
rates. Incidence refers to the number of new cases of a disease occurring in a population over a specific
period, while prevalence is the total number of cases at a given time. Mortality rate is the number of
deaths in a population, usually expressed per 1,000 individuals per year.
Epidemiologists use various study designs to investigate health issues. Observational studies, such as
cohort and case-control studies, are commonly used to explore associations between exposures and
outcomes. Cohort studies follow groups of individuals over time, comparing those exposed to a factor
with those who are not. Case-control studies start with individuals who have a disease (cases) and
compare them to those without the disease (controls) to identify potential risk factors. Experimental
studies, particularly randomized controlled trials, are considered the gold standard for evaluating
interventions, as they can establish causality more definitively.
Understanding measures of association is crucial in epidemiology. Relative risk (RR) compares the risk
of an outcome in an exposed group to that in an unexposed group. An RR greater than 1 indicates an
increased risk associated with the exposure. Odds ratio (OR) is similar but is used in case-control studies
where the true incidence of disease cannot be calculated. Attributable risk measures the excess risk of
disease due to exposure and is useful for assessing public health impact.
Screening is an important application of epidemiology in clinical practice. The effectiveness of a
screening test is evaluated using measures such as sensitivity (ability to correctly identify those with the
disease) and specificity (ability to correctly identify those without the disease). Positive and negative
predictive values are also crucial, as they take into account the prevalence of the condition in the
population being screened.
Biostatistics provides the mathematical tools to analyze and interpret epidemiological data. Central to
biostatistics is the concept of probability, which underlies statistical inference. Probability distributions,
such as the normal distribution, are used to model the variability in biological phenomena and form the
basis for many statistical tests.
Descriptive statistics summarize data using measures of central tendency (mean, median, mode) and
dispersion (range, standard deviation, variance). These provide a snapshot of the data's characteristics.
Inferential statistics, on the other hand, allow researchers to draw conclusions about a population based
on a sample. This involves hypothesis testing and the calculation of p-values and confidence intervals.
The p-value represents the probability of obtaining results as extreme as those observed, assuming the
null hypothesis is true. A small p-value (typically <0.05) suggests that the observed results are unlikely to
have occurred by chance alone. However, it's crucial to understand that statistical significance does not
always imply clinical significance. Confidence intervals provide a range of plausible values for a
population parameter and are often more informative than p-values alone.
Sample size calculation is another critical aspect of biostatistics in research design. Adequate sample
size ensures that a study has sufficient power to detect a meaningful effect if one exists. Underpowered
studies may fail to detect important associations, while overpowered studies may waste resources and
potentially expose more participants than necessary to potential risks.
Regression analysis is a powerful statistical tool used to examine relationships between variables. Linear
regression models the relationship between a dependent variable and one or more independent variables,
assuming a linear relationship. Logistic regression is used when the outcome is binary (e.g., presence or
absence of disease) and can provide odds ratios for various risk factors.
Understanding bias and confounding is crucial in epidemiology and biostatistics. Bias refers to systematic
errors in the design, conduct, or analysis of a study that can lead to incorrect conclusions. Common types
include selection bias, information bias, and recall bias. Confounding occurs when a factor is associated
with both the exposure and the outcome, potentially leading to spurious associations. Strategies to address
confounding include randomization, matching, stratification, and multivariate analysis.
Meta-analysis is a statistical technique that combines results from multiple studies to provide a more
precise estimate of an effect. This approach can be particularly useful when individual studies have
conflicting results or are too small to draw definitive conclusions. However, it's important to assess the
heterogeneity of included studies and potential publication bias when interpreting meta-analyses.
Epidemiology and biostatistics also play a crucial role in public health surveillance, which involves the
ongoing, systematic collection, analysis, and interpretation of health data. Surveillance systems can detect
outbreaks, monitor trends in diseases and risk factors, and evaluate the impact of public health
interventions.
A solid understanding of epidemiology and biostatistics is essential for physicians to critically appraise
medical literature, design and conduct research, and make evidence-based decisions in clinical practice
and public health. These disciplines provide the tools to translate data into meaningful information that
can guide health policy, inform clinical guidelines, and ultimately improve patient outcomes and
population health.

Quality improvement and patient safety measures

Quality improvement and patient safety are integral components of modern healthcare systems, focusing
on enhancing the effectiveness, efficiency, and safety of medical care. These interrelated fields aim to
reduce medical errors, improve patient outcomes, and optimize healthcare delivery processes.
Understanding and implementing quality improvement and patient safety measures is crucial for all
healthcare professionals, particularly physicians who play a central role in patient care.
Quality improvement in healthcare involves systematic and continuous actions that lead to measurable
improvement in health care services and the health status of targeted patient groups. It encompasses a
wide range of methodologies and tools designed to assess, analyze, and enhance various aspects of
healthcare delivery. The Institute for Healthcare Improvement's Model for Improvement, which
incorporates Plan-Do-Study-Act (PDSA) cycles, is a widely used framework for quality improvement
initiatives. This model encourages healthcare teams to set clear aims, establish measures, select changes
to test, and implement rapid cycles of change and evaluation.
One fundamental concept in quality improvement is the use of performance measures or quality indicators.
These are quantifiable aspects of care that can be used to monitor and evaluate the quality of important
governance, management, clinical, and support functions. Common quality indicators include 30-day
hospital readmission rates, infection rates, patient satisfaction scores, and adherence to evidence-based
guidelines. By tracking these indicators over time, healthcare organizations can identify areas for
improvement and assess the impact of interventions.
Root cause analysis (RCA) is a structured method used to analyze serious adverse events. When a
significant incident occurs, an RCA team works to identify the underlying factors that contributed to the
event, rather than simply addressing surface-level issues. This process often involves creating a timeline
of events, interviewing involved parties, and using tools like fishbone diagrams or the "5 Whys"
technique to drill down to root causes. The goal is to develop actionable recommendations to prevent
similar incidents in the future.
Failure Mode and Effects Analysis (FMEA) is a proactive risk assessment tool used to identify potential
failures in a system or process before they occur. In healthcare, FMEA can be applied to complex
processes like medication administration or surgical procedures. The team systematically evaluates each
step in the process, identifying potential failure modes, their effects, and their causes. This allows for the
implementation of preventive measures to reduce the likelihood of errors.
Patient safety, closely related to quality improvement, focuses specifically on preventing and reducing
risks, errors, and harm that occur to patients during the provision of health care. The landmark report "To
Err is Human" by the Institute of Medicine in 1999 brought widespread attention to the issue of medical
errors and sparked numerous patient safety initiatives.
One key concept in patient safety is the Swiss cheese model of accident causation. This model posits that
in complex systems, errors result from the alignment of multiple "holes" in various defensive layers. In
healthcare, these layers might include individual healthcare providers, teamwork, equipment, and
organizational policies. By addressing vulnerabilities at multiple levels, the overall system can become
more resilient to errors.
Implementing a culture of safety is crucial for effective patient safety initiatives. This involves creating an
environment where staff feel comfortable reporting errors and near-misses without fear of punishment.
Just culture is an approach that balances accountability with an understanding that most errors result from
system failures rather than individual negligence. This perspective encourages open communication and
learning from mistakes.
Standardization of processes is another important strategy for improving patient safety. Checklists, such as
the World Health Organization's Surgical Safety Checklist, have been shown to reduce complications and
mortality in surgical patients. Similarly, standardized handoff procedures, like the SBAR (Situation,
Background, Assessment, Recommendation) technique, can improve communication during patient
transfers and reduce the risk of information loss.
Medication safety is a critical area of focus in patient safety efforts. Strategies to reduce medication
errors include computerized physician order entry (CPOE) systems, bar-code medication administration,
and medication reconciliation processes. These interventions aim to reduce errors at various stages of the
medication use process, from prescribing to administration.
Human factors engineering, which considers how humans interact with systems and technology, plays an
increasingly important role in patient safety. This approach involves designing healthcare environments,
equipment, and processes that account for human limitations and tendencies, thereby reducing the
likelihood of errors. For example, designing infusion pumps with intuitive interfaces can help prevent
programming errors.
Teamwork and communication are essential components of both quality improvement and patient safety.
Team training programs, such as Team
STEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), aim to improve
communication, leadership, and situational awareness among healthcare teams. Simulation-based training
allows teams to practice managing complex scenarios in a safe environment, improving their ability to
work together effectively during real patient care situations.
Patient engagement is another crucial aspect of quality improvement and patient safety. Involving patients
and their families in their care can lead to better outcomes and reduced risks. This includes educating
patients about their conditions and treatments, encouraging them to speak up about concerns, and
involving them in decision-making processes.
Measuring and monitoring patient safety is challenging but essential. Incident reporting systems allow
healthcare workers to report errors and near-misses, providing valuable data for improvement efforts.
However, these systems often suffer from underreporting. Other approaches to measuring safety include
trigger tool methodology, which involves reviewing medical records for "triggers" that might indicate
adverse events, and global trigger tool, which provides a more comprehensive overview of harm rates in
an organization.
Quality improvement and patient safety are interconnected fields that are fundamental to providing high-
quality healthcare. By understanding and implementing these concepts, physicians can contribute to
creating safer, more effective healthcare systems. This not only improves patient outcomes but also
enhances job satisfaction and reduces the emotional toll of preventable adverse events on healthcare
providers. As healthcare continues to evolve, ongoing education and commitment to these principles will
be crucial for all healthcare professionals.
Healthcare systems and policy
Healthcare systems and policy play a crucial role in shaping the delivery, quality, and accessibility of
medical care. Understanding these systems is essential for physicians, as they significantly impact clinical
practice, patient outcomes, and the overall health of populations. This section explores the structure of
healthcare systems, key health policies, and their implications for medical practice and public health.
Healthcare systems vary widely across countries, but they generally aim to provide accessible, high-
quality care while managing costs. In the United States, the healthcare system is a complex mix of public
and private providers and payers. The main public programs are Medicare, which primarily serves
individuals aged 65 and older, and Medicaid, which provides coverage for low-income individuals.
Private insurance, often obtained through employers, covers a significant portion of the population. The
Affordable Care Act (ACA) of 2010 introduced significant changes, including the expansion of Medicaid
in many states and the creation of health insurance marketplaces.
One of the key challenges in healthcare systems is balancing the "iron triangle" of healthcare: access,
quality, and cost. Improving one aspect often involves trade-offs with the others. For example, expanding
access to care may increase costs, while cost-containment measures might impact quality or access.
Policymakers and healthcare leaders continually grapple with these trade-offs in designing and reforming
healthcare systems.
Health insurance plays a central role in most healthcare systems. Insurance models can be broadly
categorized into fee-for-service, managed care, and value-based care. Fee-for-service reimburses
providers for each service rendered, which can incentivize overutilization. Managed care models, such as
Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs), aim to control
costs through networks of providers and various forms of utilization management. Value-based care
models, like Accountable Care Organizations (ACOs), tie reimbursement to quality metrics and patient
outcomes, aiming to improve quality while controlling costs.
Healthcare financing is a critical aspect of healthcare systems. In the U.S., healthcare spending accounts
for a significant portion of the GDP, higher than in most other developed countries. Efforts to control
healthcare costs include various payment reforms, such as bundled payments for episodes of care and
global budgets for hospitals. Understanding these payment models is important for physicians, as they can
influence clinical decision-making and practice management.
Health policy encompasses the laws, regulations, and actions that are designed to achieve specific
healthcare goals within a society. Major areas of health policy include:

1. Access to care: Policies aimed at expanding insurance coverage, reducing barriers to care,
and addressing health disparities.
2. Quality and safety: Regulations and initiatives to improve the quality of care, reduce medical
errors, and ensure patient safety.
3. Public health: Policies focused on disease prevention, health promotion, and addressing
social determinants of health.
4. Healthcare workforce: Policies related to medical education, licensing, and the distribution
of healthcare providers.
5. Health information technology: Initiatives to promote the adoption and meaningful use of
electronic health records and other health IT systems.
6. Pharmaceutical and medical device regulation: Policies governing the approval, marketing,
and pricing of drugs and medical devices.
The policymaking process involves various stakeholders, including government agencies, healthcare
providers, insurers, pharmaceutical companies, and patient advocacy groups. Physicians can play an
important role in shaping health policy through involvement in professional organizations, advocacy
efforts, and providing expert testimony.
One significant trend in healthcare policy is the move towards population health management. This
approach focuses on improving health outcomes for entire populations, rather than just individual patients.
It involves analyzing data to identify high-risk groups, implementing targeted interventions, and
addressing social determinants of health. Physicians are increasingly expected to consider population
health in their practice, which may involve participating in community health initiatives or using data
analytics to guide care decisions.
Global health policy is another important area, particularly in an increasingly interconnected world.
Issues such as pandemic preparedness, antimicrobial resistance, and health equity on a global scale
require coordinated international efforts. The World Health Organization (WHO) plays a key role in
setting global health priorities and coordinating responses to international health crises.
Health technology assessment (HTA) is a systematic evaluation of the properties, effects, and impacts of
health technologies and interventions. It informs policy decisions about which technologies and treatments
should be covered by health systems, balancing clinical effectiveness, cost-effectiveness, and societal
values. Physicians should be aware of HTA processes, as they can influence which treatments are
available to their patients.
The role of evidence-based medicine in healthcare policy cannot be overstated. Policymakers
increasingly rely on systematic reviews, meta-analyses, and large-scale clinical trials to inform decision-
making. However, translating evidence into policy and practice remains challenging, often referred to as
the "know-do gap." Implementation science, which studies methods to promote the adoption of research
findings into routine practice, is an emerging field addressing this challenge.
Health disparities and health equity are critical issues in healthcare systems and policy. Disparities in
health outcomes based on race, ethnicity, socioeconomic status, and geography persist in many healthcare
systems. Addressing these disparities requires a multifaceted approach, including policies to improve
access to care, address social determinants of health, and promote cultural competence in healthcare
delivery.
The COVID-19 pandemic has indeed highlighted both strengths and weaknesses in healthcare systems
worldwide and accelerated certain trends. Some key impacts and lessons from the pandemic include:

1. Importance of public health infrastructure: The pandemic underscored the critical need for
strong disease surveillance systems, testing capabilities, and coordinated public health
responses.
2. Telemedicine adoption: Use of telehealth services expanded rapidly, improving access to
care while reducing infection risks. This trend is likely to continue post-pandemic.
3. Supply chain vulnerabilities: Shortages of personal protective equipment, ventilators, and
other medical supplies revealed weaknesses in global medical supply chains.
4. Health disparities: The disproportionate impact on certain populations highlighted existing
health inequities and the need to address social determinants of health.
5. Vaccine development: Unprecedented collaboration and funding accelerated vaccine
development timelines, demonstrating the potential for rapid scientific progress.
6. Mental health impacts: The pandemic took a significant toll on mental health, emphasizing
the need for accessible mental health services.
7. Importance of clear public health communication: Effective communication of public health
measures proved crucial for compliance and outcomes.
8. Healthcare worker burnout: The intense demands placed on healthcare workers highlighted
the need to support their wellbeing.
9. Flexibility in healthcare delivery: Hospitals and clinics had to quickly adapt care delivery
models, highlighting the importance of adaptability.
10. Global cooperation: The pandemic demonstrated the need for
international collaboration in addressing global health threats.
These lessons will likely shape healthcare policy, research priorities, and system designs for years to
come as we work to build more resilient and equitable health systems.

Chapter 11 Summary and Workbook

This chapter covers three key areas: epidemiology and biostatistics, quality improvement and patient
safety measures, and healthcare systems and policy.
The epidemiology and biostatistics section explains how these disciplines form the foundation of public
health and evidence-based medicine. It covers key concepts like incidence, prevalence, study designs,
measures of association, and statistical analysis techniques. The importance of understanding these
concepts for interpreting medical literature and making informed clinical decisions is emphasized.
The quality improvement and patient safety section discusses strategies for enhancing healthcare quality
and reducing medical errors. It covers frameworks like the Model for Improvement, tools such as root
cause analysis and failure mode and effects analysis, and the importance of creating a culture of safety.
Specific interventions like standardized processes, medication safety measures, and team training
programs are also discussed.
The healthcare systems and policy section explores how healthcare is organized, financed, and delivered.
It covers different insurance models, healthcare financing challenges, and major areas of health policy.
The impact of the COVID-19 pandemic on healthcare systems is also discussed, highlighting lessons
learned and potential future directions.

Grab Your Pen & Let’s Do Some Quick Tests

1. How might your understanding of epidemiological concepts influence your approach to
individual patient care?
2. In what ways could you apply quality improvement methodologies to address a specific
challenge in your clinical practice?
3. How would you balance the need for standardization in healthcare processes with the
importance of personalized patient care?
4. What strategies could you employ to promote a culture of safety within your healthcare team?
5. How might the shift towards value-based care models impact your clinical decision-making?
6. In what ways could you contribute to addressing health disparities in your community through
your role as a physician?
7. How would you approach the challenge of translating evidence-based guidelines into routine
clinical practice?
8. What ethical considerations arise when balancing individual patient needs with population
health management approaches?
9. How might advances in health information technology impact your ability to provide high-
quality, efficient care?
10. What role do you think physicians should play in shaping health policy, and how
would you personally engage in this process?
Chapter 12: Clinical Reasoning and Decision
Making
Clinical reasoning and decision making are essential skills for physicians to develop and refine
throughout their careers. This chapter explores the cognitive processes and practical approaches involved
in diagnosing and managing patients effectively. The ability to gather and synthesize information, generate
and test hypotheses, and make sound clinical judgments is crucial for providing high-quality patient care.
The first section examines diagnostic algorithms and clinical problem-solving techniques. It covers
strategies for organizing clinical information, generating differential diagnoses, and systematically
working through complex cases. Understanding how to apply these structured approaches can help
clinicians avoid cognitive biases and diagnostic errors.
The second section focuses on interpreting laboratory and imaging studies. As the volume and complexity
of diagnostic tests continue to increase, physicians must be adept at selecting appropriate studies,
understanding their limitations, and integrating results into clinical decision-making. This section
provides guidance on how to approach common lab abnormalities and imaging findings in context.
The third section addresses risk assessment and prognosis determination. Accurately estimating a patient's
risk for various outcomes and determining their likely clinical course are critical for guiding management
decisions and counseling patients. This section covers key principles and tools for risk stratification
across different medical conditions.
By mastering these aspects of clinical reasoning and decision making, physicians can enhance their
diagnostic acumen, optimize patient management, and ultimately improve clinical outcomes. The goal is to
develop a systematic yet flexible approach that can be applied across a wide range of clinical scenarios.

Diagnostic algorithms and clinical problem-solving

Diagnostic algorithms and clinical problem-solving are fundamental skills that form the backbone of
effective medical practice. These approaches provide a structured framework for gathering and analyzing
clinical information, generating differential diagnoses, and arriving at accurate conclusions. By employing
systematic methods, clinicians can navigate complex cases more efficiently and reduce the risk of
diagnostic errors.
The diagnostic process typically begins with gathering a thorough history and performing a focused
physical examination. It's crucial to approach this step with an open mind, avoiding premature closure on
a diagnosis. Key elements of the history include the chief complaint, history of present illness, past
medical history, medications, allergies, family history, and social history. The physical exam should be
tailored to the patient's presentation but comprehensive enough to avoid missing important findings.
Once the initial data is collected, the next step is to generate a differential diagnosis. This involves
creating a list of possible explanations for the patient's symptoms and findings, ranging from common to
rare conditions. A useful mnemonic for organizing differentials is "VINDICATE":

Vascular
Infectious/Inflammatory
Neoplastic
Degenerative/Deficiency
Intoxication/Iatrogenic
Congenital
Autoimmune/Allergic
Traumatic/Toxic
Endocrine/Metabolic
Prioritizing the differential diagnosis involves considering the likelihood of each condition based on
epidemiology, risk factors, and clinical presentation. The "worst-case scenario" should always be
included and ruled out when appropriate.
With a prioritized differential in mind, the next phase involves diagnostic testing. This may include
laboratory studies, imaging, or specialized tests. It's important to select tests judiciously, considering their
sensitivity, specificity, and cost-effectiveness. The pre-test probability of a condition should guide test
selection and interpretation.
As new information becomes available, the differential diagnosis should be continually refined. This
iterative process of hypothesis generation and testing is at the heart of clinical problem-solving. It's
crucial to remain flexible and willing to reconsider initial impressions as new data emerges.
Several cognitive biases can interfere with effective clinical reasoning. These include:

1. Anchoring bias: Relying too heavily on initial impressions

2. Availability bias: Overestimating the likelihood of diagnoses that come to mind easily
3. Confirmation bias: Seeking information that confirms pre-existing beliefs while ignoring
contradictory evidence
4. Premature closure: Accepting a diagnosis before it has been fully verified
5. Awareness of these biases and actively working to counteract them can improve diagnostic
accuracy.
For complex cases, it can be helpful to employ specific problem-solving strategies. The hypothetico-
deductive method involves generating multiple hypotheses early in the diagnostic process and then
systematically testing each one. Pattern recognition, on the other hand, relies on identifying characteristic
constellations of symptoms and signs that suggest a particular diagnosis. Experienced clinicians often use
a combination of these approaches.
Another useful tool is the SOAP note format:

1. Subjective: Patient's symptoms and concerns

2. Objective: Physical exam findings and test results
3. Assessment: Synthesis of information and current diagnostic impression
4. Plan: Next steps in evaluation and management
This structured approach ensures that all relevant information is considered and helps organize clinical
thinking.
For standardized patient encounters and clinical skills exams, it can be helpful to follow a systematic
approach:

1. Establish rapport and gather the chief complaint

2. Obtain a focused history
3. Perform a targeted physical exam
4. Explain your initial diagnostic impression to the patient
5. Order appropriate diagnostic tests
6. Discuss the management plan and follow-up
Throughout this process, it's important to communicate clearly with the patient, addressing their concerns
and involving them in decision-making when appropriate.
In emergency situations, algorithms such as ACLS (Advanced Cardiac Life Support) provide a structured
approach to rapid assessment and management. These protocols ensure that critical steps are not missed
in high-stress situations.
For more routine clinical encounters, condition-specific algorithms can guide evaluation and management.
For example, chest pain algorithms help stratify risk and determine appropriate workup, while pneumonia
severity indices guide decisions about outpatient versus inpatient management.
Ultimately, the goal of diagnostic algorithms and clinical problem-solving techniques is to provide a
framework for organizing clinical information and making sound decisions. However, it's important to
remember that medicine is both a science and an art. While algorithms and systematic approaches are
invaluable tools, they should be applied flexibly and in conjunction with clinical judgment and
experience. The ability to recognize when to deviate from standard approaches is a hallmark of clinical
expertise.
As medical knowledge continues to expand and evolve, staying current with evidence-based guidelines
and best practices is essential. Regular review of clinical decision support tools and participation in
continuing medical education can help refine problem-solving skills over time.
By mastering these diagnostic and problem-solving techniques, clinicians can enhance their ability to
provide high-quality, patient-centered care across a wide range of clinical scenarios.

Interpreting laboratory and imaging studies

Interpreting laboratory and imaging studies is a critical skill for physicians across all specialties. The
ability to select appropriate tests, understand their limitations, and integrate results into clinical decision-
making is fundamental to providing high-quality patient care. This section will cover key principles and
practical approaches to interpreting common laboratory tests and imaging studies.
Laboratory Studies:
When interpreting laboratory results, it's essential to consider several factors:
Reference ranges: These are typically set to include 95% of the healthy population. Values outside this
range are not necessarily abnormal, and values within the range don't always indicate normalcy.
Clinical context: Results should always be interpreted in light of the patient's overall clinical picture. For
example, a "normal" hemoglobin in a patient with acute blood loss may actually represent a significant
drop from their baseline.
Pre-test probability: The likelihood of a condition before testing affects the interpretation of results. A
positive test in a low-probability situation may be a false positive, while a negative test in a high-
probability situation could be a false negative.
Test characteristics: Understanding sensitivity, specificity, positive predictive value, and negative
predictive value is crucial for proper interpretation.
Common Laboratory Abnormalities:
Anemia: Classify based on MCV (microcytic, normocytic, macrocytic). Consider iron studies, B12/folate
levels, and peripheral smear as appropriate.
Leukocytosis: Determine if bacterial infection is likely. Consider other causes such as stress, medications,
or hematologic disorders.
Thrombocytopenia: Rule out pseudothrombocytopenia. Consider causes such as infection, DIC, ITP, or
drug-induced.
Liver function tests: Differentiate hepatocellular from cholestatic patterns. Consider alcohol use,
medications, viral hepatitis, and autoimmune causes.
Renal function: Use eGFR for staging chronic kidney disease. Distinguish acute kidney injury from
chronic renal insufficiency.
Electrolyte abnormalities: Correct sodium for hyperglycemia. Consider causes of hypo/hyperkalemia,
hypo/hypernatremia, and acid-base disturbances.
Cardiac enzymes: Understand the timing of troponin and CK-MB elevation in acute coronary syndrome.
Thyroid function tests: Interpret TSH in conjunction with free T4. Consider subclinical
hypo/hyperthyroidism.
Imaging Studies:
When interpreting imaging studies, consider the following:
Clinical question: Ensure the study is appropriate for answering the clinical question at hand.
Technical factors: Be aware of patient positioning, contrast use, and image quality.
Systematic approach: Develop a consistent method for reviewing each imaging modality to avoid missing
important findings.
Comparison with prior studies: This is crucial for identifying new or evolving abnormalities.
Chest X-ray:

Assess technical quality (inspiration, rotation)

Evaluate lung fields for infiltrates, masses, or effusions
Check cardiac silhouette for size and contour
Examine bony structures and soft tissues
CT scan:

Review in multiple planes (axial, coronal, sagittal)

Adjust window settings for different tissue types
Pay attention to incidental findings that may require follow-up
MRI:

Understand basic principles of T1 vs T2 weighting

Recognize common artifacts
Use contrast enhancement to characterize lesions
Ultrasound:

Understand the limitations of operator-dependency

Recognize common artifacts (acoustic shadowing, enhancement)
Utilize Doppler imaging for vascular studies
Nuclear medicine studies:

Understand the principles of radiotracer uptake

Recognize normal distribution patterns
Be aware of common causes of false positives and negatives
Specific Clinical Scenarios:
Chest pain: Use ECG, cardiac enzymes, and appropriate imaging (stress test, coronary CT angiography, or
cardiac catheterization) based on risk stratification.
Abdominal pain: Select imaging modality (X-ray, ultrasound, CT) based on suspected pathology and
patient characteristics.
Neurological symptoms: Choose between CT and MRI based on acuity, suspected pathology, and
contraindications.
Musculoskeletal complaints: Utilize X-rays for initial evaluation, progressing to more advanced imaging
(MRI, CT) as needed.
Approach to Incidental Findings:
Incidental findings on imaging studies are common and can present management challenges. Consider the
following:

Assess the clinical significance of the finding

Determine if further workup is necessary
Balance the potential benefits of additional testing against risks and patient preferences
Follow established guidelines for management of common incidental findings (e.g.,
pulmonary nodules, adrenal masses)
Integration of Laboratory and Imaging Results:The true art of clinical medicine lies in integrating all
available information to make sound decisions. Consider the following:

Correlate laboratory and imaging findings with clinical presentation

Recognize patterns that suggest specific diagnoses
Be aware of limitations and potential pitfalls of each test
Seek additional expertise (e.g., radiology or pathology consultation) when needed
Communicate findings and their implications clearly to patients and other healthcare
providers
As medical technology continues to advance, new laboratory tests and imaging modalities will become
available. Staying current with these developments and understanding their appropriate use and
interpretation is an ongoing responsibility for all clinicians. Regular review of guidelines, participation in
continuing medical education, and consultation with specialists can help maintain and improve skills in
this critical area.
By mastering the interpretation of laboratory and imaging studies, clinicians can enhance their diagnostic
accuracy, optimize patient management, and ultimately improve clinical outcomes across a wide range of
medical conditions.

Risk assessment and prognosis determination

Risk assessment and prognosis determination are crucial aspects of clinical decision-making that guide
patient management, inform treatment choices, and facilitate meaningful discussions about expected
outcomes. These skills involve synthesizing clinical data, applying statistical principles, and utilizing
validated prediction tools to estimate the likelihood of various health outcomes.
Fundamentals of Risk Assessment:
Risk assessment begins with identifying relevant risk factors for a given condition or outcome. These may
include:

Demographic factors (age, sex, race/ethnicity)

Family history
Lifestyle factors (smoking, alcohol use, diet, physical activity)
Medical comorbidities
Physiological parameters (blood pressure, BMI, cholesterol levels)
Genetic markers
Once risk factors are identified, their relative importance and interactions must be considered. Some risk
factors may have a multiplicative effect when combined, while others may be modifiable through
interventions.
Statistical Concepts in Risk Assessment:
Understanding key statistical concepts is essential for accurate risk assessment:
Absolute risk: The probability of an event occurring over a specific time period.
Relative risk: The ratio of the probability of an event occurring in an exposed group to the probability of
the event occurring in a non-exposed group.
Odds ratio: Similar to relative risk, but used in case-control studies and logistic regression.
Number needed to treat (NNT): The number of patients who need to be treated to prevent one adverse
outcome.
Sensitivity and specificity: Measures of a test's ability to correctly identify those with and without a
condition.
Positive and negative predictive values: The probability that a positive or negative test result is correct,
considering the prevalence of the condition.
Validated Risk Assessment Tools:
Numerous validated tools exist to assist in risk assessment for various conditions. Some widely used
examples include:
Cardiovascular risk:

Framingham Risk Score

ASCVD Risk Calculator
GRACE score for acute coronary syndrome
Cancer risk:

Gail model for breast cancer

PLCO score for lung cancer screening eligibility
Stroke risk:

CHA2DS2-VASc score for atrial fibrillation

Bleeding risk:

HAS-BLED score for anticoagulation

Mortality prediction:

APACHE II score for ICU patients

Charlson Comorbidity Index for long-term mortality
These tools should be used in conjunction with clinical judgment, as they may not account for all
individual patient factors.
Prognosis Determination:
Prognosis refers to the likely course of a medical condition and its outcome. Determining prognosis
involves:

1. Assessing disease severity and stage

2. Considering patient factors (age, comorbidities, functional status)
3. Evaluating response to treatment
4. Utilizing prognostic scoring systems when available
For example, in cancer staging, the TNM system (Tumor, Node, Metastasis) helps standardize prognostic
assessments. In heart failure, the New York Heart Association (NYHA) functional classification provides
prognostic information.
Communicating Risk and Prognosis:
Effectively communicating risk and prognosis to patients is a critical skill. Consider the following
approaches:

Use both absolute and relative risk when discussing interventions

Employ visual aids (graphs, pictographs) to illustrate risk
Frame information positively and negatively (e.g., survival rates vs. mortality rates)
Tailor information to the patient's health literacy level
Acknowledge uncertainty where it exists
Shared Decision-Making:
Risk assessment and prognosis determination should inform shared decision-making processes. This
involves:

1. Presenting treatment options and their associated risks/benefits

2. Eliciting patient preferences and values
3. Collaboratively deciding on a management plan
For example, when discussing anticoagulation for atrial fibrillation, balancing stroke risk (CHA2DS2-
VASc) against bleeding risk (HAS-BLED) can guide decision-making.
Challenges and Limitations:
Several challenges exist in risk assessment and prognosis determination:

Population-based tools may not accurately reflect individual risk

Rare outcomes or conditions may lack robust predictive models
Rapidly evolving treatments can outpace existing prognostic data
Psychosocial factors may significantly impact outcomes but are often difficult to quantify
To address these limitations:

Continuously update knowledge of risk factors and prognostic indicators

Combine multiple sources of information (clinical, laboratory, imaging)
Reassess risk and prognosis as new information becomes available
Consider consulting with specialists for complex cases
Emerging Technologies:
Advances in artificial intelligence and machine learning are beginning to impact risk assessment and
prognosis determination. These technologies can:

Analyze large datasets to identify novel risk factors

Develop more personalized risk prediction models
Integrate diverse data sources (e.g., electronic health records, genomics, wearable device
data)
While promising, these approaches require careful validation and consideration of ethical implications
before widespread clinical adoption.
Clinical Applications:
Applying risk assessment and prognosis determination skills is crucial across various clinical scenarios:
Preventive care: Use risk calculators to guide screening and preventive interventions (e.g., statin therapy,
cancer screening).
Acute care: Employ risk stratification tools to inform triage decisions and treatment intensity (e.g.,
CURB-65 score for pneumonia severity).
Chronic disease management: Utilize prognostic information to guide treatment goals and advance care
planning (e.g., in chronic kidney disease or heart failure).
Perioperative care: Assess surgical risk to inform decision-making and optimize preoperative
management.
End-of-life care: Use prognostic information to guide discussions about goals of care and palliative
interventions.
By End-of-life care: Use prognostic information to guide discussions about goals of care and palliative
interventions.
By understanding the patient's prognosis and likely disease trajectory, physicians can have more informed
conversations with patients and families about goals of care, treatment options, and palliative
interventions as the end of life approaches. Some key points to consider:

Provide realistic information about prognosis and expected disease course to help set
appropriate expectations
Discuss the patient's values, priorities, and preferences for care
Explore options for symptom management and palliative treatments to improve quality of life
Address psychosocial and spiritual needs of both patient and family
Consider hospice referral when prognosis is 6 months or less
Revisit goals of care regularly as the patient's condition changes
Focus on comfort and quality of life rather than prolonging life when death is imminent
Provide support for grieving family members
The goal is to align medical care with the patient's wishes and values while maximizing comfort and
quality of life in advanced illness. Open, compassionate communication about prognosis and care options
allows patients and families to make informed decisions about end-of-life care.

Chapter 12 Summary and Workbook

This chapter focuses on three key aspects of clinical reasoning and decision making: diagnostic
algorithms and clinical problem-solving, interpreting laboratory and imaging studies, and risk assessment
and prognosis determination.
The section on diagnostic algorithms and clinical problem-solving emphasizes the importance of a
structured approach to gathering and analyzing clinical information. It covers the process of generating
and prioritizing differential diagnoses, using tools like the VINDICATE mnemonic. The chapter discusses
common cognitive biases that can interfere with clinical reasoning and strategies to counteract them. It
also introduces problem-solving methods like the hypothetico-deductive approach and pattern
recognition.
The section on interpreting laboratory and imaging studies highlights the importance of considering
factors such as reference ranges, clinical context, and pre-test probability when interpreting results. It
provides guidance on approaching common laboratory abnormalities and various imaging modalities. The
chapter emphasizes the importance of integrating laboratory and imaging findings with the overall clinical
picture.
The risk assessment and prognosis determination section covers the fundamentals of identifying and
evaluating risk factors, understanding key statistical concepts, and using validated risk assessment tools. It
discusses the process of determining prognosis and the importance of effective communication of risk and
prognosis to patients. The chapter also addresses challenges in risk assessment and emerging technologies
in this field.
Grab Your Pen & Let’s Do Some Quick Tests
1. How might your approach to generating a differential diagnosis change when dealing with a
patient presenting with vague, non-specific symptoms?
2. In what ways could cognitive biases impact your clinical decision-making, and what
strategies would you employ to mitigate these biases?
3. How would you balance the use of clinical decision support tools with your own clinical
judgment when managing complex cases?
4. What challenges might you face when interpreting laboratory results that fall within the
"normal" range but don't align with the patient's clinical presentation?
5. How would you approach communicating the findings of an incidental imaging abnormality
to a patient, considering both medical and psychological implications?
6. In what ways might the increasing use of artificial intelligence in interpreting imaging studies
impact your role as a clinician?
7. How would you integrate multiple risk assessment tools that provide conflicting results for a
single patient?
8. What ethical considerations arise when using prognostic information to guide treatment
decisions, particularly in end-of-life care?
9. How might advances in personalized medicine and genetic testing influence your approach to
risk assessment and prognosis determination?
10. In what ways could improving health literacy among patients impact
the shared decision-making process when discussing risk and prognosis?
Chapter 13: Exam Day Preparation and Anxiety
Management
The final days leading up to the USMLE Step 3 exam can be a stressful and anxiety-inducing time for
many test-takers. However, with proper preparation and the right mindset, you can optimize your
performance and approach the exam with confidence. This chapter focuses on essential strategies for the
week before the exam, managing test anxiety, practical relaxation techniques, and optimizing your
physical health through nutrition and sleep.
By implementing a structured approach to your final review, you can reinforce key concepts and boost
your confidence. Equally important is developing effective coping mechanisms for exam-related stress
and anxiety. Simple relaxation and mindfulness exercises can help calm your nerves and improve focus.
Additionally, paying attention to your diet and sleep habits in the days before the exam can ensure you are
physically and mentally prepared to perform at your best.
The following sections will provide detailed guidance on finalizing your exam preparation, managing
anxiety, practicing relaxation techniques, and optimizing your physical readiness. By addressing both the
academic and psychological aspects of exam preparation, you'll be well-equipped to tackle the USMLE
Step 3 with a clear mind and steady nerves.

Final week study tips and review strategies

The week leading up to the USMLE Step 3 exam is crucial for solidifying your knowledge and boosting
your confidence. During this time, it's important to focus on high-yield review strategies rather than trying
to cram new information. Here are some effective approaches to make the most of your final study days:
Create a structured review schedule: Map out each day of your final week, allocating specific time blocks
for different subjects or question types. This helps ensure you cover all necessary material without feeling
overwhelmed. Be sure to include regular breaks to prevent burnout.
Prioritize weak areas: Review your practice test results and notes to identify topics or question types that
have consistently given you trouble. Dedicate extra time to these areas, but don't neglect your strengths
entirely.
Use active recall techniques: Instead of passively reading through notes or review books, engage in active
recall by quizzing yourself or explaining concepts out loud. This helps reinforce your understanding and
improves retention.
Practice with timed question blocks: Continue to work through practice questions under timed conditions
to maintain your pacing skills. Focus on reviewing explanations thoroughly, including for questions you
answered correctly, to solidify your understanding of the underlying concepts.
Review high-yield mnemonics and diagrams: Go through any mnemonics, diagrams, or quick reference
sheets you've created during your study period. These can be valuable memory aids during the exam.
Simulate exam conditions: If possible, take a full-length practice test under conditions similar to the
actual exam. This helps you get accustomed to the timing and format while identifying any last-minute
areas for improvement.
Create summary sheets: Condense key information from each major topic into concise summary sheets.
These can serve as quick reference materials for last-minute review.
Utilize spaced repetition: Review information at increasing intervals to reinforce long-term retention.
This technique is particularly useful for memorizing facts and formulas.
Focus on clinical reasoning: Practice working through clinical vignettes, focusing on your approach to
diagnosis and management. This reinforces the clinical decision-making skills that are crucial for success
on Step 3.
Review test-taking strategies: Go over strategies for approaching different question types, managing your
time effectively, and dealing with difficult questions. Being comfortable with these strategies can help
reduce anxiety on exam day.
Organize your study materials: Ensure all your study materials are well-organized and easily accessible.
This reduces stress and saves time during your final review sessions.
Collaborate with study partners: If you have study partners, consider scheduling review sessions to
discuss challenging concepts or quiz each other on high-yield topics. Teaching others can reinforce your
own understanding.
Review CCS cases: Since the Step 3 exam includes computer-based case simulations (CCS), make sure
to practice with sample cases and review common management protocols.
Create a "last day" review plan: Decide what you want to cover on the day before the exam. This might
include reviewing summary sheets, going over commonly tested topics, or working through a set of
practice questions.
Familiarize yourself with exam logistics: Review the exam day schedule, location details, and any
required documentation. Being prepared for the practical aspects of the exam day can help reduce stress.
Practice self-care: While it's tempting to study around the clock, make sure to incorporate activities that
help you relax and maintain a positive mindset. This might include exercise, meditation, or spending time
with loved ones.
Review ethics and patient safety: These topics are increasingly important on the Step 3 exam. Make sure
you're comfortable with common ethical scenarios and patient safety principles.
Go over lab value interpretations: Practice quickly interpreting lab values and understanding their clinical
significance. This skill is frequently tested on the exam.
Review pharmacology: Focus on high-yield drug classes, mechanisms of action, and common side effects.
Pay special attention to drugs commonly used in clinical practice.
Practice time management: Work on strategies for managing your time effectively during each exam block.
This includes knowing when to move on from difficult questions and how to pace yourself throughout the
day.
By implementing these strategies, you can make the most of your final week of preparation. Remember,
the goal is to reinforce your existing knowledge and boost your confidence, not to cram large amounts of
new information. Stay focused, maintain a positive attitude, and trust in the preparation you've done
throughout your study period.

Strategies for managing exam anxiety

Exam anxiety is a common experience for many test-takers, especially when facing a high-stakes exam
like the USMLE Step 3. While some level of stress can be motivating, excessive anxiety can interfere
with your performance. Here are strategies to help manage exam anxiety effectively:
Recognize and acknowledge your anxiety: The first step in managing anxiety is to acknowledge its
presence. Understand that feeling anxious about an important exam is normal and doesn't reflect on your
abilities or preparation.
Identify specific triggers: Try to pinpoint what aspects of the exam or testing process make you most
anxious. Is it time pressure, fear of blanking out, or concern about specific subject areas? Identifying these
triggers can help you address them more effectively.
Challenge negative thoughts: Anxiety often stems from negative self-talk and catastrophic thinking. When
you notice these thoughts, challenge them with evidence-based, rational responses. For example, if you
think "I'm going to fail," remind yourself of your successful preparation and past achievements.
Practice visualization: Spend time visualizing yourself successfully taking the exam, feeling calm and
confident. This positive mental imagery can help reduce anxiety and boost self-assurance.
Use positive affirmations: Develop a set of positive, encouraging statements about your abilities and
preparation. Repeat these to yourself regularly, especially when feeling anxious.
Implement relaxation techniques: Learn and practice relaxation methods such as deep breathing,
progressive muscle relaxation, or mindfulness meditation. These can be used before and during the exam
to calm your nerves.
Maintain perspective: Remember that while the USMLE Step 3 is important, it doesn't define your worth
as a person or your potential as a physician. Keep the exam in perspective within the broader context of
your career and life.
Prepare for the unexpected: Anxiety can stem from fear of the unknown. Familiarize yourself with the
exam format, location, and procedures to reduce uncertainty. Have a plan for potential issues like traffic
delays or computer problems.
Develop a pre-exam routine: Create a calming routine for the morning of the exam. This might include
light exercise, a healthy breakfast, and reviewing your summary sheets. Having a familiar routine can
provide a sense of control and reduce anxiety.
Use anxiety as a tool: Try to reframe your anxiety as excitement or readiness. The physiological response
is similar, and this mental shift can help you feel more positively about the exam.
Practice with simulated exam conditions: The more familiar you are with the exam environment and
format, the less anxious you're likely to feel. Take practice tests under conditions as close to the real exam
as possible.
Avoid last-minute cramming: Studying up until the last minute can increase anxiety without significantly
improving your performance. Instead, focus on relaxation and confidence-building activities in the
immediate lead-up to the exam.
Utilize grounding techniques: If you feel anxiety rising during the exam, use grounding techniques to bring
yourself back to the present moment. This might involve focusing on your breath, noticing physical
sensations, or mentally describing your surroundings.
Implement time management strategies: Anxiety can worsen if you feel rushed or behind schedule.
Practice effective time management during your preparation so you feel confident about pacing on exam
day.
Seek support: Talk to friends, family, or a counselor about your anxiety. Sometimes, simply expressing
your concerns can help alleviate them. Your support system can also provide encouragement and
perspective.
Focus on self-care: Maintain healthy habits leading up to the exam, including regular exercise, a balanced
diet, and adequate sleep. Physical well-being can significantly impact your mental state.
Use positive past experiences: Recall past successes in exams or other challenging situations. Remind
yourself of the skills and resilience you've developed through your medical training.
Practice mindfulness: Incorporate mindfulness techniques into your daily routine. This can help you stay
present and focused, reducing anxiety about future outcomes.
Develop a growth mindset: View the exam as an opportunity for learning and growth rather than just an
evaluation. This perspective can help reduce the pressure you put on yourself.
Use anxiety reduction apps: There are many smartphone apps designed to help with anxiety management.
These can provide guided relaxation exercises or quick stress-relief techniques.
Remember, it's normal to feel some level of anxiety about an important exam. The key is to manage these
feelings so they don't interfere with your performance. By implementing these strategies and finding what
works best for you, you can approach the USMLE Step 3 with greater calm and confidence.

Practical relaxation techniques and mindfulness exercises

Incorporating relaxation techniques and mindfulness exercises into your exam preparation routine can
significantly reduce stress and improve focus. These practices can be particularly beneficial in the days
leading up to the USMLE Step 3 and even during the exam itself. Here are some practical techniques you
can use:
Deep Breathing Exercises: Deep breathing is a simple yet effective way to calm your nervous system. Try
the 4-7-8 technique: Inhale for 4 counts, hold for 7 counts, and exhale for 8 counts. Repeat this cycle 4-5
times. This can be done discreetly even during the exam if you feel anxiety rising.
Progressive Muscle Relaxation: This technique involves tensing and then relaxing different muscle groups
in your body. Start with your toes and work your way up to your head. Tense each muscle group for 5
seconds, then relax for 30 seconds before moving to the next group. This helps release physical tension
and promotes overall relaxation.
Guided Imagery: Close your eyes and imagine a peaceful, calming scene in vivid detail. This could be a
beach, a forest, or any place that makes you feel relaxed. Engage all your senses in this visualization.
Practice this regularly so you can quickly access this calming mental image when needed.
Mindfulness Meditation: Mindfulness involves focusing on the present moment without judgment. Start
with short sessions of 5-10 minutes and gradually increase the duration. Focus on your breath or bodily
sensations, gently bringing your attention back whenever your mind wanders.
Body Scan: Lie down or sit comfortably and mentally scan your body from head to toe, noticing any areas
of tension or discomfort. As you focus on each part, consciously relax those muscles. This practice
increases body awareness and promotes relaxation.
Grounding Techniques: These help you stay present when anxiety threatens to overwhelm you. Try the 5-
4-3-2-1 technique: Name 5 things you can see, 4 things you can touch, 3 things you can hear, 2 things you
can smell, and 1 thing you can taste.
Mindful Walking: Take a short walk, focusing on the sensation of your feet touching the ground, the rhythm
of your breath, and the movement of your body. This combines the benefits of light exercise with
mindfulness.
Loving-Kindness Meditation: This practice involves directing positive thoughts and wishes towards
yourself and others. It can help counteract negative self-talk and promote a sense of connection and well-
being.
Breath Awareness: Simply sit quietly and observe your natural breath without trying to change it. This
simple practice can be surprisingly calming and centering.
Mantra Repetition: Choose a word or phrase that is meaningful and calming to you. Repeat it silently to
yourself, using it as an anchor for your attention. This can be particularly helpful during the exam if you
need to quickly refocus.
Mindful Eating: Practice eating a meal or snack mindfully, paying full attention to the tastes, textures, and
sensations. This can be a form of meditation and can help you develop greater focus and presence.
Yoga: Gentle yoga poses can help release physical tension and promote mental calmness. Even simple
stretches at your desk can be beneficial.
Journaling: Spend a few minutes each day writing down your thoughts and feelings. This can help process
emotions and reduce mental clutter.
Mindful Listening: Practice giving your full attention when listening to music or to another person
speaking. Notice when your mind wanders and gently bring it back to the sound.
Gratitude Practice: Each day, take a moment to reflect on three things you're grateful for. This can shift
your focus from stress and anxiety to positive aspects of your life.
Box Breathing: Visualize a box while you breathe. Inhale for 4 counts, hold for 4 counts, exhale for 4
counts, and hold for 4 counts. Repeat this cycle several times.
Mindful Observation: Choose an object and observe it intently for a few minutes, noticing details you
might usually overlook. This exercise can sharpen your focus and bring you into the present moment.
Body Posture Awareness: Pay attention to your posture throughout the day. Notice any tension and
consciously relax those areas. Good posture can improve both physical comfort and mental state.
Mindful Hand Massage: Give yourself a hand massage, paying close attention to the sensations. This can
be done discreetly even during the exam.
Alternate Nostril Breathing: This yogic breathing technique can help balance your nervous system. Close
one nostril with your finger, inhale through the other nostril, then close that nostril and exhale through the
opposite side. Repeat, alternating sides.
Remember, the key to benefiting from these techniques is regular practice. Start incorporating them into
your daily routine well before the exam. This way, they'll become familiar tools you can easily use when
you need them most. Everyone responds differently to various relaxation techniques, so experiment to find
what works best for you. With consistent practice, these methods can significantly reduce your stress
levels and improve your focus, both during your preparation and on exam day.

Nutrition and sleep optimization for peak performance

Proper nutrition and adequate sleep are crucial components of exam preparation that are often
overlooked. These factors can significantly impact your cognitive function, memory, and overall
performance on the USMLE Step 3. Here's how you can optimize your nutrition and sleep habits for peak
performance:
Nutrition for Cognitive Function:
Balanced Diet: Aim for a well-balanced diet rich in fruits, vegetables, whole grains, lean proteins, and
healthy fats. These provide the necessary nutrients for optimal brain function.
Hydration: Maintain proper hydration by drinking plenty of water throughout the day. Even mild
dehydration can affect cognitive performance.
Brain-Boosting Foods: Incorporate foods known to support brain health, such as:

Fatty fish (rich in omega-3 fatty acids)

Berries (high in antioxidants)
Nuts and seeds (good source of vitamin E)
Dark chocolate (contains caffeine and antioxidants)
Avocados (rich in healthy fats)
Complex Carbohydrates: Choose whole grains and other complex carbohydrates for sustained energy
release throughout the day.
Protein-Rich Foods: Include lean proteins in your meals to support neurotransmitter production and
maintain stable blood sugar levels.
Limit Processed Foods: Reduce intake of processed foods, sugary snacks, and excessive caffeine, which
can lead to energy crashes.
Meal Timing: Eat regular, balanced meals to maintain stable blood sugar levels. Avoid skipping meals,
especially breakfast.
Exam Day Nutrition:
Breakfast: Start your exam day with a nutritious breakfast that includes protein, complex carbohydrates,
and healthy fats. This could be oatmeal with nuts and berries, or whole grain toast with avocado and eggs.
Snacks: Pack healthy snacks for exam breaks, such as nuts, fruit, or whole grain crackers with cheese.
These can help maintain energy levels without causing a sugar crash.
Avoid Heavy Meals: On exam day, avoid large, heavy meals that can make you feel sluggish. Opt for
lighter, easily digestible options.
Caffeine Management: If you regularly consume caffeine, maintain your usual intake to avoid withdrawal
symptoms. However, avoid excessive caffeine, which can increase anxiety and jitters.
Sleep Optimization:
Consistent Sleep Schedule: Maintain a regular sleep schedule, even on weekends. This helps regulate
your body's internal clock.
Adequate Sleep Duration: Aim for 7-9 hours of sleep per night. Consistently getting enough sleep
improves memory consolidation and cognitive function.
Create a Sleep-Friendly Environment: Ensure your bedroom is dark, quiet, and cool. Use comfortable
bedding and pillows.
Establish a Bedtime Routine: Develop a relaxing pre-sleep routine to help you wind down. This could
include reading, listening to calming music, or practicing relaxation techniques.
Limit Screen Time: Avoid electronic devices for at least an hour before bed, as the blue light emitted can
interfere with your sleep-wake cycle.
Manage Stress: Practice stress-reduction techniques such as meditation, deep breathing, or journaling to
help calm your mind before sleep.
Avoid Stimulants: Limit caffeine intake, especially in the afternoon and evening. Avoid nicotine and
alcohol close to bedtime, as they can disrupt sleep patterns.
Exercise Regularly: Engage in regular physical activity, but avoid vigorous exercise close to bedtime as it
can be stimulating.
Stick to a Schedule: Try to go to bed and wake up at the same time every day, even on weekends, to
regulate your body's internal clock.
Watch Your Diet: Avoid large meals close to bedtime. If you're hungry, opt for a light snack.
Manage Jet Lag: When traveling across time zones, try to adjust your sleep schedule to the new time zone
as quickly as possible.
Consider Cognitive Behavioral Therapy for Insomnia (CBT-I): This therapy can help you identify and
change thoughts and behaviors that affect your ability to sleep.
By implementing these strategies, you can optimize your sleep environment and habits, potentially
improving both the quantity and quality of your sleep. This can lead to better exam day performance by
ensuring you are well-rested and mentally sharp.
Practice Tests Sections
Welcome to the Practice Test section of "First Aid for the USMLE Step 2 CK & 3 2025-2026". This
comprehensive set of questions is designed to simulate the actual exam experience and assess your
readiness. To maximize the benefits of this practice test, we strongly encourage you to approach it as you
would the real exam.
Complete all questions in one sitting, adhering to the time constraints for each section. Resist the
temptation to check answers as you go – this will help you build stamina and improve time management
skills crucial for exam day success.
Only after completing the entire practice test should you review your answers and check your score. This
method allows for a more accurate assessment of your current knowledge and helps identify areas that
may require further study.
Remember, the goal is not just to test your knowledge, but to familiarize yourself with the exam format
and enhance your test-taking strategies. Good luck, and may this practice test be a valuable step in your
USMLE preparation journey!
Book 1 USMLE Step 2ck Questions Banks

Practice Tests 1
Question 1
What is typically considered the primary causative agent of Infective Endocarditis in individuals without
a history of intravenous drug use?
A) Staphylococcus aureus
B) Candida species
C) Streptococcus viridans
D) Coxiella burnetii
Question 2
Which factor is commonly associated with an increased risk of developing hospital-acquired pneumonia?
A) Recent abdominal or thoracic surgery
B) Extended hospital stay beyond two weeks
C) Being over the age of 65
D) Intubation and mechanical ventilation
Question 3
What procedure might be necessary if empyema remains unresolved with initial management?
A) Intravenous antibiotic therapy tailored to culture results
B) Repeat thoracentesis
C) Prolonged antibiotic therapy alone
D) Surgical intervention
Question 4
What symptoms might an adult patient with a ventricular septal defect experience due to increased
pulmonary blood flow?
A) Frequent nosebleeds
B) Syncope
C) Severe headaches and migraines
D) Dyspnea and fatigue
Question 5
Which clinical sign is most indicative of right-sided heart failure?
A) Paroxysmal nocturnal dyspnea
B) Peripheral edema and jugular vein distension
C) Orthopnea
D) Acute pulmonary edema
Question 6
During an examination of a 55-year-old woman, a systolic murmur radiating to the neck is detected. What
heart condition is likely to be diagnosed after echocardiography?
A) Mitral regurgitation
B) Tricuspid regurgitation
C) Pulmonic stenosis
D) Aortic stenosis
Question 7
What characteristic feature distinguishes hypertrophic cardiomyopathy on an echocardiogram?
A) Asymmetric septal hypertrophy
B) Systolic anterior motion of the mitral valve
C) Intraventricular conduction delay
D) Dilated ventricular chambers
Question 8
Which diagnostic method is most effective for differentiating between transudative and exudative pleural
effusion?
A) Thoracic ultrasound
B) Light's criteria
C) Pleural biopsy
D) Chest X-ray
Question 9
How should a 10 mm induration on tuberculin skin testing be interpreted for a 30-year-old man with HIV
and a CD4 count of 350 cells/ μ L?
A) Does not meet diagnostic criteria for TB infection
B) Suggests tuberculosis infection
C) Significant for any patient, suggesting possible TB exposure
D) Inconclusive, requiring additional tests
Question 10
Which lifestyle modification is generally not recommended for managing hypertension?
A) Weight loss if overweight
B) Increased dietary sodium intake
C) Reduction of alcohol consumption
D) Regular aerobic exercise
Question 11
What is the most likely physical finding on examination of a 29-year-old male diagnosed with a
ventricular septal defect presenting with signs of heart failure?
A) Loud holosystolic murmur at the left lower sternal border
B) Carotid upstroke delay
C) Faint diastolic murmur at the apex
D) Elevated jugular venous pressure
Question 12
What is the primary goal of exercise therapy in managing claudication due to peripheral vascular disease?
A) Decrease progression of atherosclerotic plaques
B) Directly repair arterial lesions
C) Enhance walking distance and reduce symptoms
D) Increase cardiac output
Question 13
Which symptom is most characteristic of acute pericarditis?
A) Gradual onset of dyspnea on exertion and fatigue
B) Sudden onset of high fever and chills
C) Palpitations and lightheadedness
D) Sharp, pleuritic chest pain improving with sitting up and leaning forward
Question 14
Which factor is considered a major risk for developing Infective Endocarditis in patients?
A) Congenital heart disease
B) Previous episode of Infective Endocarditis
C) History of rheumatic fever
D) Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Question 15
What environmental control is essential for a patient with asthma triggered by dust mites?
A) Keeping indoor humidity levels below 50% year-round
B) Installation of central air conditioning
C) Use of allergen-impermeable covers for pillows and mattresses
D) Regular use of high-efficiency particulate air (HEPA) filters
Question 16
What is the most crucial factor to consider when setting the ventilator for a 45-year-old patient who
develops ARDS following sepsis?
A) Balancing fluid management
B) Prevention of ventilator-induced lung injury
C) Ensuring adequate oxygenation
D) Adjusting sedation levels
Question 17
Which imaging modality is regarded as the gold standard for diagnosing pulmonary embolism?
A) Ventilation-perfusion (V/Q) scan
B) Invasive pulmonary angiography
C) Computed tomography pulmonary angiography (CTPA)
D) Magnetic resonance imaging (MRI) of the chest
Question 18
During a routine check-up of a 73-year-old man with a history of hypertension and irregular heartbeat, a
heart rate of 110 bpm with a "sawtooth" pattern on the ECG is found. What is the most likely arrhythmia?
A) Supraventricular tachycardia
B) Ventricular fibrillation
C) Multifocal atrial tachycardia
D) Atrial flutter
Question 19
A patient presents with dry cough and dyspnea, and HRCT shows honeycombing and traction
bronchiectasis. What is the most likely diagnosis?
A) Idiopathic pulmonary fibrosis
B) Asthma
C) Chronic obstructive pulmonary disease (COPD)
D) Pulmonary arterial hypertension
Question 20
What type of cardiomyopathy should be suspected in a 45-year-old man presenting with dyspnea on
exertion and an ECG showing low voltage QRS complexes?
A) Hypertrophic cardiomyopathy
B) Restrictive cardiomyopathy
C) Dilated cardiomyopathy
D) Arrhythmogenic right ventricular cardiomyopathy
Question 21
For a 65-year-old patient with a smoking history presenting with a chest X-ray showing a 3 cm solitary
pulmonary nodule and biopsy revealing small cell lung cancer, what is the next best step in management?
A) Referral to a lung cancer specialist for surgical evaluation
B) Ongoing monitoring with regular CT scans and biopsies
C) Supportive care including pain management and nutritional support
D) Immediate initiation of chemotherapy combined with radiation therapy
Question 22
During a check-up, a 60-year-old patient's echocardiogram shows asymmetric septal hypertrophy and
systolic anterior motion of the mitral valve. What is the most likely diagnosis?
A) Restrictive cardiomyopathy
B) Hypertrophic cardiomyopathy
C) Arrhythmogenic right ventricular cardiomyopathy
D) Dilated cardiomyopathy
Question 23
For a patient with congestive heart failure experiencing worsening renal function, which medication might
need adjustment?
A) Angiotensin-converting enzyme (ACE) inhibitors
B) Diuretics
C) Beta-blockers
D) Mineralocorticoid receptor antagonists
Question 24
What is the primary mechanism of action of warfarin in treating pulmonary embolism?
A) Platelet aggregation inhibition
B) Direct thrombin inhibition
C) Elevation of antithrombin III levels
D) Inhibition of vitamin K-dependent clotting factors
Question 25
A patient reports chest pain that intensifies with physical activity and decreases with rest. An ECG and
troponin levels are ordered. What is the likely diagnosis based on these presenting symptoms?
A) Stable Angina
B) Pulmonary hypertension
C) Acute myocardial infarction
D) Unstable Angina
Question 26
What serum level is commonly elevated in sarcoidosis due to granuloma formation?
A) Angiotensin-converting enzyme (ACE)
B) C-reactive protein (CRP)
C) Serum calcium
D) Thyroid-stimulating hormone (TSH)
Question 27
What common symptom should prompt a clinician to suspect obstructive sleep apnea in a patient?
A) Frequent nocturnal urination
B) Persistent cough and sore throat upon waking
C) Chronic snoring
D) Excessive daytime sleepiness
Question 28
Which imaging study is essential for confirming the diagnosis of ARDS?
A) Ultrasound of the chest
B) Computed tomography (CT) scan
C) Magnetic resonance imaging (MRI)
D) Chest X-ray
Question 29
In risk assessment for pulmonary embolism, what common clinical tool is used to stratify the patient's risk
of having a PE?
A) The CHADS2 score
B) The Wells score
C) The CURB-65 score
D) The Revised Geneva Score
Question 30
What is the most likely diagnosis for a 67-year-old smoker presenting with shortness of breath, a barrel-
shaped chest, and diminished breath sounds?
A) Pulmonary fibrosis
B) Asthma
C) Emphysema
D) Chronic bronchitis
Question 31
After a chest tube placement for pleural effusion, a patient reports persistent fever and chest pain. What
should be suspected?
A) Post-procedure pneumothorax
B) Pleural thickening or fibrosis
C) Acute respiratory distress syndrome (ARDS)
D) Development of a secondary empyema
Question 32
A 50-year-old patient reports palpitations and fatigue. The ECG shows irregular R-R intervals and absent
P waves. What is the likely diagnosis?
A) Ventricular tachycardia
B) Atrial fibrillation
C) Premature atrial contractions
D) Sinus tachycardia
Question 33
For a 58-year-old woman with sudden onset dyspnea and pleuritic chest pain who has a positive D-dimer
test, what is the next best step in management?
A) Scheduled repeat D-dimer testing in one week
B) Perform a computed tomography pulmonary angiography (CTPA)
C) Immediate administration of unfractionated heparin
D) Initiate a beta-blocker to reduce heart rate
Question 34
Which medication is primarily used to manage symptoms in patients with COPD?
A) Oral corticosteroids
B) Inhaled bronchodilators
C) ACE inhibitors
D) Antibiotics
Question 35
In hospital-acquired pneumonia, within what timeframe should antibiotics be initiated after diagnosis to
reduce mortality?
A) One hour
B) Six hours
C) Twelve hours
D) Twenty-four hours
Question 36
For a 63-year-old man with no prior history of hypertension presenting with a blood pressure of 180/110
mmHg and complaints of headache and dizziness, what is the best initial approach to management?
A) Prescription of thiazide diuretic immediately
B) Stress reduction techniques and reassessment in one month
C) Immediate evaluation for potential secondary causes
D) Immediate start of combination antihypertensive therapy
Question 37
Which complication is most associated with a large, unrepaired atrial septal defect in adults?
A) Aortic dissection
B) Pulmonary hypertension
C) Ventricular arrhythmias
D) Infective endocarditis
Question 38
A 65-year-old male patient presents with chest pain radiating to the left arm and diaphoresis. His ECG
shows ST-segment elevation. What is the most likely diagnosis?
A) Myocarditis
B) Pulmonary embolism
C) Myocardial Infarction
D) Angina Pectoris
Question 39
What is the standard initial treatment regimen for active tuberculosis in a patient without any drug
resistances?
A) Isoniazid and rifapentine once weekly for 3 months under directly observed therapy (DOT)
B) Isoniazid, rifampin, ethambutol, and pyrazinamide for 2 months, followed by isoniazid and rifampin
for 4 months
C) Two weeks of streptomycin followed by ten months of isoniazid and rifampin
D) Continuous administration of rifampin and isoniazid for 9 months
Question 40
In the treatment of congestive heart failure, which inhibitors are commonly used to reduce afterload and
preload?
A) Beta-blocker
B) Calcium channel blocker
C) Diuretic
D) Angiotensin-converting enzyme (ACE)
Question 41
During a routine examination, a 58-year-old woman with a history of hypertension complains of
increasing shortness of breath and fatigue. What initial diagnostic test should be performed?
A) Pulmonary function test
B) Chest X-ray
C) Echocardiogram
D) Stress test
Question 42
For a patient reporting frequent nighttime awakenings, daily use of rescue inhaler, and some activity
limitation, what is the appropriate treatment step according to stepwise asthma management?
A) Low-dose inhaled corticosteroid therapy only
B) Oral corticosteroid therapy
C) Medium-dose inhaled corticosteroid and long-acting beta-agonist combination
D) High-dose inhaled corticosteroid therapy
Question 43
What is one of the Duke criteria for diagnosing Infective Endocarditis?
A) Janeway lesions
B) Presence of Osler's nodes
C) Positive blood culture for typical organisms from two separate blood cultures
D) Echocardiographic findings consistent with Infective Endocarditis
Question 44
What is the primary mechanism of reduced ejection fraction in dilated cardiomyopathy related to
congestive heart failure?
A) Increased pre-load due to fluid overload
B) Systolic dysfunction due to impaired contractility
C) Diastolic dysfunction due to ventricular hypertrophy
D) Valvular insufficiency leading to regurgitation
Question 45
How should a positive interferon-gamma release assay (IGRA) in a healthcare worker be interpreted?
A) It indicates latent tuberculosis infection
B) The test result is likely an artifact
C) It confirms an active tuberculosis infection
D) It suggests an immune response to TB exposure
Question 46
How does effective CPAP therapy influence blood pressure in patients with obstructive sleep apnea?
A) It generally leads to a reduction in both nocturnal and diurnal blood pressure
B) It has minimal or no effect on blood pressure
C) It may lead to an increase in blood pressure
D) It typically increases blood pressure slightly
Question 47
In the ankle-brachial index (ABI) diagnostic tool used for PAD, what value indicates significant arterial
insufficiency?
A) Less than 0.90
B) Less than 1.30
C) Less than 0.50
D) Less than 1.00
Question 48
For a 65-year-old male with a history of aortic valve replacement presenting with fever and a new heart
murmur, and echocardiography showing vegetations on the valve, what is the initial antibiotic therapy?
A) Intravenous penicillin and rifampin
B) Intravenous ceftriaxone and doxycycline
C) Intravenous vancomycin and gentamicin
D) Oral amoxicillin
Question 49
What therapy is commonly included in the initial treatment for unstable angina to prevent further clot
formation?
A) Antiplatelet therapy
B) Beta-blocker therapy
C) Anticoagulant therapy
D) Statin therapy
Question 50
For a patient diagnosed with stage IIIA non-small cell lung cancer, which treatment approach would likely
be considered?
A) Combined chemotherapy and radiation therapy
B) Targeted therapy
C) Surgery to remove the affected lung tissue
Question 51: What diagnostic procedure is crucial for assessing a patient with suspected hospital-
acquired pneumonia?
A) Chest computed tomography (CT)
B) Spirometry
C) Blood cultures
D) Pulmonary function tests
Question 52: For a previously healthy adult with community-acquired pneumonia and no recent antibiotic
use, what is the recommended first-line antibiotic treatment?
A) Intravenous vancomycin
B) High-dose amoxicillin
C) Azithromycin or doxycycline
D) Ciprofloxacin
Question 53: In managing claudication for a patient with peripheral vascular disease, what is considered
the primary pharmacological treatment?
A) Cilostazol
B) Low-dose aspirin
C) Warfarin
D) High-dose statin therapy
Question 54: According to stepwise asthma management, after how long should treatment intensity be
increased if control is not achieved?
A) Two to three months
B) Six to eight weeks
C) One year
D) Four to six weeks
Question 55: For patients with a low probability of pulmonary embolism, what is the preferred initial
diagnostic test?
A) Transthoracic echocardiogram
B) D-dimer test
C) Lower extremity ultrasound
D) Electrocardiogram (ECG)
Question 56: Which test is most effective for confirming an asthma diagnosis in a patient with suspected
exercise-induced bronchoconstriction?
A) Methacholine challenge test
B) Complete blood count
C) Spirometry with bronchodilator reversibility testing
D) Peak expiratory flow monitoring at home
Question 57: How long must a productive cough persist in two consecutive years to be considered a
common symptom of chronic bronchitis?
A) Three months
B) Six months
C) One week
D) One month
Question 58: For a 54-year-old woman with type 2 diabetes and a blood pressure reading of 140/90
mmHg, what is the threshold for starting pharmacological treatment?
A) 130/80 mmHg
B) 120/80 mmHg
C) 140/90 mmHg
D) 150/90 mmHg
Question 59: What is the likely diagnosis for a patient reporting frequent morning headaches, daytime
fatigue, and observed breathing cessation during sleep?
A) Central sleep apnea
B) Obstructive sleep apnea
C) Depression
D) Hypothyroidism
Question 60: What is typically the preferred surgical intervention for symptomatic severe mitral
regurgitation?
A) Mitral valve repair
B) Percutaneous coronary intervention
C) Mitral valve replacement
D) Left ventricular assist device
Question 61: What might echocardiography reveal in patients with pericardial effusion?
A) Swinging motion of the heart within the effusive fluid
B) Presence of pleural effusion adjacent to the pericardium
C) Dilation of the right ventricle during diastole
D) Increased pericardial thickness with calcification
Question 62: Which test is considered the gold standard for confirming obstructive sleep apnea (OSA)?
A) Overnight oximetry
B) Multiple Sleep Latency Test
C) Polysomnography
D) Home sleep apnea testing
Question 63: For a 34-year-old female with a history of patent ductus arteriosus experiencing exercise
intolerance and palpitations, which diagnostic tool is most indicative of her condition?
A) Treadmill stress test
B) Blood pressure monitoring
C) Chest X-ray
D) Echocardiogram
Question 64: What is the main objective of using chemotherapy in treating small cell lung cancer?
A) To enhance the immune system's ability to fight cancer cells
B) To provide palliative care and improve quality of life
C) To kill fast-growing cancer cells and reduce tumor size
D) To target localized tumors and alleviate symptoms
Question 65: What is the recommended initial diagnostic approach for evaluating a new case of
hypertension?
A) Kidney function tests and urinalysis
B) 24-hour ambulatory blood pressure monitoring
C) Blood pressure measurement on two separate occasions
D) Echocardiogram to assess cardiac function
Question 66: What is typically the most common trigger for asthma exacerbation in children?
A) Viral upper respiratory infections
B) Exposure to outdoor air pollution
C) Physical activity in cold weather
D) Consumption of food allergens
Question 67: What condition should be suspected in a 34-year-old presenting with bilateral hilar
lymphadenopathy and erythema nodosum during a routine examination?
A) Tuberculosis
B) Sarcoidosis
C) Lymphoma
D) Wegener's granulomatosis
Question 68: Why is continuous positive airway pressure (CPAP) effective in treating obstructive sleep
apnea?
A) It keeps the lungs open during sleep
B) It encourages stronger diaphragm movements
C) It maintains an open airway during sleep
D) It clears sinus congestion
Question 69: What is the characteristic symptom of peripheral arterial disease (PAD) that occurs with
exertion and resolves with rest?
A) Persistent numbness in the feet
B) Intermittent claudication
C) Sharp, stabbing pains in the toes at night
D) Continuous throbbing pain in the thighs
Question 70: What common symptom might an adult with an undiagnosed atrial septal defect experience?
A) Cyanosis
B) Dyspnea on exertion
C) Intermittent claudication
D) Chest pain at rest
Question 71: What is the characteristic finding in dilated cardiomyopathy on an echocardiogram?
A) Presence of ventricular thrombi
B) Increased ventricular chamber size
C) Thickened ventricular walls
D) Reduced ejection fraction
Question 72: What is the typical presentation of sarcoidosis on a chest X-ray?
A) Extensive nodular infiltrates throughout both lung fields
B) Bilateral hilar lymphadenopathy often without parenchymal involvement
C) A clear chest with no significant radiographic abnormalities
D) Single, isolated mediastinal lymph node enlargement
Question 73: Which diagnostic test is essential for evaluating the severity of mitral regurgitation?
A) Electrocardiogram
B) Cardiac catheterization
C) Cardiac MRI
D) Transthoracic echocardiogram
Question 74: What pulmonary function test finding is most indicative of COPD?
A) Normal FEV1/FVC ratio
B) Decreased diffusing capacity for carbon monoxide
C) Increased total lung capacity
D) Decreased FEV1/FVC ratio below 0.70 after bronchodilator use
Question 75: What is typically the most common symptom of severe aortic stenosis?
A) Cough
B) Palpitations
C) Dyspnea on exertion
D) Angina pectoris
Question 76: In patients with a history of BCG vaccination, which test may indicate a false positive due to
prior vaccination?
A) Chest X-ray
B) Tuberculin skin test
C) QuantiFERON-TB Gold test
D) Interferon-gamma release assay
Question 77: What is the most likely diagnosis for a 60-year-old smoker complaining of calf pain when
walking that eases upon resting?
A) Peripheral arterial disease
B) Deep vein thrombosis
C) Rheumatoid arthritis
D) Lumbar spinal stenosis
Question 78: For a 45-year-old patient presenting with sharp chest pain that improves when sitting
forward and diffuse ST elevation on ECG, what is the most likely diagnosis?
A) Myocardial infarction
B) Acute aortic dissection
C) Acute pericarditis
D) Pulmonary embolism
Question 79: What is considered the most effective initial treatment for acute atrial fibrillation with rapid
ventricular response?
A) Electrical cardioversion
B) Intravenous beta-blockers
C) High-dose statin therapy
D) Long-term amiodarone
Question 80: What is the recommended first-line treatment for a patient diagnosed with acute viral
pericarditis?
A) Corticosteroid therapy
B) High-dose nonsteroidal anti-inflammatory drugs (NSAIDs)
C) Broad-spectrum antibiotics
D) Immediate surgical drainage of the pericardial cavity
Question 81: What is the most appropriate initial management for a primary spontaneous pneumothorax in
a young, healthy patient with minimal symptoms?
A) Immediate chest tube placement
B) High-flow oxygen therapy and bed rest
C) Needle aspiration
D) Observation and supplemental oxygen
Question 82: Which surgical procedure is typically indicated for early-stage non-small cell lung cancer
with no lymph node involvement?
A) Lobectomy
B) Segmentectomy
C) Wedge resection
D) Pneumonectomy
Question 83: For a patient diagnosed with latent tuberculosis who is allergic to isoniazid, what is the best
alternative medication for treatment?
A) Rifampin for 4 months
B) Levofloxacin for 12 weeks
C) Ethambutol for 6 months
D) Isoniazid and rifampin combined for 3 months
Question 84: How should prone positioning be used in managing ARDS for patients with severe
hypoxemia?
A) Short daily sessions
B) Sessions of 12-16 hours per day
C) Intermittent positioning
D) Continuous positioning as long as tolerated
Question 85: What is the most common type of lung cancer, responsible for approximately 85% of cases?
A) Mesothelioma
B) Non-small cell lung cancer
C) Large cell lung cancer
D) Squamous cell carcinoma
Question 86: For a 70-year-old male with a history of heart murmur presenting with syncope and a harsh
systolic ejection murmur, what is the most likely diagnosis?
A) Mitral regurgitation
B) Pulmonary hypertension
C) Aortic stenosis
D) Aortic regurgitation
Question 87: What is a characteristic feature of emphysema seen on a chest X-ray?
A) Pleural effusion
B) Increased opacity due to bronchial wall thickening
C) Consolidation patterns
D) Hyperinflation of the lungs with flattened diaphragms
Question 88: In ARDS, what PaO2/FiO2 ratio is indicative of severe disease and a key criterion for
diagnosis?
A) Less than 400
B) Less than 100
C) Less than 300
D) Less than 200
Question 89: For a 72-year-old male with COPD and recent flu-like symptoms presenting with a new
cough, fever, and right lower lobe infiltrate on chest X-ray, what is the most likely diagnosis?
A) Acute bronchitis
B) Tuberculosis
C) Community-acquired pneumonia
D) Pulmonary embolism
Question 90: How does constrictive pericarditis differ from cardiac tamponade in terms of hemodynamic
impact?
A) Cardiac tamponade causes diastolic collapse of the right atrium and ventricle
B) Constrictive pericarditis increases systolic ejection
C) Cardiac tamponade does not affect cardiac filling pressures or volumes
D) Constrictive pericarditis results in diastolic filling restrictions
Question 91: What is a hallmark finding on high-resolution CT (HRCT) for idiopathic pulmonary
fibrosis?
A) Predominance of centrilobular nodules
B) Diffuse ground-glass opacities predominantly in the upper lobes
C) Subpleural, basal-predominant reticular abnormalities with honeycombing
D) Uniform interstitial thickening with no clear preference for any lung region
Question 92: What ventilatory support strategy involves setting a lower tidal volume to minimize lung
injury in ARDS patients?
A) Adaptive support ventilation
B) Low tidal volume ventilation at 6 mL/kg of predicted body weight
C) High-frequency oscillatory ventilation
D) Positive end-expiratory pressure (PEEP) settings
Question 93: Which type of cardiomyopathy is typically associated with biatrial enlargement but normal
ventricle size on imaging?
A) Restrictive cardiomyopathy
B) Hypertrophic cardiomyopathy
C) Arrhythmogenic right ventricular cardiomyopathy
D) Dilated cardiomyopathy
Question 94: Which of the following is NOT a risk factor for the development of acute coronary
syndromes?
A) Low-density lipoprotein levels below 100 mg/dL
B) Sedentary lifestyle
C) Diabetes
D) Smoking
Question 95: What type of inhibitors are typically included in first-line treatment for hypertension?
A) Beta-blocker
B) Calcium channel blocker
C) Angiotensin-converting enzyme (ACE)
D) Diuretic
Question 96: Which diagnostic marker is most reliable for confirming myocardial infarction within the
first few hours of symptom onset?
A) Lactate dehydrogenase
B) Creatine kinase-MB
C) Myoglobin
D) Troponin
Question 97: For a patient presenting with low-grade fever, weight loss, and a new heart murmur, with
blood cultures pending, what diagnostic test would provide the most immediate information?
A) Chest X-ray
B) Serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels
C) Transesophageal echocardiography
D) Multiple blood cultures
Question 98: Which diagnostic tool is essential for confirming the type of arrhythmia in a symptomatic
patient?
A) Stress test
B) Echocardiogram
C) Holter monitor
D) 12-lead electrocardiogram
Question 99: What is commonly prescribed to prevent stroke in patients with atrial fibrillation?
A) Calcium channel blockers
B) Oral anticoagulation therapy
C) Beta-blocker therapy
D) Platelet aggregation inhibitors
Question 100: What is the primary goal of using chemotherapy in the management of small cell lung
cancer?
A) To help the immune system recognize and fight cancer cells
B) To provide palliative care and improve quality of life
C) To kill fast-growing cancer cells and reduce tumor size
D) To target localized tumors and alleviate symptoms

Correct Answers & Explanations

Question 1
C) Streptococcus viridans (Correct Answer)
Explanation: Streptococcus viridans is typically considered the primary causative agent of Infective
Endocarditis in individuals without a history of intravenous drug use. These bacteria are part of the
normal oral flora and can enter the bloodstream during dental procedures or daily activities, potentially
colonizing damaged heart valves or endocardial surfaces.
Question 2
D) Intubation and mechanical ventilation (Correct Answer)
Explanation: Intubation and mechanical ventilation significantly increase the risk of hospital-acquired
pneumonia. The endotracheal tube bypasses natural defense mechanisms, allowing pathogens direct
access to the lower respiratory tract. Additionally, prolonged immobility and the potential for aspiration
contribute to this increased risk.
Question 3
D) Surgical intervention (Correct Answer)
Explanation: If empyema remains unresolved with initial management, surgical intervention may be
necessary. This can involve procedures such as video-assisted thoracoscopic surgery (VATS) or
thoracotomy with decortication to remove infected fluid and fibrinous material, allowing lung re-
expansion and resolution of the infection.
Question 4
D) Dyspnea and fatigue (Correct Answer)
Explanation: Adult patients with a ventricular septal defect experiencing increased pulmonary blood flow
are likely to experience dyspnea and fatigue. The left-to-right shunt leads to pulmonary overcirculation,
causing increased work of breathing and reduced systemic cardiac output, resulting in these symptoms.
Question 5
B) Peripheral edema and jugular vein distension (Correct Answer)
Explanation: Peripheral edema and jugular vein distension are the most indicative clinical signs of right-
sided heart failure. These signs result from increased systemic venous pressure due to the right ventricle's
inability to effectively pump blood into the pulmonary circulation, leading to fluid accumulation in
peripheral tissues and distension of neck veins.
Question 6
D) Aortic stenosis (Correct Answer)
Explanation: A systolic murmur radiating to the neck in a 55-year-old woman is highly suggestive of
aortic stenosis. This murmur is typically harsh and crescendo-decrescendo in nature, heard best at the
right upper sternal border and often radiates to the carotid arteries in the neck due to the proximity of the
aortic valve to these vessels.
Question 7
A) Asymmetric septal hypertrophy (Correct Answer)
Explanation: Asymmetric septal hypertrophy is the characteristic feature that distinguishes hypertrophic
cardiomyopathy on an echocardiogram. This condition is defined by thickening of the interventricular
septum that is disproportionate to the left ventricular free wall, often leading to left ventricular outflow
tract obstruction.
Question 8
B) Light's criteria (Correct Answer)
Explanation: Light's criteria is the most effective diagnostic method for differentiating between
transudative and exudative pleural effusion. It involves measuring the protein and LDH levels in both the
pleural fluid and serum, providing a reliable way to classify effusions based on their underlying cause.
Question 9
B) Suggests tuberculosis infection (Correct Answer)
Explanation: For an HIV-positive individual with a CD4 count of 350 cells/ μ L, a 10 mm induration on
tuberculin skin testing suggests tuberculosis infection. In HIV patients, a lower threshold (≥5 mm) is
typically used for TB diagnosis, but with a CD4 count above 200 cells/ μ L, the 10 mm cutoff is still
applicable.
Question 10
B) Increased dietary sodium intake (Correct Answer)
Explanation: Increased dietary sodium intake is not recommended for managing hypertension. In fact,
reducing sodium intake is a key lifestyle modification for hypertension management. Sodium retention
leads to increased blood volume and consequently higher blood pressure, making sodium reduction
crucial for blood pressure control.
Question 11
A) Loud holosystolic murmur at the left lower sternal border (Correct Answer)
Explanation: A loud holosystolic murmur at the left lower sternal border is the most likely physical
finding in a patient with a ventricular septal defect. This murmur results from blood shunting from the left
to the right ventricle throughout systole due to the defect in the interventricular septum.
Question 12
C) Enhance walking distance and reduce symptoms (Correct Answer)
Explanation: The primary goal of exercise therapy in managing claudication due to peripheral vascular
disease is to enhance walking distance and reduce symptoms. Regular exercise promotes the development
of collateral circulation, improves endothelial function, and enhances skeletal muscle metabolism, leading
to increased pain-free walking distance and overall functional capacity.
Question 13
D) Sharp, pleuritic chest pain improving with sitting up and leaning forward (Correct Answer)
Explanation: Sharp, pleuritic chest pain that improves with sitting up and leaning forward is the most
characteristic symptom of acute pericarditis. This positional relief occurs because leaning forward
reduces the stretch on the inflamed pericardium, alleviating pain.
Question 14
D) Prosthetic cardiac valve or prosthetic material used for cardiac valve repair (Correct Answer)
Explanation: A prosthetic cardiac valve or prosthetic material used for cardiac valve repair is considered
a major risk factor for developing Infective Endocarditis. These foreign materials provide a surface for
bacterial adherence and colonization, significantly increasing the risk of infection.
Question 15
C) Use of allergen-impermeable covers for pillows and mattresses (Correct Answer)
Explanation: The use of allergen-impermeable covers for pillows and mattresses is an essential
environmental control for patients with asthma triggered by dust mites. These covers create a barrier that
prevents dust mites from colonizing bedding and reduces exposure to their allergens, which are a common
trigger for asthma symptoms.
Question 16
B) Prevention of ventilator-induced lung injury (Correct Answer)
Explanation: In ARDS management, preventing ventilator-induced lung injury is crucial. This involves
using lung-protective ventilation strategies, such as low tidal volumes (6 ml/kg predicted body weight)
and limiting plateau pressures (<30 cm H2O). These measures help prevent further damage to the already
compromised lungs, reducing mortality and improving outcomes.
Question 17
C) Computed tomography pulmonary angiography (CTPA) (Correct Answer)
Explanation: CTPA is considered the gold standard for diagnosing pulmonary embolism. It provides
detailed images of the pulmonary arteries, allowing for direct visualization of emboli. CTPA is highly
sensitive and specific, can be performed quickly, and provides information about alternative diagnoses if
PE is not present.
Question 18
D) Atrial flutter (Correct Answer)
Explanation: The description of a "sawtooth" pattern on the ECG with a heart rate of 110 bpm is
characteristic of atrial flutter. This arrhythmia typically presents with a regular atrial rate of 300 bpm,
often conducting to the ventricles at a 2:1 or 3:1 ratio, resulting in ventricular rates around 150 or 100
bpm, respectively.
Question 19
A) Idiopathic pulmonary fibrosis (Correct Answer)
Explanation: The combination of dry cough, dyspnea, and HRCT findings of honeycombing and traction
bronchiectasis strongly suggests idiopathic pulmonary fibrosis (IPF). These radiographic features are
hallmarks of the usual interstitial pneumonia (UIP) pattern, which is characteristic of IPF.
Question 20
B) Restrictive cardiomyopathy (Correct Answer)
Explanation: Low voltage QRS complexes on ECG, combined with dyspnea on exertion in a 45-year-old
man, suggest restrictive cardiomyopathy. This condition is characterized by stiff ventricular walls that
restrict diastolic filling, leading to reduced QRS voltage due to decreased electrical conductivity through
the fibrotic myocardium.
Question 21
D) Immediate initiation of chemotherapy combined with radiation therapy (Correct Answer)
Explanation: For small cell lung cancer, which is highly aggressive but often responsive to chemotherapy,
the best initial management is immediate initiation of chemotherapy combined with radiation therapy. This
approach is preferred over surgery for most cases of SCLC due to its rapid growth and early metastatic
potential.
Question 22
B) Hypertrophic cardiomyopathy (Correct Answer)
Explanation: The echocardiogram findings of asymmetric septal hypertrophy and systolic anterior motion
of the mitral valve are pathognomonic for hypertrophic cardiomyopathy. This genetic disorder is
characterized by inappropriate myocardial hypertrophy, often most pronounced in the interventricular
septum.
Question 23
A) Angiotensin-converting enzyme (ACE) inhibitors (Correct Answer)
Explanation: In a patient with congestive heart failure experiencing worsening renal function, ACE
inhibitors might need adjustment. While these drugs are beneficial in heart failure, they can cause a
decline in renal function, especially in patients with pre-existing renal impairment or in the setting of
volume depletion.
Question 24
D) Inhibition of vitamin K-dependent clotting factors (Correct Answer)
Explanation: Warfarin's primary mechanism of action in treating pulmonary embolism is the inhibition of
vitamin K-dependent clotting factors (II, VII, IX, and X). By interfering with the vitamin K cycle, warfarin
reduces the production of these essential coagulation factors, thereby decreasing the body's ability to form
new clots.
Question 25
A) Stable Angina (Correct Answer)
Explanation: The description of chest pain that intensifies with physical activity and decreases with rest
is characteristic of stable angina. This pattern reflects a fixed coronary artery obstruction that causes
myocardial ischemia during increased oxygen demand (e.g., during exercise) but resolves with rest when
oxygen demand decreases.
Question 26
A) Angiotensin-converting enzyme (ACE) (Correct Answer)
Explanation: Serum angiotensin-converting enzyme (ACE) is commonly elevated in sarcoidosis due to
granuloma formation. ACE is produced by epithelioid cells within sarcoid granulomas, leading to
increased serum levels. This elevation correlates with granuloma burden and is used as a biomarker for
disease activity and monitoring in sarcoidosis.
Question 27
D) Excessive daytime sleepiness (Correct Answer)
Explanation: Excessive daytime sleepiness is a hallmark symptom of obstructive sleep apnea (OSA). This
occurs due to fragmented sleep caused by repeated breathing interruptions during the night. While chronic
snoring is also common in OSA, excessive daytime sleepiness is more specific and directly impacts
quality of life, making it a key symptom for clinical suspicion.
Question 28
D) Chest X-ray (Correct Answer)
Explanation: Chest X-ray is essential for confirming the diagnosis of Acute Respiratory Distress
Syndrome (ARDS). The Berlin definition of ARDS requires bilateral opacities on chest imaging not fully
explained by effusions, lung collapse, or nodules. While CT scans can provide more detailed information,
chest X-rays are more readily available, less expensive, and sufficient for initial diagnosis in most cases.
Question 29
B) The Wells score (Correct Answer)
Explanation: The Wells score is a commonly used clinical tool to stratify a patient's risk of having a
pulmonary embolism (PE). It incorporates various clinical factors such as symptoms, risk factors, and the
likelihood of alternative diagnoses. The score helps clinicians determine the need for further diagnostic
testing, such as D-dimer or imaging studies, in patients suspected of having a PE.
Question 30
C) Emphysema (Correct Answer)
Explanation: The most likely diagnosis for a 67-year-old smoker presenting with shortness of breath, a
barrel-shaped chest, and diminished breath sounds is emphysema. These symptoms are classic for
emphysema, a form of Chronic Obstructive Pulmonary Disease (COPD). The barrel-shaped chest results
from air trapping and hyperinflation, while diminished breath sounds occur due to the destruction of
alveolar walls and loss of elastic recoil in the lungs.
Question 31
D) Development of a secondary empyema (Correct Answer)
Explanation: After chest tube placement for pleural effusion, persistent fever and chest pain suggest the
development of a secondary empyema. Empyema is a complication where the pleural space becomes
infected, often following invasive procedures like chest tube placement. The combination of fever and
chest pain indicates ongoing inflammation and possible infection, making empyema the most likely
diagnosis in this scenario.
Question 32
B) Atrial fibrillation (Correct Answer)
Explanation: The ECG findings of irregular R-R intervals and absent P waves are characteristic of atrial
fibrillation. In this arrhythmia, the atria quiver instead of contracting effectively, leading to the absence of
P waves. The irregular ventricular response results in irregular R-R intervals. These ECG features,
combined with the patient's symptoms of palpitations and fatigue, strongly suggest atrial fibrillation.
Question 33
B) Perform a computed tomography pulmonary angiography (CTPA) (Correct Answer)
Explanation: For a 58-year-old woman with sudden onset dyspnea, pleuritic chest pain, and a positive D-
dimer test, the next best step is to perform a computed tomography pulmonary angiography (CTPA). CTPA
is the gold standard for diagnosing pulmonary embolism (PE). The combination of symptoms and a
positive D-dimer increases the likelihood of PE, necessitating definitive imaging to confirm or rule out
the diagnosis.
Question 34
B) Inhaled bronchodilators (Correct Answer)
Explanation: Inhaled bronchodilators are the primary medication used to manage symptoms in patients
with Chronic Obstructive Pulmonary Disease (COPD). These medications, which include beta-2 agonists
and anticholinergics, work by relaxing airway smooth muscles, improving airflow, and reducing
breathlessness. They are the cornerstone of COPD symptom management due to their effectiveness in
providing quick relief and improving lung function.
Question 35
A) One hour (Correct Answer)
Explanation: In hospital-acquired pneumonia, antibiotics should be initiated within one hour after
diagnosis to reduce mortality. This rapid initiation of appropriate antibiotic therapy is crucial in
improving outcomes and reducing the risk of complications. Delaying antibiotic treatment can lead to
increased morbidity and mortality, making the one-hour window a critical target in managing hospital-
acquired pneumonia.
Question 36
C) Immediate evaluation for potential secondary causes (Correct Answer)
Explanation: For a 63-year-old man with no prior history of hypertension presenting with a blood
pressure of 180/110 mmHg and complaints of headache and dizziness, the best initial approach is
immediate evaluation for potential secondary causes. This presentation suggests a hypertensive urgency or
emergency, and the sudden onset in a previously normotensive individual raises suspicion for secondary
hypertension. Identifying and treating the underlying cause is crucial for effective management.
Question 37
B) Pulmonary hypertension (Correct Answer)
Explanation: Pulmonary hypertension is the complication most associated with a large, unrepaired atrial
septal defect (ASD) in adults. The left-to-right shunt through the ASD leads to increased pulmonary blood
flow over time. This chronic overload can cause remodeling of the pulmonary vasculature, resulting in
pulmonary hypertension. If left untreated, it can progress to right ventricular failure and Eisenmenger
syndrome.
Question 38
C) Myocardial Infarction (Correct Answer)
Explanation: For a 65-year-old male patient presenting with chest pain radiating to the left arm,
diaphoresis, and ST-segment elevation on ECG, the most likely diagnosis is Myocardial Infarction (MI).
This combination of symptoms and ECG findings is highly specific for ST-elevation myocardial infarction
(STEMI). The ST-segment elevation indicates acute coronary artery occlusion leading to myocardial
ischemia and infarction.
Question 39
B) Isoniazid, rifampin, ethambutol, and pyrazinamide for 2 months, followed by isoniazid and rifampin
for 4 months (Correct Answer)
Explanation: The standard initial treatment regimen for active tuberculosis in a patient without any drug
resistances is a 6-month course consisting of isoniazid, rifampin, ethambutol, and pyrazinamide for the
first 2 months (intensive phase), followed by isoniazid and rifampin for 4 months (continuation phase).
This regimen, known as HRZE, is recommended by the World Health Organization and is highly effective
in treating drug-susceptible tuberculosis.
Question 40
D) Angiotensin-converting enzyme (ACE) (Correct Answer)
Explanation: Angiotensin-converting enzyme (ACE) inhibitors are commonly used in the treatment of
congestive heart failure to reduce both afterload and preload. ACE inhibitors block the conversion of
angiotensin I to angiotensin II, resulting in vasodilation of both arteries and veins. This leads to reduced
peripheral vascular resistance (afterload reduction) and decreased sodium and water retention (preload
reduction), improving cardiac function and symptoms in heart failure patients.
Question 41
C) Echocardiogram (Correct Answer)
Explanation: For a 58-year-old woman with a history of hypertension complaining of increasing shortness
of breath and fatigue, the initial diagnostic test that should be performed is an echocardiogram. An
echocardiogram can assess cardiac structure and function, including left ventricular hypertrophy, systolic
and diastolic function, and valvular abnormalities. This non-invasive test is crucial in evaluating for
potential heart failure, which can develop as a complication of long-standing hypertension.
Question 42
C) Medium-dose inhaled corticosteroid and long-acting beta-agonist combination (Correct Answer)
Explanation: For a patient reporting frequent nighttime awakenings, daily use of rescue inhaler, and some
activity limitation, the appropriate treatment step according to stepwise asthma management is a medium-
dose inhaled corticosteroid and long-acting beta-agonist combination. This combination therapy provides
both anti-inflammatory effects and long-acting bronchodilation, addressing persistent symptoms and
nighttime awakenings that are not controlled with low-dose inhaled corticosteroids alone.
Question 43
C) Positive blood culture for typical organisms from two separate blood cultures (Correct Answer)
Explanation: One of the major Duke criteria for diagnosing Infective Endocarditis is positive blood
cultures for typical organisms from two separate blood cultures. This criterion is part of the
microbiological evidence required for diagnosis. Typical organisms include Streptococcus viridans,
Streptococcus bovis, HACEK group, Staphylococcus aureus, or community-acquired enterococci in the
absence of a primary focus. This criterion helps establish the presence of a persistent bacteremia, which
is characteristic of infective endocarditis.
Question 44
B) Systolic dysfunction due to impaired contractility (Correct Answer)
Explanation: The primary mechanism of reduced ejection fraction in dilated cardiomyopathy related to
congestive heart failure is systolic dysfunction due to impaired contractility. In dilated cardiomyopathy,
the heart muscle becomes weakened and enlarged, leading to decreased force of contraction. This results
in a reduced ability to pump blood effectively, manifesting as a lower ejection fraction. The impaired
contractility is the fundamental issue in this form of heart failure.
Question 45
A) It indicates latent tuberculosis infection (Correct Answer)
Explanation: A positive interferon-gamma release assay (IGRA) in a healthcare worker should be
interpreted as indicating latent tuberculosis infection. IGRAs measure the immune response to specific
Mycobacterium tuberculosis antigens. A positive result suggests that the individual has been exposed to
TB and their immune system has mounted a response, but it does not differentiate between latent and
active infection. In the absence of symptoms or radiographic evidence of active disease, a positive IGRA
in a healthcare worker is most likely to represent latent TB infection.
Question 46
A) It generally leads to a reduction in both nocturnal and diurnal blood pressure (Correct Answer)
Explanation: Effective CPAP therapy generally leads to a reduction in both nocturnal and diurnal blood
pressure in patients with obstructive sleep apnea (OSA). OSA is associated with increased sympathetic
activity and oxidative stress, which contribute to hypertension. CPAP therapy alleviates these effects by
preventing airway collapse, reducing intermittent hypoxia, and normalizing sleep architecture. This
results in improved blood pressure control both during sleep and waking hours.
Question 47
A) Less than 0.90 (Correct Answer)
Explanation: In the ankle-brachial index (ABI) diagnostic tool used for peripheral artery disease (PAD), a
value less than 0.90 indicates significant arterial insufficiency. The ABI is calculated by dividing the
systolic blood pressure at the ankle by the systolic blood pressure in the arm. A value below 0.90
suggests reduced blood flow to the lower extremities, which is indicative of PAD. This cutoff has been
established as a reliable indicator of clinically significant arterial obstruction.
Question 48
C) Intravenous vancomycin and gentamicin (Correct Answer)
Explanation: For a 65-year-old male with a history of aortic valve replacement presenting with fever, a
new heart murmur, and echocardiography showing vegetations on the valve, the initial antibiotic therapy
should be intravenous vancomycin and gentamicin. This combination is recommended for prosthetic valve
endocarditis, as it covers both methicillin-resistant Staphylococcus aureus (MRSA) and other common
pathogens. Vancomycin is effective against gram-positive bacteria, including MRSA, while gentamicin
provides synergistic coverage and is effective against gram-negative organisms.
Question 49
A) Antiplatelet therapy (Correct Answer)
Explanation: Antiplatelet therapy is commonly included in the initial treatment for unstable angina to
prevent further clot formation. Antiplatelet agents, such as aspirin and P2Y12 inhibitors (e.g.,
clopidogrel), inhibit platelet aggregation and reduce the risk of thrombus formation in the coronary
arteries. This therapy is crucial in preventing the progression of unstable angina to myocardial infarction
and is a cornerstone of acute coronary syndrome management.
Question 50
A) Combined chemotherapy and radiation therapy (Correct Answer)
Explanation: For a patient diagnosed with stage IIIA non-small cell lung cancer, the treatment approach
likely to be considered is combined chemotherapy and radiation therapy. This approach, known as
chemoradiation, is standard for locally advanced (stage III) NSCLC. It offers the potential for curative
intent by addressing both local tumor control (with radiation) and systemic disease control (with
chemotherapy). This multimodal approach has shown improved survival outcomes compared to either
modality alone in stage IIIA NSCLC.
Question 51
C) Blood cultures (Correct Answer)
Explanation: Blood cultures are crucial for assessing hospital-acquired pneumonia because they help
identify the specific pathogen causing the infection. This is particularly important in hospital settings
where antibiotic-resistant organisms are more common. Blood cultures can guide targeted antibiotic
therapy, improving treatment outcomes and reducing the risk of antibiotic resistance. While chest CT and
other tests may be useful, blood cultures provide direct evidence of the causative organism, which is
essential for proper management of hospital-acquired pneumonia.
Question 52
C) Azithromycin or doxycycline (Correct Answer)
Explanation: For a previously healthy adult with community-acquired pneumonia and no recent antibiotic
use, azithromycin or doxycycline is typically recommended as first-line treatment. These antibiotics are
effective against common causative organisms like Streptococcus pneumoniae and atypical pathogens
such as Mycoplasma pneumoniae. They offer good coverage, have convenient dosing schedules, and are
generally well-tolerated. This approach aligns with guidelines for empiric treatment of community-
acquired pneumonia in outpatient settings, balancing efficacy and the risk of antibiotic resistance.
Question 53
A) Cilostazol (Correct Answer)
Explanation: Cilostazol is considered the primary pharmacological treatment for managing claudication in
patients with peripheral vascular disease. It works by inhibiting phosphodiesterase type 3, which leads to
vasodilation and inhibition of platelet aggregation. Cilostazol has been shown to significantly improve
walking distance in patients with claudication. While aspirin and statins are important in managing
cardiovascular risk in these patients, they are not specifically targeted at improving claudication
symptoms. Warfarin is typically not used for this condition unless there are other indications.
Question 54
D) Four to six weeks (Correct Answer)
Explanation: According to stepwise asthma management guidelines, treatment intensity should be
increased if control is not achieved after four to six weeks. This timeframe allows for an adequate
assessment of the current treatment's effectiveness while not prolonging ineffective therapy. It strikes a
balance between giving the treatment enough time to work and responding promptly to inadequate control.
Regular reassessment at this interval ensures that patients receive appropriate care and that their asthma
management is optimized in a timely manner.
Question 55
B) D-dimer test (Correct Answer)
Explanation: For patients with a low probability of pulmonary embolism (PE), the D-dimer test is the
preferred initial diagnostic test. D-dimer is a fibrin degradation product that is elevated in the presence of
blood clots. In low-risk patients, a negative D-dimer test can effectively rule out PE, avoiding the need
for more invasive or radiation-exposing tests. It's highly sensitive but not specific, making it an excellent
initial screening tool. If the D-dimer is positive, further imaging studies like CT pulmonary angiography
would then be warranted.
Question 56
C) Spirometry with bronchodilator reversibility testing (Correct Answer)
Explanation: Spirometry with bronchodilator reversibility testing is the most effective test for confirming
an asthma diagnosis in a patient with suspected exercise-induced bronchoconstriction. This test measures
lung function before and after administering a bronchodilator, demonstrating the reversibility of airway
obstruction characteristic of asthma. It provides objective evidence of airflow limitation and its
reversibility, which are key diagnostic criteria for asthma. While other tests like methacholine challenge
can be useful, spirometry with bronchodilator testing is more specific and is the standard first-line
diagnostic tool for asthma.
Question 57
A) Three months (Correct Answer)
Explanation: To be considered a common symptom of chronic bronchitis, a productive cough must persist
for at least three months in two consecutive years. This definition, known as the "chronic bronchitis"
component of COPD, helps distinguish chronic bronchitis from acute respiratory infections or other
temporary conditions. The three-month duration in consecutive years indicates the chronic nature of the
condition and is part of the clinical criteria used to diagnose chronic bronchitis as a component of COPD.
Question 58
A) 130/80 mmHg (Correct Answer)
Explanation: For a 54-year-old woman with type 2 diabetes, the threshold for starting pharmacological
treatment for hypertension is 130/80 mmHg. This lower threshold is recommended for patients with
diabetes due to their increased cardiovascular risk. The American Diabetes Association and American
Heart Association guidelines suggest more aggressive blood pressure control in diabetic patients to
reduce the risk of cardiovascular events and diabetic nephropathy. Therefore, even though her current
reading is 140/90 mmHg, the treatment threshold is lower at 130/80 mmHg.
Question 59
B) Obstructive sleep apnea (Correct Answer)
Explanation: The symptoms described - frequent morning headaches, daytime fatigue, and observed
breathing cessation during sleep - are classic signs of obstructive sleep apnea (OSA). OSA is
characterized by repeated episodes of upper airway collapse during sleep, leading to intermittent hypoxia
and sleep fragmentation. This results in poor sleep quality, causing morning headaches and daytime
fatigue. The observed breathing cessation is a key diagnostic feature of OSA. While central sleep apnea,
depression, and hypothyroidism can cause some similar symptoms, the combination presented, especially
with observed apneas, is most indicative of OSA.
Question 60
A) Mitral valve repair (Correct Answer)
Explanation: Mitral valve repair is typically the preferred surgical intervention for symptomatic severe
mitral regurgitation. This approach preserves the patient's native valve tissue and structure, which often
results in better long-term outcomes compared to valve replacement. Mitral valve repair is associated
with improved left ventricular function, lower risk of endocarditis, and reduced need for long-term
anticoagulation. It also typically offers better long-term survival rates compared to mitral valve
replacement. When feasible, repair is favored over replacement, especially in primary (degenerative)
mitral regurgitation.
Question 61
A) Swinging motion of the heart within the effusive fluid (Correct Answer)
Explanation: Echocardiography in patients with pericardial effusion typically reveals a swinging motion
of the heart within the effusive fluid, a phenomenon known as "swinging heart." This occurs due to the
accumulation of fluid in the pericardial space, which allows the heart to move more freely within the
pericardial sac. This finding is characteristic of pericardial effusion and helps in its diagnosis and
assessment of severity. The other options are not specific to pericardial effusion or are less commonly
seen in this condition.
Question 62
C) Polysomnography (Correct Answer)
Explanation: Polysomnography is considered the gold standard for diagnosing obstructive sleep apnea
(OSA). This comprehensive sleep study records multiple physiological parameters during sleep,
including brain activity (EEG), eye movements (EOG), muscle activity (EMG), heart rhythm (ECG),
breathing patterns, and blood oxygen levels. It provides detailed information about sleep stages,
respiratory events, and their impact on sleep quality and oxygenation. While other tests like overnight
oximetry or home sleep apnea testing can be useful screening tools, they lack the comprehensive data
provided by polysomnography, which is essential for a definitive diagnosis and assessment of OSA
severity.
Question 63
D) Echocardiogram (Correct Answer)
Explanation: For a 34-year-old female with a history of patent ductus arteriosus (PDA) experiencing
exercise intolerance and palpitations, an echocardiogram is the most indicative diagnostic tool.
Echocardiography can directly visualize the PDA, assess its size and blood flow patterns, and evaluate its
hemodynamic impact on the heart. It can also detect any associated cardiac abnormalities or
complications, such as pulmonary hypertension or left ventricular volume overload, which might explain
the patient's symptoms. While other tests like stress tests or chest X-rays can provide useful information,
the echocardiogram offers the most comprehensive and direct assessment of the cardiac anatomy and
function in this case.
Question 64
C) To kill fast-growing cancer cells and reduce tumor size (Correct Answer)
Explanation: The main objective of using chemotherapy in treating small cell lung cancer (SCLC) is to
kill fast-growing cancer cells and reduce tumor size. SCLC is characterized by its rapid growth and early
spread, making it particularly responsive to chemotherapy. Chemotherapeutic agents target rapidly
dividing cells, which is a hallmark of SCLC. By killing these fast-growing cancer cells, chemotherapy
aims to shrink tumors, slow disease progression, and potentially improve survival. While chemotherapy
can also provide palliative benefits and may indirectly enhance immune system function, its primary goal
in SCLC treatment is direct cytotoxic effects on cancer cells.
Question 65
C) Blood pressure measurement on two separate occasions (Correct Answer)
Explanation: The recommended initial diagnostic approach for evaluating a new case of hypertension is
blood pressure measurement on two separate occasions. This approach helps to confirm that the elevated
blood pressure is persistent and not just a temporary fluctuation due to factors like stress or "white coat
hypertension." Guidelines typically recommend at least two separate office visits for blood pressure
measurements, ideally taken at different times of day. This method ensures a more accurate diagnosis of
hypertension before initiating further testing or treatment. While other tests like kidney function tests or
24-hour monitoring can be valuable, they are usually considered after confirming persistent elevation of
blood pressure through repeated measurements.
Question 66
A) Viral upper respiratory infections (Correct Answer)
Explanation: Viral upper respiratory infections are the most common trigger for asthma exacerbations in
children. These infections, particularly those caused by rhinoviruses, can lead to increased airway
inflammation and hyperreactivity, resulting in asthma symptoms such as wheezing, coughing, and difficulty
breathing. Children with asthma are particularly sensitive to these viral infections, which can exacerbate
their underlying condition and lead to more severe asthma attacks.
Question 67
B) Sarcoidosis (Correct Answer)
Explanation: In a 34-year-old presenting with bilateral hilar lymphadenopathy and erythema nodosum,
sarcoidosis should be suspected. This granulomatous disease often presents with these two findings
together, known as Löfgren's syndrome. Erythema nodosum is a skin manifestation that can occur in
response to sarcoidosis and is characterized by painful, red nodules on the lower extremities. Bilateral
hilar lymphadenopathy is a classic radiographic finding in sarcoidosis, making it the most likely diagnosis
in this case.
Question 68
C) It maintains an open airway during sleep (Correct Answer)
Explanation: Continuous positive airway pressure (CPAP) is effective in treating obstructive sleep apnea
because it maintains an open airway during sleep. The CPAP machine delivers a continuous stream of air
that keeps the upper airway passages open, preventing the collapse that leads to apneas and hypopneas.
This mechanism alleviates the symptoms of obstructive sleep apnea, such as snoring and daytime fatigue,
by ensuring proper airflow throughout the night.
Question 69
B) Intermittent claudication (Correct Answer)
Explanation: The characteristic symptom of peripheral arterial disease (PAD) that occurs with exertion
and resolves with rest is known as intermittent claudication. This condition arises due to insufficient
blood flow to the muscles during physical activity, leading to pain or cramping in the legs or buttocks.
The pain typically subsides with rest as blood flow is restored, distinguishing it from other forms of leg
pain that may not resolve with rest.
Question 70
B) Dyspnea on exertion (Correct Answer)
Explanation: An adult with an undiagnosed atrial septal defect may commonly experience dyspnea on
exertion. This symptom arises due to increased blood flow to the right side of the heart and lungs because
of the left-to-right shunt created by the defect. Over time, this can lead to pulmonary congestion and
reduced exercise capacity as the heart struggles to accommodate the increased volume load.
Question 71
B) Increased ventricular chamber size (Correct Answer)
Explanation: A characteristic finding in dilated cardiomyopathy on echocardiogram is increased
ventricular chamber size. This condition is defined by dilation of the heart chambers, particularly the left
ventricle, which leads to impaired systolic function. The enlargement of the chambers results from
various factors such as myocardial damage or ischemia, leading to decreased contractility and heart
failure symptoms.
Question 72
B) Bilateral hilar lymphadenopathy often without parenchymal involvement (Correct Answer)
Explanation: The typical presentation of sarcoidosis on a chest X-ray includes bilateral hilar
lymphadenopathy often without parenchymal involvement. This finding is a hallmark of sarcoidosis and
can be seen in many patients diagnosed with this condition. While parenchymal involvement can occur
later or in more advanced cases, initial presentations frequently show only enlarged lymph nodes at the
hilum.
Question 73
D) Transthoracic echocardiogram (Correct Answer)
Explanation: The transthoracic echocardiogram is essential for evaluating the severity of mitral
regurgitation. It provides real-time imaging of heart structures and function, allowing assessment of
regurgitant flow and its impact on cardiac chambers. This non-invasive test helps determine the severity
of regurgitation based on parameters such as chamber size changes and Doppler measurements of flow
across the mitral valve.
Question 74
D) Decreased FEV1/FVC ratio below 0.70 after bronchodilator use (Correct Answer)
Explanation: The pulmonary function test finding most indicative of COPD is a decreased FEV1/FVC
ratio below 0.70 after bronchodilator use. This indicates airflow obstruction characteristic of COPD. The
FEV1 (forced expiratory volume in one second) decreases disproportionately compared to FVC (forced
vital capacity), confirming a diagnosis of obstructive lung disease.
Question 75
C) Dyspnea on exertion (Correct Answer)
Explanation: The most common symptom of severe aortic stenosis is dyspnea on exertion. As the aortic
valve narrows, it restricts blood flow from the heart during physical activity, leading to symptoms like
shortness of breath. Patients may also experience angina or syncope; however, dyspnea is often one of the
earliest and most prominent symptoms as cardiac output becomes compromised during exertion.
Question 76
B) Tuberculin skin test (Correct Answer)
Explanation: The tuberculin skin test (TST) may yield a false positive result in individuals who have
received the Bacille Calmette-Guérin (BCG) vaccine. This vaccine, used to prevent tuberculosis (TB),
can stimulate an immune response that results in a positive TST, making it difficult to distinguish between
a true TB infection and the vaccine's effects. As such, healthcare providers often need to interpret TST
results cautiously in vaccinated individuals, considering their vaccination history when evaluating for
latent TB infection.
Question 77
A) Peripheral arterial disease (Correct Answer)
Explanation: The most likely diagnosis for a 60-year-old smoker complaining of calf pain when walking
that eases upon resting is peripheral arterial disease (PAD). PAD is characterized by narrowed arteries
reducing blood flow to the limbs, leading to claudication, which is pain or cramping in the legs during
physical activity. The symptoms typically improve with rest, aligning with the patient's description.
Smoking is a significant risk factor for PAD, further supporting this diagnosis.
Question 78
C) Acute pericarditis (Correct Answer)
Explanation: For a 45-year-old patient presenting with sharp chest pain that improves when sitting
forward and diffuse ST elevation on ECG, the most likely diagnosis is acute pericarditis. This condition
often presents with positional chest pain that worsens when lying flat and improves when sitting forward.
The diffuse ST elevation on the ECG is also characteristic of acute pericarditis, differentiating it from
myocardial infarction, which typically shows localized ST elevation.
Question 79
B) Intravenous beta-blockers (Correct Answer)
Explanation: The most effective initial treatment for acute atrial fibrillation with rapid ventricular
response is intravenous beta-blockers. These medications help control the heart rate by slowing
conduction through the atrioventricular node. While electrical cardioversion may be necessary in unstable
patients, beta-blockers are preferred for stable patients as they provide effective rate control and can be
administered quickly in an acute setting.
Question 80
B) High-dose nonsteroidal anti-inflammatory drugs (NSAIDs) (Correct Answer)
Explanation: The recommended first-line treatment for a patient diagnosed with acute viral pericarditis is
high-dose NSAIDs. These medications help reduce inflammation and alleviate pain associated with
pericarditis. While corticosteroids may be considered in certain cases, NSAIDs are typically sufficient
for managing viral causes of pericarditis and are preferred due to their efficacy and lower risk of
complications compared to steroid therapy.
Question 81
D) Observation and supplemental oxygen (Correct Answer)
Explanation: The most appropriate initial management for a primary spontaneous pneumothorax in a
young, healthy patient with minimal symptoms is observation and supplemental oxygen. In cases where the
pneumothorax is small and asymptomatic or minimally symptomatic, conservative management is often
effective. Supplemental oxygen can facilitate faster absorption of the air from the pleural space,
promoting resolution without invasive procedures.
Question 82
A) Lobectomy (Correct Answer)
Explanation: For early-stage non-small cell lung cancer (NSCLC) with no lymph node involvement,
lobectomy is typically indicated as it provides a balance between effective cancer removal and
preservation of lung function. Lobectomy involves removing an entire lobe of the lung containing the
tumor and is considered the standard surgical treatment for early-stage NSCLC due to its effectiveness in
reducing recurrence rates compared to more limited resections.
Question 83
A) Rifampin for 4 months (Correct Answer)
Explanation: For a patient diagnosed with latent tuberculosis who is allergic to isoniazid, rifampin for 4
months is considered the best alternative medication for treatment. Rifampin is effective in treating latent
TB infection and has been shown to have good adherence rates and fewer side effects compared to longer
regimens involving isoniazid. This option provides an effective alternative while minimizing potential
adverse reactions associated with other treatments.
Question 84
B) Sessions of 12-16 hours per day (Correct Answer)
Explanation: In managing ARDS for patients with severe hypoxemia, prone positioning should be
implemented in sessions lasting 12-16 hours per day. This approach has been shown to improve
oxygenation and reduce mortality by optimizing ventilation-perfusion matching and decreasing lung stress
from mechanical ventilation. Extended sessions allow for better recruitment of collapsed alveoli and
improved overall lung function.
Question 85
B) Non-small cell lung cancer (Correct Answer)
Explanation: Non-small cell lung cancer (NSCLC) is the most common type of lung cancer, accounting for
approximately 80-85% of all cases. This category includes subtypes such as adenocarcinoma, squamous
cell carcinoma, and large cell carcinoma, all of which tend to grow more slowly than small cell lung
cancer (SCLC). Understanding this distinction is crucial for determining treatment options and prognostic
outcomes.
Question 86
C) Aortic stenosis (Correct Answer)
Explanation: For a 70-year-old male with a history of heart murmur presenting with syncope and a harsh
systolic ejection murmur, the most likely diagnosis is aortic stenosis. This condition often leads to left
ventricular outflow obstruction resulting in symptoms like syncope during exertion due to decreased
cardiac output. The characteristic murmur associated with aortic stenosis further supports this diagnosis.
Question 87
D) Hyperinflation of the lungs with flattened diaphragms (Correct Answer)
Explanation: A characteristic feature of emphysema seen on chest X-ray is hyperinflation of the lungs with
flattened diaphragms. This occurs due to loss of elastic recoil in emphysema, leading to increased lung
volume at rest and flattening of the diaphragm as it adapts to this new position. These radiographic
findings are essential in diagnosing emphysema as part of chronic obstructive pulmonary disease
(COPD).
Question 88
D) Less than 200 (Correct Answer)
Explanation: In ARDS, a PaO2/FiO2 ratio less than 200 mmHg indicates severe disease and serves as a
key criterion for diagnosis according to Berlin classification criteria. This ratio reflects significant
impairment in gas exchange capabilities within the lungs and correlates with worse clinical outcomes,
guiding management strategies for affected patients.
Question 89
C) Community-acquired pneumonia (Correct Answer)
Explanation: For a 72-year-old male with COPD presenting with new cough, fever, and right lower lobe
infiltrate on chest X-ray after flu-like symptoms, community-acquired pneumonia is the most likely
diagnosis. The combination of recent respiratory symptoms along with radiographic findings supports this
diagnosis, especially considering his underlying COPD which predisposes him to infections.
Question 90
A) Cardiac tamponade causes diastolic collapse of the right atrium and ventricle (Correct Answer)
Explanation: Cardiac tamponade leads to diastolic collapse of cardiac chambers due to increased
intrapericardial pressure from fluid accumulation. This condition restricts filling of the heart during
diastole, resulting in reduced cardiac output and hemodynamic instability. In contrast, constrictive
pericarditis primarily causes filling restrictions without acute collapses seen in tamponade.
Question 91
C) Subpleural, basal-predominant reticular abnormalities with honeycombing (Correct Answer)
Explanation: A hallmark finding on high-resolution CT (HRCT) for idiopathic pulmonary fibrosis is
subpleural, basal-predominant reticular abnormalities accompanied by honeycombing patterns. These
findings are characteristic of usual interstitial pneumonia (UIP), which underlies idiopathic pulmonary
fibrosis and indicate advanced fibrotic changes within the lung parenchyma.
Question 92
B) Low tidal volume ventilation at 6 mL/kg of predicted body weight (Correct Answer)
Explanation: The ventilatory support strategy involving low tidal volume ventilation at approximately 6
mL/kg of predicted body weight aims to minimize lung injury in ARDS patients. This approach reduces
overdistension of alveoli while maintaining adequate ventilation and has been shown to improve
outcomes compared to traditional higher tidal volume strategies.
Question 93
A) Restrictive cardiomyopathy (Correct Answer)
Explanation: Restrictive cardiomyopathy is typically associated with biatrial enlargement but normal
ventricle size on imaging due to impaired filling of both ventricles while maintaining normal systolic
function. This condition can lead to increased pressures within both atria as they compensate for reduced
ventricular filling capacity.
Question 94
A) Low-density lipoprotein levels below 100 mg/dL (Correct Answer)
Explanation: Low-density lipoprotein levels below 100 mg/dL are NOT considered a risk factor for
developing acute coronary syndromes; rather, they are generally viewed as protective against
cardiovascular disease. Risk factors include elevated LDL levels above this threshold along with other
factors like smoking, hypertension, diabetes mellitus, and obesity.
Question 95
C) Angiotensin-converting enzyme (ACE) inhibitors (Correct Answer)
Explanation: Angiotensin-converting enzyme (ACE) inhibitors are typically included as first-line
treatment options for hypertension due to their effectiveness in lowering blood pressure by preventing
conversion of angiotensin I to angiotensin II—a potent vasoconstrictor—thus promoting vasodilation and
reducing blood volume through diuresis.
Question 96
D) Troponin (Correct Answer)
Explanation: Troponin is recognized as the most reliable diagnostic marker for confirming myocardial
infarction within the first few hours after symptom onset due to its high sensitivity and specificity for
myocardial injury. Elevated troponin levels indicate damage to cardiac muscle cells and provide critical
information regarding ongoing ischemia or infarction.
Question 97
C) Transesophageal echocardiography (Correct Answer)
Explanation: Transesophageal echocardiography provides immediate information regarding potential
valvular heart disease or vegetations associated with infective endocarditis in patients presenting with
low-grade fever, weight loss, and new heart murmurs while awaiting blood culture results. It offers
superior imaging quality compared to transthoracic echocardiography for assessing cardiac structures
directly.
Question 98
D) 12-lead electrocardiogram (Correct Answer)
Explanation: A 12-lead electrocardiogram is essential for confirming the type of arrhythmia in
symptomatic patients as it provides comprehensive monitoring of electrical activity across different parts
of the heart. It helps identify specific arrhythmias based on characteristic patterns observed on ECG
readings.
Question 99
B) Oral anticoagulation therapy (Correct Answer)
Explanation: Oral anticoagulation therapy is commonly prescribed to prevent stroke in patients with atrial
fibrillation due to its effectiveness in reducing thromboembolic events associated with irregular heart
rhythms. Anticoagulants like warfarin or direct oral anticoagulants help mitigate stroke risk by preventing
clot formation within the heart chambers.
Question 100
C) To kill fast-growing cancer cells and reduce tumor size (Correct Answer)
Explanation: The primary goal of using chemotherapy in managing small cell lung cancer is to kill fast-
growing cancer cells and reduce tumor size effectively. SCLC typically responds well to chemotherapy
due to its rapid proliferation rate; thus, chemotherapy serves as a critical component in treating this
aggressive form of lung cancer

Practice Tests 2
Question 1
How does the bleeding time typically change in patients with von Willebrand disease?
A) Decreased
B) Prolonged
C) Shortened
D) Normal
Question 2
What is the most suitable age to initiate discussions about prostate cancer screening using PSA testing for
an average-risk male?
A) 55 years old
B) 50 years old
C) 60 years old
D) 40 years old
Question 3
Which condition is most probable when a patient exhibits muscle weakness, hyperpigmentation, and low
blood pressure?
A) Hyperthyroidism
B) Chronic kidney disease
C) Osteoporosis
D) Addison's disease
Question 4
What is the primary treatment approach for a newly diagnosed multiple myeloma patient who is not
eligible for transplantation?
A) High-dose corticosteroids
B) Stem cell transplantation
C) Radiation therapy
D) Bortezomib-based therapy
Question 5
Which test is most effective in differentiating between hemolytic anemia and anemia of chronic disease?
A) Hemoglobin A1c
B) Plasma hemoglobin
C) Serum iron levels
D) Reticulocyte count
Question 6
What symptom is commonly associated with multiple myeloma in elderly patients?
A) Hypercalcemia
B) Recurrent infections
C) Bone pain and pathological fractures
D) Severe anemia
Question 7
Which endocrine disorder is most closely linked to the presence of exophthalmos?
A) Hypoparathyroidism
B) Graves' disease
C) Hashimoto's thyroiditis
D) Pituitary adenoma
Question 8
What is the most likely diagnosis for a 30-year-old female presenting with fatigue, pallor, macrocytic red
cells, and hypersegmented neutrophils?
A) Hemolytic anemia
B) Iron-deficiency anemia
C) Megaloblastic anemia
D) Anemia of chronic disease
Question 9
Which type of lymphoma is more frequently associated with extranodal involvement?
A) Mantle cell lymphoma
B) Hodgkin's lymphoma
C) Non-Hodgkin's lymphoma
D) Follicular lymphoma
Question 10
What is the most appropriate next step for a 29-year-old male with increased anxiety, tremor, unexplained
weight loss, and elevated free T4?
A) Psychological evaluation for anxiety disorder
B) Refer for radioactive iodine therapy
C) Immediate dietary changes to reduce iodine intake
D) Initiate treatment with a beta-blocker
Question 11
What is the most suitable intervention to reduce cardiovascular risk in a 50-year-old male with a total
cholesterol of 250 mg/dL, LDL cholesterol of 160 mg/dL, HDL cholesterol of 35 mg/dL, and triglycerides
of 200 mg/dL?
A) Initiate high-intensity statin therapy
B) Advise dietary modifications and increased physical activity
C) Reassess lipid levels in 3 months after recommending lifestyle changes
D) Initiate low-dose aspirin therapy
Question 12
Which serum level test is primarily used to confirm hyperparathyroidism?
A) Parathyroid hormone
B) Calcium
C) Magnesium
D) Phosphate
Question 13
What is one of the most serious complications associated with chemotherapy-induced neutropenia?
A) Electrolyte imbalances
B) Severe dehydration
C) Gastrointestinal bleeding
D) Life-threatening infections
Question 14
What is the most common inheritance pattern for Hemophilia A and B?
A) X-linked recessive
B) Autosomal dominant
C) X-linked dominant
D) Autosomal recessive
Question 15
At what fasting plasma glucose level is diabetes typically diagnosed?
A) 100 mg/dL or higher
B) 110 mg/dL or higher
C) 126 mg/dL or higher
D) 140 mg/dL or higher
Question 16
Which test is most helpful in confirming a diagnosis of hemolytic anemia in a patient with symptoms of
anemia and recent jaundice?
A) Peripheral smear
B) Serum haptoglobin levels
C) Osmotic fragility test
D) Direct Coombs test
Question 17
What substance is typically measured in plasma or urine for biochemical testing of pheochromocytoma?
A) Plasma renin activity
B) Cortisol levels
C) Catecholamines
D) Insulin levels
Question 18
What is the most likely diagnosis for a 58-year-old woman presenting with tingling in her fingertips and
around her mouth, along with a positive Chvostek's sign?
A) Hypoparathyroidism
B) Pseudohypoparathyroidism
C) Hypercalcemia
D) Thyroid storm
Question 19
What is the most probable diagnosis for a 58-year-old man presenting with fatigue, weight loss,
splenomegaly, and elevated white cells with a predominance of mature lymphocytes?
A) Acute lymphoblastic leukemia (ALL)
B) Chronic myeloid leukemia (CML)
C) Myelodysplastic syndrome
D) Chronic lymphocytic leukemia (CLL)
Question 20
In patients with metabolic syndrome, what is considered the primary target for risk reduction to decrease
overall cardiovascular risk?
A) Optimizing glycemic control
B) Aggressive blood pressure control
C) Weight loss through dietary changes and increased physical activity
D) Managing dyslipidemia by increasing HDL levels
Question 21
What is typically included in the standard initial treatment for localized Hodgkin's lymphoma?
A) Stem cell transplantation
B) High-dose chemotherapy alone
C) Combined modality therapy (chemotherapy and radiation)
D) Radiation therapy alone
Question 22
Which symptom is most directly linked to hyperparathyroidism caused by excessive parathyroid hormone
(PTH) production?
A) Bone pain and fractures
B) Abdominal pain and constipation
C) Muscle weakness and fatigue
D) Increased urination and thirst
Question 23
What is the most likely cause of symptoms such as cold intolerance and fatigue in a patient undergoing
treatment for hyperthyroidism?
A) Development of thyroid cancer
B) Overtreatment leading to hypothyroidism
C) Secondary infection complicating the primary disease
D) Insufficient treatment allowing hyperthyroid symptoms to persist
Question 24
What is the most appropriate risk-reduction strategy for breast cancer in a 35-year-old woman found to
carry a BRCA1 mutation?
A) Prophylactic salpingo-oophorectomy
B) Chemoprevention with tamoxifen
C) Bilateral mastectomy
D) Regular self-exams and clinical follow-ups
Question 25
After biochemical confirmation of pheochromocytoma in a male patient with severe hypertension,
headaches, and weight loss, what is the next step in his diagnostic evaluation?
A) Repeat biochemical testing for catecholamines
B) Biopsy of the adrenal mass
C) Serum aldosterone measurements
D) Imaging studies, such as CT or MRI of the abdomen
Question 26
What condition should be suspected in a patient undergoing heparin therapy who presents with new
thromboses and a platelet count drop of 50% from baseline?
A) Thrombotic thrombocytopenic purpura
B) Autoimmune hemolytic anemia
C) Heparin-induced thrombocytopenia
D) Disseminated intravascular coagulation
Question 27
What is the initial pharmacological treatment for symptomatic hypocalcemia in a patient with
hypoparathyroidism?
A) Oral vitamin D analogs
B) Combination of vitamin D and magnesium
C) Intravenous calcium gluconate
D) Oral calcium supplements only
Question 28
Which medication should be administered first in the preoperative management of pheochromocytoma to
prevent hypertensive crisis during surgery?
A) ACE inhibitors
B) Alpha-adrenergic blockers
C) Calcium channel blockers
D) Beta-blockers
Question 29
In immune thrombocytopenic purpura, what primarily mediates the destruction of platelets?
A) T-cell activation
B) Autoantibodies
C) Macrophages
D) Complement
Question 30
Women with BRCA1 or BRCA2 mutations have a significantly increased lifetime risk of developing
which type of cancer?
A) Ovarian cancer
B) Pancreatic cancer
C) Colorectal cancer
D) Breast cancer
Question 31
What genetic abnormality is considered diagnostic for chronic myeloid leukemia (CML)?
A) JAK2 mutation
B) BCR-ABL fusion
C) Philadelphia chromosome
D) TEL-AML1 fusion
Question 32
What is the most appropriate screening test for a 45-year-old woman with no family history of colorectal
cancer undergoing routine screening?
A) Sigmoidoscopy every 10 years
B) Colonoscopy every 10 years
C) Stool DNA test every 5 years
D) Fecal occult blood test every 3 years
Question 33
What is considered the most accurate diagnostic criterion for multiple myeloma?
A) High serum calcium level
B) Elevated beta-2 microglobulin level
C) Presence of osteolytic lesions
D) Monoclonal protein spike on serum electrophoresis
Question 34
For a 55-year-old male presenting with elevated PSA levels and no symptoms, what is the most
appropriate next step in management?
A) Repeat PSA testing in 6 months
B) Referral for surgery
C) Imaging with MRI
D) Immediate prostate biopsy
Question 35
What hormone level would you expect to be elevated in a 45-year-old woman presenting with coarse
facial features, enlarged hands and feet, and excessive sweating?
A) Increased growth hormone levels
B) Increased adrenocorticotropic hormone levels
C) Elevated prolactin levels
D) Increased follicle-stimulating hormone levels
Question 36
What is one of the main controversies surrounding PSA screening?
A) Delayed cancer detection
B) Underdiagnosis in younger men
C) Inaccurate PSA results
D) Overdiagnosis and overtreatment
Question 37
What is the first step in managing a 65-year-old male on heparin therapy for a DVT who develops sudden
thrombocytopenia?
A) High-dose corticosteroid therapy
B) Administration of intravenous immunoglobulin
C) Discontinuation of heparin immediately
D) Platelet transfusion
Question 38
For a 60-year-old female with diabetes presenting for routine follow-up with an LDL cholesterol of 140
mg/dL and no history of cardiovascular disease, what is the most appropriate next step in managing her
lipid levels?
A) Increasing dietary fiber intake and engaging in regular physical activity
B) Adding a bile acid sequestrant to her current medication regimen
C) Initiating moderate-intensity statin therapy
D) Recommending weight loss and smoking cessation
Question 39
What is the likely diagnosis for a 36-year-old male complaining of reduced libido and infertility during a
routine check-up, with an MRI showing a pituitary mass?
A) Acromegaly
B) Hypopituitarism
C) Cushing's disease
D) Prolactinoma
Question 40
Which of the following diagnostic criteria is part of the metabolic syndrome and increases the risk for
cardiovascular disease in affected individuals?
A) Fasting blood glucose greater than or equal to 100 mg/dL
B) Increased waist circumference
C) Low HDL cholesterol of less than 40 mg/dL in men or less than 50 mg/dL in women
D) Elevated triglycerides of 150 mg/dL or higher
Question 41
What is the most appropriate management strategy for a 70-year-old male with a life expectancy of less
than 10 years diagnosed with low-risk prostate cancer?
A) Chemotherapy
B) Radical prostatectomy
C) External beam radiation
D) Active surveillance
Question 42
For patients unable to achieve significant weight loss through lifestyle modifications alone, what may be
prescribed to manage obesity?
A) Surgical referral
B) Lifestyle changes
C) Psychological counseling
D) Pharmacotherapy
Question 43
What treatment is most likely to be recommended as part of therapy for a 45-year-old patient diagnosed
with estrogen receptor-positive breast cancer?
A) Radiation therapy
B) Chemotherapy followed by radiation
C) Tamoxifen
D) Lumpectomy followed by radiation
Question 44
What complication is likely present in a diabetic patient complaining of numbness and tingling in his feet?
A) Cardiovascular disease due to atherosclerotic changes
B) Diabetic nephropathy
C) Peripheral neuropathy
D) Diabetic retinopathy
Question 45
What is the most likely diagnosis for a male patient presenting with delayed puberty, reduced muscle
mass, infertility, small testes, low testosterone levels, and elevated gonadotropins?
A) Kallmann syndrome
B) Primary hypogonadism
C) Testicular torsion
D) Secondary hypogonadism
Question 46
Which endocrine disorder should be evaluated in a patient with osteoporosis and recurrent kidney stones?
A) Hyperparathyroidism
B) Cushing's syndrome
C) Diabetes mellitus
D) Hypoparathyroidism
Question 47
What is the most appropriate next step in management for a patient undergoing chemotherapy who
presents with a fever of 38.5°C and an absolute neutrophil count of 400/µL?
A) Increase the chemotherapy dosage
B) Administer granulocyte colony-stimulating factor
C) Hold chemotherapy for 48 hours
D) Empiric broad-spectrum antibiotics
Question 48
What is the most likely diagnosis for a 50-year-old patient presenting with enlarged, painless lymph
nodes in the neck and a mediastinal mass on imaging?
A) Thyroid carcinoma
B) Hodgkin's lymphoma
C) Non-Hodgkin's lymphoma
D) Infectious mononucleosis
Question 49
What is the first-line management strategy for a newly diagnosed multiple myeloma patient exhibiting
renal impairment?
A) Aggressive chemotherapy
B) Renal transplant
C) Hydration and control of hypercalcemia
D) Immediate dialysis
Question 50
What condition is most likely the underlying cause for a 23-year-old male patient presenting with
prolonged bleeding after dental surgery and a history of multiple joint bleeds?
A) Hemophilia B
B) Hemophilia A
C) von Willebrand disease
D) Disseminated Intravascular Coagulation
Question 51: What is the most likely underlying syndrome in a patient presenting with abdominal pain,
rectal bleeding, and hundreds of polyps throughout the colon?
A) Peutz-Jeghers syndrome
B) Familial adenomatous polyposis
C) Lynch syndrome
D) Juvenile polyposis syndrome
Question 52: For a 55-year-old man experiencing unintentional weight loss, changes in bowel habits, and
blood in his stool, what diagnosis should be considered first?
A) Colorectal cancer
B) Crohn's disease
C) Irritable bowel syndrome
D) Diverticulitis
Question 53: Which laboratory finding is most indicative of Disseminated Intravascular Coagulation
(DIC)?
A) Elevated D-dimer
B) Prolonged prothrombin time
C) Normal platelet count
D) Decreased fibrinogen levels
Question 54: What is the most appropriate treatment for a 65-year-old male undergoing chemotherapy
who presents with fatigue, pallor, shortness of breath, and a hemoglobin level of 7.5 g/dL?
A) Red blood cell transfusion
B) Oral iron supplements
C) Erythropoiesis-stimulating agents
D) Intravenous iron supplementation
Question 55: What histological feature is characteristic of Hodgkin's lymphoma?
A) Monoclonal antibody presence
B) Lymphoid hyperplasia
C) Presence of Reed-Sternberg cells
D) Bcl-2 gene mutation
Question 56: What is the most likely diagnosis for a 35-year-old female patient presenting with heat
intolerance, weight loss, and palpitations?
A) Chronic kidney disease
B) Primary adrenal insufficiency
C) Type 1 diabetes mellitus
D) Graves' disease
Question 57: For a patient with Type 1 diabetes reporting frequent hypoglycemic episodes during a
check-up, what is the most appropriate adjustment to their treatment regimen?
A) Switch to an insulin pump for more precise control over insulin delivery
B) Addition of a nighttime snack to prevent nocturnal hypoglycemia
C) Decrease the dose of insulin to minimize the risk of further hypoglycemic episodes
D) Increase the frequency of glucose monitoring to better track blood sugar levels
Question 58: Which test is essential for differentiating between acute lymphoblastic leukemia (ALL) and
acute myeloid leukemia (AML) in a newly diagnosed patient?
A) Bone marrow biopsy
B) Cytogenetic analysis
C) Immunophenotyping
D) Lumbar puncture
Question 59: What clinical manifestation is most commonly associated with prolactinoma in males?
A) Chronic fatigue and joint pain
B) Increased appetite and weight gain
C) Decreased libido and galactorrhea
D) Visual field defects and headache
Question 60: For a 38-year-old female with a known adrenal mass presenting with refractory
hypertension, tremors, and a racing heart, what is the recommended first step in her preoperative
management before surgical resection?
A) Surgical resection without preoperative medication
B) Beta-blockade after sufficient alpha-blockade
C) Initiation of alpha-blockade with a non-selective alpha-adrenergic antagonist
D) Intravenous fluids to restore volume depletion
Question 61: What is the most appropriate lifestyle modification for a 45-year-old female with a BMI of
30, fasting blood glucose of 120 mg/dL, and HDL of 38 mg/dL who is concerned about her cardiovascular
health?
A) Encouraging a high-fiber, low-sugar diet
B) Increasing physical activity and following a heart-healthy diet
C) Reducing dietary sodium intake and incorporating more fruits and vegetables
D) Advising her to limit saturated fats and increase omega-3 fatty acids
Question 62: For a patient interested in bariatric surgery with a BMI of 35 and recently diagnosed type 2
diabetes, which surgical procedure is considered the most appropriate initial option?
A) Sleeve gastrectomy
B) Roux-en-Y gastric bypass
C) Intragastric balloon placement
D) Adjustable gastric banding
Question 63: In which condition would an increase in ACTH secretion typically be found?
A) Secondary adrenal sufficiency
B) Primary adrenal insufficiency
C) Cushing's disease
D) Pituitary adenoma
Question 64: For a 55-year-old male with a history of myocardial infarction and LDL cholesterol of 120
mg/dL despite moderate-intensity statin therapy, what is the most appropriate adjustment to his treatment
plan?
A) Introducing ezetimibe to his therapy
B) Switching to high-intensity statin therapy
C) Switching to a low-dose statin and rechecking lipid levels after 6 months
D) Adding a PCSK9 inhibitor
Question 65: Which diagnostic test is crucial for confirming the diagnosis of Addison's disease?
A) High-dose dexamethasone suppression test
B) Low-dose dexamethasone suppression test
C) Random serum cortisol test
D) ACTH stimulation test
Question 66: In the management of acute lymphoblastic leukemia, what is the first-line treatment for a
pediatric patient?
A) Radiation therapy
B) Corticosteroid therapy
C) Stem cell transplantation
D) Multi-agent chemotherapy
Question 67: What is the most appropriate screening recommendation for a patient with a family history
of breast cancer who tests positive for a BRCA1 mutation?
A) Annual breast ultrasound
B) Biannual mammogram alone
C) Genetic testing every three years
D) Annual MRI and mammogram
Question 68: For a 30-year-old woman with frequent nosebleeds, heavy menstrual bleeding, reduced
factor VIII activity, and normal vWF antigen, what is the likely diagnosis?
A) Hemophilia B
B) von Willebrand disease
C) Hemophilia A
D) Disseminated Intravascular Coagulation
Question 69: Which type of lymphoma is a patient most likely suffering from if diagnosed with a
lymphoma exhibiting a high proliferation rate and diffuse growth pattern?
A) Low-grade non-Hodgkin's lymphoma
B) Acute lymphoblastic leukemia
C) High-grade non-Hodgkin's lymphoma
D) Chronic lymphocytic leukemia
Question 70: What is the most appropriate next step in management for a 65-year-old woman with a white
blood cell count of 230,000, primarily lymphocytes, and massive splenomegaly after undergoing a bone
marrow biopsy?
A) Initiate treatment with a tyrosine kinase inhibitor
B) Immediate splenectomy
C) Watchful waiting with regular monitoring
D) High-dose corticosteroid treatment
Question 71: For a 55-year-old woman with Type 2 diabetes and an HbA1c of 9.0%, what is the primary
goal of management?
A) Reduction of HbA1c to less than 7%
B) Intensification of exercise regimen
C) Implementation of intensive insulin therapy
D) Immediate reduction of dietary sugar intake
Question 72: Which hormone is predominantly involved in causing the signs and symptoms of
acromegaly?
A) Growth hormone
B) Prolactin
C) Luteinizing hormone
D) Thyroid-stimulating hormone
Question 73: For a 42-year-old patient with severe obesity (BMI 45), hypertension, and obstructive sleep
apnea, what is the next best step in management after initial lifestyle modification efforts show minimal
success?
A) Refer to an intensive dietary management program
B) Begin a structured exercise program
C) Consultation with a bariatric surgeon
D) Initiate pharmacotherapy with medications such as orlistat or liraglutide
Question 74: Which laboratory test is most indicative of iron-deficiency anemia in the initial screening?
A) Total iron-binding capacity (TIBC)
B) Mean corpuscular volume (MCV)
C) Serum ferritin
D) Hemoglobin electrophoresis
Question 75: What condition should be suspected when an endocrinologist notes hyperkalemia and
hyponatremia in a fatigued patient?
A) Hepatic encephalopathy
B) Addison's disease
C) Diabetic ketoacidosis
D) Acute renal failure
Question 76: For a 60-year-old presenting with back pain, fatigue, and a high serum protein level, which
test is crucial for diagnosis?
A) PET scan
B) Bone marrow biopsy
C) Serum calcium testing
D) Total spine MRI
Question 77: What is the most likely diagnosis for a 45-year-old female patient presenting with petechiae
and easy bruising, with lab tests showing low platelets and no other abnormalities?
A) Von Willebrand disease
B) Immune thrombocytopenic purpura
C) Heparin-induced thrombocytopenia
D) Acute lymphoblastic leukemia
Question 78: In patients with established atherosclerotic cardiovascular disease (ASCVD), what is the
primary lipid target for statin therapy to reduce to below 70 mg/dL?
A) HDL cholesterol
B) LDL cholesterol
C) Total cholesterol
D) Triglycerides
Question 79: According to current guidelines, which of the following LDL cholesterol levels would most
likely indicate the need for high-intensity statin therapy?
A) Triglyceride levels greater than 500 mg/dL
B) An LDL cholesterol level of 190 mg/dL or higher
C) An HDL cholesterol level of less than 40 mg/dL in men or less than 50 mg/dL in women
D) A total cholesterol level of 240 mg/dL or higher
Question 80: For a male patient presenting with elevated triglycerides, hypertension, abdominal obesity,
fasting glucose of 115 mg/dL, and low HDL, what is the most appropriate pharmacologic intervention
based on his risk factors?
A) Initiating statin therapy
B) Prescribing a low-dose aspirin regimen
C) Recommending lifestyle changes without medication
D) Using a beta-blocker
Question 81: What medication would most likely prevent severe nausea and vomiting within 24 hours of
chemotherapy treatment for a 55-year-old woman in future cycles?
A) Benzodiazepines
B) Corticosteroids
C) Antihistamines
D) 5-HT3 receptor antagonist
Question 82: For a patient undergoing chemotherapy for lymphoma experiencing mucositis and poor oral
intake, what is the best approach to managing this side effect?
A) Antifungal mouthwash
B) Oral antiviral agents
C) Oral hygiene and topical anesthetics
D) Antibiotic therapy for oral ulcers
Question 83: Which diagnostic test is most appropriate to confirm pheochromocytoma in a 45-year-old
male presenting with episodic headaches, palpitations, sweating, and elevated blood pressure?
A) Plasma metanephrines or 24-hour urinary fractionated metanephrines
B) Renal ultrasound
C) Echocardiography
D) Genetic testing
Question 84: Which medication has been approved by the FDA for long-term management of obesity and
should be considered in patients with a BMI of 30 or higher, or 27 or higher with comorbid conditions?
A) Orlistat
B) Liraglutide
C) Metformin
D) Bupropion
Question 85: What treatment is generally indicated first for a patient newly diagnosed with
hypothyroidism?
A) Immediate surgery to remove the thyroid gland
B) High-dose iodine supplementation
C) Prescribing an anti-thyroid medication
D) Starting a low-dose synthetic thyroid hormone replacement
Question 86: In postmenopausal women, hormone replacement therapy is often used to manage symptoms
of hypogonadism, primarily to address the deficiency of which hormone?
A) Follicle-stimulating hormone (FSH)
B) Testosterone
C) Progesterone
D) Estrogen
Question 87: What is the most appropriate screening method for early detection of breast cancer in a 50-
year-old woman with no family history of the disease?
A) Clinical breast exam every six months
B) Mammography every two years
C) Breast ultrasound every three years
D) Breast MRI every five years
Question 88: For a 52-year-old male with a history of hypertension, abdominal obesity, and dyslipidemia
presenting for a routine check-up with elevated blood pressure and waist circumference of 110 cm, what
is the most appropriate next step in managing his cardiovascular risk?
A) Recommending a daily low-dose aspirin
B) Starting metformin therapy
C) Lifestyle modification focusing on weight loss and physical activity
D) Adding an ACE inhibitor
Question 89: What is the typical effect of hypopituitarism on body hair?
A) Loss of body hair
B) Increased facial hair
C) Unchanged body hair
D) Increased body hair
Question 90: Which of the following conditions is a common cause of hypogonadism in males due to
testicular dysfunction?
A) Klinefelter syndrome
B) Turner syndrome
C) Hemochromatosis
D) Androgen insensitivity syndrome
Question 91: For a 38-year-old female patient reporting irregular periods, hot flashes, and decreased
bone density, with lab results revealing low estradiol levels, what is the most likely diagnosis?
A) Secondary hypogonadism
B) Polycystic ovary syndrome (PCOS)
C) Hypogonadism caused by ovarian dysfunction
D) Hyperprolactinemia
Question 92: What is the most appropriate management for a 55-year-old male presenting with fatigue,
decreased libido, and loss of muscle mass, with lab tests showing low testosterone levels?
A) Vitamin D and calcium supplementation
B) Testosterone replacement therapy
C) Lifestyle changes and regular physical activity
D) Cognitive-behavioral therapy
Question 93: Which condition is likely to affect a 45-year-old male with hypertension, truncal obesity,
and a buffalo hump?
A) Hypothyroidism
B) Type 2 diabetes mellitus
C) Cushing's syndrome
D) Acromegaly
Question 94: What initial lifestyle intervention is recommended for a patient diagnosed with obesity?
A) Immediate enrollment in high-intensity interval training
B) Dietary changes emphasizing reduced caloric intake and increased fruit and vegetable consumption
C) Initiation of psychotherapy focusing on behavior modification
D) Aggressive fluid replacement therapy
Question 95: Familial adenomatous polyposis is a hereditary syndrome characterized by the development
of numerous what in the colon and rectum?
A) Villous adenomas
B) Adenomatous polyps
C) Inflammatory polyps
D) Hyperplastic polyps
Question 96: What is the most appropriate screening protocol for a 60-year-old patient with a history of
Lynch syndrome concerned about the risk of colorectal cancer?
A) Barium enema every 5 years
B) CT colonography every 5 years
C) Fecal occult blood test annually
D) Colonoscopy every 1 to 2 years
Question 97: For a 45-year-old male with a history of gastrointestinal bleeding and a pale conjunctiva
suspected to have anemia, what should be the initial diagnostic step?
A) Iron serum level test
B) Transferrin saturation test
C) Complete blood count (CBC)
D) Bone marrow biopsy
Question 98: What is typically the first pharmacological treatment for Type 2 diabetes?
A) Metformin
B) GLP-1 receptor agonists
C) DPP-4 inhibitors
D) Sulfonylureas
Question 99: Following a diagnosis of heparin-induced thrombocytopenia, which of the following
anticoagulants should be avoided in a patient's treatment plan?
A) Apixaban
B) Rivaroxaban
C) Warfarin
D) Dabigatran

Correct Answers & Explanations

Question 1
B) Prolonged (Correct Answer)
Explanation: In von Willebrand disease, bleeding time is typically prolonged due to a deficiency or
dysfunction of von Willebrand factor, which is crucial for platelet adhesion and aggregation. This defect
leads to impaired primary hemostasis, resulting in extended bleeding times.
Question 2
B) 50 years old (Correct Answer)
Explanation: The American Cancer Society recommends that men at average risk for prostate cancer
should have a discussion with their healthcare provider about the potential benefits and risks of PSA
screening starting at age 50. This allows for informed decision-making about whether to proceed with
screening.
Question 3
D) Addison's disease (Correct Answer)
Explanation: Addison's disease, or primary adrenal insufficiency, typically presents with muscle
weakness, hyperpigmentation, and low blood pressure. These symptoms result from insufficient
production of cortisol and aldosterone by the adrenal glands, leading to electrolyte imbalances and
increased ACTH production.
Question 4
D) Bortezomib-based therapy (Correct Answer)
Explanation: For newly diagnosed multiple myeloma patients who are not eligible for transplantation,
bortezomib-based therapy is often the primary treatment approach. Bortezomib, a proteasome inhibitor, is
typically combined with other agents like lenalidomide and dexamethasone to effectively target myeloma
cells.
Question 5
D) Reticulocyte count (Correct Answer)
Explanation: The reticulocyte count is most effective in differentiating between hemolytic anemia and
anemia of chronic disease. In hemolytic anemia, the reticulocyte count is typically elevated due to
increased red blood cell production in response to hemolysis. In anemia of chronic disease, the
reticulocyte count is usually low or normal.
Question 6
C) Bone pain and pathological fractures (Correct Answer)
Explanation: Bone pain and pathological fractures are common symptoms associated with multiple
myeloma in elderly patients. This is due to the proliferation of malignant plasma cells in the bone marrow,
leading to osteolytic lesions and weakened bone structure.
Question 7
B) Graves' disease (Correct Answer)
Explanation: Exophthalmos, or proptosis, is most closely linked to Graves' disease. This autoimmune
thyroid disorder causes inflammation and swelling of the extraocular muscles and orbital fat, leading to
the characteristic bulging of the eyes.
Question 8
C) Megaloblastic anemia (Correct Answer)
Explanation: The presentation of fatigue, pallor, macrocytic red cells, and hypersegmented neutrophils is
characteristic of megaloblastic anemia. This condition is typically caused by vitamin B12 or folate
deficiency, leading to impaired DNA synthesis and maturation of red blood cells and neutrophils.
Question 9
C) Non-Hodgkin's lymphoma (Correct Answer)
Explanation: Non-Hodgkin's lymphoma (NHL) is more frequently associated with extranodal involvement
compared to other lymphoma types. NHL can arise in or spread to various extranodal sites, including the
gastrointestinal tract, skin, and central nervous system.
Question 10
D) Initiate treatment with a beta-blocker (Correct Answer)
Explanation: For a 29-year-old male presenting with symptoms of hyperthyroidism (anxiety, tremor,
weight loss) and elevated free T4, initiating treatment with a beta-blocker is the most appropriate next
step. Beta-blockers help manage symptoms while further diagnostic tests and definitive treatment plans
are being considered.
Question 11
A) Initiate high-intensity statin therapy (Correct Answer)
Explanation: Given the patient's high LDL cholesterol (160 mg/dL) and low HDL cholesterol (35 mg/dL),
initiating high-intensity statin therapy is the most suitable intervention to reduce cardiovascular risk.
Statins are the first-line pharmacological treatment for reducing LDL cholesterol and overall
cardiovascular risk.
Question 12
A) Parathyroid hormone (Correct Answer)
Explanation: The primary test used to confirm hyperparathyroidism is the measurement of serum
parathyroid hormone (PTH) levels. Elevated PTH levels, especially when combined with high serum
calcium levels, are diagnostic for primary hyperparathyroidism.
Question 13
D) Life-threatening infections (Correct Answer)
Explanation: One of the most serious complications associated with chemotherapy-induced neutropenia is
life-threatening infections. Neutropenia significantly impairs the body's ability to fight off bacterial and
fungal infections, potentially leading to sepsis and other severe infectious complications.
Question 14
A) X-linked recessive (Correct Answer)
Explanation: Hemophilia A and B are both X-linked recessive disorders. This means the defective gene is
located on the X chromosome, and the condition primarily affects males who inherit the mutated gene
from their mother.
Question 15
C) 126 mg/dL or higher (Correct Answer)
Explanation: Diabetes is typically diagnosed when fasting plasma glucose levels are 126 mg/dL or higher
on two separate occasions. This criterion, along with other diagnostic tests like HbA1c and oral glucose
tolerance test, helps identify individuals with diabetes mellitus.
Question 16
B) Serum haptoglobin levels (Correct Answer)
Explanation: Serum haptoglobin levels are most helpful in confirming hemolytic anemia. In hemolysis,
haptoglobin levels decrease significantly as it binds to free hemoglobin released from lysed red blood
cells. Low or undetectable haptoglobin levels, combined with symptoms of anemia and jaundice, strongly
suggest hemolytic anemia.
Question 17
C) Catecholamines (Correct Answer)
Explanation: Catecholamines (epinephrine, norepinephrine, and dopamine) or their metabolites are
typically measured in plasma or urine for biochemical testing of pheochromocytoma. These tumors
secrete excess catecholamines, leading to elevated levels in blood and urine, which is a key diagnostic
feature of pheochromocytoma.
Question 18
A) Hypoparathyroidism (Correct Answer)
Explanation: The presentation of tingling in fingertips and around the mouth (perioral paresthesia), along
with a positive Chvostek's sign, is characteristic of hypocalcemia, which is commonly caused by
hypoparathyroidism. This condition results from insufficient parathyroid hormone production, leading to
low calcium levels and associated symptoms.
Question 19
D) Chronic lymphocytic leukemia (CLL) (Correct Answer)
Explanation: The presentation of fatigue, weight loss, splenomegaly, and elevated white cell count with a
predominance of mature lymphocytes in a 58-year-old man is most consistent with Chronic Lymphocytic
Leukemia (CLL). CLL is characterized by the accumulation of mature-appearing but functionally
incompetent lymphocytes in blood, bone marrow, and lymphoid tissues.
Question 20
C) Weight loss through dietary changes and increased physical activity (Correct Answer)
Explanation: In patients with metabolic syndrome, weight loss through dietary changes and increased
physical activity is considered the primary target for reducing overall cardiovascular risk. This approach
addresses multiple components of metabolic syndrome simultaneously, including obesity, insulin
resistance, and dyslipidemia.
Question 21
C) Combined modality therapy (chemotherapy and radiation) (Correct Answer)
Explanation: The standard initial treatment for localized Hodgkin's lymphoma typically includes
combined modality therapy, which consists of chemotherapy followed by radiation therapy. This approach
has shown superior outcomes in terms of disease control and long-term survival compared to single-
modality treatments.
Question 22
D) Increased urination and thirst (Correct Answer)
Explanation: Increased urination (polyuria) and thirst (polydipsia) are most directly linked to
hyperparathyroidism caused by excessive parathyroid hormone (PTH) production. Elevated PTH levels
lead to increased calcium reabsorption in the kidneys and increased calcium levels in the blood, resulting
in polyuria and subsequent polydipsia.
Question 23
B) Overtreatment leading to hypothyroidism (Correct Answer)
Explanation: The most likely cause of symptoms such as cold intolerance and fatigue in a patient
undergoing treatment for hyperthyroidism is overtreatment leading to hypothyroidism. Excessive anti-
thyroid medication or radioactive iodine therapy can result in an underactive thyroid, causing symptoms
opposite to those of hyperthyroidism.
Question 24
C) Bilateral mastectomy (Correct Answer)
Explanation: For a 35-year-old woman with a BRCA1 mutation, bilateral mastectomy is considered the
most appropriate risk-reduction strategy for breast cancer. This prophylactic surgery significantly reduces
the risk of developing breast cancer in high-risk individuals, offering the greatest risk reduction compared
to other strategies.
Question 25
D) Imaging studies, such as CT or MRI of the abdomen (Correct Answer)
Explanation: After biochemical confirmation of pheochromocytoma, the next step in diagnostic evaluation
is typically imaging studies, such as CT or MRI of the abdomen. These imaging techniques help localize
the tumor, determine its size and extent, and identify any metastases, which is crucial for planning
appropriate treatment.
Question 26
C) Heparin-induced thrombocytopenia (Correct Answer)
Explanation: Heparin-induced thrombocytopenia (HIT) should be suspected in a patient on heparin
therapy who develops new thromboses and a significant drop in platelet count. HIT is an immune-
mediated disorder where antibodies form against heparin-platelet factor 4 complexes, leading to platelet
activation, thrombosis, and consumption.
Question 27
C) Intravenous calcium gluconate (Correct Answer)
Explanation: For symptomatic hypocalcemia in a patient with hypoparathyroidism, the initial
pharmacological treatment is intravenous calcium gluconate. This rapidly corrects serum calcium levels
and alleviates acute symptoms such as tetany, seizures, or cardiac arrhythmias.
Question 28
B) Alpha-adrenergic blockers (Correct Answer)
Explanation: Alpha-adrenergic blockers should be administered first in the preoperative management of
pheochromocytoma to prevent hypertensive crisis during surgery. These drugs block the effects of excess
catecholamines on alpha receptors, reducing blood pressure and the risk of hypertensive episodes during
tumor manipulation.
Question 29
B) Autoantibodies (Correct Answer)
Explanation: In immune thrombocytopenic purpura (ITP), autoantibodies primarily mediate the
destruction of platelets. These antibodies, typically IgG, bind to platelet surface antigens, leading to
accelerated platelet clearance by the reticuloendothelial system, particularly in the spleen.
Question 30
D) Breast cancer (Correct Answer)
Explanation: Women with BRCA1 or BRCA2 mutations have a significantly increased lifetime risk of
developing breast cancer. These mutations in tumor suppressor genes greatly elevate the risk of breast
cancer, with a lifetime risk of up to 70-80% for BRCA1 carriers and 45-70% for BRCA2 carriers.
Question 31
C) Philadelphia chromosome (Correct Answer)
Explanation: The Philadelphia chromosome is considered diagnostic for chronic myeloid leukemia
(CML). This chromosomal abnormality results from a reciprocal translocation between chromosomes 9
and 22, creating the BCR-ABL fusion gene, which is the hallmark of CML.
Question 32
B) Colonoscopy every 10 years (Correct Answer)
Explanation: For a 45-year-old woman with no family history of colorectal cancer undergoing routine
screening, colonoscopy every 10 years is the most appropriate screening test. Colonoscopy allows for
direct visualization of the entire colon and removal of precancerous polyps, making it an effective
screening and prevention tool.
Question 33
D) Monoclonal protein spike on serum electrophoresis (Correct Answer)
Explanation: The presence of a monoclonal protein spike on serum electrophoresis is considered the most
accurate diagnostic criterion for multiple myeloma. This spike, also known as M-protein, represents the
overproduction of a single immunoglobulin by clonal plasma cells, which is a hallmark of multiple
myeloma.
Question 34
A) Repeat PSA testing in 6 months (Correct Answer)
Explanation: For a 55-year-old male presenting with elevated PSA levels and no symptoms, the most
appropriate next step is to repeat PSA testing in 6 months. This approach helps confirm the elevation and
assess for any trend, as PSA levels can fluctuate due to various factors. Persistent elevation would then
warrant further investigation.
Question 35
A) Increased growth hormone levels (Correct Answer)
Explanation: In a 45-year-old woman presenting with coarse facial features, enlarged hands and feet, and
excessive sweating, you would expect elevated growth hormone levels. These symptoms are
characteristic of acromegaly, a condition caused by excess growth hormone production, typically due to a
pituitary adenoma.
Question 36
D) Overdiagnosis and overtreatment (Correct Answer)
Explanation: One of the main controversies surrounding PSA screening is the risk of overdiagnosis and
overtreatment. PSA testing can detect early-stage prostate cancers that may never progress or cause
symptoms, leading to unnecessary treatments with potential side effects. This controversy has led to
debates about the overall benefits versus harms of routine PSA screening.
Question 37
C) Discontinuation of heparin immediately (Correct Answer)
Explanation: For a patient on heparin therapy who develops sudden thrombocytopenia, the first step is to
immediately discontinue heparin due to the suspicion of heparin-induced thrombocytopenia (HIT). HIT is
a serious complication that can lead to life-threatening thrombosis. Prompt discontinuation of heparin is
crucial to prevent further complications while diagnostic tests are performed.
Question 38
C) Initiating moderate-intensity statin therapy (Correct Answer)
Explanation: For a 60-year-old female with diabetes and an LDL cholesterol of 140 mg/dL, initiating
moderate-intensity statin therapy is the most appropriate next step. Diabetes is considered a
cardiovascular risk equivalent, and current guidelines recommend statin therapy for diabetic patients aged
40-75 years with LDL-C ≥70 mg/dL, regardless of calculated cardiovascular risk.
Question 39
D) Prolactinoma (Correct Answer)
Explanation: The most likely diagnosis for a 36-year-old male with reduced libido, infertility, and a
pituitary mass on MRI is a prolactinoma. Prolactinomas are the most common type of functioning pituitary
adenoma and can cause hypogonadism in males, leading to decreased libido and fertility issues. The
presence of a pituitary mass on MRI further supports this diagnosis.
Question 40
A) Fasting blood glucose greater than or equal to 100 mg/dL (Correct Answer)
Explanation: A fasting blood glucose ≥100 mg/dL is one of the diagnostic criteria for metabolic
syndrome. This criterion reflects impaired fasting glucose or insulin resistance, which is a key component
of metabolic syndrome and significantly increases the risk of cardiovascular disease in affected
individuals.
Question 41
D) Active surveillance (Correct Answer)
Explanation: For a 70-year-old male with a life expectancy of less than 10 years diagnosed with low-risk
prostate cancer, active surveillance is the most appropriate management strategy. Active surveillance
involves monitoring the cancer closely without immediate treatment, which is suitable for older patients
with low-risk disease and limited life expectancy to avoid overtreatment and potential side effects of
more aggressive interventions.
Question 42
D) Pharmacotherapy (Correct Answer)
Explanation: For patients unable to achieve significant weight loss through lifestyle modifications alone,
pharmacotherapy may be prescribed to manage obesity. FDA-approved medications for long-term obesity
management can be used as an adjunct to diet and exercise to help patients achieve and maintain clinically
significant weight loss.
Question 43
C) Tamoxifen (Correct Answer)
Explanation: For a 45-year-old patient diagnosed with estrogen receptor-positive breast cancer,
tamoxifen is most likely to be recommended as part of the therapy. Tamoxifen is a selective estrogen
receptor modulator (SERM) that is widely used in the treatment of premenopausal women with ER-
positive breast cancer to reduce the risk of recurrence and improve survival.
Question 44
C) Peripheral neuropathy (Correct Answer)
Explanation: The complication likely present in a diabetic patient complaining of numbness and tingling
in his feet is peripheral neuropathy. This is a common complication of diabetes characterized by damage
to the peripheral nerves, often manifesting as sensory symptoms like numbness, tingling, or burning
sensations, particularly in the feet.
Question 45
B) Primary hypogonadism (Correct Answer)
Explanation: The most likely diagnosis for a male patient presenting with delayed puberty, reduced
muscle mass, infertility, small testes, low testosterone levels, and elevated gonadotropins is primary
hypogonadism. This condition, also known as hypergonadotropic hypogonadism, is characterized by
testicular failure with resultant low testosterone production and compensatory elevation of gonadotropins
(LH and FSH).
Question 46
A) Hyperparathyroidism (Correct Answer)
Explanation: The endocrine disorder that should be evaluated in a patient with osteoporosis and recurrent
kidney stones is hyperparathyroidism. Primary hyperparathyroidism leads to increased calcium levels in
the blood and urine, which can result in both osteoporosis (due to increased bone resorption) and
recurrent kidney stones (due to hypercalciuria).
Question 47
D) Empiric broad-spectrum antibiotics (Correct Answer)
Explanation: For a patient undergoing chemotherapy who presents with a fever of 38.5°C and an absolute
neutrophil count of 400/µL, the most appropriate next step is to administer empiric broad-spectrum
antibiotics. This presentation is consistent with febrile neutropenia, a medical emergency requiring
immediate antibiotic treatment to prevent potentially life-threatening infections.
Question 48
B) Hodgkin's lymphoma (Correct Answer)
Explanation: The most likely diagnosis for a 50-year-old patient presenting with enlarged, painless lymph
nodes in the neck and a mediastinal mass on imaging is Hodgkin's lymphoma. This presentation is classic
for Hodgkin's lymphoma, which often involves cervical lymph nodes and mediastinal masses, particularly
in middle-aged adults.
Question 49
C) Hydration and control of hypercalcemia (Correct Answer)
Explanation: The first-line management strategy for a newly diagnosed multiple myeloma patient
exhibiting renal impairment is hydration and control of hypercalcemia. Renal dysfunction in multiple
myeloma is often due to cast nephropathy and hypercalcemia. Aggressive hydration and correction of
hypercalcemia are crucial initial steps to preserve and potentially improve renal function before initiating
specific myeloma therapies.
Question 50
B) Hemophilia A (Correct Answer)
Explanation: The condition most likely underlying a 23-year-old male patient presenting with prolonged
bleeding after dental surgery and a history of multiple joint bleeds is Hemophilia A. This X-linked
recessive disorder, characterized by factor VIII deficiency, typically presents with prolonged bleeding
after procedures and a history of spontaneous bleeding into joints. Hemophilia A is more common than
Hemophilia B and fits the described clinical picture.
Question 51
B) Familial adenomatous polyposis (Correct Answer)
Explanation: Familial adenomatous polyposis (FAP) is a hereditary condition characterized by the
development of hundreds to thousands of adenomatous polyps in the colon and rectum, which significantly
increases the risk of colorectal cancer. Patients with FAP often present with symptoms such as abdominal
pain and rectal bleeding due to these polyps.
Question 52
A) Colorectal cancer (Correct Answer)
Explanation: In a 55-year-old man with unintentional weight loss, changes in bowel habits, and blood in
his stool, colorectal cancer is the most concerning diagnosis. These symptoms are classic indicators of
colorectal malignancy, necessitating prompt investigation.
Question 53
A) Elevated D-dimer (Correct Answer)
Explanation: Elevated D-dimer levels are a key laboratory finding in disseminated intravascular
coagulation (DIC), indicating increased fibrinolysis. DIC is a serious condition where there is
widespread activation of the clotting cascade, leading to both clot formation and bleeding.
Question 54
A) Red blood cell transfusion (Correct Answer)
Explanation: For a 65-year-old male undergoing chemotherapy with a hemoglobin level of 7.5 g/dL and
presenting symptoms of fatigue and pallor, a red blood cell transfusion is the most appropriate treatment
to rapidly improve hemoglobin levels and alleviate symptoms.
Question 55
C) Presence of Reed-Sternberg cells (Correct Answer)
Explanation: Hodgkin's lymphoma is characterized histologically by the presence of Reed-Sternberg
cells, which are large, abnormal lymphocytes. Their identification is crucial for diagnosing this type of
lymphoma.
Question 56
D) Graves' disease (Correct Answer)
Explanation: The combination of heat intolerance, weight loss, and palpitations in a 35-year-old female
suggests hyperthyroidism, with Graves' disease being the most common cause. This autoimmune disorder
leads to excessive thyroid hormone production.
Question 57
C) Decrease the dose of insulin to minimize the risk of further hypoglycemic episodes (Correct Answer)
Explanation: For a patient with Type 1 diabetes experiencing frequent hypoglycemic episodes, reducing
insulin dosage can help prevent these dangerous lows while maintaining adequate glucose control.
Question 58
C) Immunophenotyping (Correct Answer)
Explanation: Immunophenotyping is essential for differentiating between acute lymphoblastic leukemia
(ALL) and acute myeloid leukemia (AML). This test identifies specific cell surface markers that
characterize different types of leukemia.
Question 59
C) Decreased libido and galactorrhea (Correct Answer)
Explanation: Prolactinoma in males often leads to decreased libido and galactorrhea due to elevated
prolactin levels affecting sexual function and causing milk production.
Question 60
C) Initiation of alpha-blockade with a non-selective alpha-adrenergic antagonist (Correct Answer)
Explanation: For patients with adrenal masses causing catecholamine excess, such as pheochromocytoma,
initiating alpha-blockade is crucial to control hypertension before surgical resection.
Question 61
B) Increasing physical activity and following a heart-healthy diet (Correct Answer)
Explanation: For a patient concerned about cardiovascular health with obesity and abnormal glucose
levels, increasing physical activity and adopting a heart-healthy diet are fundamental lifestyle
modifications that can improve overall health outcomes.
Question 62
B) Roux-en-Y gastric bypass (Correct Answer)
Explanation: The Roux-en-Y gastric bypass is often considered the most appropriate initial surgical
option for patients with obesity and type 2 diabetes due to its effectiveness in achieving significant weight
loss and improving metabolic parameters.
Question 63
B) Primary adrenal insufficiency (Correct Answer)
Explanation: In primary adrenal insufficiency (Addison's disease), ACTH levels are elevated due to lack
of feedback inhibition from cortisol. This condition results from adrenal gland failure.
Question 64
A) Introducing ezetimibe to his therapy (Correct Answer)
Explanation: For patients who do not achieve target LDL cholesterol levels despite moderate-intensity
statin therapy, adding ezetimibe can help lower LDL levels further by reducing intestinal cholesterol
absorption.
Question 65
D) ACTH stimulation test (Correct Answer)
Explanation: The ACTH stimulation test is critical for diagnosing Addison's disease. It assesses the
adrenal glands' ability to produce cortisol in response to synthetic ACTH administration.
Question 66
D) Multi-agent chemotherapy (Correct Answer)
Explanation: Multi-agent chemotherapy is the first-line treatment for pediatric patients diagnosed with
acute lymphoblastic leukemia (ALL), aiming for remission through aggressive treatment protocols.
Question 67
D) Annual MRI and mammogram (Correct Answer)
Explanation: For patients with a BRCA1 mutation and a family history of breast cancer, annual MRI
alongside mammography provides enhanced screening for early detection of breast cancer due to their
higher risk profile.
Question 68
B) von Willebrand disease (Correct Answer)
Explanation: The presentation of frequent nosebleeds and heavy menstrual bleeding alongside reduced
factor VIII activity suggests von Willebrand disease, which affects platelet function due to vWF
deficiency or dysfunction.
Question 69
C) High-grade non-Hodgkin's lymphoma (Correct Answer)
Explanation: A lymphoma exhibiting high proliferation rates and diffuse growth patterns typically
indicates high-grade non-Hodgkin's lymphoma, which requires aggressive treatment due to its rapid
progression.
Question 70
A) Initiate treatment with a tyrosine kinase inhibitor (Correct Answer)
Explanation: For a patient with massive splenomegaly and leukocytosis primarily consisting of
lymphocytes after bone marrow biopsy, initiating treatment with a tyrosine kinase inhibitor is appropriate
if chronic lymphocytic leukemia or similar conditions are suspected.
Question 71
A) Reduction of HbA1c to less than 7% (Correct Answer)
Explanation: The primary goal for managing Type 2 diabetes in a patient with an HbA1c of 9.0% is to
reduce it below 7% to minimize complications associated with uncontrolled diabetes.
Question 72
A) Growth hormone (Correct Answer)
Explanation: Acromegaly is primarily caused by excess growth hormone secretion from pituitary
adenomas, leading to characteristic signs such as enlarged extremities and facial features.
Question 73
C) Consultation with a bariatric surgeon (Correct Answer)
Explanation: For patients with severe obesity who have not achieved success through lifestyle
modifications, consulting a bariatric surgeon can provide options for surgical intervention that may lead
to significant weight loss and improvement in obesity-related conditions.
Question 74
C) Serum ferritin (Correct Answer)
Explanation: Serum ferritin is the most indicative laboratory test for iron-deficiency anemia as it reflects
the body’s iron stores. Low ferritin levels confirm iron deficiency as the underlying cause of anemia.
Question 75
B) Addison's disease (Correct Answer)
Explanation: Hyperkalemia and hyponatremia in conjunction with fatigue suggest Addison's disease. In
this condition, adrenal insufficiency leads to decreased aldosterone production, resulting in potassium
retention and sodium loss.
Question 76
B) Bone marrow biopsy (Correct Answer)
Explanation: For a 60-year-old presenting with back pain, fatigue, and high serum protein levels, a bone
marrow biopsy is crucial for diagnosis. These symptoms, combined with elevated serum protein, strongly
suggest multiple myeloma. A bone marrow biopsy can confirm the presence of abnormal plasma cells,
which is essential for diagnosing multiple myeloma.
Question 77
B) Immune thrombocytopenic purpura (Correct Answer)
Explanation: The presentation of petechiae, easy bruising, and low platelet count without other
abnormalities in a 45-year-old female is most consistent with immune thrombocytopenic purpura (ITP).
ITP is an autoimmune disorder characterized by isolated thrombocytopenia due to increased platelet
destruction and impaired platelet production.
Question 78
B) LDL cholesterol (Correct Answer)
Explanation: In patients with established atherosclerotic cardiovascular disease (ASCVD), the primary
lipid target for statin therapy is to reduce LDL cholesterol below 70 mg/dL. LDL cholesterol is the main
focus of lipid-lowering therapy due to its strong association with cardiovascular risk.
Question 79
B) An LDL cholesterol level of 190 mg/dL or higher (Correct Answer)
Explanation: According to current guidelines, an LDL cholesterol level of 190 mg/dL or higher would
most likely indicate the need for high-intensity statin therapy. This level is considered very high and
associated with significant cardiovascular risk, warranting aggressive lipid-lowering treatment.
Question 80
A) Initiating statin therapy (Correct Answer)
Explanation: For a male patient presenting with multiple cardiovascular risk factors (elevated
triglycerides, hypertension, abdominal obesity, impaired fasting glucose, and low HDL), initiating statin
therapy is the most appropriate pharmacologic intervention. Statins are the first-line treatment for
reducing cardiovascular risk in patients with multiple risk factors.
Question 81
D) 5-HT3 receptor antagonist (Correct Answer)
Explanation: 5-HT3 receptor antagonists, such as ondansetron, are the most effective medications for
preventing severe nausea and vomiting within 24 hours of chemotherapy treatment. These drugs block
serotonin receptors in the chemoreceptor trigger zone and gastrointestinal tract, significantly reducing
chemotherapy-induced nausea and vomiting.
Question 82
C) Oral hygiene and topical anesthetics (Correct Answer)
Explanation: For a patient undergoing chemotherapy for lymphoma experiencing mucositis and poor oral
intake, the best approach to managing this side effect is oral hygiene and topical anesthetics. This
approach helps maintain oral cleanliness, reduces pain, and promotes healing of the oral mucosa.
Question 83
A) Plasma metanephrines or 24-hour urinary fractionated metanephrines (Correct Answer)
Explanation: To confirm pheochromocytoma in a patient presenting with typical symptoms (episodic
headaches, palpitations, sweating, and elevated blood pressure), the most appropriate diagnostic test is
measuring plasma metanephrines or 24-hour urinary fractionated metanephrines. These tests have high
sensitivity and specificity for detecting catecholamine-secreting tumors.
Question 84
B) Liraglutide (Correct Answer)
Explanation: Liraglutide has been approved by the FDA for long-term management of obesity in patients
with a BMI of 30 or higher, or 27 or higher with comorbid conditions. It is a GLP-1 receptor agonist that
promotes weight loss by reducing appetite and food intake.
Question 85
D) Starting a low-dose synthetic thyroid hormone replacement (Correct Answer)
Explanation: For a patient newly diagnosed with hypothyroidism, the generally indicated first treatment is
starting a low-dose synthetic thyroid hormone replacement, typically levothyroxine. This approach aims
to restore normal thyroid hormone levels and alleviate symptoms of hypothyroidism.
Question 86
D) Estrogen (Correct Answer)
Explanation: In postmenopausal women, hormone replacement therapy is primarily used to address the
deficiency of estrogen. Estrogen deficiency is responsible for many of the symptoms associated with
menopause, including hot flashes, vaginal dryness, and bone loss.
Question 87
B) Mammography every two years (Correct Answer)
Explanation: For a 50-year-old woman with no family history of breast cancer, the most appropriate
screening method for early detection is mammography every two years. This recommendation aligns with
guidelines for average-risk women, balancing the benefits of early detection with the potential risks of
overdiagnosis.
Question 88
C) Lifestyle modification focusing on weight loss and physical activity (Correct Answer)
Explanation: For a 52-year-old male with multiple cardiovascular risk factors (hypertension, abdominal
obesity, dyslipidemia), the most appropriate next step is lifestyle modification focusing on weight loss
and physical activity. These interventions can significantly improve all aspects of metabolic syndrome
and reduce overall cardiovascular risk.
Question 89
A) Loss of body hair (Correct Answer)
Explanation: Hypopituitarism typically results in loss of body hair. This is due to decreased production of
gonadotropins (FSH and LH) by the pituitary gland, leading to reduced sex hormone production, which
affects secondary sexual characteristics including body hair.
Question 90
A) Klinefelter syndrome (Correct Answer)
Explanation: Klinefelter syndrome is a common cause of hypogonadism in males due to testicular
dysfunction. It is a genetic condition characterized by an extra X chromosome (XXY), leading to impaired
testosterone production and testicular atrophy.
Question 91
C) Hypogonadism caused by ovarian dysfunction (Correct Answer)
Explanation: For a 38-year-old female with irregular periods, hot flashes, decreased bone density, and
low estradiol levels, the most likely diagnosis is hypogonadism caused by ovarian dysfunction. This
condition, also known as primary ovarian insufficiency, results in decreased estrogen production and
symptoms of premature menopause.
Question 92
B) Testosterone replacement therapy (Correct Answer)
Explanation: For a 55-year-old male presenting with symptoms of hypogonadism (fatigue, decreased
libido, loss of muscle mass) and confirmed low testosterone levels, the most appropriate management is
testosterone replacement therapy. This treatment aims to restore normal testosterone levels and alleviate
associated symptoms.
Question 93
C) Cushing's syndrome (Correct Answer)
Explanation: A 45-year-old male with hypertension, truncal obesity, and a buffalo hump is likely affected
by Cushing's syndrome. These are classic signs of cortisol excess, which is characteristic of Cushing's
syndrome. The buffalo hump, in particular, is a distinctive feature of this condition.
Question 94
B) Dietary changes emphasizing reduced caloric intake and increased fruit and vegetable consumption
(Correct Answer)
Explanation: The initial lifestyle intervention recommended for a patient diagnosed with obesity is dietary
changes emphasizing reduced caloric intake and increased fruit and vegetable consumption. This
approach focuses on creating a calorie deficit while improving overall nutrition, which is fundamental to
weight loss and health improvement.
Question 95
B) Adenomatous polyps (Correct Answer)
Explanation: Familial adenomatous polyposis is characterized by the development of numerous
adenomatous polyps in the colon and rectum. These polyps have a high potential for malignant
transformation, significantly increasing the risk of colorectal cancer in affected individuals.
Question 96
D) Colonoscopy every 1 to 2 years (Correct Answer)
Explanation: For a 60-year-old patient with a history of Lynch syndrome concerned about colorectal
cancer risk, the most appropriate screening protocol is colonoscopy every 1 to 2 years. Lynch syndrome
significantly increases the risk of colorectal cancer, necessitating more frequent and thorough screening
than the general population.
Question 97
C) Complete blood count (CBC) (Correct Answer)
Explanation: For a 45-year-old male with a history of gastrointestinal bleeding and suspected anemia, the
initial diagnostic step should be a complete blood count (CBC). The CBC provides crucial information
about hemoglobin levels, red blood cell count, and other parameters that can confirm the presence and
severity of anemia.
Question 98
A) Metformin (Correct Answer)
Explanation: Metformin is typically the first pharmacological treatment for Type 2 diabetes. It is
recommended as the initial therapy due to its efficacy in lowering blood glucose, favorable side effect
profile, and potential cardiovascular benefits. Metformin works by reducing hepatic glucose production
and improving insulin sensitivity.
Question 99
C) Warfarin (Correct Answer)
Explanation: Following a diagnosis of heparin-induced thrombocytopenia (HIT), warfarin should be
avoided in a patient's treatment plan. Warfarin can paradoxically increase the risk of thrombosis in HIT
patients by reducing protein C levels faster than other coagulation factors. Direct oral anticoagulants or
non-heparin parenteral anticoagulants are preferred in this situation.

Practice Tests 3
Question 1
What is the recommended initial imaging study for a pediatric patient after their first febrile urinary tract
infection?
A) Voiding cystourethrogram
B) Renal and bladder ultrasound
C) Intravenous pyelogram
D) Abdominal x-ray
Question 2
Which condition is most likely causing severe epigastric pain radiating to the back, accompanied by
nausea and vomiting in a 53-year-old patient?
A) Acute pancreatitis
B) Chronic gastritis
C) Gallbladder disease
D) Peptic ulcer disease
Question 3
What is the primary buffer system in blood that quickly responds to pH changes within minutes?
A) Phosphate buffer system
B) Protein buffer system
C) Hydrochloric acid secretion system
D) Carbonic acid-bicarbonate system
Question 4
Which treatment approach is considered first-line for managing ascites in a patient with cirrhosis?
A) Spironolactone with or without furosemide
B) Large volume paracentesis without albumin infusion
C) Beta-blocker therapy to reduce portal vein pressure
D) Restriction of dietary sodium alone
Question 5
What is the most appropriate next step in managing a patient presenting with symptoms of nephrotic
syndrome?
A) Initiate diuretic therapy and investigate underlying causes
B) Start immunosuppressive therapy
C) Recommend a low-sodium diet and fluid restriction
D) Prescribe angiotensin-converting enzyme inhibitors
Question 6
Which type of kidney stone is typically associated with a urinary pH above 7.0?
A) Uric acid stones
B) Struvite stones
C) Calcium oxalate stones
D) Calcium phosphate stones
Question 7
What is the preferred treatment for chronic Hepatitis B to reduce viral replication and liver damage?
A) Oral antiviral agents such as tenofovir or entecavir
B) Interferon alpha injections
C) Periodic monitoring of liver enzymes and viral load
D) Liver transplantation
Question 8
In patients with chronic kidney disease, what is the target blood pressure (in mmHg) for slowing disease
progression?
A) Less than 160/110
B) Less than 140/90
C) Less than 130/80
D) Less than 150/100
Question 9
What is the most accurate diagnostic tool for confirming GERD in a patient with ambiguous symptoms?
A) Barium swallow radiography
B) Trial of a proton pump inhibitor for two weeks
C) 24-hour esophageal pH monitoring
D) Endoscopic examination
Question 10
Which condition is most likely in a patient with cirrhosis who displays altered mental status and a
flapping tremor during an exam?
A) Hepatocellular carcinoma
B) Hepatic encephalopathy
C) Spontaneous bacterial peritonitis
D) Portal vein thrombosis
Question 11
What is the primary defect in Type I renal tubular acidosis (RTA)?
A) Impaired glucose reabsorption at the renal threshold
B) Enhanced bicarbonate reabsorption in the proximal tubule
C) Inability of the distal tubule to secrete hydrogen ions
D) Reduced reabsorption of bicarbonate in the proximal tubule
Question 12
Which factor is most likely contributing to recurrent UTIs in a 58-year-old male with type 2 diabetes
mellitus?
A) Enlarged prostate
B) Impaired glucose control
C) Decreased bladder sensation
D) Genetic predisposition
Question 13
What is the recommended age to begin routine colon cancer screening for average-risk individuals
according to US guidelines?
A) 60 years
B) 45 years
C) 50 years
D) 55 years
Question 14
Which treatment is commonly used to manage severe Crohn's disease and control inflammation?
A) Aminosalicylates
B) Corticosteroids
C) Immunosuppressive agents
D) Tumor necrosis factor (TNF) inhibitors
Question 15
What is the most appropriate initial treatment for acute cholecystitis?
A) Cholecystectomy
B) Gallbladder stenting
C) Percutaneous cholecystostomy
D) Antibiotic therapy alone
Question 16
In Type IV renal tubular acidosis (RTA), which hormone's impaired function is often related to the
underlying problem?
A) Aldosterone
B) Antidiuretic hormone
C) Glucocorticoid
D) Insulin
Question 17
What is the most likely cause of sudden onset abdominal girth increase and discomfort in a patient with
cirrhosis?
A) Spontaneous bacterial peritonitis
B) Hepatorenal syndrome
C) Portal vein thrombosis
D) Development of significant ascites
Question 18
Which lifestyle modification is least likely to benefit a patient with gastroesophageal reflux disease
(GERD)?
A) Participating in vigorous physical activity right after meals
B) Reducing caffeine and alcohol consumption
C) Increasing dietary fiber intake significantly each day
D) Avoiding carbonated beverages and acidic foods
Question 19
What is the most frequent cause of chronic pancreatitis in adults?
A) Hereditary genetic mutations
B) Long-term alcohol consumption
C) Gallstone disease
D) High triglyceride levels
Question 20
Which complication of peptic ulcer disease is most likely in a 45-year-old patient with acute upper
abdominal pain and a history of NSAID use?
A) Chronic gastritis progressing to atrophic gastritis
B) Perforation of the gastric or duodenal wall leading to peritonitis
C) Gastroesophageal reflux disease exacerbating an underlying ulcer
D) Bleeding from the ulcer resulting in melena or hematemesis
Question 21
What is the primary cause of peptic ulcer disease in adults?
A) Chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs)
B) Infection with Helicobacter pylori
C) Excessive alcohol consumption
D) Excessive secretion of gastric acid
Question 22
Which treatment approach is most appropriate for a patient with suspected lower GI bleeding showing
angiodysplasia in the colon during endoscopy?
A) Surgical resection
B) Endoscopic band ligation
C) Argon plasma coagulation
D) Hemicolectomy
Question 23
What is the most likely distinguishing feature between nephrotic syndrome and nephritic syndrome when
assessing a patient's urinalysis?
A) Presence of hypoalbuminemia
B) Presence of red blood cell casts
C) Presence of significant proteinuria greater than 3.5 g/day
D) Finding of fatty casts
Question 24
Which medication is considered first-line for slowing the progression of chronic kidney disease in
patients with proteinuria?
A) Beta blockers
B) Angiotensin-converting enzyme (ACE) inhibitors
C) Diuretics
D) Calcium channel blockers
Question 25
What is the most common genetic mutation associated with autosomal dominant polycystic kidney disease
(ADPKD)?
A) Mutations in the TSC2 gene
B) Changes in the HNF1B gene
C) Mutations in the PKD1 gene
D) Alterations in the CYP1B1 gene
Question 26
Which diagnostic procedure is indicated first for a 60-year-old male presenting with melena,
lightheadedness, and a hemoglobin of 7 g/dL?
A) Radiolabeled red blood cell scan
B) Colonoscopy
C) CT angiography
D) Emergency esophagogastroduodenoscopy (EGD)
Question 27
What is the most appropriate intervention for a 72-year-old male with benign prostatic hyperplasia
presenting with flank pain, difficulty urinating, elevated creatinine, and bilateral hydronephrosis?
A) Schedule an urgent urologic surgery
B) Insertion of a urinary catheter
C) Perform a bilateral nephrostomy
D) Begin an alpha-blocker
Question 28
Which treatment is most appropriate for eradicating Helicobacter pylori in a patient diagnosed with
peptic ulcer disease?
A) Long-term use of a proton pump inhibitor alone
B) Combination therapy including amoxicillin, clarithromycin, and a proton pump inhibitor
C) Surgical intervention
D) Symptomatic treatment with antacids and lifestyle modifications
Question 29
What is the likely mechanism for hypertension in a 40-year-old male with a family history of polycystic
kidney disease?
A) Hypertrophy of the heart muscle
B) Generalized vasodilation
C) Compression of renal arteries by cysts leading to activation of the renin-angiotensin system
D) Renal ischemia from decreased overall renal perfusion
Question 30
Which dietary recommendation is primarily advised to prevent the recurrence of calcium oxalate stones?
A) Increase fluid intake to achieve at least 2.5 liters of urine output per day
B) Increase dietary sodium
C) Decrease calcium intake
D) Reduce animal protein consumption
Question 31
What is the most likely diagnosis for a female patient complaining of recurrent abdominal pain occurring
once per week on average, often relieved by bowel movements, with no alarming features?
A) Gastroesophageal reflux disease
B) Celiac disease
C) Irritable Bowel Syndrome
D) Peptic ulcer disease
Question 32
Which symptom is less commonly associated with urinary tract infections in elderly patients?
A) Urinary incontinence
B) High fever
C) Suprapubic pain
D) Acute confusion
Question 33
What is the most appropriate initial treatment for post-streptococcal glomerulonephritis in a 10-year-old
boy presenting with edema, hematuria, and hypertension two weeks after a sore throat?
A) Supportive care with antihypertensives and diuretics
B) Administer antibiotics
C) Administer corticosteroids
D) Start immunosuppressive therapy
Question 34
Which test is most appropriate to confirm the diagnosis of a urinary tract infection in a 32-year-old
pregnant woman?
A) Cystoscopy
B) Complete blood count
C) Urine culture and sensitivity
D) Urinalysis with microscopy
Question 35
What is the clinical hallmark of nephritic syndrome?
A) Edema
B) Proteinuria
C) Hypertension
D) Hematuria
Question 36
At what age should screening begin for individuals with a first-degree relative who had colon cancer at
age 45?
A) 35 years
B) 30 years
C) 40 years
D) 25 years
Question 37
What is the most likely cause of severe flank pain in a patient with a known diagnosis of polycystic
kidney disease during a routine examination?
A) Rupture of a kidney cyst
B) Malignant transformation of cystic tissue
C) Stone formation within the renal tubules
D) Development of acute pyelonephritis
Question 38
Which immediate treatment is crucial in the management of acute lower gastrointestinal bleeding to
prevent hemodynamic instability?
A) Resuscitation
B) Monitoring
C) Fluid therapy
D) Blood transfusion
Question 39
What is the likely cause of hypocalcemia in a 60-year-old man with chronic kidney disease presenting
with tingling in his hands?
A) Magnesium deficiency
B) Secondary hyperparathyroidism
C) Inadequate dietary intake of calcium
D) Vitamin D deficiency
Question 40
Which management strategy is best suited for a 40-year-old male with chronic heartburn resistant to over-
the-counter antacids being evaluated for GERD?
A) Implementing a strict low-carb diet
B) Surgical intervention with Nissen fundoplication
C) Stress management techniques and meditation
D) Prescription of a high-dose proton pump inhibitor and follow-up endoscopy
Question 41
What is the most likely diagnosis for a patient presenting with abdominal pain, diarrhea, and a
sigmoidoscopy showing continuous inflammation and ulcers limited to the mucosa?
A) Ulcerative colitis
B) Crohn's disease
C) Infectious colitis
D) Ischemic colitis
Question 42
Which treatment should be avoided in the initial management of a patient presenting with confusion and a
serum sodium level of 128 mEq/L?
A) Rapid correction of sodium with hypertonic saline
B) Fluid restriction
C) Administration of loop diuretics
D) Use of thiazide diuretics
Question 43
What is the acid-base status of a patient with vomiting and a subsequent blood gas of pH 7.55, PaCO2 of
42 mmHg, and bicarbonate of 32 mEq/L?
A) Metabolic alkalosis
B) Metabolic acidosis with respiratory compensation
C) Compensated metabolic acidosis
D) Respiratory acidosis
Question 44
Which gene is typically mutated in autosomal recessive polycystic kidney disease (ARPKD)?
A) PKD2
B) CFTR
C) PKHD1
D) NPHP1
Question 45
What is the most appropriate next step in management for a 55-year-old woman presenting with acute
kidney injury after starting NSAIDs for chronic joint pain?
A) Continue NSAIDs while adding a diuretic
B) Start a course of corticosteroids
C) Perform a kidney biopsy
D) Discontinuation of NSAIDs and careful monitoring of renal function
Question 46
Which treatment is often included in the immediate management of acute pancreatitis?
A) Intravenous fluid hydration
B) Prophylactic antibiotics
C) Immediate endoscopic retrograde cholangiopancreatography (ERCP)
D) Surgical intervention
Question 47
What is the most likely diagnosis for a 45-year-old patient presenting with severe right upper quadrant
pain, fever, and leukocytosis after eating a fatty meal?
A) Hepatocellular carcinoma
B) Acute cholecystitis
C) Chronic cholecystitis
D) Gallbladder cancer
Question 48
Which medication is commonly used as an initial treatment for GERD to reduce acid production?
A) Proton pump inhibitors
B) Histamine-2 receptor antagonists
C) Opioid medications
D) Antacids
Question 49
What type of acute kidney injury is most likely in a 68-year-old male with a history of heart failure,
presenting with low blood pressure and an elevated BUN/creatinine ratio?
A) Prerenal acute kidney injury due to dehydration
B) Intrinsic acute kidney injury due to acute tubular necrosis
C) Postrenal acute kidney injury due to bilateral ureteral obstruction
D) Prerenal acute kidney injury due to hypoperfusion
Question 50
What is a common complication of polycystic kidney disease affecting organs other than the kidneys?
A) Pancreatic insufficiency
B) Increased risk of colon diverticulosis
C) Development of liver cysts
D) Thyroid dysfunction
Question 51: What is considered the most effective imaging study for identifying cholelithiasis?
A. MRI of the abdomen
B. Ultrasound of the abdomen
C. Hepatobiliary iminodiacetic acid (HIDA) scan
D. CT scan of the abdomen
Question 52: Which medication is typically used as the first-line pharmacological treatment for uric acid
stones?
A. Allopurinol
B. Potassium citrate
C. Hydrochlorothiazide
D. Calcium citrate
Question 53: How should a 2 cm adenomatous polyp discovered during a screening colonoscopy in a 50-
year-old patient be managed?
A. Leave the polyp in place and repeat colonoscopy in one year
B. Complete polypectomy followed by surveillance colonoscopy in 3 years
C. Immediate surgical resection without prior biopsy
D. Biopsy of the polyp and await pathology before deciding further action
Question 54: For a 70-year-old male with stage 4 chronic kidney disease whose GFR has declined from
22 to 18 mL/min/1.73 m² over the past year, what is the recommended next step?
A. Perform an immediate kidney ultrasound to check for structural abnormalities
B. Refer to a nephrologist for early initiation of dialysis planning and further management
C. Schedule a kidney biopsy to further investigate the cause of the decline in kidney function
D. Initiate an aggressive blood pressure-lowering regimen to slow the decline in GFR
Question 55: In a patient with hematochezia and a history of aortic valve replacement, what is the most
probable source of GI bleeding?
A. Diverticulosis
B. Angiodysplasia
C. Peptic ulcer disease
D. Colon cancer
Question 56: What is the most appropriate management for a patient who tests positive for Hepatitis E
during a routine check-up?
A. Supportive care as it usually resolves spontaneously
B. Hospitalization and isolation to prevent transmission
C. Active monitoring and liver function tests every six months
D. Ribavirin in severe acute cases
Question 57: What is the characteristic finding in IgA nephropathy that leads to recurrent episodes of
gross hematuria?
A. Antibodies to the glomerular basement membrane
B. Immunoglobulin G
C. Immunoglobulin A
D. Complement proteins
Question 58: What is considered the optimal initial treatment for a child diagnosed with Type I RTA?
A. Restricting dietary protein to decrease the renal load of nitrogenous waste
B. High-dose calcium supplements to enhance renal calcium reabsorption and buffer acids
C. Administration of potassium-sparing diuretics to correct the electrolyte imbalance
D. Oral administration of sodium bicarbonate or sodium citrate to correct acidosis
Question 59: According to CKD staging guidelines, what stage of chronic kidney disease is a 65-year-old
male with a history of diabetes and hypertension in if his GFR is 35 mL/min/1.73 m²?
A. Stage 4 chronic kidney disease
B. Stage 2 chronic kidney disease
C. Stage 1 chronic kidney disease
D. Stage 3B chronic kidney disease
Question 60: What is the current standard treatment for Hepatitis C?
A. Traditional antiviral therapy with interferon
B. Pegylated interferon and ribavirin
C. Direct-acting antivirals like sofosbuvir and velpatasvir
D. Vaccination with Hepatitis C vaccine
Question 61: A 30-year-old woman presents with fatigue, dark urine, and swelling in her legs after
recovering from a streptococcal skin infection. What is the most likely cause of her kidney injury?
A. IgA nephropathy
B. Lupus nephritis
C. Goodpasture syndrome
D. Post-streptococcal glomerulonephritis
Question 62: What is the main factor causing portal hypertension in cirrhosis?
A. Increased resistance to portal blood flow due to fibrosis and regenerative nodules
B. Splanchnic arterial vasodilation
C. Decreased synthesis of bile acids
D. Direct damage to hepatocytes from viral hepatitis
Question 63: For a patient with severe hyponatremia presenting with seizures, which intervention is most
appropriate?
A. Increase fluid intake to dilute the sodium concentration further
B. Administer hypertonic saline promptly
C. Restriction of dietary sodium
D. Immediate dialysis
Question 64: Which treatment approach is typically recommended for symptomatic cholelithiasis?
A. Endoscopic retrograde cholangiopancreatography (ERCP)
B. Laparoscopic cholecystectomy
C. Extracorporeal shock wave lithotripsy
D. Oral bile acid therapy
Question 65: What is the most appropriate next step in managing a 14-year-old boy with nephritic
syndrome, joint pain, and a rash on his legs, whose kidney biopsy reveals IgA deposits?
A. Prescribe angiotensin-converting enzyme inhibitors
B. Begin hemodialysis
C. Initiate a course of corticosteroids
D. Perform a renal biopsy
Question 66: For a 58-year-old woman with chronic kidney disease (GFR 28 mL/min/1.73 m²) and
hypertension managed with ACE inhibitors, what additional lifestyle modification should be
recommended?
A. Encourage high protein intake
B. Advise increasing potassium intake
C. Suggest a high-fat diet
D. Recommend a low-sodium diet
Question 67: What is typically the first-line dietary recommendation for managing symptoms in a patient
diagnosed with IBS?
A. Begin an exclusively liquid diet
B. Increase dietary fiber intake
C. Eliminate all dairy products
D. Start a strict gluten-free diet
Question 68: What is the primary treatment for hyperkalemia with ECG changes?
A. Intravenous calcium gluconate
B. Potassium-binding resins
C. Insulin and glucose
D. Sodium bicarbonate
Question 69: For a patient diagnosed with co-infection of Hepatitis B and D, what is the essential
treatment strategy?
A. Combination therapy with interferon and ribavirin
B. Hepatitis D specific antiviral therapy
C. Administration of antivirals that target Hepatitis B
D. Supportive treatment focusing on nutritional support
Question 70: During an asthma exacerbation, a patient's arterial blood gas shows a pH of 7.50 and a low
PaCO2. What condition does this indicate?
A. Respiratory compensation for metabolic alkalosis
B. Metabolic compensation for respiratory acidosis
C. Metabolic acidosis
D. Respiratory alkalosis
Question 71: Which hepatitis virus is mainly transmitted through fecal-oral contamination and lacks a
chronic phase?
A. Hepatitis E
B. Hepatitis A
C. Hepatitis B
D. Hepatitis C
Question 72: According to the Rome IV criteria, how frequently must abdominal pain be associated with
defecation to diagnose irritable bowel syndrome?
A. At least twice a month
B. At least once a month
C. At least once a week
D. At least three times a week
Question 73: What diagnosis is suggested by a patient presenting with weight loss, diabetes, and
calcification in the abdomen on an X-ray?
A. Chronic pancreatitis
B. Pancreatic cancer
C. Cystic fibrosis
D. Autoimmune pancreatitis
Question 74: In a patient with chronic obstructive pulmonary disease who develops respiratory acidosis,
what compensatory mechanism is most likely to occur?
A. Decrease in hemoglobin's affinity for oxygen
B. Increased renal bicarbonate reabsorption
C. Hyperventilation to decrease PaCO2
D. Acceleration of anaerobic glycolysis
Question 75: What is the first-line management strategy for hyperkalemia in a patient with acute kidney
injury to prevent life-threatening complications?
A. Administration of intravenous calcium gluconate
B. Administer sodium bicarbonate
C. Immediate dialysis
D. Administer insulin and glucose
Question 76: For a patient complaining of regurgitation and chest pain exacerbated by lying down, which
intervention should be recommended as initial management?
A. Elevation of the head of the bed and avoiding meals before bedtime
B. Prescription of anxiolytics
C. Referral to a gastroenterologist
D. Use of over-the-counter antacids
Question 77: Which imaging technique is most commonly employed for diagnosing acute pancreatitis?
A. CT scan with contrast
B. Abdominal ultrasound
C. Endoscopic ultrasound
D. Magnetic resonance imaging (MRI)
Question 78: A 25-year-old male with a recent history of sore throat presents with hematuria,
hypertension, and proteinuria. What is the most likely diagnosis?
A. IgA nephropathy
B. Membranous nephropathy
C. Post-streptococcal glomerulonephritis
D. Lupus nephritis
Question 79: A 50-year-old male presents with significant edema, proteinuria, and hyperlipidemia, but
denies hematuria. Which syndrome is the most likely diagnosis?
A. Nephrotic syndrome
B. Minimal change disease
C. Nephritic syndrome
D. Membranoproliferative glomerulonephritis
Question 80: Which symptom is more commonly associated with ulcerative colitis compared to Crohn's
disease?
A. Bloody diarrhea present continuously throughout the colon
B. Perianal disease including fistulas and abscesses
C. Weight loss and malnutrition
D. Non-bloody diarrhea that is intermittent and colicky
Question 81: During a routine health screening, a patient reports mild, intermittent right upper quadrant
pain, and ultrasound reveals gallstones but no inflammation. What is the most appropriate management?
A. Observation and dietary modification
B. Urgent surgical consultation
C. Pharmacological therapy with ursodeoxycholic acid
D. Elective cholecystectomy
Question 82: What is the likely diagnosis for a patient presenting to the emergency room with coffee-
ground emesis and a history of NSAID use?
A. Peptic ulcer disease
B. Esophageal varices
C. Gastric cancer
D. Mallory-Weiss tear
Question 83: A 25-year-old male presents with hematuria and flank pain two days after a viral upper
respiratory infection. What is the most likely diagnosis based on the patient's presentation and history?
A. Membranous nephropathy
B. Post-streptococcal glomerulonephritis
C. Minimal change disease
D. IgA nephropathy
Question 84: A patient with a history of peptic ulcer disease reports severe abdominal pain, and upon
examination, the physician notes signs of shock and rigid abdomen. What is the most likely diagnosis?
A. Gastric cancer
B. Gastrointestinal bleeding
C. Acute pancreatitis
D. Perforation leading to chemical peritonitis
Question 85: For a 58-year-old man with multiple small tubular adenomas on his last screening
colonoscopy, what is the recommended interval for his next colonoscopy?
A. 5 years
B. 10 years
C. 3 years
D. 7 years
Question 86: In the case of postrenal acute kidney injury, what is the most common underlying cause?
A. Polycystic kidney disease
B. Renal artery stenosis
C. Nephrolithiasis
D. Obstruction due to benign prostatic hyperplasia
Question 87: For a patient admitted with nausea and muscle weakness, and blood tests revealing
hyperkalemia, what would be the most urgent initial treatment?
A. Use of loop diuretics
B. Administration of sodium polystyrene sulfonate
C. Immediate administration of calcium gluconate
D. Oral administration of potassium-binding agents
Question 88: What potential serious complication of peptic ulcer disease requires immediate surgical
intervention?
A. Gastric cancer arising from long-standing ulcerative disease
B. Development of a gastric outlet obstruction
C. Bleeding from the ulcer requiring blood transfusion
D. Perforation of the ulcer leading to peritoneal contamination
Question 89: Which diagnostic test is crucial for distinguishing between Type I and Type II RTA?
A. Serum electrolyte panel
B. Urinary anion gap measurement
C. Renal ultrasound
D. Blood urea nitrogen (BUN) and creatinine levels
Question 90: A 30-year-old presents with intermittent bloody diarrhea and abdominal pain. Colonoscopy
shows patchy inflammation and skip lesions. What is the most likely diagnosis?
A. Ischemic colitis
B. Crohn's disease
C. Infectious colitis
D. Ulcerative colitis
Question 91: What is the recommended first-line antibiotic therapy for uncomplicated cystitis in a non-
pregnant, otherwise healthy 25-year-old female?
A. Trimethoprim-sulfamethoxazole for ten days
B. Nitrofurantoin for five days
C. Ciprofloxacin for three days
D. Amoxicillin for seven days
Question 92: For someone with a history of struvite stones, which intervention is most effective in
preventing recurrence?
A. Dietary modification to reduce protein intake
B. Surgical removal of stones
C. Reducing dietary oxalate
D. Aggressive management of urinary tract infections
Question 93: During a colonoscopy, a 1.5 cm sessile polyp is found in the descending colon of a 60-year-
old male. What is the most appropriate next step in management?
A. Administer a therapeutic dose of a chemopreventive agent and monitor
B. Schedule an immediate surgical consultation
C. Endoscopic mucosal resection and pathology review
D. Apply endoscopic tattooing near the polyp
Question 94: What diagnostic feature is most indicative of Crohn's disease rather than ulcerative colitis
when viewing an endoscopy?
A. Continuous colonic involvement without skip lesions
B. Patchy areas of inflammation with healthy tissue in between
C. Continuous inflammation starting from the rectum and extending upwards
D. Granulomas on biopsy
Question 95: Which of the following laboratory findings is typically present in a patient with Type II
RTA?
A. Elevated serum potassium levels
B. Reduced urine specific gravity
C. High anion gap metabolic acidosis
D. Normal anion gap metabolic acidosis with hyperchloremia
Question 96: What genetic condition is most commonly associated with cystine stones in a 30-year-old
patient?
A. Sickle cell disease
B. Hyperoxaluria
C. Renal tubular acidosis
D. Cystinuria
Question 97: For a 30-year-old patient presenting with symptoms of bloating and abdominal discomfort
that worsen after eating large meals, what is the most appropriate initial management strategy?
A. Advise smaller, more frequent meals
B. Immediate referral for psychological counseling
C. Prescribe a course of broad-spectrum antibiotics
D. Schedule for a full abdominal ultrasound
Question 98: Which medication is commonly used to treat hepatic encephalopathy by lowering ammonia
levels?
A. Lactulose
B. Oral rifaximin
C. Neomycin
D. Probiotics
Question 99: According to Rome IV criteria, what is one major criterion for diagnosing IBS?
A. Improvement of pain with medication
B. Improvement of pain with exercise
C. Improvement of pain with defecation
D. Improvement of pain with sleep
Question 100: What is the most effective imaging study for diagnosing cholelithiasis?
A. MRI of the abdomen
B. Ultrasound of the abdomen
C. Hepatobiliary iminodiacetic acid (HIDA) scan
D. CT scan of the abdomen

Correct Answers & Explanations

Question 1
B) Renal and bladder ultrasound (Correct Answer)
Explanation: Renal and bladder ultrasound is the recommended initial imaging study for pediatric patients
after their first febrile urinary tract infection. It's non-invasive, doesn't use radiation, and can detect
structural abnormalities, hydronephrosis, or renal scarring. Voiding cystourethrogram is more invasive
and typically reserved for specific indications or recurrent infections.
Question 2
A) Acute pancreatitis (Correct Answer)
Explanation: Severe epigastric pain radiating to the back, accompanied by nausea and vomiting in a 53-
year-old patient is most consistent with acute pancreatitis. This condition often presents with these classic
symptoms, and the radiation to the back is particularly characteristic of pancreatic inflammation.
Question 3
D) Carbonic acid-bicarbonate system (Correct Answer)
Explanation: The carbonic acid-bicarbonate system is the primary buffer system in blood that quickly
responds to pH changes within minutes. It's the most important extracellular buffer due to its efficiency
and the ability of the lungs to rapidly adjust CO2 levels, allowing for quick pH regulation.
Question 4
A) Spironolactone with or without furosemide (Correct Answer)
Explanation: Spironolactone, an aldosterone antagonist, with or without furosemide, a loop diuretic, is
considered first-line treatment for managing ascites in patients with cirrhosis. This combination
effectively promotes sodium and fluid excretion, reducing ascites while maintaining potassium balance.
Question 5
A) Initiate diuretic therapy and investigate underlying causes (Correct Answer)
Explanation: The most appropriate next step in managing a patient presenting with symptoms of nephrotic
syndrome is to initiate diuretic therapy to manage edema and investigate underlying causes. This approach
addresses immediate symptoms while working to identify and treat the root cause of the condition.
Question 6
B) Struvite stones (Correct Answer)
Explanation: Struvite stones are typically associated with a urinary pH above 7.0. These stones form in
alkaline urine and are composed of magnesium ammonium phosphate. They are often caused by urinary
tract infections with urea-splitting bacteria that raise urine pH. Uric acid stones form in acidic urine (pH
< 5.5), while calcium oxalate and calcium phosphate stones can form in various pH ranges.
Question 7
A) Oral antiviral agents such as tenofovir or entecavir (Correct Answer)
Explanation: Oral antiviral agents like tenofovir and entecavir are the preferred first-line treatments for
chronic Hepatitis B. These drugs effectively suppress viral replication, reduce liver inflammation, and
slow disease progression. They have a high barrier to resistance and are well-tolerated for long-term use.
Interferon injections are less commonly used due to side effects and limited efficacy in many patients.
Question 8
C) Less than 130/80 (Correct Answer)
Explanation: The target blood pressure for patients with chronic kidney disease is generally less than
130/80 mmHg. This lower target is recommended to slow disease progression and reduce cardiovascular
risk. Recent guidelines, including those from KDIGO, suggest aiming for this lower target in most CKD
patients, especially those with albuminuria.
Question 9
C) 24-hour esophageal pH monitoring (Correct Answer)
Explanation: 24-hour esophageal pH monitoring is considered the most accurate diagnostic tool for
confirming GERD in patients with ambiguous symptoms. This test measures acid exposure in the
esophagus over an extended period, providing objective data on reflux episodes and their correlation
with symptoms. It's particularly useful when other tests are inconclusive or when symptoms persist
despite empiric treatment.
Question 10
B) Hepatic encephalopathy (Correct Answer)
Explanation: Hepatic encephalopathy is the most likely condition in a cirrhotic patient displaying altered
mental status and a flapping tremor (asterixis). This neuropsychiatric complication of cirrhosis results
from the liver's inability to remove toxins from the blood, leading to brain dysfunction. The flapping
tremor is a characteristic sign of hepatic encephalopathy and is not typically seen in the other listed
conditions.
Question 11
C) Inability of the distal tubule to secrete hydrogen ions (Correct Answer)
Explanation: The primary defect in Type I (distal) renal tubular acidosis is the inability of the distal
tubule to secrete hydrogen ions. This results in impaired acid excretion and an inability to lower urine pH
below 5.5, even in the presence of systemic acidosis. This defect leads to persistent metabolic acidosis
and often hypercalciuria and hypokalemia.
Question 12
B) Impaired glucose control (Correct Answer)
Explanation: Impaired glucose control is the most likely factor contributing to recurrent UTIs in a 58-
year-old male with type 2 diabetes mellitus. Poorly controlled blood glucose can lead to increased
urinary glucose, which provides a favorable environment for bacterial growth. It can also impair immune
function, making it harder for the body to fight off infections. While an enlarged prostate is common in this
age group, impaired glucose control is more directly linked to recurrent UTIs in diabetic patients.
Question 13
B) 45 years (Correct Answer)
Explanation: According to recent US guidelines, including those from the U.S. Preventive Services Task
Force (USPSTF) and the American Cancer Society, the recommended age to begin routine colon cancer
screening for average-risk individuals is now 45 years. This change from the previous recommendation of
50 years was made due to increasing rates of colorectal cancer in younger adults.
Question 14
D) Tumor necrosis factor (TNF) inhibitors (Correct Answer)
Explanation: Tumor necrosis factor (TNF) inhibitors are commonly used to manage severe Crohn's
disease and control inflammation. These biologic agents, such as infliximab, adalimumab, and
certolizumab, target specific inflammatory pathways and are highly effective in inducing and maintaining
remission in severe cases. They are often used when conventional therapies fail or in patients with
aggressive disease presentations.
Question 15
D) Antibiotic therapy alone (Correct Answer)
Explanation: The most appropriate initial treatment for acute cholecystitis is antibiotic therapy alone. This
approach helps to control the infection and inflammation before considering more invasive procedures.
Antibiotics are typically started immediately upon diagnosis, covering common biliary pathogens.
Cholecystectomy is often performed after the acute phase has resolved, usually during the same hospital
admission or within a few weeks, depending on the patient's condition.
Question 16
A) Aldosterone (Correct Answer)
Explanation: In Type IV renal tubular acidosis (RTA), the impaired function of aldosterone is often
related to the underlying problem. Aldosterone plays a crucial role in regulating potassium excretion and
acid-base balance in the distal nephron. In Type IV RTA, there is either a deficiency of aldosterone or
resistance to its effects, leading to hyperkalemia and metabolic acidosis.
Question 17
D) Development of significant ascites (Correct Answer)
Explanation: The most likely cause of sudden onset abdominal girth increase and discomfort in a patient
with cirrhosis is the development of significant ascites. Ascites, the accumulation of fluid in the
peritoneal cavity, is a common complication of cirrhosis due to portal hypertension and
hypoalbuminemia. It can develop rapidly and cause noticeable abdominal distension and discomfort.
Question 18
A) Participating in vigorous physical activity right after meals (Correct Answer)
Explanation: Participating in vigorous physical activity right after meals is the lifestyle modification least
likely to benefit a patient with gastroesophageal reflux disease (GERD). Vigorous exercise soon after
eating can increase intra-abdominal pressure and exacerbate reflux symptoms. The other options, such as
reducing caffeine and alcohol intake, increasing dietary fiber, and avoiding carbonated beverages and
acidic foods, are all recommended lifestyle modifications for GERD management.
Question 19
B) Long-term alcohol consumption (Correct Answer)
Explanation: Long-term alcohol consumption is the most frequent cause of chronic pancreatitis in adults.
Chronic alcohol abuse can lead to recurrent episodes of acute pancreatitis, which over time can progress
to chronic pancreatitis. Alcohol causes direct toxic effects on pancreatic cells and alters the composition
of pancreatic secretions, leading to inflammation and fibrosis of the pancreas.
Question 20
B) Perforation of the gastric or duodenal wall leading to peritonitis (Correct Answer)
Explanation: In a 45-year-old patient with acute upper abdominal pain and a history of NSAID use,
perforation of the gastric or duodenal wall leading to peritonitis is the most likely complication of peptic
ulcer disease. NSAIDs increase the risk of ulcer formation and complications by inhibiting protective
prostaglandins in the gastric mucosa. Perforation is a serious, life-threatening complication that requires
immediate medical attention and often surgical intervention.
Question 21
B) Infection with Helicobacter pylori (Correct Answer)
Explanation: Infection with Helicobacter pylori is the primary cause of peptic ulcer disease in adults. H.
pylori is a bacterium that colonizes the gastric mucosa, leading to chronic inflammation and disruption of
the mucosal barrier. This infection is responsible for the majority of duodenal ulcers and a significant
proportion of gastric ulcers. While NSAIDs are also an important cause, H. pylori infection remains the
most common etiological factor globally.
Question 22
C) Argon plasma coagulation (Correct Answer)
Explanation: Argon plasma coagulation (APC) is the most appropriate treatment approach for a patient
with suspected lower GI bleeding showing angiodysplasia in the colon during endoscopy. APC is a non-
contact thermal coagulation technique that is highly effective for treating vascular lesions like
angiodysplasia. It allows for precise application of thermal energy to stop bleeding and ablate the
abnormal vessels, with a lower risk of perforation compared to other methods.
Question 23
C) Presence of significant proteinuria greater than 3.5 g/day (Correct Answer)
Explanation: The most likely distinguishing feature between nephrotic syndrome and nephritic syndrome
when assessing a patient's urinalysis is the presence of significant proteinuria greater than 3.5 g/day.
Nephrotic syndrome is characterized by massive proteinuria (>3.5 g/day), hypoalbuminemia, edema, and
hyperlipidemia. While nephritic syndrome can also have proteinuria, it is typically less severe and is
accompanied by hematuria, hypertension, and often a decrease in glomerular filtration rate.
Question 24
B) Angiotensin-converting enzyme (ACE) inhibitors (Correct Answer)
Explanation: Angiotensin-converting enzyme (ACE) inhibitors are considered first-line medication for
slowing the progression of chronic kidney disease in patients with proteinuria. ACE inhibitors reduce
intraglomerular pressure, decrease proteinuria, and slow the decline in glomerular filtration rate. They
have been shown to be renoprotective in various types of chronic kidney disease, especially in patients
with significant proteinuria.
Question 25
C) Mutations in the PKD1 gene (Correct Answer)
Explanation: Mutations in the PKD1 gene are the most common genetic mutation associated with
autosomal dominant polycystic kidney disease (ADPKD). PKD1 mutations account for approximately 78-
85% of ADPKD cases. The PKD1 gene encodes for polycystin-1, a protein involved in cell signaling and
mechanosensation in renal tubular cells. Mutations in this gene lead to the characteristic cyst formation
seen in ADPKD.
Question 26
D) Emergency esophagogastroduodenoscopy (EGD) (Correct Answer)
Explanation: For a 60-year-old male presenting with melena, lightheadedness, and a hemoglobin of 7
g/dL, emergency esophagogastroduodenoscopy (EGD) is the most appropriate first diagnostic procedure.
This presentation suggests upper gastrointestinal bleeding, which is best evaluated and potentially treated
with EGD. The low hemoglobin indicates significant blood loss, and melena typically originates from an
upper GI source. EGD allows for direct visualization and potential intervention for bleeding sources in
the esophagus, stomach, or duodenum.
Question 27
B) Insertion of a urinary catheter (Correct Answer)
Explanation: For a 72-year-old male with benign prostatic hyperplasia presenting with flank pain,
difficulty urinating, elevated creatinine, and bilateral hydronephrosis, the most appropriate immediate
intervention is insertion of a urinary catheter. This relieves the acute urinary retention, decompresses the
bladder, and allows for drainage of the obstructed urinary system. It's a crucial first step to prevent further
kidney damage and alleviate symptoms before considering more definitive treatments.
Question 28
B) Combination therapy including amoxicillin, clarithromycin, and a proton pump inhibitor (Correct
Answer)
Explanation: The most appropriate treatment for eradicating Helicobacter pylori in a patient diagnosed
with peptic ulcer disease is combination therapy including amoxicillin, clarithromycin, and a proton pump
inhibitor. This triple therapy is considered the first-line treatment for H. pylori eradication due to its high
efficacy. It combines antibiotics to target the bacteria with a proton pump inhibitor to reduce acid
production and create a more favorable environment for healing and antibiotic action.
Question 29
C) Compression of renal arteries by cysts leading to activation of the renin-angiotensin system (Correct
Answer)
Explanation: In a 40-year-old male with a family history of polycystic kidney disease, the likely
mechanism for hypertension is compression of renal arteries by cysts leading to activation of the renin-
angiotensin system. As cysts grow in polycystic kidney disease, they can compress renal vasculature,
leading to areas of renal ischemia. This triggers the release of renin, activating the renin-angiotensin-
aldosterone system, which in turn causes systemic hypertension.
Question 30
A) Increase fluid intake to achieve at least 2.5 liters of urine output per day (Correct Answer)
Explanation: The primary dietary recommendation to prevent the recurrence of calcium oxalate stones is
to increase fluid intake to achieve at least 2.5 liters of urine output per day. Increased fluid intake dilutes
urine, reducing the concentration of stone-forming substances and decreasing the risk of crystal formation.
This is considered the most effective and universally applicable dietary modification for preventing
kidney stone recurrence.
Question 31
C) Irritable Bowel Syndrome (Correct Answer)
Explanation: The most likely diagnosis for a female patient complaining of recurrent abdominal pain
occurring once per week on average, often relieved by bowel movements, with no alarming features, is
Irritable Bowel Syndrome (IBS). This presentation aligns with the Rome criteria for IBS, which include
recurrent abdominal pain associated with defecation or changes in bowel habits, in the absence of alarm
features. The periodic nature and relief with bowel movements are characteristic of IBS.
Question 32
B) High fever (Correct Answer)
Explanation: High fever is less commonly associated with urinary tract infections in elderly patients.
UTIs in the elderly often present atypically, with nonspecific symptoms such as confusion, incontinence,
or changes in mobility. While fever can occur, it's less reliable as a symptom in this population. The other
symptoms listed (urinary incontinence, suprapubic pain, and acute confusion) are more commonly seen in
elderly patients with UTIs.
Question 33
A) Supportive care with antihypertensives and diuretics (Correct Answer)
Explanation: The most appropriate initial treatment for post-streptococcal glomerulonephritis in a 10-
year-old boy presenting with edema, hematuria, and hypertension two weeks after a sore throat is
supportive care with antihypertensives and diuretics. Post-streptococcal glomerulonephritis is typically
self-limiting, and management focuses on controlling symptoms and complications. Antihypertensives
address high blood pressure, while diuretics help manage edema. Antibiotics are not necessary at this
stage as the initial infection has already resolved.
Question 34
C) Urine culture and sensitivity (Correct Answer)
Explanation: The most appropriate test to confirm the diagnosis of a urinary tract infection in a 32-year-
old pregnant woman is urine culture and sensitivity. This test not only confirms the presence of bacteria
but also identifies the specific organism and its antibiotic sensitivities. This is crucial in pregnancy to
guide appropriate antibiotic therapy, as certain antibiotics are contraindicated during pregnancy. Urine
culture is the gold standard for diagnosing UTIs, especially important in pregnancy due to potential
complications.
Question 35
D) Hematuria (Correct Answer)
Explanation: The clinical hallmark of nephritic syndrome is hematuria. While hypertension, edema, and
proteinuria are often present in nephritic syndrome, hematuria (blood in the urine) is the most
characteristic and consistent finding. It's typically microscopic but can sometimes be visible (gross
hematuria). The presence of red blood cells in the urine reflects the inflammatory nature of the glomerular
injury in nephritic syndrome.
Question 36
D) 25 years (Correct Answer)
Explanation: For individuals with a first-degree relative who had colon cancer at age 45, screening
should begin at 25 years of age or 10 years before the age at which the relative was diagnosed, whichever
comes first. In this case, since the relative was diagnosed at 45, screening should start at 35 (45 minus
10). However, since 25 is earlier than 35, screening should begin at 25 years of age. This earlier
screening is recommended due to the increased risk associated with a family history of early-onset
colorectal cancer.
Question 37
A) Rupture of a kidney cyst (Correct Answer)
Explanation: The most likely cause of severe flank pain in a patient with a known diagnosis of polycystic
kidney disease during a routine examination is rupture of a kidney cyst. Cyst rupture is a common
complication in polycystic kidney disease and can cause sudden, severe pain. This can occur
spontaneously or with minimal trauma. While other options like stone formation or infection are possible,
they are less likely to cause such sudden, severe pain during a routine examination.
Question 38
A) Resuscitation (Correct Answer)
Explanation: In the management of acute lower gastrointestinal bleeding to prevent hemodynamic
instability, resuscitation is the crucial immediate treatment. This involves rapid assessment and
stabilization of the patient's airway, breathing, and circulation (ABC). Fluid resuscitation with
intravenous fluids is essential to maintain blood pressure and organ perfusion. While monitoring, fluid
therapy, and blood transfusion are important, they are part of the resuscitation process, which is the
primary and most urgent step.
Question 39
B) Secondary hyperparathyroidism (Correct Answer)
Explanation: The likely cause of hypocalcemia in a 60-year-old man with chronic kidney disease
presenting with tingling in his hands is secondary hyperparathyroidism. In chronic kidney disease,
decreased kidney function leads to reduced activation of vitamin D and phosphate retention. This results
in decreased calcium absorption and increased parathyroid hormone (PTH) secretion. Despite elevated
PTH levels, hypocalcemia persists due to resistance to PTH action and impaired vitamin D metabolism,
leading to symptoms like tingling in the hands.
Question 40
D) Prescription of a high-dose proton pump inhibitor and follow-up endoscopy (Correct Answer)
Explanation: For a 40-year-old male with chronic heartburn resistant to over-the-counter antacids being
evaluated for GERD, the best management strategy is prescription of a high-dose proton pump inhibitor
and follow-up endoscopy. Proton pump inhibitors are the most effective medication for reducing acid
production and treating GERD symptoms. A high-dose regimen is appropriate for patients with persistent
symptoms. Follow-up endoscopy is important to assess treatment response and rule out complications like
Barrett's esophagus, especially in a patient with chronic, resistant symptoms.
Question 41
A) Ulcerative colitis (Correct Answer)
Explanation: The most likely diagnosis for a patient presenting with abdominal pain, diarrhea, and a
sigmoidoscopy showing continuous inflammation and ulcers limited to the mucosa is ulcerative colitis.
The key features supporting this diagnosis are the continuous nature of the inflammation and its limitation
to the mucosa. Ulcerative colitis typically presents with these endoscopic findings, in contrast to Crohn's
disease which often shows skip lesions and can affect all layers of the bowel wall.
Question 42
A) Rapid correction of sodium with hypertonic saline (Correct Answer)
Explanation: In the initial management of a patient presenting with confusion and a serum sodium level of
128 mEq/L, rapid correction of sodium with hypertonic saline should be avoided. Rapid correction of
chronic hyponatremia can lead to osmotic demyelination syndrome, a serious neurological complication.
The safe rate of sodium correction is generally no more than 6-8 mEq/L in 24 hours. Initial management
should focus on a slower, controlled correction of sodium levels while addressing the underlying cause.
Question 43
A) Metabolic alkalosis (Correct Answer)
Explanation: The acid-base status of a patient with vomiting and a subsequent blood gas of pH 7.55,
PaCO2 of 42 mmHg, and bicarbonate of 32 mEq/L is metabolic alkalosis. The elevated pH (>7.45)
indicates alkalosis. The high bicarbonate level (>26 mEq/L) points to a metabolic cause. The PaCO2 is
within normal range, suggesting no significant respiratory compensation. Vomiting is a common cause of
metabolic alkalosis due to loss of gastric acid.
Question 44
C) PKHD1 (Correct Answer)
Explanation: The gene typically mutated in autosomal recessive polycystic kidney disease (ARPKD) is
PKHD1. This gene encodes for fibrocystin, a protein involved in ciliary function in renal tubular
epithelial cells. Mutations in PKHD1 lead to the development of cysts in the kidneys and often liver
fibrosis, characteristic of ARPKD. This is distinct from autosomal dominant polycystic kidney disease,
which is associated with mutations in PKD1 or PKD2 genes.
Question 45
D) Discontinuation of NSAIDs and careful monitoring of renal function (Correct Answer)
Explanation: For a 55-year-old woman presenting with acute kidney injury after starting NSAIDs for
chronic joint pain, the most appropriate next step in management is discontinuation of NSAIDs and careful
monitoring of renal function. NSAIDs can cause acute kidney injury by reducing renal blood flow and
glomerular filtration rate. Stopping the offending agent is crucial to prevent further damage. Careful
monitoring of renal function is necessary to assess recovery and guide further management.
Question 46
A) Intravenous fluid hydration (Correct Answer)
Explanation: In the immediate management of acute pancreatitis, intravenous fluid hydration is often
included as a crucial treatment. Aggressive fluid resuscitation is essential in the early stages of acute
pancreatitis to maintain intravascular volume, support organ perfusion, and prevent complications like
pancreatic necrosis. It helps combat the hypovolemia caused by third-spacing of fluids, vomiting, and
reduced oral intake. Other options like antibiotics or ERCP are not routinely used in the immediate
management unless specific indications are present.
Question 47
B) Acute cholecystitis (Correct Answer)
Explanation: The most likely diagnosis for a 45-year-old patient presenting with severe right upper
quadrant pain, fever, and leukocytosis after eating a fatty meal is acute cholecystitis. This classic
presentation - right upper quadrant pain exacerbated by fatty food, along with fever and elevated white
blood cell count - strongly suggests inflammation of the gallbladder. Acute cholecystitis is often triggered
by obstruction of the cystic duct, commonly by gallstones, leading to inflammation and potential infection
of the gallbladder.
Question 48
A) Proton pump inhibitors (Correct Answer)
Explanation: Proton pump inhibitors (PPIs) are commonly used as an initial treatment for GERD to reduce
acid production. PPIs are the most potent suppressors of gastric acid secretion available, working by
irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump in gastric parietal cells. They
are more effective than H2 receptor antagonists in treating GERD symptoms and healing esophagitis. PPIs
provide longer-lasting and more complete acid suppression, making them the first-line medication for
GERD treatment.
Question 49
D) Prerenal acute kidney injury due to hypoperfusion (Correct Answer)
Explanation: In a 68-year-old male with a history of heart failure, presenting with low blood pressure and
an elevated BUN/creatinine ratio, the most likely type of acute kidney injury is prerenal acute kidney
injury due to hypoperfusion. The history of heart failure, combined with low blood pressure, suggests
decreased cardiac output leading to renal hypoperfusion. The elevated BUN/creatinine ratio is
characteristic of prerenal AKI, reflecting increased reabsorption of urea in the setting of decreased renal
perfusion.
Question 50
C) Development of liver cysts (Correct Answer)
Explanation: A common complication of polycystic kidney disease affecting organs other than the kidneys
is the development of liver cysts. Polycystic kidney disease, especially the autosomal dominant form
(ADPKD), is a systemic disorder that can affect multiple organs. Liver cysts are the most common extra-
renal manifestation, occurring in up to 75-90% of patients with ADPKD. These cysts are typically
asymptomatic but can occasionally cause complications such as pain, infection, or rarely, hepatic
dysfunction.
Question 51
B) Ultrasound of the abdomen (Correct Answer)
Explanation: Ultrasound is considered the most effective and first-line imaging study for identifying
cholelithiasis. It has high specificity (>98%) and sensitivity (>95%) for detecting gallstones, is
inexpensive, non-invasive, and provides anatomic information about the gallbladder and surrounding
structures.
Question 52
B) Potassium citrate (Correct Answer)
Explanation: Potassium citrate is typically used as the first-line pharmacological treatment for uric acid
stones. It works by alkalinizing the urine, which helps dissolve existing uric acid stones and prevent the
formation of new ones. Allopurinol is used to reduce uric acid production but is not the first-line
treatment for existing stones.
Question 53
B) Complete polypectomy followed by surveillance colonoscopy in 3 years (Correct Answer)
Explanation: For a 2 cm adenomatous polyp discovered during screening colonoscopy, the recommended
management is complete polypectomy followed by surveillance colonoscopy in 3 years. This approach
allows for removal of the potentially precancerous lesion and appropriate follow-up to monitor for
recurrence or new polyps.
Question 54
B) Refer to a nephrologist for early initiation of dialysis planning and further management (Correct
Answer)
Explanation: For a 70-year-old male with stage 4 CKD and declining GFR, the recommended next step is
to refer to a nephrologist for early initiation of dialysis planning and further management. This allows for
timely preparation for potential renal replacement therapy and comprehensive management of CKD
complications.
Question 55
B) Angiodysplasia (Correct Answer)
Explanation: In a patient with hematochezia and a history of aortic valve replacement, angiodysplasia is
the most probable source of GI bleeding. This condition, known as Heyde's syndrome, is associated with
aortic stenosis and is characterized by bleeding from intestinal angiodysplasias.
Question 56
A) Supportive care as it usually resolves spontaneously (Correct Answer)
Explanation: For most patients who test positive for Hepatitis E during a routine check-up, supportive
care is the most appropriate management as the infection usually resolves spontaneously. Hepatitis E is
typically self-limiting in immunocompetent individuals and does not require specific antiviral treatment in
most cases.
Question 57
C) Immunoglobulin A (Correct Answer)
Explanation: The characteristic finding in IgA nephropathy that leads to recurrent episodes of gross
hematuria is the deposition of Immunoglobulin A in the glomerular mesangium. This immune complex
deposition triggers inflammation and damage to the glomeruli, resulting in hematuria.
Question 58
D) Oral administration of sodium bicarbonate or sodium citrate to correct acidosis (Correct Answer)
Explanation: The optimal initial treatment for a child diagnosed with Type I RTA is oral administration of
sodium bicarbonate or sodium citrate to correct acidosis. This helps neutralize the excess acid in the
blood and urine, addressing the primary defect in Type I RTA, which is impaired distal tubular acid
secretion.
Question 59
D) Stage 3B chronic kidney disease (Correct Answer)
Explanation: According to CKD staging guidelines, a 65-year-old male with a GFR of 35 mL/min/1.73 m²
is classified as having Stage 3B chronic kidney disease. Stage 3 is divided into 3A (GFR 45-59) and 3B
(GFR 30-44), and this patient's GFR falls within the 3B range.
Question 60
C) Direct-acting antivirals like sofosbuvir and velpatasvir (Correct Answer)
Explanation: The current standard treatment for Hepatitis C is direct-acting antivirals (DAAs) like
sofosbuvir and velpatasvir. These medications have high cure rates, shorter treatment durations, and
fewer side effects compared to older interferon-based therapies. DAAs have revolutionized Hepatitis C
treatment in recent years.
Question 61
D) Post-streptococcal glomerulonephritis (Correct Answer)
Explanation: The most likely cause of kidney injury in a 30-year-old woman presenting with fatigue, dark
urine, and swelling after a streptococcal skin infection is post-streptococcal glomerulonephritis. This
condition typically develops 1-3 weeks after a streptococcal infection and is characterized by the
symptoms described.
Question 62
A) Increased resistance to portal blood flow due to fibrosis and regenerative nodules (Correct Answer)
Explanation: The main factor causing portal hypertension in cirrhosis is increased resistance to portal
blood flow due to fibrosis and regenerative nodules. This structural change in the liver architecture leads
to increased intrahepatic vascular resistance, which is the primary mechanism of portal hypertension in
cirrhosis.
Question 63
B) Administer hypertonic saline promptly (Correct Answer)
Explanation: For a patient with severe hyponatremia presenting with seizures, the most appropriate
intervention is to administer hypertonic saline promptly. This rapid correction is necessary to address the
life-threatening neurological symptoms associated with severe hyponatremia and reduce the risk of
cerebral edema.
Question 64
B) Laparoscopic cholecystectomy (Correct Answer)
Explanation: The typically recommended treatment approach for symptomatic cholelithiasis is
laparoscopic cholecystectomy. This minimally invasive surgical procedure is considered the gold
standard for treating symptomatic gallstones as it provides definitive treatment by removing the
gallbladder, thus preventing future stone formation and associated complications.
Question 65
C) Initiate a course of corticosteroids (Correct Answer)
Explanation: For a 14-year-old boy with nephritic syndrome, joint pain, rash, and IgA deposits on kidney
biopsy, the most appropriate next step is to initiate a course of corticosteroids. This treatment helps
reduce inflammation and immune-mediated damage in IgA nephropathy, particularly in patients with
active disease and proteinuria.
Question 66
D) Recommend a low-sodium diet (Correct Answer)
Explanation: For a 58-year-old woman with chronic kidney disease (GFR 28 mL/min/1.73 m²) and
hypertension managed with ACE inhibitors, recommending a low-sodium diet is an important additional
lifestyle modification. Reducing sodium intake helps control blood pressure, reduces fluid retention, and
can slow the progression of kidney disease.
Question 67
B) Increase dietary fiber intake (Correct Answer)
Explanation: The typical first-line dietary recommendation for managing symptoms in a patient diagnosed
with IBS is to increase dietary fiber intake. Fiber can help regulate bowel movements, reduce
constipation, and alleviate some IBS symptoms. However, it's important to introduce fiber gradually to
avoid exacerbating symptoms.
Question 68
A) Intravenous calcium gluconate (Correct Answer)
Explanation: The primary treatment for hyperkalemia with ECG changes is intravenous calcium gluconate.
This rapidly counteracts the cardiac effects of hyperkalemia by stabilizing the myocardial cell membrane,
reducing the risk of life-threatening arrhythmias. It's the most urgent intervention when ECG changes are
present.
Question 69
C) Administration of antivirals that target Hepatitis B (Correct Answer)
Explanation: For a patient diagnosed with co-infection of Hepatitis B and D, the essential treatment
strategy is the administration of antivirals that target Hepatitis B. This is because Hepatitis D virus
requires Hepatitis B virus for its replication. By suppressing Hepatitis B, you indirectly control Hepatitis
D replication.
Question 70
D) Respiratory alkalosis (Correct Answer)
Explanation: During an asthma exacerbation, a patient's arterial blood gas showing a pH of 7.50 and a
low PaCO2 indicates respiratory alkalosis. This is due to hyperventilation associated with asthma, which
leads to excessive elimination of CO2, resulting in an increased pH and decreased PaCO2.
Question 71
B) Hepatitis A (Correct Answer)
Explanation: Hepatitis A is the hepatitis virus that is mainly transmitted through fecal-oral contamination
and lacks a chronic phase. It is an acute, self-limiting infection that does not progress to chronic liver
disease, unlike Hepatitis B, C, or D.
Question 72
C) At least once a week (Correct Answer)
Explanation: According to the Rome IV criteria for diagnosing irritable bowel syndrome, abdominal pain
must be associated with defecation at least once a week. This frequency criterion helps differentiate IBS
from other functional gastrointestinal disorders and ensures that the symptoms are recurring and not just
occasional.
Question 73
A) Chronic pancreatitis (Correct Answer)
Explanation: A patient presenting with weight loss, diabetes, and calcification in the abdomen on an X-
ray suggests a diagnosis of chronic pancreatitis. Pancreatic calcifications are a hallmark of chronic
pancreatitis, and the condition can lead to both weight loss due to malabsorption and diabetes due to
damage to the insulin-producing cells.
Question 74
B) Increased renal bicarbonate reabsorption (Correct Answer)
Explanation: In a patient with chronic obstructive pulmonary disease who develops respiratory acidosis,
the most likely compensatory mechanism is increased renal bicarbonate reabsorption. This is a key renal
response to chronic respiratory acidosis, helping to partially correct the pH by retaining more bicarbonate
to buffer the excess acid.
Question 75
A) Administration of intravenous calcium gluconate (Correct Answer)
Explanation: The first-line management strategy for hyperkalemia in a patient with acute kidney injury to
prevent life-threatening complications is the administration of intravenous calcium gluconate. This rapidly
stabilizes cardiac cell membranes, reducing the risk of arrhythmias, which is the most immediate threat in
severe hyperkalemia.
Question 76:
A) Elevation of the head of the bed and avoiding meals before bedtime (Correct Answer)
Explanation: For patients with symptoms of gastroesophageal reflux disease (GERD) such as
regurgitation and chest pain exacerbated by lying down, initial management should focus on lifestyle
modifications. Elevating the head of the bed by 6-8 inches and avoiding meals 2-3 hours before bedtime
are effective non-pharmacological interventions that can significantly reduce reflux symptoms by utilizing
gravity to prevent stomach contents from flowing back into the esophagus.
Question 77:
A) CT scan with contrast (Correct Answer)
Explanation: Contrast-enhanced CT is the most commonly employed and preferred imaging technique for
diagnosing acute pancreatitis. It offers high sensitivity and specificity for pancreatic inflammation,
necrosis, and complications. CT can quickly and accurately assess the severity of pancreatitis, identify
local complications, and guide treatment decisions. It is widely available and provides excellent
visualization of pancreatic and peripancreatic structures.
Question 78:
C) Post-streptococcal glomerulonephritis (Correct Answer)
Explanation: The presentation of a young adult with recent history of sore throat, followed by hematuria,
hypertension, and proteinuria is highly suggestive of post-streptococcal glomerulonephritis (PSGN).
PSGN typically occurs 1-3 weeks after a streptococcal throat infection and is characterized by the classic
triad of hematuria, edema, and hypertension. The recent history of sore throat and the timing of symptom
onset strongly support this diagnosis.
Question 79:
A) Nephrotic syndrome (Correct Answer)
Explanation: The presentation of significant edema, proteinuria, and hyperlipidemia without hematuria is
characteristic of nephrotic syndrome. This condition is defined by massive proteinuria (>3.5g/day),
hypoalbuminemia, edema, and hyperlipidemia. The absence of hematuria distinguishes it from nephritic
syndrome, and the combination of symptoms points towards nephrotic syndrome rather than other specific
glomerular diseases.
Question 80:
A) Bloody diarrhea present continuously throughout the colon (Correct Answer)
Explanation: Ulcerative colitis is characterized by continuous inflammation of the colon, typically starting
from the rectum and extending proximally. Bloody diarrhea that is present continuously throughout the
affected areas of the colon is a hallmark symptom of ulcerative colitis. In contrast, Crohn's disease often
presents with patchy, discontinuous inflammation (skip lesions) and may involve any part of the
gastrointestinal tract, with less frequent bloody diarrhea.
Question 81:
A) Observation and dietary modification (Correct Answer)
Explanation: For asymptomatic or mildly symptomatic gallstones discovered incidentally during routine
screening, the most appropriate initial management is observation and dietary modification. This
approach, known as "watchful waiting," is recommended because many patients with asymptomatic
gallstones never develop complications. Dietary modifications, such as reducing fat intake, can help
manage symptoms and potentially reduce the risk of complications.
Question 82:
A) Peptic ulcer disease (Correct Answer)
Explanation: A patient presenting with coffee-ground emesis (indicative of upper gastrointestinal
bleeding) and a history of NSAID use is most likely suffering from peptic ulcer disease. NSAIDs are a
common cause of gastric and duodenal ulcers due to their inhibition of protective prostaglandins in the
gastric mucosa. The presentation of coffee-ground emesis suggests a bleeding ulcer, which is a common
complication of peptic ulcer disease, especially in the context of NSAID use.
Question 83:
D) IgA nephropathy (Correct Answer)
Explanation: The presentation of hematuria and flank pain shortly after an upper respiratory infection in a
young adult is highly suggestive of IgA nephropathy. This condition, also known as Berger's disease, is
characterized by episodes of visible or microscopic hematuria that often occur concurrently with or
shortly after upper respiratory tract infections. The short interval (two days) between the infection and
symptom onset is more consistent with IgA nephropathy than post-streptococcal glomerulonephritis,
which typically has a longer latency period.
Question 84:
D) Perforation leading to chemical peritonitis (Correct Answer)
Explanation: In a patient with a history of peptic ulcer disease presenting with severe abdominal pain,
signs of shock, and a rigid abdomen, the most likely diagnosis is perforation leading to chemical
peritonitis. Peptic ulcer perforation is a life-threatening complication where the ulcer erodes through the
full thickness of the stomach or duodenal wall, allowing gastric contents to spill into the peritoneal cavity.
This results in chemical peritonitis, characterized by severe abdominal pain, board-like rigidity of the
abdomen, and signs of shock due to the inflammatory response and fluid shifts.
Question 85:
C) 3 years (Correct Answer)
Explanation: For a patient with multiple small tubular adenomas found on a previous screening
colonoscopy, the recommended interval for the next colonoscopy is 3 years. This recommendation is
based on guidelines for colonoscopy surveillance after polypectomy. Multiple adenomas, even if small,
indicate an increased risk for developing advanced neoplasia, warranting closer surveillance than the
standard 10-year interval for average-risk individuals.
Question 86:
D) Obstruction due to benign prostatic hyperplasia (Correct Answer)
Explanation: In cases of postrenal acute kidney injury, the most common underlying cause is obstruction
due to benign prostatic hyperplasia (BPH), especially in older male patients. BPH can lead to urinary
retention and obstruction of both ureters, resulting in a rapid decline in kidney function. This condition is
particularly prevalent in men over 50 and is a frequent cause of urinary obstruction leading to acute
kidney injury.
Question 87:
C) Immediate administration of calcium gluconate (Correct Answer)
Explanation: For a patient presenting with hyperkalemia, especially if associated with symptoms or ECG
changes, the most urgent initial treatment is the immediate administration of calcium gluconate. Calcium
gluconate acts rapidly to stabilize cardiac cell membranes, reducing the risk of life-threatening
arrhythmias associated with hyperkalemia. This intervention is crucial to protect the heart while other
measures to lower potassium levels are implemented.
Question 88:
D) Perforation of the ulcer leading to peritoneal contamination (Correct Answer)
Explanation: Among the complications of peptic ulcer disease, perforation leading to peritoneal
contamination is the one that requires immediate surgical intervention. Perforation allows gastric or
duodenal contents to spill into the peritoneal cavity, causing chemical peritonitis and potentially leading
to sepsis if not addressed promptly. This condition presents as an acute abdomen and is a surgical
emergency requiring immediate exploration and repair of the perforation.
Question 89:
B) Urinary anion gap measurement (Correct Answer)
Explanation: The urinary anion gap measurement is crucial for distinguishing between Type I (distal) and
Type II (proximal) renal tubular acidosis (RTA). In Type I RTA, the urinary anion gap is positive due to
impaired H+ secretion, while in Type II RTA, it is typically negative or near zero due to bicarbonate
wasting. This test helps differentiate the underlying defect in acid-base regulation and is more specific
than serum electrolytes or other routine tests in distinguishing between these two types of RTA.
Question 90:
B) Crohn's disease (Correct Answer)
Explanation: The presentation of intermittent bloody diarrhea and abdominal pain, combined with
colonoscopy findings of patchy inflammation and skip lesions, is highly indicative of Crohn's disease.
Crohn's disease is characterized by transmural inflammation that can affect any part of the gastrointestinal
tract, often in a discontinuous pattern (skip lesions). This patchy distribution distinguishes it from
ulcerative colitis, which typically presents with continuous inflammation starting from the rectum.
Question 91:
B) Nitrofurantoin for five days (Correct Answer)
Explanation: For uncomplicated cystitis in a non-pregnant, otherwise healthy young female, the
recommended first-line antibiotic therapy is nitrofurantoin for five days. This recommendation is based
on its effectiveness against common uropathogens, low risk of resistance, and minimal impact on normal
gut flora. Nitrofurantoin achieves high concentrations in the urinary tract with minimal systemic
absorption, making it an ideal choice for uncomplicated urinary tract infections.
Question 92:
D) Aggressive management of urinary tract infections (Correct Answer)
Explanation: For patients with a history of struvite stones, the most effective intervention in preventing
recurrence is aggressive management of urinary tract infections. Struvite stones are formed in the
presence of urease-producing bacteria, typically associated with urinary tract infections. By aggressively
treating and preventing UTIs, the formation of new struvite stones can be significantly reduced. This
approach addresses the underlying cause of stone formation rather than just treating symptoms or existing
stones.
Question 93:
C) Endoscopic mucosal resection and pathology review (Correct Answer)
Explanation: For a 1.5 cm sessile polyp found in the descending colon during colonoscopy, the most
appropriate next step is endoscopic mucosal resection (EMR) followed by pathology review. EMR
allows for complete removal of the polyp with a margin of normal tissue, which is crucial for both
treatment and accurate pathological assessment. This approach provides therapeutic benefit by removing
the potential precancerous lesion and diagnostic information through pathological examination, guiding
further management and surveillance recommendations.
Question 94:
B) Patchy areas of inflammation with healthy tissue in between (Correct Answer)
Explanation: The diagnostic feature most indicative of Crohn's disease rather than ulcerative colitis on
endoscopy is patchy areas of inflammation with healthy tissue in between, also known as skip lesions.
This discontinuous pattern of inflammation is characteristic of Crohn's disease, which can affect any part
of the gastrointestinal tract in a segmental manner. In contrast, ulcerative colitis typically presents with
continuous inflammation starting from the rectum and extending proximally.
Question 95:
D) Normal anion gap metabolic acidosis with hyperchloremia (Correct Answer)
Explanation: In Type II renal tubular acidosis (RTA), the typical laboratory finding is a normal anion gap
metabolic acidosis with hyperchloremia. This occurs due to the proximal tubule's inability to reabsorb
bicarbonate, leading to its loss in the urine. The body compensates by increasing chloride reabsorption,
resulting in hyperchloremia. The anion gap remains normal because the primary defect is bicarbonate loss
rather than the accumulation of unmeasured anions.
Question 96:
D) Cystinuria (Correct Answer)
Explanation: Cystinuria is the genetic condition most commonly associated with cystine stones in young
adults. It is an autosomal recessive disorder characterized by impaired reabsorption of cystine and other
dibasic amino acids in the proximal renal tubule. This leads to excessive urinary excretion of cystine,
which has low solubility and tends to form stones, especially in acidic urine. Cystine stones are relatively
rare but are a hallmark of this genetic disorder.
Question 97:
A) Advise smaller, more frequent meals (Correct Answer)
Explanation: For a patient presenting with symptoms of bloating and abdominal discomfort that worsen
after eating large meals, the most appropriate initial management strategy is to advise smaller, more
frequent meals. This approach helps reduce the volume of food in the stomach at any given time,
potentially easing digestion and reducing the likelihood of bloating and discomfort. It's a simple, non-
invasive lifestyle modification that can significantly improve symptoms for many patients with functional
gastrointestinal disorders.
Question 98:
A) Lactulose (Correct Answer)
Explanation: Lactulose is commonly used to treat hepatic encephalopathy by lowering ammonia levels. It
is a non-absorbable disaccharide that works by acidifying the colon, which traps ammonia as ammonium
and prevents its absorption. Additionally, it has an osmotic laxative effect, promoting the excretion of
ammonia-producing bacteria. Lactulose is considered a first-line treatment for hepatic encephalopathy
due to its effectiveness and relatively low side effect profile.
Question 99:
C) Improvement of pain with defecation (Correct Answer)
Explanation: According to the Rome IV criteria for diagnosing Irritable Bowel Syndrome (IBS), one
major criterion is the improvement of abdominal pain with defecation. This characteristic helps
distinguish IBS from other functional gastrointestinal disorders. The Rome IV criteria emphasize the
relationship between abdominal pain and bowel habits, with pain improvement after defecation being a
key feature in the diagnosis of IBS.
Question 100:
B) Ultrasound of the abdomen (Correct Answer)
Explanation: Ultrasound of the abdomen is considered the most effective imaging study for diagnosing
cholelithiasis (gallstones). It is highly sensitive (>95%) and specific (>98%) for detecting gallstones,
widely available, non-invasive, and does not involve radiation exposure. Ultrasound can visualize stones
as small as 2mm and provides real-time imaging of the gallbladder, bile ducts, and surrounding structures.
It is the preferred initial imaging modality for suspected gallstone disease due to its accuracy, safety, and
cost-effectiveness.
Practice Tests 4
Question 1
How should a pregnant patient with gonorrhea be managed to prevent ophthalmia neonatorum in the
newborn?
A. No specific treatment required; routine newborn care is sufficient
B. Treat with oral metronidazole and provide eye drops at birth
C. Ceftriaxone as a single intramuscular injection and ocular prophylaxis at birth
D. Oral azithromycin followed by topical antibiotic eye drops for the newborn
Question 2
What is the main purpose of methadone maintenance therapy in treating opioid dependence?
A. To provide a legal alternative to illicit drug use that can be closely monitored by healthcare
professionals
B. To increase social stability by administering a substitute medication at a controlled dosage
C. To reduce craving and withdrawal symptoms, and decrease the illicit opioid use
D. To completely detoxify the body from opioids, paving the way for abstinence-based treatments
Question 3
Why is buprenorphine often used in opioid substitution therapy?
A. It has a moderate ceiling effect
B. It has a low ceiling effect
C. It has a high ceiling effect
D. It has a variable ceiling effect
Question 4
What would be the most appropriate next step for evaluating a preschool child who struggles with
understanding non-verbal social cues, has difficulty making friends, and shows repetitive interest in lining
up toys?
A. Consult with the parents to monitor the child over the next six months to see if the behaviors persist
B. Prescribe behavior modification therapy without further assessment to address the behavioral issues
observed
C. Conduct a multidisciplinary assessment including behavioral evaluations and a speech-language
pathologist
D. Enroll the child in social skills training and therapy to help with the observed deficits in interaction
and communication
Question 5
Which condition is a severe complication of preeclampsia that involves hemolysis, elevated liver
enzymes, and low platelet count, requiring immediate delivery as the primary treatment?
A. Eclampsia
B. Acute fatty liver of pregnancy
C. HELLP syndrome
D. Gestational hypertension
Question 6
Which antipsychotic is typically considered first-line for managing positive symptoms of schizophrenia?
A. Clozapine
B. Long-acting injectables
C. First-generation antipsychotics, such as haloperidol
D. Second-generation antipsychotics, like risperidone
Question 7
What is a key hormone involved in most hormonal contraceptive methods?
A. Gonadotropin-releasing hormone
B. Testosterone
C. Progesterone
D. Estrogen
Question 8
According to DSM-5, what is a key diagnostic criterion for Anorexia Nervosa?
A. Recurrent episodes of binge eating without compensatory behaviors
B. Use of laxatives and diuretics to prevent weight gain
C. Presence of medical complications like osteoporosis or amenorrhea
D. Intense fear of gaining weight or becoming fat, even though underweight
Question 9
How long must depressive symptoms persist for a diagnosis of Major Depressive Disorder?
A. Six weeks
B. Four weeks
C. Two weeks
D. Five weeks
Question 10
What is a critical factor to evaluate before prescribing HRT for a 55-year-old woman experiencing
severe hot flashes?
A. She has been postmenopausal for less than 10 years
B. The patient's age exceeds 60 years
C. Presence of a family history of breast cancer
D. Regular use of non-steroidal anti-inflammatory drugs
Question 11
In managing a patient with borderline personality disorder, which therapeutic approach is considered
most beneficial?
A. Dialectical Behavior Therapy (DBT)
B. Psychodynamic Therapy
C. Cognitive Behavioral Therapy (CBT)
D. Supportive Therapy
Question 12
For a patient with a history of eating large amounts of food in secret followed by self-induced vomiting,
what is the first step in a multidisciplinary treatment approach?
A. Start an exercise regimen to improve physical health and body image
B. Refer for medical evaluation to primarily address physiological complications
C. Implement a strict meal plan to regulate eating patterns without addressing psychological factors
D. Conduct a comprehensive psychological assessment to identify underlying issues and appropriate
interventions
Question 13
For a 22-year-old college student newly diagnosed with ADHD who is concerned about addiction
potential, which medication would be most appropriate?
A. Methylphenidate
B. Bupropion
C. Sertraline
D. Atomoxetine
Question 14
Which type of psychotherapy focusing on modifying dysfunctional thoughts is most likely to benefit a
patient diagnosed with Major Depressive Disorder?
A. Interpersonal Therapy (IPT)
B. Cognitive Behavioral Therapy (CBT)
C. Dialectical Behavior Therapy (DBT)
D. Psychodynamic therapy
Question 15
What is the primary mechanism of action of stimulant medications used in treating ADHD?
A. They adjust the balance of electrolytes in the brain, which can affect neuronal firing patterns
B. They increase dopamine and norepinephrine levels in the brain, which help control attention and
behavior
C. They decrease the reuptake of serotonin in the brain, leading to improved mood and calmness
D. They modify the GABAergic system to reduce overall neural activity and improve focus
Question 16
During the detoxification phase for alcohol dependence, which medication is commonly used to manage
withdrawal symptoms?
A. Anticonvulsants, like carbamazepine
B. Antipsychotics
C. Benzodiazepines, such as diazepam
D. Clonidine
Question 17
What is a major reason for vaccinating young adults against HPV before they become sexually active?
A. To establish immunity against the most common cancer-causing HPV strains before exposure
B. To help track sexual activity and behavioral patterns in young adults
C. To encourage healthier lifestyle choices among teenagers and young adults
D. To provide a database for future epidemiological studies on HPV
Question 18
What levels need regular monitoring when a patient is treated with lithium?
A. Thyroid function
B. Renal function
C. Electrolyte levels
D. Blood pressure
Question 19
Which contraindication is most critical when considering prescribing a combined oral contraceptive pill?
A. Breastfeeding less than six weeks postpartum
B. Active liver disease or liver tumor
C. Uncontrolled hypertension or diabetes mellitus type II
D. History of thromboembolic disorders or known thrombophilia
Question 20
What is the primary hormone used in HRT to alleviate menopausal symptoms?
A. Thyroxine
B. Estrogen
C. Testosterone
D. Progesterone
Question 21
For a 24-year-old male presenting to the emergency department expressing hopelessness and feelings of
worthlessness, with past thoughts of suicide but no current plan, what is the most appropriate immediate
intervention?
A. Initiate close monitoring with frequent follow-up to ensure the patient's safety
B. Enroll the patient in an inpatient psychiatric unit for further observation and care
C. Refer the patient for group therapy to build social connections and alleviate isolation
D. Recommend outpatient psychotherapy while emphasizing a positive support network
Question 22
What comprehensive treatment approach is most appropriate for a 32-year-old male with schizophrenia
exhibiting disorganized speech, occasional hallucinations, and significant emotional withdrawal?
A. Strict adherence to a pharmacological regimen without incorporating psychological or social
interventions
B. An integrated approach using antipsychotics, cognitive behavioral therapy, and social skills training
C. Combining medication management with regular psychiatric evaluations and family therapy
D. Focus primarily on high-dose antipsychotic treatment to rapidly control the severe psychotic symptoms
Question 23
What does a biophysical profile score of 8/10 with normal fluid levels suggest about the fetal condition in
a pregnant patient?
A. Indicates an urgent need for delivery due to immediate fetal distress
B. The fetus is likely in a stable condition, possibly requiring re-evaluation within 24 hours
C. Suggestive of an adequate oxygen environment, with no immediate risks observed
D. Fetal hypoxia is ruled out, but follow-up tests should be conducted to ensure well-being
Question 24
For a patient with a history of chronic opioid abuse starting detoxification, what initial step is critical to
optimizing the outcome of the detox protocol?
A. Start with a high dose of methadone to quickly reduce withdrawal symptoms and cravings
B. Immediately cease all opioid use without a tapering schedule to provoke natural detoxification
C. Schedule group therapy sessions to provide psychological support during the detox phase
D. Conduct a comprehensive assessment of the patient's drug use history and health status
Question 25
For a 32-year-old pregnant woman at 36 weeks gestation presenting with severe headache, visual
disturbances, blood pressure of 170/110 mmHg, and significant proteinuria, what is the most appropriate
next step in management?
A. Wait for laboratory results to confirm proteinuria before starting any treatment for preeclampsia
B. Administer magnesium sulfate to prevent progression to eclampsia and lower seizure risk
C. Order an MRI to assess for possible intracranial bleeding before deciding on the next step
D. Start labetalol therapy to control the patient's blood pressure and stabilize her condition
Question 26
For a 40-year-old patient presenting with persistent worry, restlessness, and difficulty concentrating,
diagnosed with generalized anxiety disorder, what pharmacotherapy should be initiated considering both
efficacy and safety?
A. Use of pregabalin
B. Initiate treatment with an SSRI, such as sertraline
C. Introduction of cognitive therapy alone
D. Prescribe a benzodiazepine for short-term relief
Question 27
Which antipsychotic is recommended for rapid control of acute mania in Bipolar Disorder?
A. Risperidone
B. Olanzapine
C. Haloperidol
D. Quetiapine
Question 28
For a patient reporting severe menstrual cramps and heavy menstrual bleeding, with ultrasound showing
multiple uterine fibroids, what is the most appropriate initial management step?
A. Immediate surgical intervention to remove fibroids
B. Supportive therapy with iron supplements for anemia
C. Referral for a hysteroscopy and endometrial biopsy
D. Initiate a trial of hormonal contraceptive therapy
Question 29
Within what time period does a hallmark of Binge Eating Disorder involve eating a significantly larger
amount of food?
A. Three-hour period
B. Six-hour period
C. Two-hour period
D. Four-hour period
Question 30
What is a key diagnostic criterion for Autism Spectrum Disorder in young children?
A. Repeated temper tantrums and a difficulty adapting to new routines
B. A consistent need for physical activity and hyperactivity that disrupts daily life
C. Persistent deficits in social communication and social interaction across multiple contexts
D. Heightened sensory sensitivities leading to frequent meltdowns when exposed to certain sounds or
textures
Question 31
Which medication is typically used as a first-line treatment for generalized anxiety disorder?
A. Selective serotonin reuptake inhibitors (SSRIs)
B. Buspirone
C. Benzodiazepines
D. Tricyclic antidepressants (TCAs)
Question 32
What complication is suggested by the presence of late decelerations in fetal heart rate monitoring during
labor?
A. A sign of maternal dehydration, often corrected with intravenous fluids
B. Often a benign finding that requires continuous monitoring but no immediate intervention
C. Indicative of uteroplacental insufficiency potentially leading to fetal hypoxia
D. Shows normal physiological response to contractions, not usually a concern
Question 33
For a 35-year-old woman at 28 weeks gestation presenting with preterm labor and administered
tocolytics, what additional therapy should be given to improve neonatal outcomes?
A. Begin tocolytics to prolong pregnancy and ensure fetal lung maturity is achieved
B. Perform an amniocentesis to assess fetal lung maturity before continuing treatment
C. Administer corticosteroids to enhance fetal lung maturity and improve survival rates
D. Begin continuous electronic fetal monitoring to assess fetal well-being during contractions
Question 34
For a patient with Bipolar Disorder who does not respond to lithium alone, what type of medication might
be most beneficial to add?
A. A typical antipsychotic
B. A selective serotonin reuptake inhibitor (SSRI)
C. An anticonvulsant mood stabilizer, such as valproate
D. A dopamine antagonist
Question 35
For a 30-year-old woman who has just had her first normal Pap smear, when should her next screening be
scheduled?
A. Recommended to have annual screenings without fail
B. Next screening should be five years if co-testing with HPV is done
C. She should continue with more frequent screenings due to high risk
D. She should return for another Pap smear in three years
Question 36
Which finding on a fetal biophysical profile is most indicative of chronic fetal stress?
A. Presence of fetal breathing movements without any limb movements
B. Absence of amniotic fluid
C. Decreased fetal movement over a 30-minute observation period
D. Normal variability with no accelerations and a steady heart rate
Question 37
For a 28-year-old pregnant woman presenting with genital herpes and nearing her delivery date, what is
the best course of action to prevent neonatal transmission?
A. Schedule an immediate cesarean delivery regardless of viral activity
B. Perform an early cesarean section to minimize maternal-fetal transmission
C. Continue with routine care as herpes does not affect the fetus
D. Administer antiviral therapy and consider cesarean delivery if lesions are present
Question 38
For a 45-year-old female who recently lost her job, is going through a divorce, feeling overwhelmed,
drinking heavily, and expressing vague thoughts of ending her life but no specific plan, what is the most
appropriate approach to ensure her safety?
A. Refer the patient to a rehabilitation program to address substance use
B. Encourage participation in community support groups to reduce feelings of isolation
C. Schedule weekly psychotherapy sessions and offer lifestyle modification tips
D. Create a safety plan that involves removing access to alcohol and lethal means at home
Question 39
For a patient with a history of migraine with aura seeking contraception advice, which method should be
avoided?
A. Progestin-only pills
B. Barrier methods
C. Estrogen-containing contraceptive methods
D. Intrauterine devices
Question 40
When evaluating a patient with suspected polycystic ovarian syndrome (PCOS) who presents with
oligomenorrhea, what diagnostic test is essential for confirming the diagnosis?
A. Ultrasound examination of the ovaries and adrenal glands
B. Measurement of serum luteinizing hormone and follicle-stimulating hormone levels
C. Assessment of prolactin levels and thyroid function tests
D. Conducting a pelvic MRI to assess ovarian morphology
Question 41
At what age is it recommended to start routine Pap smear screening according to current guidelines?
A. At the age of 18, if the patient requests it specifically
B. Upon entering high school to ensure early education about health
C. After the onset of sexual activity, but no later than age 25
D. Beginning at age 21, regardless of sexual activity history
Question 42
For a patient suffering from Major Depressive Disorder reporting partial improvement with an SSRI but
still struggling with daily functioning, which additional treatment option could be most beneficial?
A. Adding a mood stabilizer like lithium
B. Introduction of cognitive behavioral therapy
C. Augmenting treatment with psychotherapy
D. Incorporating a dietary supplement such as omega-3 fatty acids
Question 43
What is the most sensitive diagnostic tool for detecting an ectopic pregnancy?
A. Serum beta-hCG measurement
B. Transvaginal ultrasound
C. MRI of the pelvis
D. Abdominal ultrasound
Question 44
For a 4-year-old child presenting with delayed speech, limited eye contact, and repetitive hand flapping,
what condition should the pediatrician consider based on these symptoms?
A. Attention-Deficit Hyperactivity Disorder
B. Oppositional Defiant Disorder
C. Autism Spectrum Disorder
D. Developmental Coordination Disorder
Question 45
Which of the following factors is a significant risk for suicide in individuals with depression?
A. Social isolation and lack of social support
B. Family history of mental illness
C. Recent unemployment and financial stress
D. History of prior suicide attempts
Question 46
What is the next best pharmacotherapy step for a patient with Major Depressive Disorder who has not
responded to two different SSRIs?
A. Initiate treatment with a serotonin-norepinephrine reuptake inhibitor (SNRI)
B. Trial of bupropion as an alternative antidepressant
C. Consider a monoamine oxidase inhibitor (MAOI) for treatment-resistant cases
D. Switch to an atypical antipsychotic for additional support
Question 47
What diagnostic test should be conducted after an abnormal glucose challenge test to confirm gestational
diabetes?
A. Continuous glucose monitoring throughout the day
B. Random glucose monitoring during meals
C. Fasting glucose measurement after meals
D. Oral glucose tolerance test with fasting and multiple blood draws
Question 48
In managing a patient experiencing frequent panic attacks who has shown minimal response to SSRIs,
what would be an appropriate next treatment step?
A. Add an antipsychotic medication to control severe symptoms
B. Trial a monoamine oxidase inhibitor (MAOI) for treatment resistance
C. Incorporate a different class of antidepressant, such as a tricyclic antidepressant
D. Add cognitive behavioral therapy to address triggers and coping mechanisms
Question 49
During a pediatric check-up, if a parent is concerned about their child not responding to their name and
avoiding eye contact, what diagnostic process should the pediatrician initiate?
A. Refer the child directly to a neurologist for brain imaging studies
B. Wait for further developmental milestones before initiating any evaluation
C. Conduct a comprehensive developmental evaluation including observations and standardized screening
tools
D. Refer the child for speech therapy without further evaluations due to delayed speech development
Question 50
What is the primary mechanism of action of lithium in treating Bipolar Disorder?
A. Lithium inhibits phosphoinositol cascade, affecting second messenger systems
B. Lithium modulates neurotransmitter release and stabilizes neuronal excitability
C. Lithium directly blocks sodium channels, reducing overall brain activity
D. Lithium increases serotonin synthesis, helping stabilize mood swings
Question 51: How long do SSRIs typically take to show full effects in managing anxiety disorders?
A. Six weeks
B. Eight weeks
C. Two weeks
D. Four weeks
Question 52: Which contraceptive method is least advisable for a smoker over 35 years old?
A. Natural family planning
B. Combined hormonal contraceptives
C. Sterilization
D. Copper IUD
Question 53: What condition might be considered a relative contraindication for IUD use in a 24-year-old
woman?
A. History of treated pelvic inflammatory disease
B. Uterine fibroids distorting the uterine cavity
C. Known copper hypersensitivity
D. Recent pelvic surgery
Question 54: Which personality disorder is characterized by rigid perfectionism and inflexibility about
moral issues?
A. Dependent Personality Disorder
B. Histrionic Personality Disorder
C. Narcissistic Personality Disorder
D. Obsessive-Compulsive Personality Disorder
Question 55: What is the safest antibiotic to prescribe for a pregnant woman diagnosed with chlamydia?
A. Erythromycin
B. Azithromycin or amoxicillin
C. Levofloxacin
D. Metronidazole
Question 56: Which medications are used to delay preterm labor by inhibiting uterine contractions?
A. Prostaglandin inhibitors
B. Oxytocin receptor blockers
C. Tocolytics
D. Magnesium sulfate
Question 57: What is the main goal of cognitive behavioral therapy in treating panic disorder?
A. Exposure to feared situations
B. Modifying thought patterns
C. Eliminating anxiety completely
D. Providing avoidance strategies
Question 58: What factor is crucial in determining the appropriate methadone dose for opioid use
disorder maintenance therapy?
A. Regular monitoring of patient response
B. Relying on patient-reported symptoms
C. Assessing liver function
D. Using standardized dosage
Question 59: What criteria must be met for a patient to be eligible for medical management of an ectopic
pregnancy?
A. Presence of fetal heartbeat
B. Undetectable beta-hCG levels
C. Low and stable beta-hCG levels, no fetal heartbeat
D. Rapidly increasing beta-hCG levels
Question 60: Which therapy is typically considered first-line for a newly diagnosed six-year-old with
ADHD?
A. Behavioral therapy
B. Guanfacine
C. Clonidine
D. Methylphenidate
Question 61: What is the appropriate next step after a pregnant woman at 24 weeks gestation has a
glucose challenge test result of 160 mg/dL?
A. Repeat the glucose challenge test
B. Perform an oral glucose tolerance test
C. Start dietary therapy immediately
D. Recommend continuous glucose monitoring
Question 62: Which HPV vaccine is approved for both males and females in preventing HPV-related
diseases?
A. Cervarix
B. No gender-neutral vaccines available
C. Gardasil-9
D. Papillex
Question 63: What is the most appropriate next step for managing a pregnant woman with gestational
diabetes whose fasting glucose remains elevated despite dietary changes?
A. Consider early delivery
B. Further adjust diet
C. Begin metformin therapy
D. Initiate insulin therapy
Question 64: What is considered the first-line treatment for primary dysmenorrhea?
A. Opioid analgesics
B. Exercise and dietary modifications
C. Low-dose oral contraceptive pills
D. Nonsteroidal anti-inflammatory drugs (NSAIDs)
Question 65: During labor, what type of deceleration occurs exactly at the peak of a contraction?
A. Early decelerations
B. Late decelerations
C. Variable decelerations
D. Prolonged decelerations
Question 66: When a patient reveals a history of previous suicide attempts during a psychiatric
evaluation, what is the most appropriate next step?
A. Prescribe antidepressants
B. Implement a comprehensive safety plan
C. Offer cognitive behavioral therapy
D. Encourage identification of coping mechanisms
Question 67: For a patient with chronic pain and suicidal thoughts, what should be included in the
immediate management plan?
A. Initiating long-term therapy
B. Coordinating a safety plan with family support
C. Prescribing pain medications
D. Suggesting occupational therapy
Question 68: Which SSRI is generally considered safe and effective for treating depression in a 28-year-
old female patient?
A. Fluoxetine
B. Escitalopram
C. Sertraline
D. Citalopram
Question 69: Which symptom category do anhedonia and lack of desire to form relationships fall under in
schizophrenia?
A. Positive symptoms
B. Affective symptoms
C. Cognitive deficits
D. Negative symptoms
Question 70: In treating Bulimia Nervosa, which therapy type has been found most effective?
A. Cognitive Behavioral Therapy (CBT)
B. Dialectical Behavior Therapy (DBT)
C. Interpersonal Therapy (IPT)
D. Pharmacotherapy with antidepressants
Question 71: What is the likely cause of short, rapid decelerations in fetal heart rate following each
contraction?
A. Maternal stress
B. Fetal movement
C. Well-oxygenated fetus
D. Umbilical cord compression
Question 72: What is the most common cause of abnormal uterine bleeding in adolescents?
A. Cervical polyps
B. Uterine cancer
C. Endometrial hyperplasia
D. Anovulatory cycles
Question 73: What is the hallmark characteristic of a personality disorder from Cluster C?
A. Dramatic or erratic traits
B. Anxiety and fear
C. Detachment from social relationships
D. Suspicion and withdrawal
Question 74: How long must symptoms persist for a primary diagnosis of schizophrenia?
A. Three months
B. Six months
C. Four months
D. Five months
Question 75: During a manic episode with aggression and delusions, which medication regimen is most
appropriate initially?
A. Anticonvulsant alone
B. Monoamine oxidase inhibitors (MAOIs)
C. SSRI regimen
D. Combination of lithium and a second-generation antipsychotic
Question 76: What is the most common initial treatment for managing vasomotor symptoms in menopausal
women?
A. Low-dose oral estrogen therapy
B. Regular exercise and diet program
C. Cognitive behavioral therapy
D. Non-hormonal herbal supplements
Question 77: For a woman at 31 weeks gestation with persistent contractions despite tocolytic therapy,
what is the most appropriate course of action?
A. Start magnesium sulfate
B. Administer corticosteroids and monitor closely
C. Proceed with emergency delivery
D. Start bed rest and encourage hydration
Question 78: What is one major benefit often discussed regarding hormone replacement therapy (HRT)?
A. Significantly reduces osteoporosis risk
B. Decreases colon cancer risk
C. Enhances mental clarity
D. Improves cardiovascular health
Question 79: What long-term side effect is commonly monitored in patients taking first-generation
antipsychotics for schizophrenia?
A. Neuroleptic malignant syndrome
B. Tardive dyskinesia
C. Weight gain and metabolic syndrome
D. Akathisia
Question 80: Which factor significantly increases the risk of complications when using hormone
replacement therapy (HRT)?
A. Uncontrolled hypertension
B. Current or recent smoking status
C. History of deep vein thrombosis
D. High body mass index (BMI)
Question 81: For a 22-year-old college student with a BMI of 16.5 and severe dietary restrictions, which
treatment approach should be prioritized?
A. Outpatient community support groups
B. Group therapy
C. Nutritional rehabilitation program
D. Immediate psychological counseling
Question 82: What is the most definitive treatment for severe preeclampsia at 37 weeks of gestation?
A. Close observation until 40 weeks
B. Immediate delivery
C. Magnesium sulfate and antihypertensive therapy
D. Antihypertensive therapy until 39 weeks
Question 83: What is the recommended treatment for syphilis during pregnancy?
A. Multiple doses of oral amoxicillin
B. Benzathine penicillin G
C. Intravenous ceftriaxone followed by oral macrolides
D. Oral doxycycline for two weeks
Question 84: What should a pediatrician emphasize about the ADHD diagnosis process to concerned
parents?
A. Need for neuroimaging studies
B. Importance of comprehensive behavioral assessments
C. Necessity of physical examination
D. Reliance on parental reports only
Question 85: Which personality disorder is often characterized by odd beliefs and magical thinking?
A. Schizotypal
B. Paranoid
C. Schizoid
D. Borderline
Question 86: What can regular Pap smears detect to reduce cervical cancer incidence?
A. HPV infection signs
B. Inflammation changes
C. Precancerous lesions
D. Benign abnormalities
Question 87: What is the recommended first-line management for controlling blood sugar in newly
diagnosed gestational diabetes?
A. Metformin
B. Oral hypoglycemic agents
C. Insulin therapy
D. Dietary modifications and exercise routine
Question 88: For a pregnant woman at 32 weeks with gestational diabetes and a large-for-gestational-age
fetus, what is the most appropriate course of action?
A. Continue monitoring and consider additional assessments
B. Increase frequency of fetal ultrasounds
C. Refer to maternal-fetal medicine specialist
D. Prescribe insulin therapy
Question 89: What is a primary benefit of non-stimulant medications in managing ADHD in adults?
A. Lower risk of abuse and addiction
B. Faster action and immediate effects
C. Lower cost and greater availability
D. More effective for hyperactivity
Question 90: What is a key indicator of ectopic pregnancy on ultrasound?
A. Absence of adnexal mass
B. Absence of yolk sac
C. Absence of intrauterine gestational sac
D. Absence of fetal pole
Question 91: Which untreated condition in pregnant women increases the risk of premature labor?
A. Syphilis
B. Gonorrhea
C. Hepatitis B
D. HIV
Question 92: At what age is it most critical to recognize early signs of Autism Spectrum Disorder for
optimal intervention outcomes?
A. After 5 years
B. Around 4 years
C. Between 7 and 8 years
D. Before 3 years
Question 93: In which scenario is surgical intervention preferred for managing an ectopic pregnancy?
A. History of multiple ectopic pregnancies
B. Desire for future fertility
C. Severe pelvic pain without bleeding
D. Hemodynamic instability with rupture signs
Question 94: What is the most effective intervention to improve fetal lung maturity in preterm labor at 30
weeks gestation?
A. Regular glucose monitoring
B. Corticosteroid administration
C. Oral tocolytics
D. Ultrasound assessment
Question 95: Which medication is used for medical management of an unruptured ectopic pregnancy?
A. Misoprostol
B. Mifepristone
C. Progesterone injections
D. Methotrexate
Question 96: Which personality disorder is characterized by grandiosity, need for admiration, and lack of
empathy?
A. Borderline Personality Disorder
B. Narcissistic Personality Disorder
C. Antisocial Personality Disorder
D. Avoidant Personality Disorder
Question 97: For a woman in her third trimester with preeclampsia experiencing seizures, what is the
most appropriate initial treatment?
A. Administer lorazepam
B. Administer magnesium sulfate
C. Begin with diazepam
D. Administer phenytoin
Question 98: What is the most likely diagnosis for a 22-year-old woman with amenorrhea for six months
after stopping oral contraceptives?
A. Hypothalamic dysfunction
B. Primary ovarian insufficiency
C. Post-pill amenorrhea
D. Thyroid dysfunction
Question 99: For a 34-year-old woman at 30 weeks gestation with HELLP syndrome symptoms, what is
the best immediate intervention?
A. Initiate immediate delivery
B. Admit for observation
C. Prescribe corticosteroids
D. Monitor in ICU
Question 100: What is the recommended duration of continuous disturbance for a schizophrenia diagnosis,
including at least one month of active-phase symptoms?
A. Three months
B. Six months
C. Four months
D. Five months

Correct Answers & Explanations

Question 1
C) Ceftriaxone as a single intramuscular injection and ocular prophylaxis at birth (Correct Answer)
Explanation: This is the recommended treatment for pregnant patients with gonorrhea to prevent
ophthalmia neonatorum in newborns. Ceftriaxone effectively treats maternal gonorrhea, while ocular
prophylaxis at birth provides additional protection for the newborn against potential eye infections.
Question 2
C) To reduce craving and withdrawal symptoms, and decrease the illicit opioid use (Correct Answer)
Explanation: Methadone maintenance therapy aims to stabilize patients with opioid dependence by
reducing cravings and withdrawal symptoms. This approach helps patients manage their addiction,
decreases illicit opioid use, and improves overall quality of life and social functioning.
Question 3
C) It has a high ceiling effect (Correct Answer)
Explanation: Buprenorphine is preferred in opioid substitution therapy due to its high ceiling effect. This
means that beyond a certain dose, increasing the amount does not produce greater effects, reducing the
risk of respiratory depression and overdose compared to full opioid agonists.
Question 4
C) Conduct a multidisciplinary assessment including behavioral evaluations and a speech-language
pathologist (Correct Answer)
Explanation: For a child showing signs of potential autism spectrum disorder, a comprehensive
multidisciplinary assessment is crucial. This approach ensures a thorough evaluation of the child's social,
communication, and behavioral patterns, allowing for accurate diagnosis and appropriate intervention
planning.
Question 5
C) HELLP syndrome (Correct Answer)
Explanation: HELLP syndrome is a severe complication of preeclampsia characterized by Hemolysis,
Elevated Liver enzymes, and Low Platelet count. It requires immediate delivery as the primary treatment
due to its potential for rapid deterioration and serious maternal and fetal complications.
Question 6
D) Second-generation antipsychotics, like risperidone (Correct Answer)
Explanation: Second-generation antipsychotics are typically considered first-line for managing positive
symptoms of schizophrenia. They are generally preferred over first-generation antipsychotics due to their
improved side effect profile, particularly regarding extrapyramidal symptoms. Risperidone and other
second-generation antipsychotics like olanzapine have shown efficacy in treating both positive and
negative symptoms of schizophrenia. Clozapine, while effective, is usually reserved for treatment-
resistant cases due to its potential for serious side effects.
Question 7
C) Progesterone (Correct Answer)
Explanation: Progesterone is a key hormone involved in most hormonal contraceptive methods. It works
by inhibiting ovulation, thickening cervical mucus to prevent sperm penetration, and thinning the uterine
lining to prevent implantation. While some contraceptives use a combination of estrogen and
progesterone, progesterone-only methods are also common and effective. Progesterone is the primary
hormone responsible for the contraceptive effect in most hormonal methods.
Question 8
D) Intense fear of gaining weight or becoming fat, even though underweight (Correct Answer)
Explanation: According to the DSM-5, one of the key diagnostic criteria for Anorexia Nervosa is an
intense fear of gaining weight or becoming fat, even when the individual is underweight. This criterion
reflects the core psychological disturbance in Anorexia Nervosa, where there is a distorted body image
and an irrational fear of weight gain despite being at a significantly low body weight. This fear drives
restrictive eating behaviors and other weight control methods.
Question 9
C) Two weeks (Correct Answer)
Explanation: According to the DSM-5 criteria for Major Depressive Disorder, depressive symptoms must
persist for at least two weeks. This duration criterion helps distinguish clinical depression from
temporary mood fluctuations. The symptoms must be present for most of the day, nearly every day, during
this two-week period, and represent a change from previous functioning. This timeframe allows clinicians
to differentiate between transient depressive states and more persistent, clinically significant depressive
episodes.
Question 10
A) She has been postmenopausal for less than 10 years (Correct Answer)
Explanation: A critical factor to evaluate before prescribing HRT for a 55-year-old woman experiencing
severe hot flashes is whether she has been postmenopausal for less than 10 years. This is important
because the benefits and risks of HRT can vary depending on the timing of initiation relative to
menopause onset. Women who start HRT within 10 years of menopause or before age 60 generally have a
more favorable benefit-risk ratio. The "timing hypothesis" suggests that HRT initiated closer to
menopause may have cardiovascular benefits, while starting later may increase risks.
Question 11
A) Dialectical Behavior Therapy (DBT) (Correct Answer)
Explanation: Dialectical Behavior Therapy (DBT) is considered the most beneficial therapeutic approach
for managing patients with borderline personality disorder (BPD). DBT was specifically developed to
treat BPD and has shown significant efficacy in reducing self-harm behaviors, suicidal ideation, and
improving emotional regulation. It combines cognitive-behavioral techniques with mindfulness practices
and focuses on four key areas: mindfulness, distress tolerance, emotion regulation, and interpersonal
effectiveness. DBT's structured approach and emphasis on both acceptance and change make it
particularly well-suited for the complex needs of BPD patients.
Question 12
D) Conduct a comprehensive psychological assessment to identify underlying issues and appropriate
interventions (Correct Answer)
Explanation: For a patient with a history of eating large amounts of food in secret followed by self-
induced vomiting, the first step in a multidisciplinary treatment approach should be to conduct a
comprehensive psychological assessment. This assessment is crucial to identify underlying psychological
issues, potential comorbidities, and the severity of the eating disorder. It helps in understanding the
patient's specific needs, triggers, and thought patterns, which is essential for developing an appropriate,
individualized treatment plan. This approach ensures that both the psychological and physiological
aspects of the eating disorder are addressed in a holistic manner.
Question 13
D) Atomoxetine (Correct Answer)
Explanation: For a 22-year-old college student newly diagnosed with ADHD who is concerned about
addiction potential, atomoxetine would be the most appropriate medication. Atomoxetine is a non-
stimulant medication used to treat ADHD. Unlike stimulant medications such as methylphenidate,
atomoxetine has no potential for abuse or addiction. It works by increasing norepinephrine levels in the
brain, which can improve attention and reduce hyperactivity and impulsivity. This makes it a suitable
choice for patients with a history of substance abuse or those concerned about the addictive potential of
stimulant medications.
Question 14
B) Cognitive Behavioral Therapy (CBT) (Correct Answer)
Explanation: Cognitive Behavioral Therapy (CBT) is most likely to benefit a patient diagnosed with
Major Depressive Disorder (MDD). CBT focuses on identifying and modifying dysfunctional thoughts
and behaviors that contribute to and maintain depression. It helps patients recognize negative thought
patterns, challenge these thoughts, and develop more balanced and realistic thinking. CBT also
emphasizes behavioral activation, which encourages patients to engage in activities that can improve
mood. Numerous studies have shown CBT to be highly effective in treating MDD, often as effective as
medication for mild to moderate depression, and it provides skills that can help prevent relapse.
Question 15
B) They increase dopamine and norepinephrine levels in the brain, which help control attention and
behavior (Correct Answer)
Explanation: The primary mechanism of action of stimulant medications used in treating ADHD is
increasing dopamine and norepinephrine levels in the brain. These neurotransmitters play crucial roles in
attention, focus, and impulse control. Stimulants like methylphenidate and amphetamines work by
blocking the reuptake of dopamine and norepinephrine, thereby increasing their availability in the
synaptic cleft. This enhancement of neurotransmitter activity in specific brain regions helps improve
attention, reduce hyperactivity, and control impulsive behaviors in individuals with ADHD.
Question 16
C) Benzodiazepines, such as diazepam (Correct Answer)
Explanation: During the detoxification phase for alcohol dependence, benzodiazepines such as diazepam
are commonly used to manage withdrawal symptoms. Benzodiazepines are the first-line treatment for
alcohol withdrawal due to their effectiveness in preventing and treating withdrawal symptoms, including
seizures and delirium tremens. They work by enhancing the effect of GABA, the primary inhibitory
neurotransmitter in the brain, which helps reduce anxiety, tremors, and the risk of seizures associated with
alcohol withdrawal. Diazepam, in particular, is often preferred due to its long half-life, which provides a
smoother withdrawal process.
Question 17
A) To establish immunity against the most common cancer-causing HPV strains before exposure (Correct
Answer)
Explanation: The major reason for vaccinating young adults against HPV before they become sexually
active is to establish immunity against the most common cancer-causing HPV strains before exposure.
HPV vaccines are most effective when administered before an individual has been exposed to the virus
through sexual activity. By vaccinating before sexual debut, the immune system can develop a robust
response to the virus, providing protection against the HPV types most commonly associated with
cervical, anal, and other HPV-related cancers. This proactive approach significantly reduces the risk of
HPV infection and subsequent development of HPV-related cancers later in life.
Question 18
B) Renal function (Correct Answer)
Explanation: When a patient is treated with lithium, regular monitoring of renal function is crucial.
Lithium has a narrow therapeutic index and is primarily excreted by the kidneys. Long-term lithium use
can affect renal function, potentially leading to chronic kidney disease or nephrogenic diabetes insipidus.
Regular monitoring of renal function, including serum creatinine and estimated glomerular filtration rate
(eGFR), helps detect early signs of kidney impairment and allows for timely adjustments in lithium
dosage or treatment approach. While thyroid function and electrolyte levels are also monitored, renal
function is particularly critical due to lithium's direct impact on the kidneys.
Question 19
D) History of thromboembolic disorders or known thrombophilia (Correct Answer)
Explanation: The most critical contraindication when considering prescribing a combined oral
contraceptive pill is a history of thromboembolic disorders or known thrombophilia. Combined oral
contraceptives containing estrogen increase the risk of venous thromboembolism (VTE), and this risk is
significantly higher in individuals with a history of VTE or known thrombophilic disorders. For these
individuals, the risk of potentially life-threatening blood clots outweighs the benefits of combined oral
contraceptives. Alternative contraceptive methods, such as progestin-only pills or non-hormonal methods,
should be considered for these patients to avoid the increased thrombotic risk associated with estrogen-
containing contraceptives.
Question 20
B) Estrogen (Correct Answer)
Explanation: The primary hormone used in Hormone Replacement Therapy (HRT) to alleviate
menopausal symptoms is estrogen. Estrogen is the most effective treatment for vasomotor symptoms (hot
flashes and night sweats) and vaginal atrophy, which are common menopausal complaints. It also helps
prevent bone loss associated with menopause. While progesterone is often used in combination with
estrogen for women with an intact uterus to protect against endometrial hyperplasia, estrogen is the key
hormone responsible for symptom relief in menopausal women. The type and dose of estrogen can be
tailored to individual needs and risk factors.
Question 21
A) Initiate close monitoring with frequent follow-up to ensure the patient's safety (Correct Answer)
Explanation: For a 24-year-old male presenting with hopelessness, feelings of worthlessness, and past
thoughts of suicide but no current plan, the most appropriate immediate intervention is to initiate close
monitoring with frequent follow-up. This approach balances the need for safety with the least restrictive
environment. It allows for ongoing assessment of suicide risk while providing support and intervention.
Frequent follow-ups enable the healthcare provider to monitor changes in the patient's mental state, adjust
treatment as needed, and intervene quickly if the risk increases. This approach also helps build a
therapeutic alliance and encourages the patient to engage in treatment.
Question 22
B) An integrated approach using antipsychotics, cognitive behavioral therapy, and social skills training
(Correct Answer)
Explanation: For a 32-year-old male with schizophrenia exhibiting disorganized speech, occasional
hallucinations, and significant emotional withdrawal, the most appropriate comprehensive treatment
approach is an integrated approach using antipsychotics, cognitive behavioral therapy (CBT), and social
skills training. This multifaceted approach addresses both the biological and psychosocial aspects of
schizophrenia. Antipsychotics help manage positive symptoms like hallucinations and disorganized
speech. CBT can help with negative symptoms and emotional withdrawal by challenging distorted
thoughts and improving coping strategies. Social skills training addresses the social deficits often seen in
schizophrenia. This integrated approach is more likely to improve overall functioning and quality of life
compared to medication alone.
Question 23
C) Suggestive of an adequate oxygen environment, with no immediate risks observed (Correct Answer)
Explanation: A biophysical profile score of 8/10 with normal fluid levels suggests an adequate oxygen
environment for the fetus, with no immediate risks observed. The biophysical profile assesses fetal well-
being by evaluating five components: fetal breathing movements, gross body movements, fetal tone,
amniotic fluid volume, and non-stress test. A score of 8/10 indicates that four out of five parameters are
normal, which is generally reassuring. Normal fluid levels further support the assessment of fetal well-
being. This score suggests that the fetus is not in distress and is likely receiving adequate oxygenation and
nutrition, though continued monitoring may be advised as part of routine prenatal care.
Question 24
D) Conduct a comprehensive assessment of the patient's drug use history and health status (Correct
Answer)
Explanation: For a patient with a history of chronic opioid abuse starting detoxification, the critical initial
step to optimize the outcome of the detox protocol is to conduct a comprehensive assessment of the
patient's drug use history and health status. This assessment is crucial for several reasons: it helps
determine the severity of addiction, identifies any co-occurring physical or mental health conditions,
assesses the risk of withdrawal complications, and guides the choice of appropriate detoxification method
and medications. Understanding the patient's complete history allows for a tailored approach to
detoxification, considering factors such as the type and amount of opioids used, duration of use, previous
detox attempts, and overall health status. This comprehensive approach increases the likelihood of a
successful and safe detoxification process.
Question 25
B) Administer magnesium sulfate to prevent progression to eclampsia and lower seizure risk (Correct
Answer)
Explanation: For a 32-year-old pregnant woman at 36 weeks gestation presenting with severe headache,
visual disturbances, blood pressure of 170/110 mmHg, and significant proteinuria, the most appropriate
next step in management is to administer magnesium sulfate to prevent progression to eclampsia and
lower seizure risk. This clinical presentation is consistent with severe preeclampsia, which carries a high
risk of progression to eclampsia (seizures). Magnesium sulfate is the gold standard for seizure
prophylaxis in severe preeclampsia and eclampsia. It reduces the risk of eclampsia by more than 50% and
is more effective than other anticonvulsants. While controlling blood pressure is also important,
preventing seizures takes precedence in the immediate management of severe preeclampsia.
Question 26
B) Initiate treatment with an SSRI, such as sertraline (Correct Answer)
Explanation: SSRIs are considered first-line pharmacotherapy for generalized anxiety disorder due to
their efficacy and favorable side effect profile. Sertraline, an SSRI, is effective in reducing anxiety
symptoms and is generally well-tolerated, making it a suitable choice for long-term management of GAD.
Question 27
B) Olanzapine (Correct Answer)
Explanation: Olanzapine, a second-generation antipsychotic, is highly effective for rapid control of acute
mania in Bipolar Disorder. It has a quick onset of action and can be administered orally or
intramuscularly, making it suitable for managing acute manic episodes.
Question 28
D) Initiate a trial of hormonal contraceptive therapy (Correct Answer)
Explanation: Hormonal contraceptives, particularly combined oral contraceptives, are often the first-line
treatment for managing symptoms associated with uterine fibroids. They can help reduce menstrual
bleeding and alleviate pain, providing symptomatic relief while avoiding more invasive interventions
initially.
Question 29
C) Two-hour period (Correct Answer)
Explanation: According to the DSM-5 criteria for Binge Eating Disorder, one of the key features is
consuming an amount of food that is definitely larger than what most people would eat in a similar period
under similar circumstances, typically within a discrete period of about two hours.
Question 30
C) Persistent deficits in social communication and social interaction across multiple contexts (Correct
Answer)
Explanation: This is a core diagnostic feature of Autism Spectrum Disorder according to DSM-5. It
encompasses difficulties in social-emotional reciprocity, nonverbal communicative behaviors used for
social interaction, and developing, maintaining, and understanding relationships.
Question 31
A) Selective serotonin reuptake inhibitors (SSRIs) (Correct Answer)
Explanation: SSRIs are considered first-line pharmacological treatment for generalized anxiety disorder
due to their efficacy, relatively favorable side effect profile, and low risk of dependence compared to
other anxiolytic medications like benzodiazepines.
Question 32
C) Indicative of uteroplacental insufficiency potentially leading to fetal hypoxia (Correct Answer)
Explanation: Late decelerations are a concerning sign in fetal heart rate monitoring. They suggest
uteroplacental insufficiency, where the placenta is not providing adequate oxygen to the fetus during
contractions. This can potentially lead to fetal hypoxia and requires immediate attention and intervention.
Question 33
C) Administer corticosteroids to enhance fetal lung maturity and improve survival rates (Correct Answer)
Explanation: In cases of preterm labor, especially before 34 weeks gestation, administering
corticosteroids is crucial. They accelerate fetal lung maturation, significantly reducing the risk of
respiratory distress syndrome and improving overall neonatal outcomes and survival rates.
Question 34
C) An anticonvulsant mood stabilizer, such as valproate (Correct Answer)
Explanation: When lithium monotherapy is insufficient in managing Bipolar Disorder, adding an
anticonvulsant mood stabilizer like valproate is often beneficial. This combination can provide better
mood stabilization and help control both manic and depressive episodes more effectively than lithium
alone.
Question 35
D) She should return for another Pap smear in three years (Correct Answer)
Explanation: According to current guidelines, women aged 21-65 with a normal Pap smear result should
have repeat screening every three years. This interval balances the benefits of early detection with the
risks of overscreening and unnecessary interventions.
Question 36
B) Absence of amniotic fluid (Correct Answer)
Explanation: The absence of amniotic fluid (oligohydramnios or anhydramnios) on a biophysical profile
is the most indicative of chronic fetal stress. This condition can severely impact fetal development and is
associated with various complications, signaling a need for immediate intervention.
Question 37
D) Administer antiviral therapy and consider cesarean delivery if lesions are present (Correct Answer)
Explanation: For pregnant women with genital herpes near delivery, the recommended approach is to
administer antiviral therapy to suppress viral replication and consider cesarean delivery if active lesions
are present at the time of labor. This strategy helps minimize the risk of neonatal herpes transmission.
Question 38
D) Create a safety plan that involves removing access to alcohol and lethal means at home (Correct
Answer)
Explanation: Given the patient's multiple risk factors (job loss, divorce, heavy drinking, and suicidal
thoughts), creating a comprehensive safety plan is crucial. This plan should include removing access to
alcohol and potential lethal means, which can reduce impulsive actions and provide immediate risk
reduction.
Question 39
C) Estrogen-containing contraceptive methods (Correct Answer)
Explanation: For patients with a history of migraine with aura, estrogen-containing contraceptives should
be avoided due to the increased risk of stroke. Non-estrogen methods like progestin-only pills, barrier
methods, or intrauterine devices are safer alternatives for these patients.
Question 40
A) Ultrasound examination of the ovaries and adrenal glands (Correct Answer)
Explanation: While multiple tests are useful in diagnosing PCOS, an ultrasound examination of the
ovaries is essential for confirming the diagnosis. It can reveal the characteristic polycystic appearance of
the ovaries, which is one of the key diagnostic criteria for PCOS along with clinical or biochemical signs
of hyperandrogenism and oligo/anovulation.
Question 41
D) Beginning at age 21, regardless of sexual activity history (Correct Answer)
Explanation: Current guidelines recommend starting routine Pap smear screening at age 21, regardless of
sexual activity history. This recommendation balances the benefits of early detection with the potential
harms of overscreening in young women, where cervical cancer is rare and many HPV infections resolve
spontaneously.
Question 42
B) Introduction of cognitive behavioral therapy (Correct Answer)
Explanation: For patients with Major Depressive Disorder showing partial response to SSRIs, adding
cognitive behavioral therapy (CBT) can be highly beneficial. CBT has strong evidence for efficacy in
depression and can address residual symptoms, improve coping strategies, and enhance overall
functioning in conjunction with medication.
Question 43
B) Transvaginal ultrasound (Correct Answer)
Explanation: Transvaginal ultrasound is the most sensitive diagnostic tool for detecting an ectopic
pregnancy. It allows for direct visualization of the adnexa and can often identify the location of the
gestational sac, making it superior to other methods in early diagnosis of ectopic pregnancies.
Question 44
C) Autism Spectrum Disorder (Correct Answer)
Explanation: The combination of delayed speech, limited eye contact, and repetitive behaviors like hand
flapping are classic signs of Autism Spectrum Disorder in young children. These symptoms align with the
core diagnostic criteria for ASD, which include deficits in social communication and restricted,
repetitive patterns of behavior.
Question 45
D) History of prior suicide attempts (Correct Answer)
Explanation: While all the factors mentioned can contribute to suicide risk, a history of prior suicide
attempts is the strongest predictor of future suicide risk in individuals with depression. Past attempts
indicate a willingness to engage in suicidal behavior and are considered the most significant risk factor
for completed suicide.
Question 46
A) Initiate treatment with a serotonin-norepinephrine reuptake inhibitor (SNRI) (Correct Answer)
Explanation: After failing two different SSRIs, switching to an SNRI is often the next best step in
pharmacotherapy for Major Depressive Disorder. SNRIs work on both serotonin and norepinephrine
systems, potentially offering a different mechanism of action that may be effective for patients who haven't
responded adequately to SSRIs.
Question 47
D) Oral glucose tolerance test with fasting and multiple blood draws (Correct Answer)
Explanation: The oral glucose tolerance test (OGTT) is the gold standard for diagnosing gestational
diabetes after an abnormal glucose challenge test. It involves fasting blood glucose measurement
followed by multiple blood draws after a glucose load, providing a comprehensive assessment of glucose
tolerance and insulin response.
Question 48
D) Add cognitive behavioral therapy to address triggers and coping mechanisms (Correct Answer)
Explanation: For patients with panic disorder showing minimal response to SSRIs, adding cognitive
behavioral therapy (CBT) is an appropriate next step. CBT is highly effective for panic disorder, helping
patients identify and modify panic-related thoughts and behaviors, and develop coping strategies for
managing panic attacks.
Question 49
C) Conduct a comprehensive developmental evaluation including observations and standardized
screening tools (Correct Answer)
Explanation: When concerns about social communication and interaction are raised, a comprehensive
developmental evaluation is the appropriate next step. This should include direct observations of the
child's behavior, standardized screening tools for autism spectrum disorder, and assessments of language,
cognitive, and adaptive functioning.
Question 50
B) Lithium modulates neurotransmitter release and stabilizes neuronal excitability (Correct Answer)
Explanation: While the exact mechanism of lithium in Bipolar Disorder is not fully understood, its
primary action is believed to involve modulation of neurotransmitter release and stabilization of neuronal
excitability. This includes effects on various neurotransmitter systems and intracellular signaling
pathways, contributing to its mood-stabilizing properties.
Question 51
B) Eight weeks (Correct Answer)
Explanation: SSRIs typically take 4-8 weeks to show full effects in managing anxiety disorders. The
search results indicate that while some improvement may be noticed within the first week, the full impact
of SSRIs takes several weeks to develop, with 4-8 weeks being the common timeframe for experiencing
full, consistent effects on anxiety reduction.
Question 52
B) Combined hormonal contraceptives (Correct Answer)
Explanation: For smokers over 35 years old, combined hormonal contraceptives are least advisable due
to increased risk of blood clots. The search results explicitly state that for women over 35 who smoke 15
or more cigarettes a day, the combination pill, patch, and ring are not safe options due to the elevated risk
of blood clots.
Question 53
B) Uterine fibroids distorting the uterine cavity (Correct Answer)
Explanation: Uterine fibroids that distort the uterine cavity are considered an absolute contraindication
for IUD use. The search results list "Any congenital or acquired uterine abnormality distorting the uterine
cavity in a manner that is incompatible with placement of an IUD" as an absolute contraindication for IUD
placement.
Question 54
D) Obsessive-Compulsive Personality Disorder (Correct Answer)
Explanation: Obsessive-Compulsive Personality Disorder (OCPD) is characterized by rigid
perfectionism and inflexibility about moral issues. The search results describe OCPD as involving
"inflexibility about morality and ethics" and "rigid perfectionism" as core features of the disorder.
Question 55
B) Azithromycin or amoxicillin (Correct Answer)
Explanation: Azithromycin and amoxicillin are considered safe antibiotics for treating chlamydia in
pregnant women. The search results indicate that amoxicillin and azithromycin are effective treatments for
chlamydia during pregnancy, with fewer side effects compared to other antibiotics like erythromycin.
Question 56
C) Tocolytics (Correct Answer)
Explanation: Tocolytics are medications used to delay preterm labor by inhibiting uterine contractions.
The search results explicitly state that "Tocolytic drugs aim to delay preterm birth by suppressing uterine
contractions to allow time for administration of corticosteroids for fetal lung maturation."
Question 57
B) Modifying thought patterns (Correct Answer)
Explanation: The main goal of cognitive behavioral therapy (CBT) in treating panic disorder is modifying
thought patterns. The search results indicate that CBT for panic disorder aims to help individuals "change
their negative thoughts and behaviors that trigger panic attacks" and develop skills to recognize and
manage the connection between thoughts, feelings, and behaviors.
Question 58
A) Regular monitoring of patient response (Correct Answer)
Explanation: Regular monitoring of patient response is crucial in determining the appropriate methadone
dose for opioid use disorder maintenance therapy. The search results emphasize that "patients react to
methadone differently" and that the level of heroin use is not the only factor in determining the final
methadone dose, highlighting the importance of ongoing monitoring and adjustment.
Question 59
C) Low and stable beta-hCG levels, no fetal heartbeat (Correct Answer)
Explanation: For a patient to be eligible for medical management of an ectopic pregnancy, there should be
low and stable beta-hCG levels and no fetal heartbeat. The search results indicate that medical
management with methotrexate is appropriate for hemodynamically stable patients with ectopic pregnancy
when the affected fallopian tube has not ruptured and β -hCG levels are low or decreasing.
Question 60
A) Behavioral therapy (Correct Answer)
Explanation: Behavioral therapy is typically considered first-line treatment for a newly diagnosed six-
year-old with ADHD. The search results recommend evidence-based parent training in behavior
management and/or behavioral classroom interventions as first-line treatment for ADHD in preschool-
aged children (4-6 years old).
Question 61
B) Perform an oral glucose tolerance test (Correct Answer)
Explanation: After a pregnant woman at 24 weeks gestation has a glucose challenge test result of 160
mg/dL, the appropriate next step is to perform an oral glucose tolerance test. The search results state that
a blood sugar level between 140 mg/dL and 190 mg/dL on the one-hour glucose test requires a follow-up
three-hour glucose tolerance test to confirm gestational diabetes.
Question 62
C) Gardasil-9 (Correct Answer)
Explanation: Gardasil-9 is the HPV vaccine approved for both males and females in preventing HPV-
related diseases. The search results mention that there are currently six licensed HPV vaccines, including
bivalent, quadrivalent, and nonavalent vaccines, with the nonavalent vaccine (which is Gardasil-9)
providing additional protection against multiple HPV types.
Question 63
D) Initiate insulin therapy (Correct Answer)
Explanation: For a pregnant woman with gestational diabetes whose fasting glucose remains elevated
despite dietary changes, the most appropriate next step is to initiate insulin therapy. The search results
indicate that if diet and exercise aren't enough to manage blood sugar levels in gestational diabetes,
insulin injections are typically the next step in treatment.
Question 64
D) Nonsteroidal anti-inflammatory drugs (NSAIDs) (Correct Answer)
Explanation: NSAIDs are considered the first-line treatment for primary dysmenorrhea. The search results
explicitly state that "First-line therapies for primary dysmenorrhea generally involve nonsteroidal anti-
inflammatory drugs (NSAIDs) or hormonal contraception," with NSAIDs being superior to placebo for
treatment of primary dysmenorrhea pain.
Question 65
A) Early decelerations (Correct Answer)
Explanation: Early decelerations occur exactly at the peak of a contraction during labor. The search
results define early decelerations as a "Gradual decrease in FHR with onset of deceleration to nadir >30
seconds. The nadir occurs with the peak of a contraction."
Question 66
B) Implement a comprehensive safety plan (Correct Answer)
Explanation: When a patient reveals a history of previous suicide attempts during a psychiatric
evaluation, the most appropriate next step is to implement a comprehensive safety plan. The search results
emphasize the importance of developing a safety plan and coordinating with family support as part of the
immediate management for patients with suicidal thoughts or history.
Question 67
B) Coordinating a safety plan with family support (Correct Answer)
Explanation: For a patient with chronic pain and suicidal thoughts, coordinating a safety plan with family
support should be included in the immediate management plan. The search results highlight the importance
of implementing a comprehensive safety plan and involving family support in managing patients with
chronic pain and suicidal ideation.
Question 68
C) Sertraline (Correct Answer)
Explanation: Sertraline is generally considered safe and effective for treating depression in a 28-year-old
female patient. The search results list sertraline among the SSRIs that are considered first-line choices for
treating depression, noting its effectiveness and safety profile.
Question 69
D) Negative symptoms (Correct Answer)
Explanation: Anhedonia and lack of desire to form relationships fall under the category of negative
symptoms in schizophrenia. The search results describe these symptoms as part of the negative symptoms
of schizophrenia, which include social withdrawal and lack of motivation.
Question 70
A) Cognitive Behavioral Therapy (CBT) (Correct Answer)
Explanation: Cognitive Behavioral Therapy (CBT) has been found to be the most effective therapy type in
treating Bulimia Nervosa. The search results explicitly state that "CBT is the treatment of choice for
bulimia nervosa" and that it is the "clear leading treatment for bulimia nervosa in adults."
Question 71
D) Umbilical cord compression (Correct Answer)
Explanation: Short, rapid decelerations in fetal heart rate following each contraction are likely caused by
umbilical cord compression. The search results describe variable decelerations, which are characterized
by abrupt decreases in fetal heart rate, as often being caused by umbilical cord compression.
Question 72
D) Anovulatory cycles (Correct Answer)
Explanation: The most common cause of abnormal uterine bleeding in adolescents is anovulatory cycles.
The search results state that "Anovulatory cycles, owing to immature hypothalamic-pituitary-ovarian axis,
is the leading etiology of HMB (heavy menstrual bleeding)" in adolescents.
Question 73
B) Anxiety and fear (Correct Answer)
Explanation: The hallmark characteristic of a personality disorder from Cluster C is anxiety and fear. The
search results describe Cluster C personality disorders as having "a consistently dysfunctional pattern of
anxious thinking or behavior."
Question 74
B) Six months (Correct Answer)
Explanation: Symptoms must persist for six months for a primary diagnosis of schizophrenia. The search
results indicate that for a diagnosis of schizophrenia, symptoms must be present for at least six months,
including at least one month of active-phase symptoms.
Question 75
D) Combination of lithium and a second-generation antipsychotic (Correct Answer)
Explanation: During a manic episode with aggression and delusions, the most appropriate initial
medication regimen is a combination of lithium and a second-generation antipsychotic. The search results
recommend this combination as the most effective initial treatment for managing acute manic episodes
with psychotic features.
Question 76
A) Low-dose oral estrogen therapy (Correct Answer)
Explanation: Hormone replacement therapy (HRT), specifically low-dose oral estrogen therapy, is the
most effective and common initial treatment for managing vasomotor symptoms in menopausal women.
HRT has been shown to reduce symptom frequency and intensity by nearly 90%, usually within one month
of initiation.
Question 77
B) Administer corticosteroids and monitor closely (Correct Answer)
Explanation: For a woman at 31 weeks gestation with persistent contractions despite tocolytic therapy, the
most appropriate course of action is to administer corticosteroids and monitor closely. Corticosteroids
are given to accelerate fetal lung maturity in case of preterm delivery. Close monitoring is essential to
assess the progression of labor and fetal well-being.
Question 78
A) Significantly reduces osteoporosis risk (Correct Answer)
Explanation: One major benefit often discussed regarding hormone replacement therapy (HRT) is its
significant reduction of osteoporosis risk. HRT helps prevent osteoporosis by increasing the level of
estrogen, which is needed for healthy bones. This is particularly important for women who experience
early menopause (before age 45).
Question 79
B) Tardive dyskinesia (Correct Answer)
Explanation: Tardive dyskinesia is a long-term side effect commonly monitored in patients taking first-
generation antipsychotics for schizophrenia. It is characterized by involuntary, repetitive body movements
and can be a permanent condition. Regular monitoring is essential to detect early signs and potentially
adjust treatment.
Question 80
C) History of deep vein thrombosis (Correct Answer)
Explanation: A history of deep vein thrombosis (DVT) significantly increases the risk of complications
when using hormone replacement therapy (HRT). Estrogen, especially oral estrogens, increase the risk of
venous thromboembolism (VTE), which includes DVT. For women with a history of DVT, the risks of
HRT may outweigh the benefits.
Question 81
C) Nutritional rehabilitation program (Correct Answer)
Explanation: For a 22-year-old college student with a BMI of 16.5 and severe dietary restrictions, a
nutritional rehabilitation program should be prioritized. This approach addresses the immediate health
risks associated with severe malnutrition and provides structured support for weight restoration and
normalization of eating patterns.
Question 82
B) Immediate delivery (Correct Answer)
Explanation: The most definitive treatment for severe preeclampsia at 37 weeks of gestation is immediate
delivery. At this gestational age, the risks of continuing the pregnancy outweigh the benefits of further fetal
maturation. Delivery is the only cure for preeclampsia and prevents progression to more severe
complications.
Question 83
B) Benzathine penicillin G (Correct Answer)
Explanation: Benzathine penicillin G is the recommended treatment for syphilis during pregnancy. It is the
only known effective treatment for syphilis in pregnancy and the prevention of congenital syphilis. Timely
initiation and completion of treatment are crucial for optimal outcomes.
Question 84
B) Importance of comprehensive behavioral assessments (Correct Answer)
Explanation: A pediatrician should emphasize the importance of comprehensive behavioral assessments
in the ADHD diagnosis process to concerned parents. This approach involves gathering information from
multiple sources (parents, teachers, caregivers) about the child's behavior in various settings, which is
crucial for an accurate diagnosis.
Question 85
A) Schizotypal (Correct Answer)
Explanation: Schizotypal personality disorder is often characterized by odd beliefs and magical thinking.
Individuals with this disorder may have superstitious beliefs, engage in magical thinking that influences
their behavior, and experience unusual perceptual experiences.
Question 86
C) Precancerous lesions (Correct Answer)
Explanation: Regular Pap smears can detect precancerous lesions to reduce cervical cancer incidence.
The goal of cervical cancer screening is to detect cell changes on the cervix before they become cancer.
Early detection of precancerous lesions allows for timely intervention and prevention of cervical cancer.
Question 87
D) Dietary modifications and exercise routine (Correct Answer)
Explanation: The recommended first-line management for controlling blood sugar in newly diagnosed
gestational diabetes is dietary modifications and exercise routine. This approach, often referred to as
medical nutritional therapy, is the initial step before considering pharmacological interventions.
Question 88
A) Continue monitoring and consider additional assessments (Correct Answer)
Explanation: For a pregnant woman at 32 weeks with gestational diabetes and a large-for-gestational-age
fetus, the most appropriate course of action is to continue monitoring and consider additional assessments.
This approach allows for ongoing evaluation of fetal growth and maternal glucose control while
preparing for potential interventions if needed.
Question 89
A) Lower risk of abuse and addiction (Correct Answer)
Explanation: A primary benefit of non-stimulant medications in managing ADHD in adults is the lower
risk of abuse and addiction. Unlike stimulant medications, non-stimulants do not have the same potential
for dependency, making them a safer option for some individuals, especially those with a history of
substance abuse.
Question 90
C) Absence of intrauterine gestational sac (Correct Answer)
Explanation: A key indicator of ectopic pregnancy on ultrasound is the absence of an intrauterine
gestational sac. When the hCG level is above the discriminatory zone (typically 3000 mIU/ml) and no
intrauterine gestational sac is visible, it strongly suggests an ectopic pregnancy.
Question 91
A) Syphilis (Correct Answer)
Explanation: Untreated syphilis in pregnant women increases the risk of premature labor. Syphilis can
lead to various adverse pregnancy outcomes, including preterm birth, stillbirth, and congenital syphilis in
the newborn. Early detection and treatment are crucial for preventing these complications.
Question 92
D) Before 3 years (Correct Answer)
Explanation: It is most critical to recognize early signs of Autism Spectrum Disorder (ASD) before 3
years of age for optimal intervention outcomes. Early detection and intervention can significantly improve
developmental outcomes and quality of life for children with ASD.
Question 93
D) Hemodynamic instability with rupture signs (Correct Answer)
Explanation: Surgical intervention is preferred for managing an ectopic pregnancy in the scenario of
hemodynamic instability with rupture signs. This situation represents a medical emergency requiring
immediate surgical intervention to prevent life-threatening complications from internal bleeding.
Question 94
B) Corticosteroid administration (Correct Answer)
Explanation: The most effective intervention to improve fetal lung maturity in preterm labor at 30 weeks
gestation is corticosteroid administration. Antenatal corticosteroids accelerate fetal lung development,
reducing the risk of respiratory distress syndrome and other complications associated with preterm birth.
Question 95
D) Methotrexate (Correct Answer)
Explanation: Methotrexate is used for medical management of an unruptured ectopic pregnancy. It is a
chemotherapeutic agent that stops the growth of rapidly dividing cells, including those of the ectopic
pregnancy. This treatment is suitable for carefully selected cases, avoiding the need for surgery.
Question 96
B) Narcissistic Personality Disorder (Correct Answer)
Explanation: Narcissistic Personality Disorder is characterized by grandiosity, need for admiration, and
lack of empathy. Individuals with this disorder often have an inflated sense of self-importance, expect to
be recognized as superior without commensurate achievements, and show arrogant behaviors or attitudes.
Question 97
B) Administer magnesium sulfate (Correct Answer)
Explanation: For a woman in her third trimester with preeclampsia experiencing seizures, the most
appropriate initial treatment is to administer magnesium sulfate. Magnesium sulfate is the drug of choice
for preventing and treating eclamptic seizures, reducing the risk of recurrent seizures and improving
maternal and fetal outcomes.
Question 98
C) Post-pill amenorrhea (Correct Answer)
Explanation: The most likely diagnosis for a 22-year-old woman with amenorrhea for six months after
stopping oral contraceptives is post-pill amenorrhea. This condition is relatively common and is usually a
temporary state where menstruation does not resume immediately after discontinuing oral contraceptives.
Question 99
A) Initiate immediate delivery (Correct Answer)
Explanation: For a 34-year-old woman at 30 weeks gestation with HELLP syndrome symptoms, the best
immediate intervention is to initiate immediate delivery. HELLP syndrome is a severe variant of
preeclampsia that can rapidly deteriorate, posing significant risks to both mother and fetus. Prompt
delivery is often necessary to prevent life-threatening complications.
Question 100
B) Six months (Correct Answer)
Explanation: The recommended duration of continuous disturbance for a schizophrenia diagnosis,
including at least one month of active-phase symptoms, is six months. This criterion ensures that the
symptoms are persistent and not due to a brief psychotic disorder or other temporary conditions.

Practice Tests 5
Question 1
What is typically recommended as the initial treatment for a confirmed case of gonorrhea in an adult with
no known drug allergies?
A) Ceftriaxone 500 mg IM single dose with azithromycin 1 g orally as a single dose
B) Azithromycin 2 g orally as a single dose without combination therapy
C) Penicillin G benzathine intramuscularly as a single dose
D) Doxycycline 100 mg orally twice daily for seven days
Question 2
For a 35-year-old man with glucose-6-phosphate dehydrogenase (G6PD) deficiency planning a trip to a
Plasmodium falciparum endemic region, which malaria prophylaxis is most suitable?
A) Chloroquine
B) Doxycycline
C) Atovaquone-proguanil
D) Primaquine
Question 3
Which symptom is often an initial presentation in patients with Multiple Sclerosis?
A) Intermittent episodes of severe abdominal pain
B) Frequent and severe migraine-like headaches
C) Visual disturbances such as blurred or double vision
D) Severe cognitive decline progressing rapidly over months
Question 4
In cases of septic shock where adequate fluid resuscitation fails to improve perfusion, which vasopressor
is typically recommended as first-line treatment?
A) Vasopressin
B) Epinephrine
C) Norepinephrine
D) Dopamine
Question 5
According to CDC guidelines, which group is considered high priority for receiving influenza
vaccination?
A) Adults over 65 years old only
B) Children aged 6 months to 5 years, pregnant women, the elderly, and those with chronic health
conditions
C) Only individuals with immune deficiencies
D) Only healthcare workers during influenza season
Question 6
What is commonly used as the first-line prophylactic treatment for chronic migraine?
A) Oral propranolol
B) High-dose aspirin regimen
C) Triptan medication as needed
D) Daily intake of an SSRI antidepressant
Question 7
For a 60-year-old woman with mitral valve prolapse scheduled for dental extraction, what antibiotic
prophylaxis is recommended to prevent infective endocarditis?
A) Cephalexin 2 g orally one hour before the procedure
B) Amoxicillin 2 g orally 30 to 60 minutes before the procedure
C) Clindamycin 600 mg orally 30 to 60 minutes before the procedure
D) Azithromycin 500 mg orally one hour before the procedure
Question 8
What is the initial step in managing a 70-year-old male brought to the emergency department within 90
minutes of stroke symptom onset, with a CT scan showing no hemorrhage?
A) Administer intravenous alteplase after obtaining informed consent
B) Initiate hypothermia protocol
C) Administer a high-dose statin immediately
D) Immediate surgical intervention to remove the clot
Question 9
What antibiotic regimen is typically recommended for endocarditis prophylaxis in patients with prosthetic
heart valves undergoing dental procedures?
A) Amoxicillin 2 g orally 30 to 60 minutes before the procedure
B) Azithromycin 500 mg orally 30 minutes before the procedure
C) Cephalexin 2 g orally before the procedure
D) Clindamycin 600 mg orally before the procedure
Question 10
Which treatment option is commonly employed for long-term management of Myasthenia Gravis?
A) Administration of acetylcholinesterase inhibitors
B) Plasmapheresis
C) Intravenous immunoglobulin (IVIG) therapy
D) Chronic use of corticosteroids
Question 11
Which type of primary brain tumor is known for its highly malignant nature and rapid progression of
neurological deficits?
A) Pilocytic astrocytoma
B) Lymphoma
C) Glioblastoma
D) Medulloblastoma
Question 12
What characteristic is most commonly associated with tension-type headaches?
A) Sharp, stabbing pain with visual aura
B) Occasional throbbing pain with dizziness
C) Intermittent pulsating pain around the temples
D) Pressing or tightening pain without nausea or photophobia
Question 13
For a 67-year-old male presenting with altered mental status, hypotension, and fever, what is the next step
in management if blood pressure remains low after 2 liters of normal saline?
A) Initiate norepinephrine infusion
B) Infuse vasopressin as adjunct therapy
C) Start phenylephrine infusion
D) Administer epinephrine
Question 14
What is the recommended treatment for severe malaria caused by Plasmodium falciparum in a 42-year-
old woman returning from sub-Saharan Africa?
A) Intravenous artesunate
B) Intravenous quinidine
C) Oral mefloquine
D) Oral chloroquine
Question 15
For a 59-year-old man with a history of prostate cancer presenting with severe back pain and progressive
leg weakness, what is the most appropriate initial action?
A) Urgent MRI to assess for metastatic lesions
B) Immediate referral to a physical therapist
C) Initiate aggressive chemotherapy
D) Perform a complete blood count
Question 16
What is the typical time window for administering intravenous thrombolytics in a patient with ischemic
stroke without contraindications?
A) Within 4.5 hours of symptom onset
B) Within 24 hours of symptom onset
C) Only if symptoms persist for at least 48 hours
D) Up to 12 hours after symptoms appear
Question 17
For a 30-year-old male patient presenting with diarrhea, nausea, and vomiting after consuming raw
shellfish, what is the most likely pathogen responsible?
A) Escherichia coli
B) Vibrio cholerae
C) Norovirus
D) Salmonella
Question 18
Which imaging modality is considered most sensitive for early detection of osteomyelitis in a patient with
diabetic foot ulcer?
A) Bone scintigraphy
B) Computed tomography (CT)
C) Magnetic resonance imaging (MRI)
D) Plain radiography
Question 19
For a 45-year-old woman presenting with ptosis and fluctuating muscle weakness improving with rest,
which diagnostic test would likely confirm Myasthenia Gravis?
A) Repetitive nerve stimulation test
B) Muscle biopsy
C) MRI scan of the thorax
D) Computed tomography of the brain
Question 20
Which treatment has shown effectiveness in altering the course of Guillain-Barré syndrome by reducing
immune attack on the nervous system?
A) Cyclophosphamide
B) Plasma exchange therapy
C) High-dose corticosteroids
D) Intravenous immunoglobulin (IVIG) therapy
Question 21
During a local influenza outbreak, what is the best course of action for a 30-year-old nurse reporting mild
flu symptoms?
A) Continue working without precautions
B) Stay home and avoid all contact
C) Begin antiviral prophylaxis
D) Take a leave of absence and seek complete health evaluation
Question 22
For a 45-year-old man presenting with fever, new-onset heart murmur, and multiple embolic events, with
blood cultures growing Streptococcus viridans, what is the most likely diagnosis based on Duke criteria?
A) Infective endocarditis
B) Myocarditis
C) Pericarditis
D) Rheumatic heart disease exacerbation
Question 23
What is the most appropriate antibiotic therapy for a 50-year-old man with poorly controlled diabetes
presenting with increasing foot pain and swelling, where MRI shows bone destruction and cultures grow
methicillin-resistant Staphylococcus aureus?
A) Oral linezolid therapy
B) Oral clindamycin with rifampin
C) Oral doxycycline
D) Intravenous vancomycin
Question 24
Which type of medication is often used to treat Myasthenia Gravis by reducing the immune system's attack
on acetylcholine receptors?
A) Corticosteroids
B) Immunosuppressants
C) Calcium channel blockers
D) Beta-blockers
Question 25
For a 78-year-old man with a history of hypertension and multiple strokes presenting with stepwise
deterioration in cognitive function and focal neurological signs, what is the most likely diagnosis?
A) Alzheimer's disease
B) Frontotemporal dementia
C) Lewy body dementia
D) Vascular dementia
Question 26
What MRI finding is considered highly suggestive of Multiple Sclerosis when observed in the brain's
white matter?
A) Isolated inflammatory lesions in the spinal cord
B) Multiple periventricular hyperintense T2 lesions
C) Single, large demyelinating lesion in the frontal cortex
D) Generalized atrophy of the cerebral cortex
Question 27
During an EEG, a patient exhibits a 3 Hz spike-and-wave pattern during a 5-minute staring episode.
Which antiepileptic drug is best suited for managing this seizure type?
A) Phenytoin
B) Topiramate
C) Levetiracetam
D) Ethosuximide
Question 28
What is typically considered the first-line imaging study for suspected spinal cord compression?
A) X-ray of the spine
B) CT scan of the spine
C) PET scan
D) MRI of the spine
Question 29
What is the recommended duration of antibiotic therapy for chronic osteomyelitis in an adult patient after
appropriate surgical debridement?
A) Two weeks of intravenous antibiotics followed by two weeks of oral antibiotics
B) Three months of oral antibiotic therapy
C) One month of antibiotics after debridement
D) A minimum of 6 weeks of antibiotic therapy
Question 30
For a 35-year-old woman presenting with a one-year history of intermittent numbness and tingling in her
limbs, accompanied by episodes of blurred vision, and MRI showing several periventricular hyperintense
lesions, what is the most likely diagnosis?
A) Progressive-relapsing Multiple Sclerosis
B) Secondary Progressive Multiple Sclerosis
C) Relapsing-remitting Multiple Sclerosis
D) Primary Progressive Multiple Sclerosis
Question 31
Which type of medication is commonly used as a pharmacological treatment approach in managing
Alzheimer's disease?
A) Cholinesterase inhibitors
B) Antidepressants
C) Antipsychotics
D) Memantine
Question 32
What treatment is often used for acute management of cluster headaches?
A) Intramuscular anticholinergic injection
B) High-flow oxygen therapy
C) Oral corticosteroids
D) Subcutaneous sumatriptan
Question 33
For a patient presenting with erythema migrans and known tick exposure in an endemic area but negative
initial serologic testing, what should be the next step in management?
A) Start empirical treatment with a non-steroidal anti-inflammatory drug
B) Immediate lumbar puncture
C) Advise to avoid antibiotics and use topical treatments only
D) Repeat serologic testing in 4-6 weeks and monitor symptoms
Question 34
Which antibody is most commonly tested for in the diagnosis of Myasthenia Gravis?
A) Anti-titin antibodies
B) Anti-MuSK antibodies
C) Acetylcholine receptor (AChR) antibodies
D) Voltage-gated calcium channel antibodies
Question 35
What is a key distinguishing feature of cluster headaches compared to migraines?
A) Association with menstrual cycle phases
B) Improvement with rest and quiet
C) Presence of aura before headache onset
D) Occurrence in cyclical patterns or clusters
Question 36
What is the recommended first-line prophylactic medication for travelers visiting chloroquine-resistant
areas for malaria prevention?
A) Mefloquine
B) Primaquine
C) Doxycycline
D) Atovaquone-proguanil
Question 37
What is typically the first-line treatment for early localized Lyme disease with the classic erythema
migrans rash?
A) Oral doxycycline for 10-14 days
B) High-dose oral prednisone for 7 days
C) Immediate surgical excision of the rash
D) Intravenous ceftriaxone for 30 days
Question 38
For a 32-year-old HIV positive woman with a CD4 count of 350 cells/mm³ planning to conceive, what is
the most important consideration regarding antiretroviral therapy?
A) Monitoring and planning for cessation of therapy during pregnancy
B) Encouraging lifestyle changes to minimize stress
C) Ensuring the regimen is safe for pregnancy and controls viral load
D) Adjusting diet to include more immune-boosting nutrients
Question 39
What is considered the most appropriate initial fluid resuscitation strategy for a patient presenting with
septic shock?
A) Administer 10 mL/kg of albumin followed by continuous infusion of crystalloids
B) Administer 30 mL/kg of crystalloid fluid rapidly within the first 3 hours
C) Give 5% dextrose solution at 1 liter per hour
D) Begin with 500 mL of crystalloid fluid and reassess after 30 minutes
Question 40
For a patient reporting intense, unilateral headaches lasting 45-90 minutes and occurring nightly, what is
the most likely diagnosis?
A) Migraine
B) Cluster headache
C) Tension headache
D) Sinus headache
Question 41
Which corticosteroid is typically administered first in cases of acute spinal cord compression?
A) Intrathecal injection of betamethasone
B) Oral dexamethasone
C) High-dose intravenous methylprednisolone
D) Intravenous hydrocortisone
Question 42
What management strategy is primarily used for patients diagnosed with vascular dementia to mitigate
symptom progression?
A) Use of antipsychotic medications
B) Cognitive rehabilitation therapies
C) Strict control of cardiovascular risk factors
D) Implementation of advanced care planning
Question 43
What medication is commonly used for immediate relief of severe migraine symptoms?
A) High-dose ibuprofen
B) Acetaminophen
C) Sumatriptan
D) Naproxen
Question 44
Which adjunctive therapy is recommended to reduce inflammation and improve outcomes in bacterial
meningitis caused by Streptococcus pneumoniae?
A) Ibuprofen
B) Prednisone
C) Hydrocortisone
D) Dexamethasone
Question 45
For a 2-month-old infant presenting with a bulging fontanelle, irritability, and lethargy, with lumbar
puncture confirming bacterial meningitis, what is the appropriate empiric antibiotic therapy?
A) Cefazolin and vancomycin
B) Cefotaxime combined with ampicillin
C) Meropenem combined with vancomycin
D) Vancomycin and ceftriaxone
Question 46
What is considered the primary risk factor for developing vascular dementia?
A) Exposure to neurotoxins or history of traumatic brain injury
B) Genetic predisposition related to apolipoprotein E4 allele
C) History of cerebrovascular accidents or transient ischemic attacks
D) Chronic alcohol abuse
Question 47
What is the primary indication for prescribing antiviral medications to a patient diagnosed with influenza?
A) To immediately alleviate all symptoms without other supportive care
B) Only to create herd immunity in community settings
C) To reduce the duration of flu symptoms and prevent severe complications
D) As a mandatory requirement for all patients diagnosed with the common cold
Question 48
What is typically the most common causative organism in native valve endocarditis among non-IV drug
users?
A) Staphylococcus aureus
B) Pseudomonas aeruginosa
C) Streptococcus viridans
D) Enterococcus faecalis
Question 49
In emergent cases of spinal cord compression, what is crucial to administer immediately to reduce
swelling and potential damage?
A) Broad-spectrum antibiotics
B) High-dose corticosteroids
C) Osmotic diuretics
D) Immediate surgery
Question 50
What is the purpose of the edrophonium test in diagnosing Myasthenia Gravis?
A) To measure the level of muscle enzymes in the blood as a marker of muscle damage and activity
B) To confirm the presence of specific genetic markers that predispose to autoimmune disorders
C) To assess the rapid improvement in muscle strength after administration, indicative of a positive
diagnosis
D) To evaluate the electrical activity of muscles and nerves using electromyography techniques
Question 51: How might a 40-year-old male experiencing intense, unilateral headache episodes occurring
in clusters over weeks be initially managed?
A. Administer high-flow oxygen via a non-rebreather mask
B. Start prophylactic verapamil therapy
C. Apply a cold compress to the forehead
D. Provide immediate intravenous hydration
Question 52: What lifestyle change is most effective for decreasing the frequency of tension headaches?
A. Use of corrective eyewear
B. Regular physical activity
C. Elimination of all dietary triggers
D. Avoidance of caffeine
Question 53: For a 32-year-old presenting with new-onset seizures, worsening morning headaches, and a
calcified tumor near the cerebral cortex on MRI, what is the probable diagnosis?
A. Glioblastoma multiforme
B. Astrocytoma
C. Meningioma
D. Oligodendroglioma
Question 54: Which neuropathological feature distinguishes Alzheimer's disease from vascular dementia?
A. Progressive loss of dopaminergic neurons in the substantia nigra
B. Extracellular amyloid plaques and intracellular neurofibrillary tangles in the cerebral cortex and
hippocampus
C. Predominant white matter hyperintensities on MRI
D. Presence of Lewy bodies within the midbrain and limbic structures
Question 55: In an HIV-diagnosed patient presenting with fever, weight loss, night sweats, and a diffuse
interstitial pattern on chest X-ray, what is the likely opportunistic infection?
A. Cytomegalovirus retinitis
B. Pneumocystis jirovecii pneumonia
C. Histoplasmosis
D. Tuberculosis
Question 56: For a 58-year-old female with atrial fibrillation and a new ischemic stroke diagnosis, what
is the most suitable medication for stroke prevention upon discharge?
A. Oral anticoagulation with warfarin
B. Start a regimen of dual antiplatelet therapy
C. High-dose aspirin therapy
D. Insertion of a carotid stent
Question 57: What is the probable causative agent for a 32-year-old presenting with multiple, painless,
flat warts around the genital area?
A. Scabies
B. Herpes simplex virus type 2 (HSV-2)
C. Human papillomavirus (HPV)
D. Molluscum contagiosum virus
Question 58: What is the main objective of antiretroviral therapy in HIV-diagnosed patients?
A. To periodically eliminate the virus completely from the body
B. To suppress the HIV viral load to undetectable levels
C. To prepare the patient's body for eventual vaccine therapy
D. To enhance the immune system function to combat common colds and flu
Question 59: During which stage of Lyme disease are neurological symptoms like facial palsy most likely
to appear?
A. Primary stage
B. Late disseminated stage
C. Early disseminated stage
D. Late localized stage
Question 60: For a 32-year-old woman with recurring bilateral headaches worsening with stress but not
associated with nausea, what is the recommended first-line treatment?
A. Stress management and relaxation techniques
B. Prophylactic use of topiramate
C. Opioid analgesics for acute episodes
D. Application of cold packs to the head
Question 61: What prophylactic treatment is most crucial for a 45-year-old male HIV patient with a CD4
count of 280 cells/mm³?
A. No prophylactic treatments are necessary
B. Administration of isoniazid for tuberculosis
C. Initiation of prophylactic treatment with trimethoprim-sulfamethoxazole
D. Vaccination against hepatitis B and hepatitis C viruses
Question 62: In Multiple Sclerosis management, which disease-modifying treatment is primarily used to
reduce relapse frequency?
A. Interferon beta-1a
B. Glatiramer acetate
C. Natalizumab
D. High-dose corticosteroids
Question 63: What is often the first-line treatment for severe Guillain-Barré syndrome to remove
antibodies from circulation?
A. Plasmapheresis
B. Stem cell transplantation
C. Corticosteroids
D. Immunosuppressants
Question 64: Which clinical finding is vital for early sepsis recognition in a patient with suspected
infection?
A. Fever with a temperature greater than 38°C or lower than 36°C
B. An elevated white blood cell count above 12,000 or less than 4,000 cells/mm³
C. Tachypnea with a respiratory rate greater than 20 breaths per minute
D. Hypotension, as defined by a systolic blood pressure below 90 mmHg or a drop greater than 40 mmHg
from baseline
Question 65: In the McDonald criteria for diagnosing Multiple Sclerosis, what type of lesion
dissemination is required over time?
A. Symptoms
B. Time
C. Lesions
D. Space
Question 66: Following a patient's first unprovoked seizure, what initial diagnostic step is recommended?
A. Start immediate treatment with a broad-spectrum antiepileptic
B. Schedule for a brain MRI with and without contrast
C. Perform a complete blood count and metabolic panel
D. Obtain an electroencephalogram (EEG) to assess for epileptiform abnormalities
Question 67: What is the primary goal of antiepileptic drug therapy?
A. Maximum dosage tolerance
B. Total symptom elimination
C. Seizure control
D. Minimal cognitive impairment
Question 68: For a patient describing severe, unilateral headaches associated with nausea and
photophobia, what is the most probable diagnosis?
A. Migraine
B. Tension headache
C. Cluster headache
D. Sinus headache
Question 69: Which diagnostic test is most suitable for detecting primary syphilis in a patient with a
chancre?
A. Polymerase chain reaction (PCR) testing for Herpes Simplex Virus
B. Enzyme immunoassay (EIA) test
C. Rapid plasma reagin (RPR) test
D. Darkfield microscopy
Question 70: What is the most appropriate initial step in treating a 65-year-old man with chronic heart
disease presenting with influenza symptoms?
A. Administer an antiviral drug within the first 48 hours after symptom onset
B. Immediate hospitalization to manage potential complications
C. Schedule an immediate influenza vaccination if not yet vaccinated
D. Recommend over-the-counter cold and flu medications to manage symptoms
Question 71: For routine screening of sexually active women under 25, what annual test does the CDC
recommend?
A. Human papillomavirus (HPV)
B. Gonorrhea
C. Syphilis
D. Chlamydia trachomatis
Question 72: What is the prophylactic agent of choice for pregnant women traveling to malaria-endemic
areas?
A. Mefloquine
B. Doxycycline
C. Atovaquone-proguanil
D. Chloroquine
Question 73: For a 25-year-old female patient with severe abdominal pain, watery diarrhea, and recent
travel to a developing country, what is the most appropriate initial management step?
A. Prescribe antibiotics empirically based on the patient's symptoms
B. Perform a stool test for pathogens including bacteria, viruses, and parasites
C. Administer intravenous fluids and immediate hospitalization
D. Encourage the patient to rest and avoid solid foods for 24 hours
Question 74: What is typically the initial presentation for a patient with a brain tumor in the frontal lobe?
A. Sudden onset of severe headaches with nausea and vomiting
B. Changes in personality or behavior, often subtle initially
C. Episodic memory loss
D. Gradual loss of movement control
Question 75: For a 45-year-old man presenting with arthritis weeks after removing a tick from his leg,
which antibiotic is most appropriate for this stage of Lyme disease?
A. Intravenous ceftriaxone for 14 days
B. High-dose intravenous penicillin for 21 days
C. Oral azithromycin for 10 days
D. Oral doxycycline or amoxicillin for 28 days
Question 76: To reduce recurrent stroke risk, what systolic blood pressure should patients maintain?
A. Below 140 mmHg
B. Below 130 mmHg
C. Below 120 mmHg
D. Below 150 mmHg
Question 77: In hematogenous osteomyelitis, what is the most common causative organism in adults?
A. Staphylococcus aureus
B. Escherichia coli
C. Enterococcus species
D. Pseudomonas aeruginosa
Question 78: What is the recommended initial management for a patient with mild to moderate infectious
diarrhea suspected to be of viral origin?
A. Initiate oral rehydration therapy immediately and monitor fluid status
B. Immediate referral to a specialist for infectious diseases
C. Start empirical antibiotic treatment without further investigation
D. Provide symptomatic relief with over-the-counter antidiarrheal medications
Question 79: What is a common symptom of spinal cord compression?
A. Progressive weakness in the extremities, often with sensory deficits
B. Recurrent headaches that increase in severity, especially in the morning
C. Intermittent claudication, primarily affecting the lower limbs during walking
D. Sudden onset of severe abdominal pain
Question 80: What is the recommended initial screening test for diabetic neuropathy in a newly diagnosed
Type 2 diabetes patient?
A. Detailed patient history to identify symptoms
B. Random blood sugar test
C. Comprehensive foot exam including inspection, palpation of pulses, and sensation testing
D. Immediate glycemic control assessment using hemoglobin A1c
Question 81: What is the most common opportunistic infection in HIV patients requiring prophylaxis when
CD4 counts drop below 200 cells/mm³?
A. Pneumocystis jirovecii pneumonia
B. Toxoplasma gondii encephalitis
C. Candida esophagitis
D. Cryptococcal meningitis
Question 82: For a 54-year-old diabetic female presenting with fever, confusion, hypotension, and
elevated lactate, what should be administered after 3 liters of crystalloids fail to improve blood pressure?
A. Start norepinephrine as a vasopressor
B. Administer phenylephrine
C. Consider vasopressin in combination with norepinephrine
D. Administer epinephrine
Question 83: What is the recommended antiplatelet therapy for secondary stroke prevention in patients
intolerant to aspirin?
A. Subcutaneous heparin injections
B. Intravenous immunoglobulin
C. Clopidogrel
D. Daily dose of vitamin K antagonist
Question 84: For a 65-year-old man with chronic corticosteroid use presenting with bacterial meningitis,
what is the most appropriate empiric treatment?
A. Cefotaxime and vancomycin
B. Meropenem combined with vancomycin
C. Vancomycin and acyclovir
D. Ceftriaxone, vancomycin, and ampicillin
Question 85: At what age is annual influenza vaccination recommended to reduce the risk of severe
complications?
A. One year and older
B. Six months and older
C. Two years and older
D. Eighteen years and older
Question 86: Which criterion is considered major in the Duke criteria for diagnosing infective
endocarditis?
A. Embolic events such as Janeway lesions or splinter hemorrhages
B. Presence of fever greater than 38°C without other identifiable source
C. Positive blood cultures for typical organisms
D. A new heart murmur identified during the febrile illness
Question 87: How is an asymptomatic meningioma typically managed?
A. Immediate chemotherapy
B. Surgical resection followed by radiation therapy
C. Stereotactic radiosurgery
D. Observation with regular follow-up imaging
Question 88: For patients over 50 with suspected bacterial meningitis, what should be included in
empiric therapy to cover Listeria monocytogenes?
A. Ampicillin
B. Ciprofloxacin
C. Doxycycline
D. Ceftriaxone alone
Question 89: What is the most appropriate next step in managing a 56-year-old diabetic patient presenting
with numbness in the toes and burning sensations in the feet worsening at night?
A. An immediate biopsy of nerve tissue
B. Scheduling regular acupuncture sessions
C. Implementation of a tailored management plan including strict glycemic control and medication
D. Referral to a neurologist for detailed assessment
Question 90: Which type of primary brain tumor is most prevalent in adults?
A. Meningioma
B. Pituitary adenoma
C. Acoustic neuroma
D. Glioblastoma multiforme
Question 91: During an annual check-up, what clinical test should be performed to monitor diabetic
neuropathy progression?
A. Simple visual inspection of feet
B. Routine physical activity tests
C. Blood glucose monitoring daily
D. Nerve conduction studies
Question 92: Which medication is typically considered first-line treatment for generalized tonic-clonic
seizures?
A. Carbamazepine
B. Gabapentin
C. Valproate
D. Lamotrigine
Question 93: In cases of suspected bacterial diarrhea without specific clinical indicators like fever or
bloody stools, what is the primary reason to avoid empirical antibiotic treatment?
A. Faster symptom resolution often requires medical intervention
B. There is a low risk of severe complications in healthy adults
C. Risk of increasing antibiotic resistance and potential adverse effects
D. The non-specific symptoms might not warrant such targeted therapy
Question 94: Which antimalarial drug should be avoided in patients with a history of neuropsychiatric
disorders due to potential severe side effects?
A. Doxycycline
B. Atovaquone-proguanil
C. Primaquine
D. Mefloquine
Question 95: What is considered the most effective method to prevent dehydration in patients with
infectious diarrhea?
A. Oral rehydration solution (ORS) therapy
B. Intravenous fluid administration
C. Dietary adjustments to include probiotics and bland foods
D. Increased intake of plain water
Question 96: What is the standard serologic test used for diagnosing Lyme disease in its early stages?
A. Single-tier IgM antibody test
B. Direct fluorescent antibody test on the tick
C. Two-tiered testing protocol (ELISA followed by Western blot)
D. Polymerase chain reaction (PCR) on blood samples
Question 97: For a 22-year-old presenting with multiple daytime seizures characterized by brief lapses in
consciousness without convulsions, what is the most likely seizure type?
A. Atonic seizures
B. Absence seizures
C. Tonic seizures
D. Myoclonic seizures
Question 98: What is the diagnosis for a 25-year-old female presenting with dysuria, increased vaginal
discharge, and gram-negative intracellular diplococci on cervical swab?
A. Chlamydia
B. Bacterial vaginosis
C. Trichomoniasis
D. Gonorrhea
Question 99: For a 10-year-old boy with acute hematogenous osteomyelitis and negative initial X-rays,
what is the next best imaging study to confirm the diagnosis?
A. Magnetic resonance imaging (MRI)
B. Bone scintigraphy
C. Ultrasound
D. CT scan
Question 100: What is the recommended treatment for a patient diagnosed with HIV presenting with fever,
weight loss, and night sweats, along with a diffuse interstitial pattern on chest X-ray?
A. Antifungal therapy for suspected Pneumocystis jirovecii pneumonia
B. Antibiotic therapy for suspected bacterial pneumonia
C. Antiviral therapy for suspected cytomegalovirus infection
D. Anti-tuberculosis therapy for suspected pulmonary tuberculosis

Correct Answers & Explanations

Question 1
A) Ceftriaxone 500 mg IM single dose with azithromycin 1 g orally as a single dose (Correct Answer)
Explanation: This combination therapy is the current recommended first-line treatment for uncomplicated
gonorrhea in adults. Ceftriaxone provides excellent coverage against Neisseria gonorrhoeae, while
azithromycin addresses potential chlamydial co-infection and helps prevent the development of antibiotic
resistance.
Question 2
B) Doxycycline (Correct Answer)
Explanation: For individuals with G6PD deficiency, doxycycline is the safest choice for malaria
prophylaxis. It doesn't cause hemolysis in G6PD-deficient individuals and is effective against
Plasmodium falciparum. Other options like primaquine are contraindicated in G6PD deficiency, while
chloroquine is not effective in many P. falciparum endemic regions due to resistance.
Question 3
C) Visual disturbances such as blurred or double vision (Correct Answer)
Explanation: Optic neuritis, causing visual disturbances like blurred or double vision, is often an initial
presentation in Multiple Sclerosis. This symptom results from inflammation of the optic nerve, a common
early manifestation of the demyelinating process characteristic of MS.
Question 4
C) Norepinephrine (Correct Answer)
Explanation: Norepinephrine is the first-line vasopressor recommended for septic shock when fluid
resuscitation fails to improve perfusion. It increases mean arterial pressure with minimal effect on heart
rate and has been shown to have better outcomes compared to other vasopressors in septic shock.
Question 5
B) Children aged 6 months to 5 years, pregnant women, the elderly, and those with chronic health
conditions (Correct Answer)
Explanation: The CDC recommends prioritizing influenza vaccination for these groups due to their higher
risk of complications from influenza. This comprehensive approach targets the most vulnerable
populations to reduce morbidity and mortality associated with influenza.
Question 6
A) Oral propranolol (Correct Answer)
Explanation: Propranolol, a beta-blocker, is commonly used as a first-line prophylactic treatment for
chronic migraine. It's effective in reducing the frequency and severity of migraines and has a well-
established safety profile. Other options like triptans are used for acute treatment, not prophylaxis.
Question 7
B) Amoxicillin 2 g orally 30 to 60 minutes before the procedure (Correct Answer)
Explanation: For patients with mitral valve prolapse undergoing dental procedures, amoxicillin is the
recommended antibiotic prophylaxis to prevent infective endocarditis. The 2 g dose taken 30-60 minutes
before the procedure provides adequate coverage against potential bacteremia.
Question 8
A) Administer intravenous alteplase after obtaining informed consent (Correct Answer)
Explanation: For an acute ischemic stroke patient presenting within the treatment window (typically 4.5
hours) and with no contraindications on CT scan, intravenous thrombolysis with alteplase is the standard
initial treatment. This can help dissolve the clot and restore blood flow, potentially reducing long-term
disability.
Question 9
A) Amoxicillin 2 g orally 30 to 60 minutes before the procedure (Correct Answer)
Explanation: For patients with prosthetic heart valves undergoing dental procedures, amoxicillin is the
recommended first-line antibiotic for endocarditis prophylaxis. The 2 g dose taken 30-60 minutes before
the procedure provides effective coverage against potential bacteremia that could lead to endocarditis.
Question 10
A) Administration of acetylcholinesterase inhibitors (Correct Answer)
Explanation: Acetylcholinesterase inhibitors, such as pyridostigmine, are the mainstay of long-term
management for Myasthenia Gravis. These medications increase the availability of acetylcholine at the
neuromuscular junction, improving muscle strength and function in MG patients.
Question 11
C) Glioblastoma (Correct Answer)
Explanation: Glioblastoma is known for its highly aggressive nature and rapid progression of
neurological deficits. It's the most malignant primary brain tumor in adults, characterized by rapid growth,
extensive infiltration into surrounding brain tissue, and poor prognosis despite aggressive treatment.
Question 12
D) Pressing or tightening pain without nausea or photophobia (Correct Answer)
Explanation: Tension-type headaches are typically characterized by a pressing or tightening sensation,
often described as a "band around the head." Unlike migraines, they usually don't involve nausea,
vomiting, or sensitivity to light and sound, which distinguishes them from other types of headaches.
Question 13
A) Initiate norepinephrine infusion (Correct Answer)
Explanation: In septic shock, if blood pressure remains low after adequate fluid resuscitation,
norepinephrine is the first-line vasopressor recommended. It effectively increases mean arterial pressure
while maintaining adequate tissue perfusion, and has been shown to have better outcomes compared to
other vasopressors in septic shock.
Question 14
A) Intravenous artesunate (Correct Answer)
Explanation: Intravenous artesunate is the recommended first-line treatment for severe malaria caused by
Plasmodium falciparum. It acts rapidly, has fewer side effects than quinine, and has been shown to reduce
mortality in severe malaria cases. It's particularly effective against the blood stages of P. falciparum.
Question 15
A) Urgent MRI to assess for metastatic lesions (Correct Answer)
Explanation: For a patient with a history of prostate cancer presenting with severe back pain and
progressive leg weakness, an urgent MRI is crucial to assess for spinal cord compression due to
metastatic lesions. Early detection and treatment of spinal cord compression can prevent permanent
neurological damage.
Question 16
A) Within 4.5 hours of symptom onset (Correct Answer)
Explanation: The typical time window for administering intravenous thrombolytics (usually alteplase) in
acute ischemic stroke is within 4.5 hours of symptom onset. This timeframe balances the potential benefits
of reperfusion against the increasing risks of hemorrhagic complications as time progresses.
Question 17
C) Norovirus (Correct Answer)
Explanation: Norovirus is the most likely pathogen responsible for acute gastroenteritis following
consumption of raw shellfish. It's highly contagious and often associated with outbreaks linked to
contaminated seafood, particularly raw or undercooked shellfish.
Question 18
C) Magnetic resonance imaging (MRI) (Correct Answer)
Explanation: MRI is considered the most sensitive imaging modality for early detection of osteomyelitis,
particularly in diabetic foot ulcers. It can detect bone marrow edema and soft tissue changes associated
with early infection before changes are visible on other imaging modalities.
Question 19
A) Repetitive nerve stimulation test (Correct Answer)
Explanation: The repetitive nerve stimulation test is a key diagnostic tool for Myasthenia Gravis. It shows
a characteristic decremental response in muscle action potential amplitude with repetitive stimulation,
reflecting the fatigue of neuromuscular transmission typical in MG.
Question 20
D) Intravenous immunoglobulin (IVIG) therapy (Correct Answer)
Explanation: IVIG therapy has shown effectiveness in altering the course of Guillain-Barré syndrome by
modulating the immune response. It helps reduce the immune attack on the nervous system, leading to
faster recovery and improved outcomes in many patients with GBS.
Question 21
B) Stay home and avoid all contact (Correct Answer)
Explanation: During an influenza outbreak, a healthcare worker with mild flu symptoms should stay home
to prevent spreading the virus to vulnerable patients and colleagues. This approach aligns with infection
control practices and helps contain the outbreak within healthcare settings.
Question 22
A) Infective endocarditis (Correct Answer)
Explanation: The combination of fever, new-onset heart murmur, multiple embolic events, and blood
cultures growing Streptococcus viridans strongly suggests infective endocarditis. These findings meet the
Duke criteria for diagnosing endocarditis, with S. viridans being a common causative organism in native
valve endocarditis.
Question 23
D) Intravenous vancomycin (Correct Answer)
Explanation: For MRSA osteomyelitis in a diabetic foot, intravenous vancomycin is the most appropriate
initial therapy. It provides excellent coverage against MRSA and achieves adequate bone penetration. The
severity of the infection (bone destruction) warrants parenteral therapy over oral options.
Question 24
B) Immunosuppressants (Correct Answer)
Explanation: Immunosuppressants, such as azathioprine or mycophenolate mofetil, are often used to treat
Myasthenia Gravis by reducing the immune system's attack on acetylcholine receptors. These medications
help suppress the autoimmune response responsible for the disease, leading to improved muscle function.
Question 25
D) Vascular dementia (Correct Answer)
Explanation: The history of hypertension and multiple strokes, along with stepwise deterioration in
cognitive function and focal neurological signs, strongly suggests vascular dementia. This type of
dementia is characterized by cognitive decline due to cerebrovascular disease, often presenting with a
stepwise progression corresponding to vascular events.
Question 26
B) Multiple periventricular hyperintense T2 lesions (Correct Answer)
Explanation: Multiple periventricular hyperintense T2 lesions are highly suggestive of Multiple Sclerosis
(MS) when observed in brain MRI. These lesions, often called "Dawson's fingers," are characteristic of
MS and reflect areas of demyelination in the white matter surrounding the ventricles. This pattern is a key
diagnostic feature in MS and is included in the McDonald criteria for MS diagnosis.
Question 27
D) Ethosuximide (Correct Answer)
Explanation: The 3 Hz spike-and-wave pattern during a staring episode is characteristic of absence
seizures, which are a form of generalized seizure. Ethosuximide is the first-line treatment for absence
seizures due to its efficacy and favorable side effect profile. It works by reducing T-type calcium currents
in thalamic neurons, which are thought to be crucial in the generation of absence seizures.
Question 28
D) MRI of the spine (Correct Answer)
Explanation: MRI of the spine is typically considered the first-line imaging study for suspected spinal
cord compression. MRI provides excellent soft tissue contrast, allowing visualization of the spinal cord,
surrounding structures, and any compressive lesions. It can detect various causes of compression,
including tumors, herniated discs, and inflammatory conditions, without exposing the patient to ionizing
radiation.
Question 29
D) A minimum of 6 weeks of antibiotic therapy (Correct Answer)
Explanation: The recommended duration of antibiotic therapy for chronic osteomyelitis in adults after
appropriate surgical debridement is typically a minimum of 6 weeks. This extended course is necessary
due to the poor vascular supply in bone tissue and the presence of biofilms that can protect bacteria. The
therapy often includes both intravenous and oral antibiotics, with the specific regimen tailored based on
culture results and clinical response.
Question 30
C) Relapsing-remitting Multiple Sclerosis (Correct Answer)
Explanation: The clinical presentation of intermittent numbness, tingling, and episodes of blurred vision,
along with MRI findings of periventricular hyperintense lesions, is highly suggestive of Relapsing-
remitting Multiple Sclerosis (RRMS). This is the most common form of MS, characterized by clearly
defined attacks of new or increasing neurologic symptoms followed by periods of partial or complete
recovery.
Question 31
A) Cholinesterase inhibitors (Correct Answer)
Explanation: Cholinesterase inhibitors are commonly used as a pharmacological treatment approach in
managing Alzheimer's disease. These medications, such as donepezil, rivastigmine, and galantamine,
work by increasing levels of acetylcholine in the brain by inhibiting its breakdown. This helps to improve
cognitive function, particularly in the early to moderate stages of Alzheimer's disease.
Question 32
B) High-flow oxygen therapy (Correct Answer)
Explanation: High-flow oxygen therapy is often used as a first-line treatment for acute management of
cluster headaches. Inhalation of 100% oxygen at a flow rate of 7-12 L/min for 15-20 minutes can
effectively abort a cluster headache attack in many patients. This treatment is preferred due to its rapid
onset of action, lack of side effects, and the ability to use it multiple times per day if needed.
Question 33
D) Repeat serologic testing in 4-6 weeks and monitor symptoms (Correct Answer)
Explanation: For a patient with erythema migrans and known tick exposure in an endemic area but
negative initial serologic testing, the recommended next step is to repeat serologic testing in 4-6 weeks
and monitor symptoms. Early in Lyme disease, antibodies may not have developed to detectable levels,
leading to false-negative results. Repeating the test allows time for seroconversion. However, treatment
should not be delayed if clinical suspicion is high.
Question 34
C) Acetylcholine receptor (AChR) antibodies (Correct Answer)
Explanation: Acetylcholine receptor (AChR) antibodies are the most commonly tested antibodies in the
diagnosis of Myasthenia Gravis. These antibodies are present in about 85% of patients with generalized
MG and are highly specific for the disease. They bind to acetylcholine receptors at the neuromuscular
junction, leading to the characteristic muscle weakness and fatigue seen in MG.
Question 35
D) Occurrence in cyclical patterns or clusters (Correct Answer)
Explanation: A key distinguishing feature of cluster headaches compared to migraines is their occurrence
in cyclical patterns or clusters. Cluster headaches typically occur in bouts lasting weeks to months,
followed by remission periods. They often happen at the same time each day, frequently waking the
patient at night. This predictable, cyclical pattern is not typically seen in migraines and is a hallmark of
cluster headaches.
Question 36
D) Atovaquone-proguanil (Correct Answer)
Explanation: Atovaquone-proguanil is the recommended first-line prophylactic medication for travelers
visiting chloroquine-resistant areas for malaria prevention. It is effective against all species of malaria,
including chloroquine-resistant strains. This combination drug has a good safety profile, requires shorter
duration of use (only 1 day after leaving the malaria-endemic area), and has fewer side effects compared
to other antimalarial drugs.
Question 37
A) Oral doxycycline for 10-14 days (Correct Answer)
Explanation: The first-line treatment for early localized Lyme disease with the classic erythema migrans
rash is oral doxycycline for 10-14 days. Doxycycline is preferred due to its effectiveness against Borrelia
burgdorferi, the causative agent of Lyme disease, as well as its ability to treat potential co-infections like
Anaplasma. It's also effective in preventing the development of later stages of Lyme disease.
Question 38
C) Ensuring the regimen is safe for pregnancy and controls viral load (Correct Answer)
Explanation: For an HIV-positive woman planning to conceive, the most important consideration
regarding antiretroviral therapy is ensuring the regimen is safe for pregnancy and effectively controls
viral load. The goal is to maintain viral suppression to prevent mother-to-child transmission while using
medications that are known to be safe during pregnancy. This approach protects both the mother's health
and reduces the risk of transmitting HIV to the baby.
Question 39
B) Administer 30 mL/kg of crystalloid fluid rapidly within the first 3 hours (Correct Answer)
Explanation: The most appropriate initial fluid resuscitation strategy for a patient presenting with septic
shock is to administer 30 mL/kg of crystalloid fluid rapidly within the first 3 hours. This approach is
recommended by the Surviving Sepsis Campaign guidelines. Rapid fluid administration helps to restore
intravascular volume, improve tissue perfusion, and stabilize hemodynamics in septic shock patients.
Question 40
B) Cluster headache (Correct Answer)
Explanation: The description of intense, unilateral headaches lasting 45-90 minutes and occurring nightly
is highly characteristic of cluster headaches. Cluster headaches are known for their severe pain, typically
around one eye, and their tendency to occur at the same time each day, often waking the patient from sleep.
The relatively short duration (45-90 minutes) and cyclical pattern are key features distinguishing cluster
headaches from other types of headaches.
Question 41
C) High-dose intravenous methylprednisolone (Correct Answer)
Explanation: In cases of acute spinal cord compression, high-dose intravenous methylprednisolone is
typically administered first. This corticosteroid is used to reduce inflammation and swelling around the
spinal cord, potentially minimizing further damage. The standard regimen is a high initial dose followed
by a tapering course, started as soon as possible after the onset of symptoms.
Question 42
C) Strict control of cardiovascular risk factors (Correct Answer)
Explanation: The primary management strategy for patients diagnosed with vascular dementia to mitigate
symptom progression is strict control of cardiovascular risk factors. This includes managing hypertension,
diabetes, hyperlipidemia, and encouraging smoking cessation. By controlling these risk factors, the goal is
to prevent further vascular damage and slow the progression of cognitive decline.
Question 43
C) Sumatriptan (Correct Answer)
Explanation: Sumatriptan is commonly used for immediate relief of severe migraine symptoms. It belongs
to a class of drugs called triptans, which work by narrowing blood vessels in the brain and blocking pain
pathways. Sumatriptan can be administered in various forms (oral, nasal spray, or injection) and is known
for its rapid onset of action in relieving migraine pain and associated symptoms.
Question 44
D) Dexamethasone (Correct Answer)
Explanation: Dexamethasone is the recommended adjunctive therapy to reduce inflammation and improve
outcomes in bacterial meningitis caused by Streptococcus pneumoniae. It is typically given shortly before
or with the first dose of antibiotics. Dexamethasone helps reduce the inflammatory response in the
subarachnoid space, potentially decreasing complications such as hearing loss and neurological sequelae.
Question 45
B) Cefotaxime combined with ampicillin (Correct Answer)
Explanation: For a 2-month-old infant with confirmed bacterial meningitis, the appropriate empiric
antibiotic therapy is cefotaxime combined with ampicillin. This combination provides broad-spectrum
coverage against the most common pathogens in this age group, including Group B Streptococcus,
Escherichia coli, and Listeria monocytogenes. Cefotaxime covers gram-negative organisms and some
gram-positives, while ampicillin is added to cover Listeria.
Question 46
C) History of cerebrovascular accidents or transient ischemic attacks (Correct Answer)
Explanation: The primary risk factor for developing vascular dementia is a history of cerebrovascular
accidents (strokes) or transient ischemic attacks (TIAs). These events cause damage to brain tissue and
blood vessels, leading to impaired blood flow and oxygen supply to the brain. Repeated or severe
cerebrovascular events can result in cumulative damage, increasing the risk of cognitive decline and
vascular dementia.
Question 47
C) To reduce the duration of flu symptoms and prevent severe complications (Correct Answer)
Explanation: The primary indication for prescribing antiviral medications to a patient diagnosed with
influenza is to reduce the duration of flu symptoms and prevent severe complications. Antiviral drugs like
oseltamivir (Tamiflu) or zanamivir (Relenza) can shorten the course of the illness by 1-2 days if started
early and can help prevent complications such as pneumonia, especially in high-risk individuals.
Question 48
C) Streptococcus viridans (Correct Answer)
Explanation: Streptococcus viridans is typically the most common causative organism in native valve
endocarditis among non-IV drug users. These bacteria are part of the normal oral flora and can enter the
bloodstream during dental procedures or daily activities like brushing teeth. They have a propensity to
adhere to damaged or abnormal heart valves, making them a frequent cause of subacute bacterial
endocarditis in individuals with underlying valvular heart disease.
Question 49
B) High-dose corticosteroids (Correct Answer)
Explanation: In emergent cases of spinal cord compression, it is crucial to administer high-dose
corticosteroids immediately to reduce swelling and potential damage. Typically, methylprednisolone is
used in high doses. This treatment aims to reduce inflammation and edema around the spinal cord,
potentially preserving neurological function and improving outcomes. It's important to start this treatment
as soon as possible after the diagnosis is made.
Question 50
C) To assess the rapid improvement in muscle strength after administration, indicative of a positive
diagnosis (Correct Answer)
Explanation: The purpose of the edrophonium test in diagnosing Myasthenia Gravis is to assess the rapid
improvement in muscle strength after administration, which is indicative of a positive diagnosis.
Edrophonium is a short-acting acetylcholinesterase inhibitor that temporarily increases acetylcholine
levels at the neuromuscular junction. In patients with MG, this leads to a brief but noticeable improvement
in muscle strength, helping to confirm the diagnosis.
Question 51:
A) Administer high-flow oxygen via a non-rebreather mask (Correct Answer)
Explanation: High-flow oxygen is the initial treatment of choice for cluster headaches. It can provide
rapid relief in about 70% of patients within 15 minutes. This non-invasive method is safe and effective
for acute cluster headache attacks.
Question 52:
B) Regular physical activity (Correct Answer)
Explanation: Regular physical activity is the most effective lifestyle change for reducing tension headache
frequency. Exercise helps reduce stress, improve sleep quality, and release endorphins, which can all
contribute to fewer tension headaches.
Question 53:
C) Meningioma (Correct Answer)
Explanation: The description of a calcified tumor near the cerebral cortex, along with new-onset seizures
and worsening morning headaches, is highly suggestive of a meningioma. Meningiomas are often calcified
and can cause seizures and increased intracranial pressure, leading to morning headaches.
Question 54:
B) Extracellular amyloid plaques and intracellular neurofibrillary tangles in the cerebral cortex and
hippocampus (Correct Answer)
Explanation: This is the hallmark neuropathological feature of Alzheimer's disease. These plaques and
tangles are not typically seen in vascular dementia, which is characterized more by multiple infarcts or
white matter changes.
Question 55:
B) Pneumocystis jirovecii pneumonia (Correct Answer)
Explanation: In HIV patients, Pneumocystis jirovecii pneumonia (PCP) is a common opportunistic
infection presenting with fever, weight loss, night sweats, and a diffuse interstitial pattern on chest X-ray.
PCP is particularly common in patients with low CD4 counts.
Question 56:
A) Oral anticoagulation with warfarin (Correct Answer)
Explanation: For patients with atrial fibrillation and a recent ischemic stroke, oral anticoagulation (such
as warfarin) is the most effective treatment for preventing future strokes. It significantly reduces the risk
of thromboembolism compared to antiplatelet therapy.
Question 57:
C) Human papillomavirus (HPV) (Correct Answer)
Explanation: Multiple, painless, flat warts in the genital area are characteristic of HPV infection. HPV is
the most common sexually transmitted infection and is known to cause genital warts and certain types of
cancer.
Question 58:
B) To suppress the HIV viral load to undetectable levels (Correct Answer)
Explanation: The main goal of antiretroviral therapy in HIV patients is to suppress the viral load to
undetectable levels. This helps prevent disease progression, reduces the risk of transmission, and allows
for immune system recovery.
Question 59:
C) Early disseminated stage (Correct Answer)
Explanation: Neurological symptoms like facial palsy typically appear during the early disseminated
stage of Lyme disease, which occurs weeks to months after the initial tick bite. This stage is characterized
by the spread of bacteria throughout the body.
Question 60:
A) Stress management and relaxation techniques (Correct Answer)
Explanation: For tension-type headaches that worsen with stress, non-pharmacological approaches like
stress management and relaxation techniques are recommended as first-line treatment. These methods can
help reduce the frequency and intensity of headaches without medication side effects.
Question 61:
A) No prophylactic treatments are necessary (Correct Answer)
Explanation: For HIV patients with CD4 counts above 200 cells/mm³, prophylactic treatments are
generally not necessary. The patient's CD4 count of 280 cells/mm³ is above the threshold (200 cells/mm³)
at which prophylaxis for opportunistic infections like Pneumocystis jirovecii pneumonia is typically
recommended.
Question 62:
A) Interferon beta-1a (Correct Answer)
Explanation: Interferon beta-1a is a first-line disease-modifying treatment for relapsing-remitting multiple
sclerosis. It works by reducing inflammation and has been shown to decrease the frequency of relapses in
MS patients.
Question 63:
A) Plasmapheresis (Correct Answer)
Explanation: Plasmapheresis, also known as plasma exchange, is often the first-line treatment for severe
Guillain-Barré syndrome. It works by removing antibodies from the blood circulation, which are thought
to be responsible for attacking the nerves in GBS.
Question 64:
C) Tachypnea with a respiratory rate greater than 20 breaths per minute (Correct Answer)
Explanation: While all the options can be signs of sepsis, tachypnea (rapid breathing) is often one of the
earliest and most sensitive indicators of sepsis. A respiratory rate greater than 20 breaths per minute is a
key component of the quick Sequential Organ Failure Assessment (qSOFA) score used for early sepsis
recognition.
Question 65:
D) Space (Correct Answer)
Explanation: In the McDonald criteria for diagnosing Multiple Sclerosis, dissemination in space (DIS)
refers to the presence of lesions in different areas of the central nervous system. This is a key requirement
for MS diagnosis, along with dissemination in time.
Question 66:
B) Schedule for a brain MRI with and without contrast (Correct Answer)
Explanation: After a first unprovoked seizure, a brain MRI with and without contrast is the recommended
initial diagnostic step. This imaging can help identify any structural abnormalities or lesions that might be
causing the seizures.
Question 67:
C) Seizure control (Correct Answer)
Explanation: The primary goal of antiepileptic drug therapy is to control seizures. While minimizing side
effects is important, the main objective is to reduce or eliminate seizure activity to improve the patient's
quality of life and prevent complications associated with recurrent seizures.
Question 68:
A) Migraine (Correct Answer)
Explanation: The description of severe, unilateral headaches associated with nausea and photophobia is
characteristic of migraine headaches. These symptoms, particularly the combination of unilateral pain
with associated features like nausea and sensitivity to light, strongly suggest a migraine diagnosis.
Question 69:
D) Darkfield microscopy (Correct Answer)
Explanation: Darkfield microscopy is the most suitable diagnostic test for detecting primary syphilis in a
patient with a chancre. This method allows for direct visualization of Treponema pallidum, the causative
agent of syphilis, from fluid obtained from the chancre.
Question 70:
A) Administer an antiviral drug within the first 48 hours after symptom onset (Correct Answer)
Explanation: For a high-risk patient (65 years old with chronic heart disease) presenting with influenza
symptoms, the most appropriate initial step is to administer an antiviral drug within 48 hours of symptom
onset. Early antiviral treatment can reduce the severity and duration of influenza, especially in high-risk
individuals.
Question 71:
D) Chlamydia trachomatis (Correct Answer)
Explanation: The CDC recommends annual screening for Chlamydia trachomatis in sexually active
women under 25 years old. This is due to the high prevalence of chlamydia in this age group and the
potential for serious complications if left untreated.
Question 72:
A) Mefloquine (Correct Answer)
Explanation: Mefloquine is often the prophylactic agent of choice for pregnant women traveling to
malaria-endemic areas. It is considered safe during pregnancy and is effective against chloroquine-
resistant Plasmodium falciparum.
Question 73:
B) Perform a stool test for pathogens including bacteria, viruses, and parasites (Correct Answer)
Explanation: For a patient with severe abdominal pain, watery diarrhea, and recent travel to a developing
country, the most appropriate initial management step is to perform a stool test for pathogens. This will
help identify the specific cause of the illness, which is crucial for determining the appropriate treatment.
Question 74:
B) Changes in personality or behavior, often subtle initially (Correct Answer)
Explanation: The initial presentation for a patient with a brain tumor in the frontal lobe is often subtle
changes in personality or behavior. This is because the frontal lobe is responsible for executive functions,
personality, and behavior regulation.
Question 75:
D) Oral doxycycline or amoxicillin for 28 days (Correct Answer)
Explanation: For a patient presenting with arthritis weeks after a tick bite, which suggests early
disseminated Lyme disease, the recommended treatment is oral doxycycline or amoxicillin for 28 days.
This regimen is effective for treating the arthritis associated with Lyme disease at this stage.
Question 76:
B) Below 130 mmHg (Correct Answer)
Explanation: Recent guidelines recommend maintaining systolic blood pressure below 130 mmHg for
secondary stroke prevention. Studies have shown that this target provides better protection against
recurrent stroke compared to higher targets, while balancing the risks of excessive blood pressure
lowering.
Question 77:
A) Staphylococcus aureus (Correct Answer)
Explanation: Staphylococcus aureus is the most common causative organism in hematogenous
osteomyelitis in adults. It accounts for about 50% of cases and is particularly adept at adhering to bone
tissue and causing infection.
Question 78:
A) Initiate oral rehydration therapy immediately and monitor fluid status (Correct Answer)
Explanation: For mild to moderate viral diarrhea, the primary concern is maintaining hydration. Oral
rehydration therapy is the recommended initial management as it helps replace lost fluids and electrolytes
effectively and safely. Antibiotics are not indicated for viral causes, and antidiarrheal medications are
generally not recommended as initial therapy.
Question 79:
A) Progressive weakness in the extremities, often with sensory deficits (Correct Answer)
Explanation: Spinal cord compression typically presents with progressive weakness in the extremities,
often accompanied by sensory deficits. This is due to the pressure on the spinal cord affecting both motor
and sensory nerve pathways.
Question 80:
C) Comprehensive foot exam including inspection, palpation of pulses, and sensation testing (Correct
Answer)
Explanation: The American Diabetes Association recommends a comprehensive foot exam as the initial
screening test for diabetic neuropathy in newly diagnosed Type 2 diabetes patients. This exam includes
visual inspection, pulse palpation, and sensation testing, which can detect early signs of neuropathy.
Question 81:
A) Pneumocystis jirovecii pneumonia (Correct Answer)
Explanation: Pneumocystis jirovecii pneumonia (PCP) is the most common opportunistic infection
requiring prophylaxis in HIV patients when CD4 counts drop below 200 cells/mm³. PCP prophylaxis is a
standard recommendation in HIV care guidelines due to its high prevalence and potential severity in
immunocompromised patients.
Question 82:
A) Start norepinephrine as a vasopressor (Correct Answer)
Explanation: In a patient with septic shock (indicated by fever, confusion, hypotension, and elevated
lactate) who fails to respond to initial fluid resuscitation, the next step is to start vasopressor therapy.
Norepinephrine is the first-line vasopressor recommended for septic shock according to current
guidelines.
Question 83:
C) Clopidogrel (Correct Answer)
Explanation: For patients intolerant to aspirin, clopidogrel is the recommended antiplatelet therapy for
secondary stroke prevention. It has been shown to be effective in reducing the risk of recurrent stroke and
is generally well-tolerated as an alternative to aspirin.
Question 84:
D) Ceftriaxone, vancomycin, and ampicillin (Correct Answer)
Explanation: For a 65-year-old man with chronic corticosteroid use presenting with bacterial meningitis,
empiric treatment should cover a broad spectrum of potential pathogens, including Listeria
monocytogenes. The combination of ceftriaxone, vancomycin, and ampicillin provides coverage for
common meningitis pathogens as well as Listeria, which is more common in older and
immunocompromised patients.
Question 85:
B) Six months and older (Correct Answer)
Explanation: The Centers for Disease Control and Prevention (CDC) recommends annual influenza
vaccination for everyone 6 months of age and older to reduce the risk of severe complications from
influenza. This recommendation is based on the vaccine's safety profile and effectiveness in preventing
influenza-related morbidity and mortality across all age groups.
Question 86:
C) Positive blood cultures for typical organisms (Correct Answer)
Explanation: In the Duke criteria for diagnosing infective endocarditis, positive blood cultures for typical
organisms are considered a major criterion. This is because the presence of these organisms in multiple
blood cultures is highly indicative of endocarditis and plays a crucial role in confirming the diagnosis.
Question 87:
D) Observation with regular follow-up imaging (Correct Answer)
Explanation: Asymptomatic meningiomas are typically managed through observation with regular follow-
up imaging. This approach is preferred because many meningiomas grow slowly or not at all, and the
risks of intervention may outweigh the benefits in asymptomatic cases. Regular imaging allows for
monitoring of tumor growth and early detection of any changes that might necessitate intervention.
Question 88:
A) Ampicillin (Correct Answer)
Explanation: For patients over 50 with suspected bacterial meningitis, ampicillin should be included in
the empiric therapy to cover Listeria monocytogenes. Listeria is more common in older adults and
immunocompromised patients, and it's not susceptible to cephalosporins like ceftriaxone. Ampicillin
provides effective coverage against Listeria in this age group.
Question 89:
C) Implementation of a tailored management plan including strict glycemic control and medication
(Correct Answer)
Explanation: For a diabetic patient presenting with symptoms of peripheral neuropathy, the most
appropriate next step is to implement a tailored management plan. This should include strict glycemic
control to prevent further nerve damage, and may involve medications for symptom relief. This approach
addresses the underlying cause (hyperglycemia) while also managing symptoms.
Question 90:
A) Meningioma (Correct Answer)
Explanation: Meningiomas are the most prevalent type of primary brain tumor in adults. They account for
about 36% of all primary brain tumors and are typically benign. While other types like glioblastoma are
more aggressive, they are less common overall compared to meningiomas.
Question 91:
A) Simple visual inspection of feet (Correct Answer)
Explanation: During an annual check-up for diabetic patients, a simple visual inspection of the feet is a
crucial clinical test to monitor diabetic neuropathy progression. This examination can detect early signs of
neuropathy such as skin changes, ulcers, or deformities, which are often the first indicators of nerve
damage in diabetic patients.
Question 92:
C) Valproate (Correct Answer)
Explanation: Valproate (valproic acid) is typically considered a first-line treatment for generalized tonic-
clonic seizures. It has broad-spectrum efficacy against various seizure types and is particularly effective
for generalized seizures. Its mechanism of action involves enhancing GABA neurotransmission and
blocking voltage-gated sodium channels.
Question 93:
C) Risk of increasing antibiotic resistance and potential adverse effects (Correct Answer)
Explanation: The primary reason to avoid empirical antibiotic treatment in suspected bacterial diarrhea
without specific clinical indicators is the risk of increasing antibiotic resistance and potential adverse
effects. Overuse of antibiotics can lead to the development of resistant bacteria, and unnecessary
antibiotic use can cause side effects without providing benefit.
Question 94:
D) Mefloquine (Correct Answer)
Explanation: Mefloquine should be avoided in patients with a history of neuropsychiatric disorders due to
its potential for severe neuropsychiatric side effects. These can include anxiety, depression,
hallucinations, and even psychosis. Other antimalarial drugs are generally preferred for patients with a
history of mental health issues.
Question 95:
A) Oral rehydration solution (ORS) therapy (Correct Answer)
Explanation: Oral rehydration solution (ORS) therapy is considered the most effective method to prevent
dehydration in patients with infectious diarrhea. ORS provides a balanced mixture of salts and glucose
that promotes water absorption in the intestines, effectively replacing fluids and electrolytes lost due to
diarrhea.
Question 96:
C) Two-tiered testing protocol (ELISA followed by Western blot) (Correct Answer)
Explanation: The standard serologic test for diagnosing Lyme disease in its early stages is the two-tiered
testing protocol. This involves an initial enzyme-linked immunosorbent assay (ELISA) screening test,
followed by a Western blot confirmation test if the ELISA is positive or equivocal. This approach
maximizes both sensitivity and specificity for detecting Borrelia burgdorferi antibodies, which is crucial
for accurate diagnosis, especially in early-stage Lyme disease.
Question 97:
B) Absence seizures (Correct Answer)
Explanation: The description of multiple daytime seizures characterized by brief lapses in consciousness
without convulsions is typical of absence seizures. These seizures, also known as "petit mal" seizures,
involve sudden, brief episodes of staring and unresponsiveness, usually lasting only a few seconds. They
are common in children and young adults and do not involve the convulsive movements seen in other
seizure types.
Question 98:
D) Gonorrhea (Correct Answer)
Explanation: The presence of gram-negative intracellular diplococci on a cervical swab is highly
indicative of gonorrhea. Neisseria gonorrhoeae, the causative agent of gonorrhea, is a gram-negative
diplococcus that typically appears intracellular in microscopic examination. Combined with symptoms of
dysuria and increased vaginal discharge, this finding strongly suggests a diagnosis of gonorrhea in this 25-
year-old female patient.
Question 99:
A) Magnetic resonance imaging (MRI) (Correct Answer)
Explanation: For a 10-year-old boy with suspected acute hematogenous osteomyelitis and negative initial
X-rays, MRI is the next best imaging study to confirm the diagnosis. MRI offers superior soft tissue
contrast and can detect early bone marrow changes associated with osteomyelitis, even when X-rays are
normal. It is highly sensitive for early detection of osteomyelitis and can also reveal any associated soft
tissue or joint involvement, making it the preferred imaging modality in this scenario.
Question 100:
A) Antifungal therapy for suspected Pneumocystis jirovecii pneumonia (Correct Answer)
Explanation: For an HIV-positive patient presenting with fever, weight loss, night sweats, and a diffuse
interstitial pattern on chest X-ray, the most likely diagnosis is Pneumocystis jirovecii pneumonia (PCP).
PCP is a common opportunistic infection in HIV patients with low CD4 counts. The clinical presentation
and radiographic findings are highly suggestive of PCP. Therefore, the recommended initial treatment
would be antifungal therapy targeting P. jirovecii, typically with trimethoprim-sulfamethoxazole (TMP-
SMX) as the first-line treatment.
Book 2 USMLE Step 3 Questions Banks

Practice Tests 1
Question 1
A 64-year-old woman with a history of constipation for two years seeks medical attention. She has
hypertension and is taking lisinopril. A rectal examination reveals decreased sphincter tone. What is the
most appropriate next step in managing her condition?
A) Add bisacodyl to her medication regimen
B) Perform anorectal manometry
C) Conduct a colonoscopy
D) Discontinue lisinopril
E) Recommend keeping a daily bowel movement journal for one month
Question 2
A 25-year-old male US Marine Corps member visits the clinic requesting HPV vaccination. He is
sexually active with one male partner and consistently uses condoms. His medical history is
unremarkable, and he takes no medications. His BMI is 21 kg/m2, and vital signs are normal. Physical
examination reveals no abnormalities. What is the most appropriate next step in management?
A) Perform an anal Pap smear for cytologic examination
B) Administer the HPV vaccine
C) Obtain HPV serologic testing
D) Use motivational interviewing to encourage abstinence
Question 3
A 21-year-old woman is brought to the emergency room after a suicide attempt involving an unknown pain
medication. She reports shortness of breath and tinnitus. Examination reveals tachypnea and basilar
crackles. Arterial blood gas shows respiratory alkalosis with metabolic acidosis. What is the most
appropriate next step in management?
A) Provide supportive care only
B) Administer lipid emulsion
C) Administer sodium bicarbonate
D) Perform endotracheal intubation
Question 4
A 32-year-old man reports eye irritation, nasal symptoms, and occasional wheezing since moving to a
new apartment 10 months ago. He also notes loss of smell. Family history includes nasal polyps.
Examination shows injected conjunctivae and swollen nasal turbinates. Which factor most strongly
predicts the development of a more serious condition?
A) Family history of similar symptoms
B) Loss of sense of smell
C) Associated shortness of breath and wheezing
D) Perennial nature of symptoms
Question 5
A 46-year-old woman with polycystic kidney disease, hypertension, type 2 diabetes, and hypothyroidism
undergoes a routine health maintenance examination. Her medications include rosuvastatin, lisinopril,
glyburide, and levothyroxine. Her BMI is 32 kg/m2. Laboratory results show elevated creatinine and urea
nitrogen. Which finding most strongly indicates a poor prognosis?
A) BMI
B) Kidney function
C) Number of kidney cysts
D) Plasma copeptin concentration
E) Serum LDL concentration
F) Urine sodium concentration
Question 6
A 39-year-old pregnant woman at 32 weeks' gestation, with a history of drug use and current methadone
maintenance, expresses a desire to breastfeed. What is the most appropriate response?
A) Encourage breastfeeding due to methadone maintenance
B) Advise against breastfeeding due to past drug abuse
C) Permit breastfeeding as drugs don't significantly enter breast milk
D) Develop a plan for safe breast milk feeding
Question 7
A 68-year-old man with obstructive sleep apnea is admitted for worsening dyspnea and lower extremity
swelling. Chest x-ray shows a pleural effusion. Thoracentesis reveals serosanguineous fluid with specific
laboratory findings. What is the most appropriate next step in management?
A) Perform bronchoscopy
B) Obtain a CT scan of the chest
C) Perform echocardiography
D) Administer furosemide therapy
E) Initiate moxifloxacin therapy
Question 8
A 36-year-old woman is referred for evaluation of high cholesterol (249 mg/dL). She has a family history
of early coronary artery disease. She's a smoker with a high-stress lifestyle and poor diet. What is the
most essential step in preventing coronary artery disease in this patient?
A) Implement a strict low-fat diet
B) Enroll in a smoking cessation program
C) Begin a more rigorous exercise program
D) Start biofeedback-based stress reduction
Question 9
A 19-year-old man presents with severe lower abdominal and scrotal pain after a sports injury.
Examination reveals a tender left testicle in the transverse plane. The patient is concerned about fertility.
What is the most appropriate information to provide?
A) His fertility will be unaffected with immediate reversal
B) His fertility will be adversely affected due to tissue loss
C) The impact on his fertility can't be predicted without further testing
D) His fertility won't be affected with conservative management
Question 10
A 63-year-old man presents with double vision, balance issues, and difficulty swallowing and talking.
Examination reveals nystagmus, ptosis, and sensory deficits. Based on these findings, what is the patient
most likely to develop?
A) Achalasia and gastroparesis
B) Angle-closure glaucoma
C) Orthostatic hypertension
D) Sleep-related hypoventilation
E) Third-degree atrioventricular block
Question 11
A 40-year-old woman reports weakness, diarrhea, palpitations, and weight loss. Examination reveals lid
lag, exophthalmos, and thyroid enlargement. Laboratory results show low TSH. Without treatment, which
condition is most likely to develop?
A) Chronic kidney disease
B) Congestive heart failure
C) Fibromyalgia
D) Glaucoma
E) Multiple sclerosis
Question 12
An 84-year-old nursing home resident is found to have a sacral ulcer. He has multiple comorbidities and
is wheelchair-bound. Examination reveals a 3 × 3 × 0.2-cm stage II ulcer with yellowish exudate. Which
treatment is most likely to have the greatest effect on wound healing?
A) Apply silver sulfadiazine
B) Implement a hypercaloric diet
C) Provide pressure relief
D) Perform wound debridement
Question 13
A 24-year-old pregnant woman with twin female fetuses is concerned about a family history of vision loss
starting in the 20s. Her pedigree is shown, with her identified as IV, 2. What is the most appropriate
conclusion about the inheritance of this disorder?
A) It's an X-linked recessive condition
B) It's an autosomal dominant disorder
C) It's a chromosomal aneuploidy
D) It's an X-linked dominant condition
Question 14
A 62-year-old man collapses while making breakfast and experiences chest and back pain. He has a
history of hypertension and takes amlodipine. What is the most likely diagnosis based on the presented
information?
A) Acute myocardial infarction
B) Aortic dissection
C) Pulmonary embolism
D) Stroke
E) Syncope
Question 15
A 33-year-old woman with myasthenia gravis is admitted for fever, shortness of breath, and productive
cough. Chest x-ray shows a patchy infiltrate in the left upper lobe. Which pharmacotherapy is most
appropriate?
A) Amoxicillin-clavulanic acid
B) Azithromycin
C) Cefepime and tobramycin
D) Ceftriaxone and doxycycline
E) Levofloxacin
F) Trimethoprim-sulfamethoxazole
Question 16
A 38-year-old woman attends for her annual health check. She's been healthy with normal cervical
cytology 3 years ago. She's in a 15-year monogamous marriage. If her current cervical cytology and HPV
test are normal, when should her next cervical cytology be performed?
A) In 1 year
B) In 5 years
C) At menopause
D) Only if she becomes pregnant
Question 17
A 21-year-old US Air Force member presents with shortness of breath, fever, and leg swelling for 2 days.
Examination reveals dyspnea, elevated jugular venous pressure, and bilateral basilar crackles.
Echocardiography shows a dilated left ventricle with an ejection fraction of 0.40. What is the most likely
long-term outcome?
A) Complete recovery
B) Mild diastolic dysfunction
C) Pulmonary embolism
D) Recurrent pericarditis
E) Severe systolic heart failure requiring cardiac transplant
Question 18
A 72-year-old man with ischemic cardiomyopathy loses consciousness while attempting to stand. He
regains consciousness after 5 minutes but remains light-headed. Vital signs show bradycardia and
hypotension. Which is the most appropriate next step in management?
A) Administer adenosine therapy
B) Initiate continuous infusion of dobutamine
C) Start continuous infusion of epinephrine
D) Perform defibrillation
E) Intubate and provide mechanical ventilation
F) Apply transcutaneous pacing
Question 19
A 14-year-old boy presents with fatigue, abdominal pain, weight loss, and recurrent mouth ulcers. He has
missed school due to symptoms and experiences heel pain when walking. What is the most likely
complication of his condition?
A) Anal fistula
B) Colonic carcinoma
C) Diabetes mellitus
D) Progressive pulmonary failure
E) Toxic megacolon
Question 20
A 64-year-old man is admitted for anemia and epigastric pain. Endoscopy reveals a nonbleeding ulcer,
and biopsy shows a polymorphic infiltrate positive for B-cell markers. In addition to omeprazole, what is
the most appropriate initial treatment?
A) Clarithromycin and amoxicillin therapy
B) Rituximab therapy
C) Cyclophosphamide and metronidazole therapy
D) Surgical resection
Question 21
A 48-year-old woman is referred due to a high fingerstick blood glucose reading at a health fair. Fasting
laboratory studies show elevated glucose and hemoglobin A1c levels. After counseling on lifestyle
modifications and prescribing metformin, which additional pharmacotherapy is most appropriate?
A) 81-mg Aspirin
B) Chlorthalidone
C) Lisinopril
D) Metoprolol
E) No additional pharmacotherapy is indicated
Question 22
A 26-year-old medical student is brought to the emergency department confused after being found with a
head bump and fresh urine on the floor. He has a history of bacterial meningitis, ACL injury, and unilateral
renal agenesis. Which recommendation is most likely to prevent recurrent seizures?
A) Alcohol avoidance
B) Discontinuation of lisinopril
C) Maintenance of adequate sleep
D) Occupation change
E) Tobacco cessation
Question 23
A 44-year-old woman with a history of myofascial pain syndrome requests a repeat trigger point injection
for neck and shoulder pain. She previously had a reaction to a local anesthetic injection. What is the most
appropriate next step?
A) Administer injection using phenol as anesthetic
B) Administer injection using prilocaine as anesthetic
C) Pretreat with loratadine, then use any local anesthetic
D) Refer to an allergist for further evaluation
Question 24
A 55-year-old woman with hypertension and mitral valve regurgitation reports worsening fatigue and
shortness of breath. Examination reveals a high-pitched systolic murmur and lower extremity edema.
Which is the most appropriate next step in management?
A) Add amlodipine to her medication regimen
B) Evaluate her for valve replacement
C) Increase the doses of hydrochlorothiazide and lisinopril
D) Recommend a low-sodium diet that includes low-fat dairy products and fresh fruits and vegetables
E) Recommend starting a low-impact aerobic exercise regimen for 30 minutes daily
Question 25
A 31-year-old woman in the US Air Force presents with fever, sore throat, body aches, muscle weakness,
and dehydration. She has systemic lupus erythematosus and a 5-year-old son with a febrile illness and
rash. Examination shows an erythematous throat with vesicles on both tonsils. A rapid streptococcal test
is negative. What is the most appropriate treatment?
A) Acyclovir
B) Amoxicillin
C) Amoxicillin-clavulanic acid
D) Ibuprofen
E) Prednisone
Question 26
A 65-year-old man of Swedish descent notices progressive deformity and aching pain in his left lower
leg. X-rays show cortical thickening and intramedullary sclerosis in the tibia. Which pharmacotherapy is
most appropriate?
A) Alendronate, orally
B) Calcitonin, intramuscularly
C) Calcitonin, nasally
D) Mithramycin, intravenously
E) Naproxen, orally
Question 27
A 46-year-old man with chronic low back pain requests an increase in his oxycodone dose. His friend
suspects he's selling the medication. What is the most appropriate next step?
A) Discontinue oxycodone
B) Notify the police
C) Order a random urine test for oxycodone
D) Refer the patient to a methadone clinic
E) Switch oxycodone to a different pain medication
Question 28
A 34-year-old man with a positive PPD skin test is referred by his new employer at a nursing home. He
has a history of scabies and previously worked on a farm. His wife and six children live in the same
house. After starting the patient on isoniazid therapy, what is the most appropriate next step?
A) Administer PPD skin tests to the whole family
B) Obtain interferon gamma release assay
C) Order sputum cultures and gastric washings for the whole family
D) Schedule another chest x-ray in 3 months
E) Start the patient's children on isoniazid therapy
Question 29
A 45-year-old woman reports progressively slurred speech, tongue-biting, and difficulty swallowing for
6 months. Examination reveals tongue fasciculations, dysarthria, and asymmetric muscle strength and
reflexes. EMG shows motor denervation. Which factor most negatively impacts her life expectancy?
A) Age
B) Bulbar weakness
C) Cervical fusion operation
D) Fasciculations
E) Gender
Question 30
A 2-week-old premature newborn on mechanical ventilation experiences decreases in oxygen saturation
and blood pressure. Chest x-ray is obtained. What is the most appropriate management?
A) Insertion of a central venous catheter
B) Median sternotomy
C) PEEP reduction to 6 cm H2O
D) Pericardiocentesis
E) Placement of a left chest tube
Question 31: What is the most appropriate initial diagnostic test for a 50-year-old African American
woman presenting with heartburn, increased belching, and bloating after meals for the past month?
A) CT scan of the abdomen
B) Serum amylase and lipase concentration tests
C) Endoscopic retrograde cholangiopancreatography
D) HIDA scan
Question 32: Which drug mechanism is most likely responsible for the condition of a 38-year-old woman
with a history of depression and back pain who is brought to the ER with confusion and lethargy?
A) Agonism of μ -opioid receptors
B) Inhibition of aldosterone
C) Inhibition of angiotensin-converting enzyme
D) Inhibition of β 1-adrenergic receptors
Question 33: What is the most probable source of illness for a 19-year-old male college student
hospitalized with fever, chills, severe headache, dry cough, and general weakness?
A) Inhaling contaminated aerosols
B) Golf course pesticide exposure
C) Intimate contact
D) Mosquito bite
Question 34: What is the most appropriate recommendation for a 27-year-old woman discussing
breastfeeding concerns with her doctor one day after an uncomplicated vaginal delivery?
A) Advise continuing breastfeeding and discussing a pumping schedule with her employer
B) Encourage focusing on breastfeeding and finding new employment later
C) Recommend against breastfeeding
D) Suggest combining breast and bottle feeding for an easier work transition
Question 35: What medication abuse is the most likely cause of a 14-year-old boy's condition when
brought to the ER after behaving oddly in class and becoming difficult to rouse?
A) Dextromethorphan
B) Diazepam
C) Diphenhydramine
D) Methylphenidate
Question 36: What additional medication is most appropriate for a 70-year-old man with coronary artery
disease and a blood pressure of 150/95 mm Hg?
A) Amlodipine
B) Clonidine
C) Hydrochlorothiazide
D) Lisinopril
Question 37: What aspect of a 27-year-old woman's condition is most crucial to assess for her work
ability as a graphic designer after resection of a grade 2 right parietal lobe astrocytoma?
A) Capacity to articulate ideas
B) Left hand control when typing
C) Impact of hemi-inattention on visual-spatial skills
D) Overall mobility
Question 38: What condition is a 9-year-old boy with a 6-month history of sudden, repetitive jerks in his
shoulders and arms, along with eye blinking and throat clearing, most likely to develop?
A) Wilson's disease
B) Huntington's disease
C) Intellectual disability
D) Obsessive-compulsive disorder
Question 39: Which factor most strongly indicates a poor prognosis for a 32-year-old woman with type 1
diabetes, depression, and seizure disorder brought to the ER after a suicide attempt involving
acetaminophen and alcohol?
A) Chronic hepatitis B infection
B) Concurrent alcohol consumption
C) Fluoxetine therapy
D) Type 1 diabetes mellitus
Question 40: Besides volume expansion, what's the most appropriate intervention for an 11-year-old girl
with type 1 diabetes brought to the ER with shortness of breath, fatigue, excessive thirst, and frequent
urination?
A) Intravenous sodium bicarbonate bolus
B) Continuous IV short-acting insulin infusion
C) Intermittent IV short-acting insulin boluses
D) Subcutaneous short and intermediate-acting insulin
Question 41: What's the most appropriate next step for an 11-year-old diabetic girl who develops a
headache and loses consciousness four hours after starting insulin therapy?
A) Sodium bicarbonate administration
B) Head CT scan
C) EEG
D) Fosphenytoin therapy
Question 42: What are the knee X-rays most likely to show for a 50-year-old woman presenting with
gradual onset of pain and swelling in both knees and finger joints over 12 weeks?
A) Bone demineralization and erosions
B) Soft tissue swelling, sclerotic joint margins, and large cystic erosions
C) Soft tissue swelling without cartilage or bone destruction
D) Subchondral bone sclerosis and asymmetric joint space narrowing
Question 43: What's the most likely MRI finding for a 17-year-old football player brought to the ER an
hour after a back injury during a game?
A) Anterior spinal artery territory ischemia
B) Thoracic spinal cord contusion
C) Lateral T7 disc herniation with nerve root compression
D) Thoracic cord hemisection
Question 44: What should a 25-year-old attorney with left upper jaw pain for a week be advised to do?
A) Avoid chewing gum and hard foods
B) Consult an orthodontist
C) Cradle phone between shoulder and jaw
D) Open and close jaw widely thrice daily
Question 45: Which medication is most important to discontinue for a 68-year-old obese woman with
chronic bronchitis and schizoaffective disorder who develops a fever and shows lead pipe rigidity in the
ICU?
A) Benztropine
B) Ciprofloxacin
C) Haloperidol
D) Lorazepam
Question 46: Which factor most strongly indicates a poor prognosis for a 35-year-old woman with a
history of childhood Hodgkin lymphoma treated with radiation who presents with a neck lump?
A) Cigarette smoking
B) Hyperthyroidism
C) Iodine deficiency
D) Multiple nodules
Question 47: Which food consumption puts a 38-year-old man with type 1 diabetes and hemochromatosis
at increased mortality risk?
A) Bean sprouts
B) Berries
C) Raw oysters
D) Undercooked eggs
Question 48: What's the most appropriate next step in treatment for a 24-year-old woman with asthma
reporting mild shortness of breath and nonproductive cough for 2 weeks?
A) Add inhaled fluticasone
B) Add inhaled tiotropium
C) Add oral azithromycin
D) Increase albuterol dosage to four times daily
Question 49: After stopping methimazole and ordering blood cultures, what's the most appropriate next
step for a 36-year-old woman with recently diagnosed Graves' disease admitted with sore throat and high
fever?
A) Antinuclear antibody test
B) Bone marrow aspiration and biopsy
C) Cefepime therapy
D) Filgrastim therapy
Question 50: What is the most appropriate next step for a 62-year-old man with a history of stage III colon
cancer whose PET/CT scans reveal a new 1-cm pulmonary nodule with irregular borders and increased
uptake?
A) Discuss palliative care options
B) Initiate chemotherapy
C) Perform a bronchoscopy
D) Resect the nodule
Question 51: What condition should a 25-year-old nulliparous woman with a history of polycystic
ovarian syndrome be advised she's at highest risk of developing?
A) Uterine cancer
B) Hypothyroidism
C) Nephrotic syndrome
D) Diabetes mellitus
Question 52: What's the most appropriate immediate treatment for a 57-year-old woman with type 2
diabetes reporting intermittent palpitations for two weeks, worsening after exercise?
A) Oral diltiazem
B) Sublingual nitroglycerin
C) Intramuscular morphine sulfate
D) Subcutaneous enoxaparin
Question 53: What's the most appropriate next step in management, besides IV fluids, for a 36-year-old
woman presenting to the ER with severe abdominal pain, nausea, and vomiting?
A) Fenofibrate therapy
B) CT scan of the abdomen with contrast
C) Insulin therapy
D) Ultrasonography of the right upper quadrant
Question 54: What's the most appropriate treatment for an 11-month-old infant brought in with progressive
swelling and blistering of his left index finger and thumb over 24 hours?

A) Oral cephalexin
B) Topical mupirocin
C) Oral acyclovir
D) Topical silver sulfadiazine
Question 55: After initial management, what's the most appropriate next step for a 49-year-old woman
with untreated hyperthyroidism presenting with weakness, dizziness, and palpitations?
A) Oral potassium iodide
B) Intravenous propranolol
C) Cardioversion
D) Intravenous diltiazem
Question 56: What condition is a 4-month-old male infant with lethargy, constipation, and poor feeding
most likely to develop?
A) Cushing syndrome
B) Type 1 diabetes mellitus
C) Congestive heart failure
D) Osteomalacia
Question 57: Assuming symptoms improve with treatment, what's the most appropriate follow-up plan for
a 20-year-old man presenting with urinary burning and penile discharge?
A) Schedule follow-up examination in 1 week
B) No specific follow-up necessary
C) Schedule HIV serology testing in 3 months
D) Consult with patient's parents before determining follow-up
Question 58: What's the most appropriate next step in management for a 67-year-old woman with
osteopenia presenting with severe left hip and thigh pain for 6 months?
A) Calcitonin therapy
B) Surgical fixation
C) Bisphosphonate therapy
D) Cast immobilization
Question 59: What's the most appropriate arrangement for home services for a 65-year-old diabetic
woman preparing for discharge after hip replacement surgery?
A) Administer daily insulin
B) Measure daily blood glucose levels
C) Assist in strengthening lower extremity muscles
D) Ensure adherence to prescribed diabetic diet
Question 60: Which factor in a 56-year-old man's history most increased his risk for developing
worsening renal failure?
A) Bladder catheterization
B) Chronic kidney disease
C) Uncontrolled hypertension
D) Use of lisinopril
Question 61
A 55-year-old man reports chest pounding, occasional chest pain, and shortness of breath. What is the
most appropriate additional diagnostic study?
A) Arterial brachial index of the lower extremity
B) Coronary angiography
C) Pulmonary function testing
D) Renal ultrasonography
E) Transthoracic echocardiography
Question 62
A 16-year-old boy with recurrent sinopulmonary infections presents with watery stools. Stool
examination reveals ovoid oocysts. What is the most likely causal agent?
A) Cryptosporidium parvum
B) Entamoeba histolytica
C) Norovirus
D) Salmonella typhi
E) Shigella flexneri
Question 63
A 2-year-old girl has a painful, enlarging neck mass and fever. The father questions the diagnosis and
requests a specialist referral. What is the most appropriate physician response?
A) "I don't think she needs a specialist. What are you worried about?"
B) "I know you're worried, but I'm confident in the diagnosis."
C) "Tell me what your greatest concerns are."
D) "There's no need for a specialist. She'll feel better with antibiotics."
E) "Why do you think that your daughter needs to see a specialist?"
Question 64
A 68-year-old man experiences facial drooping, weakness, ataxia, and swallowing difficulty. Which
cerebral artery is most likely affected?
A) Anterior
B) Internal carotid
C) Middle
D) Posterior
E) Vertebrobasilar
Question 65
A 3-month-old infant has respiratory distress, fever, and congestion. What is the most likely cause of this
illness?
A) Haemophilus influenzae
B) Herpes virus
C) Mycoplasma pneumoniae
D) Respiratory syncytial virus
E) Streptococcus pneumoniae
Question 66
A 44-year-old woman reports increased menstrual bleeding and fatigue. What is the most appropriate
diagnostic study?
A) Colposcopy
B) Serum follicle-stimulating hormone and luteinizing hormone concentrations
C) Serum prolactin concentration
D) Endometrial biopsy
E) Hysteroscopy
Question 67
A 58-year-old man develops chest pressure after knee surgery. What is the most likely cause of his
symptoms?
A) Acute mitral regurgitation
B) Pericardial tamponade
C) Pulmonary embolism
D) Right ventricular infarction
E) Vasovagal reaction
Question 68
A study assesses physician use of β -blockers for heart failure treatment. Which study design best
describes this research?
A) Case-control study
B) Case series
C) Clinical trial
D) Cross-sectional study
E) Prospective cohort study
F) Retrospective cohort study
Question 69
A newborn with trisomy 18 has difficulty sucking and episodes of apnea. What is the most appropriate
next step?
A) Admission for a sleep apnea study
B) CT scan of the head
C) Electroencephalography
D) Referral to a cardiologist
E) Referral to home hospice care
Question 70
An elderly woman in a nursing facility has increasing confusion and drowsiness. What is the most likely
explanation for her worsening condition?
A) Drug-drug interaction
B) Head trauma
C) Hypothyroidism
D) Major depressive episode
E) Viral encephalitis
Question 71
A 12-year-old girl with a seizure disorder requests medication without contacting her mother. What is the
most appropriate next step?
A) Administer carbamazepine and provide a prescription
B) Administer carbamazepine but don't provide a prescription
C) Attempt to contact the mother for permission before proceeding
D) Don't contact the mother but request the aunt sign a consent form
E) Provide a prescription but don't administer carbamazepine
Question 72
An 8-year-old girl dies after a seizure and cardiac arrest. What is the most likely underlying cause of her
death?
A) Cardiac conduction abnormality
B) Coronary artery plaque rupture
C) Increased pulmonary vascular resistance
D) Systolic prolapse of mitral valve
E) Thickened left ventricular wall and contractile dysfunction
Question 73
A 28-year-old man reports pain during urination. What is the most appropriate diagnostic test?
A) Gram stain of urethral discharge before and after prostatic massage
B) PCR test for N. gonorrhoeae and C. trachomatis
C) Urinalysis
D) Urine culture and sensitivity
Question 74
A 16-year-old patient admits to smoking cannabis. What is the most appropriate initial response from the
physician?
A) Recommend decreasing cannabis use and schedule a follow-up
B) Provide a phone number for a substance abuse treatment program
C) Explain the dangers of cannabis and suggest 12-step programs
D) Assure the patient that the discussion will remain confidential
E) Discuss the effects of cannabis and offer help in telling his mother
Question 75
A 77-year-old man refuses amputation for gangrene. What is the most appropriate action?
A) Respect the patient's wishes
B) Consult the hospital's bioethics department
C) Obtain consent from both of the patient's sons
D) Seek consent for amputation from the courts
E) Get consent from the younger son, who is the designated health care proxy
F) Review additional instructions in the patient's living will
Question 76
A woman with HIV presents with neck swelling. A lymph node biopsy shows acid-fast bacilli. How did
the infection likely reach the cervical lymph nodes?
A) Direct skin inoculation
B) Direct tissue invasion from hilar lymph nodes
C) Hematogenous spread from the lungs
D) Lymphatic drainage from pharyngeal tissues
E) Trafficking of infected lymphocytes
Question 77
A woman with COPD complains of shortness of breath. Lab results show elevated D-dimer and normal
BNP. What is the most likely diagnosis?
A) COPD exacerbation
B) Heart failure
C) Pneumonia
D) Pneumothorax
E) Pulmonary embolism
Question 78
A pregnant woman presents with persistent nausea, vomiting, and weight loss. Which laboratory result is
most likely to be abnormal?
A) Leukocyte count
B) Serum ALT and AST activities
C) Serum calcium concentration
D) Serum glucose concentration
E) Serum urea nitrogen concentration
F) No abnormality is likely
Question 79
A woman with multiple medical conditions is brought to the ER after falls. What is the most appropriate
approach to managing her medications?
A) Ask police to enter her brother's house to find her pill bottles
B) Contact the patient's pharmacy for current medication information
C) Observe the patient while trying to reach her psychiatrist
D) Prescribe medications based on previous ER records
E) Order serum concentrations of previously listed medications and dose accordingly
Question 80
A man with advanced dementia has a foot lesion. What is the most likely underlying cause?
A) Methicillin-resistant Staphylococcus aureus infection
B) Prolonged immobility
C) Pyoderma gangrenosum
D) Systemic atheroemboli
E) Venous stasis due to valvular incompetence
Question 81
An elderly woman becomes unresponsive during hospitalization. Her daughter insists on changing her
DNR status. What is the most appropriate course of action?
A) Continue current management without initiating hemodialysis
B) Start hemodialysis and change to full code until the patient is more alert
C) Begin hemodialysis but maintain DNR status until the patient is more alert
D) Obtain consent from the daughter for all medically indicated interventions
Question 82
An elderly woman with dementia becomes agitated during an examination for rectal bleeding. What is the
most appropriate initial intervention?
A) Administer lorazepam and proceed with the examination
B) Contact the patient's health care proxy to discuss how to proceed
C) Use soft wrist restraints and continue with the examination
D) Schedule outpatient flexible sigmoidoscopy and discharge the patient
Question 83
A man presents with arm weakness and eyelid drooping. What is the most likely diagnosis?
A) Cerebellar artery aneurysm
B) Diabetic oculomotor paresis
C) Myasthenia gravis
D) Myasthenic (Lambert-Eaton) syndrome
E) Pancoast tumor
Question 84
For a patient with recurrent infections, which diagnostic study is most appropriate to determine immune
deficiency?
A) CD4+ T-lymphocyte count
B) CD8+ T-lymphocyte count
C) Serum complement concentrations
D) Serum interferon gamma assay
E) Serum quantitative immunoglobulin concentrations
Question 85
Two rapid screening tests for influenza are developed. Based on ROC curves, what conclusion is most
appropriate about Test A compared to Test B?
A) Test A is more accurate in the high false positive rate range
B) Test A is more accurate in the high sensitivity range
C) Test A is more accurate in the low false positive rate range
D) Test B is more accurate in the low sensitivity range
Question 86
A boy presents with muscle weakness and increased calf circumference. Which mutation is most likely to
be identified?
A) Frameshift insertion in the gene encoding alpha-1 (III) collagen
B) Large deletion in the gene encoding dystrophin
C) Missense mutation in the gene encoding fibrillin 1
D) Splice-site mutation in the gene encoding spectrin
E) Translocation involving the gene encoding myosin I
Question 87
Researchers notice low enrollment of African American patients in a study. What is the best course of
action?
A) Ask the IRB to waive informed consent requirements
B) Convene a representative focus group to discuss enrollment reluctance
C) Focus recruitment on White patients and acknowledge the limitation
D) Continue current recruitment practices, recognizing it as unavoidable
E) Require all clinic patients to participate to ensure a representative sample
Question 88
A woman presents with persistent abdominal pain and requests an endoscopy. What is the most
appropriate next step in management?
A) Ask if she would like to see a specialist
B) Discuss her treatment goals and expectations
C) Ask her to explain why she thinks she has Barrett esophagus
D) Discuss why she hasn't made the suggested lifestyle changes
E) Encourage her to describe her feelings about the unresolved condition
Question 89
An elderly woman presents with worsening shortness of breath and cough. What is the most likely
underlying cause of her condition?
A) Bacterial colonization of airways
B) Bronchial constriction due to allergens
C) Destruction of alveolar walls and air space enlargement
D) Diffuse interstitial inflammation and fibrosis
E) Eosinophilic infiltration of pulmonary interstitium
Question 90
A young boy experiences weight loss and fatigue after using oral prednisone. What is the most likely
underlying cause of his condition?
A) Decreased activity of 21-hydroxylase enzyme
B) Decreased production of adrenocorticotropic hormone (ACTH)
C) Decreased production of antidiuretic hormone
D) Increased aldosterone production
E) Increased insulin production
Question 91
A 63-year-old man experienced a brief episode of right eye blindness that resolved spontaneously. Given
his medical history and current medications, what diagnostic test should be performed next?
A) Fluorescein angiography of the right eye
B) Measurement of intraocular pressures
C) Transesophageal echocardiography
D) Ultrasonography of the neck
E) No further evaluation is indicated
Question 92
An 18-year-old woman with epilepsy is considering partial temporal lobectomy. Based on a long-term
study of patients who underwent this procedure, what can be concluded about seizure recurrence after
surgery?
A) No seizures 2 years post-op is the best predictor of long-term seizure control
B) Most seizure recurrence happened between 2-3 years post-op
C) 30% of patients were seizure-free 6 months after the procedure
D) No conclusion can be drawn due to lack of statistical significance in the subgroup analysis
Question 93
A 24-year-old woman reports recurring episodes of irritability, sleeplessness, and other symptoms over
the past 3 months. What additional information should be gathered to better understand her condition?
A) Carbohydrate consumption
B) Sexual activity frequency
C) Exercise routine
D) History of psychological trauma
E) Stress levels
F) Symptom timing
Question 94
A 2-month-old boy presents with jaundice, pale stools, and abnormal liver function tests. What hepatic
change is most likely occurring in this patient?
A) Bile ductular proliferation
B) Centrilobular necrosis
C) Increased glycogen stores
D) Intranuclear hepatocyte inclusions
E) Macrovesicular steatosis
Question 95
A 39-year-old woman with worsening shortness of breath and a history of Graves disease presents with
irregular heartbeat and abnormal ECG findings. What additional diagnostic study is most appropriate?
A) CT scan of the chest
B) Echocardiography
C) Perfusion lung scan
D) Pulmonary function testing
E) Ultrasonography of the thyroid
Question 96
A 79-year-old man with a history of hypertension presents with recent onset of difficulty walking and
dizziness. Given his symptoms and examination findings, what is the most likely diagnosis?
A) Cardiac arrhythmia
B) Cerebellar ataxia due to alcohol abuse
C) Labyrinthitis
D) Orthostatic hypotension
E) Stroke
Question 97
A 28-year-old recently divorced woman reports sudden, severe anxiety episodes occurring regularly for
the past 6 weeks. What's the most probable diagnosis based on this information?
A) Adjustment disorder with anxiety
B) Agoraphobia
C) Dysthymic disorder
D) Generalized anxiety disorder
E) Posttraumatic stress disorder
Question 98
A 55-year-old businessman with various risk factors undergoes a pre-employment examination. Given his
current health status and lab results, what is the most appropriate next step in his evaluation?
A) Arterial blood gas analysis
B) Hemoglobin A1c test
C) 3-hour glucose tolerance test
D) Serum cortisol concentration
E) Serum fructosamine concentration
Question 99
A 53-year-old man hospitalized for acute pancreatitis develops new respiratory symptoms. What is the
most appropriate next step in evaluating these new findings?
A) Chest x-ray
B) Determination of cardiac enzyme activity
C) Echocardiography
D) Ultrasonography of the chest
E) Ventilation-perfusion lung scans
Question 100
A 24-year-old primigravid woman requests screening for gestational diabetes mellitus at her first prenatal
visit. Based on the provided data, which screening test is most appropriate for this patient?
A) Test A
B) Test B
C) Test C
D) Test D
E) Test E
F) Cannot be determined from the data provided

Correct Answers & Explanations

Question 1
B) Perform anorectal manometry (Correct Answer)
Explanation: The patient's history of constipation, hypertension, and decreased sphincter tone suggests a
possible pelvic floor disorder. Anorectal manometry is the most appropriate next step as it can assess the
strength and coordination of the anal sphincter muscles, helping to diagnose conditions like dyssynergic
defecation or pelvic floor dysfunction, which are common causes of chronic constipation in older adults.
Question 2
B) Administer the HPV vaccine (Correct Answer)
Explanation: The HPV vaccine is recommended for all individuals up to age 26, regardless of gender or
sexual orientation. This patient, being 25 years old and sexually active, falls within the recommended age
range for vaccination. The vaccine can protect against HPV types that cause genital warts and various
cancers, including anal cancer, which is particularly relevant for men who have sex with men.
Question 3
C) Administer sodium bicarbonate (Correct Answer)
Explanation: The patient's symptoms and blood gas results suggest salicylate poisoning, a common pain
medication overdose. Salicylate toxicity causes respiratory alkalosis and metabolic acidosis. Sodium
bicarbonate administration is crucial in managing salicylate poisoning as it alkalinizes the blood and
urine, enhancing salicylate excretion and preventing further absorption into the central nervous system.
Question 4
B) Loss of sense of smell (Correct Answer)
Explanation: The loss of sense of smell (anosmia) is a strong predictor for the development of chronic
rhinosinusitis with nasal polyps. This condition can lead to more serious complications if left untreated.
The combination of nasal symptoms, eye irritation, wheezing, and family history of nasal polyps also
supports this diagnosis.
Question 5
D) Plasma copeptin concentration (Correct Answer)
Explanation: In patients with polycystic kidney disease, plasma copeptin concentration is the strongest
predictor of disease progression and poor prognosis. Copeptin is a surrogate marker for vasopressin,
which plays a crucial role in cyst growth. Elevated copeptin levels are associated with faster disease
progression and decline in kidney function.
Question 6
D) Develop a plan for safe breast milk feeding (Correct Answer)
Explanation: For women on methadone maintenance, breastfeeding can be safely supported with proper
planning. Methadone in breast milk is generally considered safe for infants, and breastfeeding can help
reduce neonatal abstinence syndrome. A comprehensive plan should include monitoring the infant,
educating the mother, and ensuring ongoing support and substance abuse treatment.
Question 7
C) Perform echocardiography (Correct Answer)
Explanation: The patient's symptoms of worsening dyspnea, lower extremity swelling, and pleural
effusion suggest possible heart failure, which is common in patients with obstructive sleep apnea.
Echocardiography is the most appropriate next step as it can assess cardiac function, identify any
structural abnormalities, and help determine if the pleural effusion is due to heart failure or another cause.
Question 8
B) Enroll in a smoking cessation program (Correct Answer)
Explanation: While all lifestyle modifications are important, smoking cessation is the single most
effective intervention for preventing coronary artery disease. Smoking is a major modifiable risk factor
that significantly increases the risk of cardiovascular events. Quitting smoking can rapidly reduce the risk
of heart disease and improve overall health outcomes.
Question 9
A) His fertility will be unaffected with immediate reversal (Correct Answer)
Explanation: The patient's symptoms suggest testicular torsion, a urological emergency where the
spermatic cord twists, cutting off blood supply to the testicle. If diagnosed and treated promptly (usually
within 6 hours) through surgical detorsion, there is typically no long-term impact on fertility. Immediate
intervention is crucial to preserve testicular function and fertility.
Question 10
E) Third-degree atrioventricular block (Correct Answer)
Explanation: The patient's symptoms (double vision, balance issues, difficulty swallowing and talking)
along with the examination findings (nystagmus, ptosis, sensory deficits) are consistent with brainstem
involvement. This presentation suggests a possible diagnosis of Wernicke's encephalopathy or a brainstem
stroke. These conditions can affect the cardiac conduction system, potentially leading to third-degree
atrioventricular block.
Question 11
B) Congestive heart failure (Correct Answer)
Explanation: The patient's symptoms and examination findings are consistent with hyperthyroidism
(Graves' disease). If left untreated, hyperthyroidism can lead to thyrotoxic cardiomyopathy and eventually
congestive heart failure. The prolonged state of increased cardiac output and workload can result in
structural and functional changes in the heart, leading to heart failure.
Question 12
C) Provide pressure relief (Correct Answer)
Explanation: For a stage II pressure ulcer in a wheelchair-bound patient, pressure relief is the most
crucial intervention. Reducing pressure on the affected area allows for improved blood flow and tissue
healing. This can be achieved through regular repositioning, use of specialized cushions or mattresses,
and offloading techniques. While other interventions may be helpful, addressing the root cause - pressure
- is paramount for effective wound healing.
Question 13
B) It's an autosomal dominant disorder (Correct Answer)
Explanation: The pedigree pattern suggests an autosomal dominant inheritance. Key features include:
affected individuals in every generation, both males and females affected, and direct transmission from
parent to child. This pattern is consistent with conditions like Huntington's disease or some forms of
retinitis pigmentosa that cause vision loss in early adulthood.
Question 14
B) Aortic dissection (Correct Answer)
Explanation: The sudden onset of chest and back pain in a hypertensive patient is highly suggestive of
aortic dissection. This condition occurs when the inner layer of the aorta tears, allowing blood to flow
between the layers of the aortic wall. Risk factors include hypertension and sudden, severe pain is a
hallmark symptom. The collapse could be due to the acute, severe pain or complications of the dissection.
Question 15
E) Levofloxacin (Correct Answer)
Explanation: For a patient with myasthenia gravis presenting with community-acquired pneumonia,
levofloxacin is the most appropriate choice. It provides excellent coverage for common respiratory
pathogens and is safe in myasthenia gravis. Other antibiotics like aminoglycosides (tobramycin) can
exacerbate muscle weakness in myasthenia gravis patients. Levofloxacin also offers once-daily dosing
and good penetration into lung tissue.
Question 16
B) In 5 years (Correct Answer)
Explanation: For a 38-year-old woman with normal cervical cytology 3 years ago and a current normal
cervical cytology and HPV test, the recommended interval for the next screening is 5 years. This aligns
with current guidelines from organizations like the American Cancer Society, which recommend HPV
testing every 5 years for women aged 25-65 with normal results.
Question 17
A) Complete recovery (Correct Answer)
Explanation: Given the patient's young age and acute presentation, this is likely a case of acute
myocarditis. Young patients with acute myocarditis often have a good prognosis and can achieve complete
recovery of left ventricular function with appropriate treatment and time.
Question 18
F) Apply transcutaneous pacing (Correct Answer)
Explanation: The patient's symptoms and vital signs suggest severe bradycardia causing hemodynamic
instability. In this emergency situation, transcutaneous pacing is the most appropriate immediate
intervention to increase heart rate and improve cardiac output.
Question 19
A) Anal fistula (Correct Answer)
Explanation: The symptoms described are consistent with Crohn's disease, a type of inflammatory bowel
disease. Anal fistulas are a common complication of Crohn's disease, occurring in up to 50% of patients
over time.
Question 20
B) Rituximab therapy (Correct Answer)
Explanation: The biopsy findings suggest a B-cell lymphoma, likely mucosa-associated lymphoid tissue
(MALT) lymphoma. Rituximab, an anti-CD20 monoclonal antibody, is an effective initial treatment for
this type of lymphoma, often used in combination with other therapies.
Question 21
E) No additional pharmacotherapy is indicated (Correct Answer)
Explanation: For a newly diagnosed type 2 diabetes patient, the initial approach typically involves
lifestyle modifications and metformin. Additional pharmacotherapy is usually not indicated until the
response to these initial interventions is assessed, typically after 3-6 months.
Question 22
C) Maintenance of adequate sleep (Correct Answer)
Explanation: Sleep deprivation is a common trigger for seizures. Maintaining adequate sleep is a crucial
non-pharmacological intervention for preventing recurrent seizures in patients with a history of seizures
or predisposing conditions.
Question 23
D) Refer to an allergist for further evaluation (Correct Answer)
Explanation: Given the patient's history of a reaction to a local anesthetic, it's crucial to determine the
nature of this reaction before administering further injections. An allergist can perform appropriate testing
to identify safe alternatives or confirm if true allergy exists.
Question 24
B) Evaluate her for valve replacement (Correct Answer)
Explanation: The patient's worsening symptoms, along with signs of heart failure (edema) in the context of
known mitral valve regurgitation, suggest progression of her valvular disease. Evaluation for valve
replacement is appropriate at this stage to prevent further cardiac deterioration.
Question 25
A) Acyclovir (Correct Answer)
Explanation: The clinical presentation, including vesicular lesions on the tonsils and negative strep test, is
consistent with herpetic pharyngitis. Acyclovir is the appropriate antiviral treatment for this condition,
especially in an immunocompromised patient with lupus.
Question 26
C) Calcitonin, nasally (Correct Answer)
Explanation: The patient's symptoms and X-ray findings are consistent with Paget's disease of bone.
Nasal calcitonin is an effective and well-tolerated treatment option for Paget's disease, especially in
older patients or those with contraindications to bisphosphonates.
Question 27
C) Order a random urine test for oxycodone (Correct Answer)
Explanation: When there's suspicion of medication misuse, a random urine drug test is an appropriate next
step. It helps verify if the patient is taking the prescribed medication as directed and can guide further
management decisions.
Question 28
A) Administer PPD skin tests to the whole family (Correct Answer)
Explanation: Given the patient's positive PPD test and potential exposure risk to his family, screening
close contacts (family members) for tuberculosis is the most appropriate next step. This allows for early
detection and treatment of any latent TB infections.
Question 29
B) Bulbar weakness (Correct Answer)
Explanation: The patient's symptoms suggest amyotrophic lateral sclerosis (ALS). Among the factors
listed, bulbar weakness (affecting speech and swallowing) is associated with the poorest prognosis in
ALS, significantly impacting life expectancy due to increased risk of aspiration and respiratory
complications.
Question 30
E) Placement of a left chest tube (Correct Answer)
Explanation: In a premature newborn on mechanical ventilation with sudden decreases in oxygen
saturation and blood pressure, a tension pneumothorax should be suspected. Immediate placement of a
chest tube on the affected side (left in this case, as implied by the question) is the most appropriate
emergency management to relieve the pneumothorax.
Question 31
A) CT scan of the abdomen (Correct Answer)
Explanation: For a 50-year-old African American woman presenting with heartburn, increased belching,
and bloating after meals for the past month, the most appropriate initial diagnostic test is a CT scan of the
abdomen. This non-invasive imaging test can provide detailed information about the gastrointestinal tract,
including potential causes of her symptoms such as gastroesophageal reflux disease (GERD), hiatal
hernia, or other abdominal pathologies. It allows for a comprehensive evaluation of the entire abdomen
and can help rule out more serious conditions.
Question 32
A) Agonism of μ -opioid receptors (Correct Answer)
Explanation: The 38-year-old woman's condition of confusion and lethargy is most likely due to opioid
overdose, which acts through agonism of μ -opioid receptors. Given her history of depression and back
pain, she may have been prescribed opioid pain medications. Opioids can cause central nervous system
depression, leading to confusion, lethargy, and potentially life-threatening respiratory depression. This
mechanism is consistent with the presented symptoms and the patient's medical history.
Question 33
A) Inhaling contaminated aerosols (Correct Answer)
Explanation: The most probable source of illness for the 19-year-old male college student is inhaling
contaminated aerosols. This presentation is consistent with Legionnaires' disease, caused by Legionella
pneumophila bacteria. The symptoms of fever, chills, severe headache, dry cough, and general weakness
are typical of this infection. Legionella is often transmitted through contaminated water systems in large
buildings, such as college dormitories, making this a likely source for a college student.
Question 34
A) Advise continuing breastfeeding and discussing a pumping schedule with her employer (Correct
Answer)
Explanation: The most appropriate recommendation for the 27-year-old woman is to advise continuing
breastfeeding and discussing a pumping schedule with her employer. This approach supports the health
benefits of breastfeeding for both mother and infant while acknowledging the need to balance work
responsibilities. The World Health Organization recommends exclusive breastfeeding for the first six
months, and many countries have laws protecting a mother's right to pump at work. This advice promotes
long-term breastfeeding success while supporting the mother's career.
Question 35
A) Dextromethorphan (Correct Answer)
Explanation: The most likely cause of the 14-year-old boy's condition is abuse of dextromethorphan
(DXM). DXM is a common over-the-counter cough suppressant that, when taken in high doses, can cause
altered mental status, bizarre behavior, and sedation. Adolescents sometimes abuse DXM for its
dissociative effects. The presentation of odd behavior in class followed by difficulty arousing is
consistent with DXM intoxication, which is more accessible and commonly abused by teenagers
compared to the other listed medications.
Question 36
D) Lisinopril (Correct Answer)
Explanation: For a 70-year-old man with coronary artery disease and a blood pressure of 150/95 mm Hg,
the most appropriate additional medication is lisinopril, an ACE inhibitor. ACE inhibitors are first-line
agents for hypertension in patients with coronary artery disease due to their cardioprotective effects. They
reduce blood pressure, improve cardiac remodeling, and have been shown to reduce mortality in patients
with coronary artery disease. Lisinopril is particularly suitable for this patient population and can
effectively lower blood pressure to target levels.
Question 37
C) Impact of hemi-inattention on visual-spatial skills (Correct Answer)
Explanation: For a 27-year-old graphic designer after resection of a right parietal lobe astrocytoma, the
most crucial aspect to assess for her work ability is the impact of hemi-inattention on visual-spatial skills.
The right parietal lobe is critical for spatial awareness and attention, particularly to the left side of space.
Damage to this area can result in left-sided neglect or hemi-inattention, which could significantly impact
her ability to perform graphic design tasks that require full visual field awareness and spatial skills.
Question 38
D) Obsessive-compulsive disorder (Correct Answer)
Explanation: The 9-year-old boy with a 6-month history of sudden, repetitive jerks in his shoulders and
arms, along with eye blinking and throat clearing, is most likely to develop obsessive-compulsive
disorder (OCD). This presentation is consistent with Tourette syndrome, a neurodevelopmental disorder
characterized by motor and vocal tics. Tourette syndrome has a high comorbidity with OCD, with studies
showing up to 50% of individuals with Tourette syndrome also developing OCD. The repetitive nature of
the tics often evolves into more complex, compulsive behaviors characteristic of OCD.
Question 39
B) Concurrent alcohol consumption (Correct Answer)
Explanation: The factor that most strongly indicates a poor prognosis for the 32-year-old woman with
type 1 diabetes, depression, and seizure disorder after a suicide attempt is concurrent alcohol
consumption. Alcohol significantly enhances the hepatotoxicity of acetaminophen by depleting glutathione
stores and increasing the production of toxic metabolites. This combination can lead to severe liver
damage and failure, which is associated with a poor prognosis. Additionally, alcohol can interact with
her other medications and exacerbate her underlying conditions, further complicating her clinical picture.
Question 40
B) Continuous IV short-acting insulin infusion (Correct Answer)
Explanation: For an 11-year-old girl with type 1 diabetes presenting with symptoms suggestive of
diabetic ketoacidosis (DKA), the most appropriate intervention besides volume expansion is continuous
IV short-acting insulin infusion. This approach allows for precise control of insulin delivery, gradual
lowering of blood glucose, and correction of metabolic acidosis. Continuous infusion is preferred over
intermittent boluses as it provides more stable glucose control and reduces the risk of rapid shifts in
osmolality, which can lead to cerebral edema, a serious complication of DKA treatment in children.
Question 41
B) Head CT scan (Correct Answer)
Explanation: For an 11-year-old diabetic girl who develops a headache and loses consciousness four
hours after starting insulin therapy, the most appropriate next step is a head CT scan. This presentation is
concerning for cerebral edema, a rare but life-threatening complication of diabetic ketoacidosis treatment,
particularly in children. A head CT can quickly identify cerebral edema or other intracranial pathologies
that may be causing her symptoms. Rapid diagnosis and management of cerebral edema is crucial to
prevent severe neurological outcomes.
Question 42
D) Subchondral bone sclerosis and asymmetric joint space narrowing (Correct Answer)
Explanation: For a 50-year-old woman presenting with gradual onset of pain and swelling in both knees
and finger joints over 12 weeks, the knee X-rays are most likely to show subchondral bone sclerosis and
asymmetric joint space narrowing. These findings are characteristic of osteoarthritis, which is the most
common form of arthritis in this age group. The gradual onset, involvement of weight-bearing joints
(knees) and hands, and the timeframe are all consistent with osteoarthritis. Subchondral sclerosis and
joint space narrowing are hallmark radiographic features of this degenerative joint disease.
Question 43
B) Thoracic spinal cord contusion (Correct Answer)
Explanation: For a 17-year-old football player brought to the ER an hour after a back injury during a
game, the most likely MRI finding is a thoracic spinal cord contusion. Football-related spinal injuries
often occur in the thoracic region due to hyperextension or axial loading forces. A contusion is more
likely than a complete cord transection or vascular injury in the context of a sports-related trauma. MRI is
the most sensitive imaging modality for detecting spinal cord contusions, which appear as areas of
increased T2 signal intensity within the cord parenchyma.
Question 44
A) Avoid chewing gum and hard foods (Correct Answer)
Explanation: For a 25-year-old attorney with left upper jaw pain for a week, the most appropriate advice
is to avoid chewing gum and hard foods. This presentation is suggestive of temporomandibular joint
(TMJ) disorder, which is common in young adults and often exacerbated by stress. Avoiding gum chewing
and hard foods reduces stress on the TMJ, allowing for rest and potential resolution of symptoms. This
conservative approach is appropriate as an initial management strategy for TMJ pain before considering
more invasive interventions.
Question 45
C) Haloperidol (Correct Answer)
Explanation: For a 68-year-old obese woman with chronic bronchitis and schizoaffective disorder who
develops fever and shows lead pipe rigidity in the ICU, the most important medication to discontinue is
haloperidol. This presentation is highly suggestive of neuroleptic malignant syndrome (NMS), a rare but
potentially life-threatening reaction to antipsychotic medications, particularly first-generation
antipsychotics like haloperidol. NMS is characterized by fever, muscle rigidity (often described as "lead
pipe" rigidity), altered mental status, and autonomic instability. Immediate discontinuation of the causative
agent (haloperidol in this case) is crucial in the management of NMS.
Question 46
D) Multiple nodules (Correct Answer)
Explanation: For a 35-year-old woman with a history of childhood Hodgkin lymphoma treated with
radiation who presents with a neck lump, the presence of multiple nodules is the strongest indicator of a
poor prognosis. This is because multiple nodules suggest a more extensive disease process and potential
metastasis. Childhood cancer survivors, especially those treated with radiation, are at increased risk for
secondary malignancies. Multiple nodules in the neck area could indicate recurrence of lymphoma or
development of thyroid cancer, which is a known late effect of neck radiation for Hodgkin lymphoma.
Question 47
C) Raw oysters (Correct Answer)
Explanation: For a 38-year-old man with type 1 diabetes and hemochromatosis, consuming raw oysters
poses the highest mortality risk. Hemochromatosis leads to iron overload, and raw oysters are high in
iron, potentially exacerbating the condition. More critically, raw oysters can contain Vibrio vulnificus, a
bacterium that poses a severe risk to individuals with compromised immune systems or liver disease
(common in hemochromatosis). Diabetes further increases susceptibility to infections. The combination of
these factors makes raw oysters particularly dangerous for this patient.
Question 48
A) Add inhaled fluticasone (Correct Answer)
Explanation: For a 24-year-old woman with asthma reporting mild shortness of breath and nonproductive
cough for 2 weeks, adding inhaled fluticasone is the most appropriate next step. Fluticasone is an inhaled
corticosteroid that helps reduce airway inflammation, which is likely causing the persistent symptoms.
This approach aligns with step-up therapy in asthma management guidelines when symptoms are not
adequately controlled with as-needed bronchodilators alone. Inhaled corticosteroids are the preferred
first-line controller medication for persistent asthma symptoms.
Question 49
C) Cefepime therapy (Correct Answer)
Explanation: For a 36-year-old woman with recently diagnosed Graves' disease admitted with sore throat
and high fever after stopping methimazole, the most appropriate next step is cefepime therapy. This
presentation suggests agranulocytosis, a rare but serious side effect of methimazole. The combination of
fever and sore throat in this context indicates a likely severe bacterial infection due to neutropenia.
Cefepime, a broad-spectrum antibiotic, is appropriate for empiric treatment of febrile neutropenia while
awaiting blood culture results. Prompt antibiotic therapy is crucial to prevent life-threatening sepsis in
this immunocompromised state.
Question 50
C) Perform a bronchoscopy (Correct Answer)
Explanation: For a 62-year-old man with a history of stage III colon cancer whose PET/CT scans reveal a
new 1-cm pulmonary nodule with irregular borders and increased uptake, performing a bronchoscopy is
the most appropriate next step. This presentation is highly suspicious for metastatic disease to the lung. A
bronchoscopy with biopsy can provide a definitive diagnosis, which is crucial for determining the
appropriate treatment plan. It allows for direct visualization of the airways and sampling of the suspicious
nodule. This diagnostic approach is preferred over immediate aggressive interventions like resection or
chemotherapy without confirming the nature of the nodule.
Question 51
D) Diabetes mellitus (Correct Answer)
Explanation: A 25-year-old nulliparous woman with a history of polycystic ovarian syndrome (PCOS)
should be advised that she is at highest risk of developing diabetes mellitus. PCOS is strongly associated
with insulin resistance, which significantly increases the risk of developing type 2 diabetes. Studies have
shown that women with PCOS have a 5-10 times higher risk of developing type 2 diabetes compared to
women without PCOS. The risk is particularly high in young women, even in the absence of obesity. Early
counseling and preventive measures are crucial for these patients.
Question 52
A) Oral diltiazem (Correct Answer)
Explanation: For a 57-year-old woman with type 2 diabetes reporting intermittent palpitations for two
weeks, worsening after exercise, oral diltiazem is the most appropriate immediate treatment. The
symptoms suggest possible atrial fibrillation, a common arrhythmia in patients with diabetes. Diltiazem, a
calcium channel blocker, can help control heart rate and reduce symptoms of palpitations. It's particularly
suitable for patients with diabetes as it doesn't affect glucose metabolism significantly. Diltiazem can be
safely administered orally for rate control in stable patients with new-onset or paroxysmal atrial
fibrillation.
Question 53
B) CT scan of the abdomen with contrast (Correct Answer)
Explanation: For a 36-year-old woman presenting to the ER with severe abdominal pain, nausea, and
vomiting, the most appropriate next step in management, besides IV fluids, is a CT scan of the abdomen
with contrast. This imaging study can quickly and accurately diagnose various acute abdominal conditions
such as appendicitis, diverticulitis, bowel obstruction, or pancreatitis. The use of contrast enhances the
visibility of vascular structures and helps in identifying inflammation or infection. A CT scan provides
detailed information about the abdominal organs, which is crucial for determining the cause of severe
abdominal pain and guiding further management.
Question 54
A) Oral cephalexin (Correct Answer)
Explanation: For an 11-month-old infant with progressive swelling and blistering of his left index finger
and thumb over 24 hours, oral cephalexin is the most appropriate treatment. This presentation suggests a
bacterial skin infection, likely cellulitis or impetigo. Cephalexin, a first-generation cephalosporin, is
effective against common skin pathogens such as Staphylococcus aureus and Streptococcus pyogenes. It's
well-tolerated in infants and has good oral bioavailability. Systemic antibiotic therapy is preferred over
topical treatments for progressive infections in young children to prevent spread and potential
complications.
Question 55
B) Intravenous propranolol (Correct Answer)
Explanation: For a 49-year-old woman with untreated hyperthyroidism presenting with weakness,
dizziness, and palpitations, after initial management, the most appropriate next step is intravenous
propranolol. Propranolol, a non-selective beta-blocker, rapidly alleviates symptoms of hyperthyroidism
such as palpitations and tremors. It also helps prevent the peripheral conversion of T4 to T3. Intravenous
administration allows for quick onset of action and titration of dose based on heart rate response. This
treatment provides symptomatic relief while more definitive therapy for hyperthyroidism is being
planned.
Question 56
C) Congestive heart failure (Correct Answer)
Explanation: A 4-month-old male infant presenting with lethargy, constipation, and poor feeding is most
likely to develop congestive heart failure. These symptoms, particularly in an infant this age, are
concerning for congenital hypothyroidism. Untreated hypothyroidism in infants can lead to various
complications, with congestive heart failure being a severe and potentially life-threatening one. The lack
of thyroid hormone affects cardiac muscle function and can result in decreased cardiac output, leading to
heart failure. Early recognition and treatment of hypothyroidism is crucial to prevent such complications.
Question 57
C) Schedule HIV serology testing in 3 months (Correct Answer)
Explanation: For a 20-year-old man presenting with urinary burning and penile discharge, assuming
symptoms improve with treatment, the most appropriate follow-up plan is to schedule HIV serology
testing in 3 months. The symptoms suggest a sexually transmitted infection (STI), likely gonorrhea or
chlamydia. While immediate treatment is necessary, it's crucial to recognize that the presence of one STI
increases the risk of other STIs, including HIV. The 3-month window for HIV testing is recommended to
account for the potential window period of HIV seroconversion. This follow-up ensures comprehensive
STI care and early detection of HIV if present.
Question 58
C) Bisphosphonate therapy (Correct Answer)
Explanation: For a 67-year-old woman with osteopenia presenting with severe left hip and thigh pain for
6 months, the most appropriate next step in management is bisphosphonate therapy. This presentation
suggests possible insufficiency fractures or progression to osteoporosis. Bisphosphonates are the first-
line treatment for osteoporosis and can also be used in severe osteopenia to prevent fractures. They work
by inhibiting bone resorption, increasing bone density, and reducing fracture risk. Starting bisphosphonate
therapy is crucial in this case to prevent further bone loss and reduce the risk of future fractures,
especially given the prolonged pain suggestive of possible undiagnosed fractures.
Question 59
C) Assist in strengthening lower extremity muscles (Correct Answer)
Explanation: For a 65-year-old diabetic woman preparing for discharge after hip replacement surgery, the
most appropriate arrangement for home services is to assist in strengthening lower extremity muscles.
Post-operative rehabilitation focusing on muscle strengthening is crucial for recovery after hip
replacement. It helps improve mobility, reduces the risk of falls, and enhances overall functional
outcomes. While diabetes management is important, the immediate post-operative period should prioritize
physical rehabilitation to ensure successful recovery from the surgery. Strengthening exercises also
contribute to better glycemic control by improving insulin sensitivity.
Question 60
C) Uncontrolled hypertension (Correct Answer)
Explanation: For a 56-year-old man, uncontrolled hypertension is the factor in his history that most
increased his risk for developing worsening renal failure. Chronic, uncontrolled hypertension is a leading
cause of kidney damage and progression of chronic kidney disease. It causes damage to the blood vessels
in the kidneys, impairing their ability to filter blood effectively. Over time, this can lead to significant
kidney function decline. While other factors like chronic kidney disease and use of ACE inhibitors (like
lisinopril) are relevant, uncontrolled hypertension is likely the primary driver of worsening renal function
in this scenario.
Question 61
E) Transthoracic echocardiography (Correct Answer)
Explanation: For a 55-year-old man with chest pounding, occasional chest pain, and shortness of breath, a
transthoracic echocardiography is the most appropriate initial diagnostic study. It can assess cardiac
structure and function, detect valvular abnormalities, and evaluate for potential causes of the patient's
symptoms such as left ventricular hypertrophy or reduced ejection fraction.
Question 62
A) Cryptosporidium parvum (Correct Answer)
Explanation: The presence of ovoid oocysts in the stool examination of a patient with recurrent
sinopulmonary infections and watery diarrhea strongly suggests Cryptosporidium parvum infection. This
protozoan parasite is known to cause persistent diarrhea, especially in immunocompromised individuals,
and the clinical presentation aligns with the patient's history.
Question 63
C) "Tell me what your greatest concerns are." (Correct Answer)
Explanation: This response is the most appropriate as it demonstrates empathy and encourages open
communication. By asking the father to express his concerns, the physician can address specific worries,
provide reassurance, and potentially avoid unnecessary referrals while maintaining a positive doctor-
patient relationship.
Question 64
E) Vertebrobasilar (Correct Answer)
Explanation: The combination of facial drooping, weakness, ataxia, and swallowing difficulty in a 68-
year-old man suggests involvement of the vertebrobasilar artery system. This arterial system supplies the
brainstem and cerebellum, and its occlusion can lead to the described symptoms, including cranial nerve
deficits and cerebellar signs.
Question 65
D) Respiratory syncytial virus (Correct Answer)
Explanation: In a 3-month-old infant with respiratory distress, fever, and congestion, Respiratory
Syncytial Virus (RSV) is the most likely cause. RSV is a common viral infection in infants, especially
during winter months. It typically causes upper respiratory symptoms and can lead to lower respiratory
tract infections like bronchiolitis. The age of the infant and the presenting symptoms strongly suggest RSV
as the most probable etiology.
Question 66
D) Endometrial biopsy (Correct Answer)
Explanation: For a 44-year-old woman reporting increased menstrual bleeding and fatigue, an
endometrial biopsy is the most appropriate diagnostic study. This procedure can help rule out endometrial
hyperplasia or cancer, which are important considerations in perimenopausal women with abnormal
uterine bleeding. It also allows for direct examination of the endometrial tissue, providing valuable
diagnostic information about the cause of the increased bleeding.
Question 67
C) Pulmonary embolism (Correct Answer)
Explanation: In a 58-year-old man developing chest pressure after knee surgery, pulmonary embolism
(PE) is the most likely cause. Surgery, especially orthopedic procedures, increases the risk of deep vein
thrombosis, which can lead to PE. The sudden onset of chest pressure post-surgery is highly suggestive of
this complication. PE is a serious and potentially life-threatening condition that requires immediate
attention and treatment.
Question 68
F) Retrospective cohort study (Correct Answer)
Explanation: A study assessing physician use of β -blockers for heart failure treatment is best described
as a retrospective cohort study. This type of study looks back in time at a group of individuals (in this
case, heart failure patients) and examines their exposure (use of β -blockers) in relation to outcomes. It
allows researchers to analyze existing data on prescribing patterns and patient outcomes without the need
for prospective follow-up.
Question 69
E) Referral to home hospice care (Correct Answer)
Explanation: For a newborn with trisomy 18 experiencing difficulty sucking and episodes of apnea,
referral to home hospice care is the most appropriate next step. Trisomy 18 is a severe chromosomal
disorder with a very poor prognosis. Most affected infants do not survive beyond the first year of life.
Given the condition's severity and limited treatment options, focusing on comfort care and family support
through hospice services is often the most compassionate approach.
Question 70
A) Drug-drug interaction (Correct Answer)
Explanation: In an elderly woman in a nursing facility experiencing increasing confusion and drowsiness,
a drug-drug interaction is the most likely explanation. Older adults in nursing facilities often have multiple
medical conditions and take several medications, increasing the risk of drug interactions. These
interactions can lead to altered mental status, including confusion and drowsiness. It's crucial to review
the patient's medication list and consider potential interactions as a primary cause of her worsening
condition.
Question 70
A) Drug-drug interaction (Correct Answer)
Explanation: In an elderly woman in a nursing facility experiencing increasing confusion and drowsiness,
a drug-drug interaction is the most likely explanation. Older adults often have multiple medical conditions
and take several medications, increasing the risk of drug interactions. These interactions can lead to
altered mental status, including confusion and drowsiness. It's crucial to review the patient's medication
list and consider potential interactions as a primary cause of her worsening condition.
Question 71
C) Attempt to contact the mother for permission before proceeding (Correct Answer)
Explanation: For a 12-year-old girl with a seizure disorder requesting medication without contacting her
mother, the most appropriate next step is to attempt to contact the mother for permission. Minors generally
cannot provide consent for medical treatment, and parental consent is typically required. Attempting to
reach the parent shows respect for parental rights and follows legal and ethical guidelines while ensuring
the child receives necessary care.
Question 72
E) Thickened left ventricular wall and contractile dysfunction (Correct Answer)
Explanation: In an 8-year-old girl who dies after a seizure and cardiac arrest, the most likely underlying
cause is thickened left ventricular wall and contractile dysfunction, indicative of hypertrophic
cardiomyopathy. This condition can cause sudden cardiac death in children and young adults, especially
during physical exertion or stress. The seizure may have been a manifestation of decreased cerebral
perfusion due to the cardiac event.
Question 73
B) PCR test for N. gonorrhoeae and C. trachomatis (Correct Answer)
Explanation: For a 28-year-old man reporting pain during urination, a PCR test for N. gonorrhoeae and C.
trachomatis is the most appropriate diagnostic test. These are common causes of urethritis in young adults.
PCR testing is highly sensitive and specific for detecting these pathogens. It's non-invasive and can detect
infections even with minimal symptoms, making it the preferred initial test for suspected sexually
transmitted infections causing urethral discomfort.
Question 74
D) Assure the patient that the discussion will remain confidential (Correct Answer)
Explanation: When a 16-year-old patient admits to smoking cannabis, the most appropriate initial
response is to assure the patient that the discussion will remain confidential. This approach builds trust
and encourages open communication. Adolescents are more likely to share health information and seek
help if they feel their privacy is respected. After establishing confidentiality, the physician can then
proceed to discuss the health implications of cannabis use and explore the patient's motivations for using
it.
Question 75
A) Respect the patient's wishes (Correct Answer)
Explanation: For a 77-year-old man refusing amputation for gangrene, the most appropriate action is to
respect the patient's wishes. This upholds the ethical principle of patient autonomy. As long as the patient
is of sound mind and has been fully informed of the risks and benefits of refusing treatment, his decision
should be respected, even if it may lead to negative health outcomes. It's important to ensure the patient
understands the consequences of his decision and to provide palliative care as needed.
Question 76
D) Lymphatic drainage from pharyngeal tissues (Correct Answer)
Explanation: In HIV patients with cervical lymphadenopathy showing acid-fast bacilli, the most likely
route of infection is through lymphatic drainage from pharyngeal tissues. HIV increases susceptibility to
mycobacterial infections, particularly tuberculosis. The mycobacteria typically enter through the
respiratory tract, infect the pharyngeal tissues, and then spread to cervical lymph nodes via lymphatic
drainage.
Question 77
E) Pulmonary embolism (Correct Answer)
Explanation: For a COPD patient with shortness of breath, elevated D-dimer, and normal BNP, pulmonary
embolism is the most likely diagnosis. Elevated D-dimer suggests active blood clot formation, while
normal BNP makes heart failure less likely. COPD patients are at increased risk for pulmonary embolism,
and this combination of findings warrants further investigation for PE, such as CT pulmonary angiography.
Question 78
E) Serum urea nitrogen concentration (Correct Answer)
Explanation: In a pregnant woman with persistent nausea, vomiting, and weight loss (symptoms of
hyperemesis gravidarum), the serum urea nitrogen concentration is most likely to be abnormal. Severe
vomiting leads to dehydration, which causes pre-renal azotemia and elevated blood urea nitrogen. Other
electrolyte abnormalities may occur, but BUN elevation is typically the earliest and most consistent
laboratory finding in this condition.
Question 79
B) Contact the patient's pharmacy for current medication information (Correct Answer)
Explanation: For a woman with multiple medical conditions brought to the ER after falls, contacting the
patient's pharmacy for current medication information is the most appropriate approach. This method
provides the most accurate and up-to-date information about the patient's medications, helping to identify
potential drug interactions or medications that may increase fall risk. It's also the least invasive and most
ethical approach compared to the other options.
Question 80
B) Prolonged immobility (Correct Answer)
Explanation: In a man with advanced dementia and a foot lesion, prolonged immobility is the most likely
underlying cause. Advanced dementia often leads to decreased mobility and prolonged periods in one
position. This can result in pressure ulcers, particularly on bony prominences or areas with decreased
circulation, such as the feet. Prolonged immobility is a common and significant risk factor for skin
breakdown in patients with advanced dementia.
Question 81
A) Continue current management without initiating hemodialysis (Correct Answer)
Explanation: When an elderly woman becomes unresponsive during hospitalization and has a pre-existing
DNR order, the most appropriate course of action is to continue current management without initiating
hemodialysis. The DNR order should be respected unless there is clear evidence that the patient's wishes
have changed. The daughter's insistence does not override the patient's previously expressed wishes.
Initiating new invasive treatments like hemodialysis would go against the spirit of the DNR order.
Question 82
B) Contact the patient's health care proxy to discuss how to proceed (Correct Answer)
Explanation: For an elderly woman with dementia who becomes agitated during an examination for rectal
bleeding, the most appropriate initial intervention is to contact the patient's health care proxy to discuss
how to proceed. This approach respects the patient's autonomy by involving their designated decision-
maker, allows for a more comprehensive discussion of the risks and benefits of proceeding with the
examination, and avoids unnecessary use of chemical or physical restraints.
Question 83
C) Myasthenia gravis (Correct Answer)
Explanation: A man presenting with arm weakness and eyelid drooping is most likely suffering from
myasthenia gravis. This autoimmune disorder affects neuromuscular junctions, leading to fatigable muscle
weakness. Ocular symptoms, such as ptosis (drooping eyelids), are often the first manifestation,
frequently accompanied by weakness in other muscle groups, including the arms. The combination of
these symptoms is highly suggestive of myasthenia gravis.
Question 84
E) Serum quantitative immunoglobulin concentrations (Correct Answer)
Explanation: For a patient with recurrent infections, serum quantitative immunoglobulin concentrations
are the most appropriate initial diagnostic study to determine immune deficiency. This test measures
levels of IgG, IgA, and IgM, providing a broad overview of humoral immunity. Low levels of one or more
immunoglobulin classes can indicate various primary or secondary immunodeficiencies, making this a
valuable screening tool for patients with recurrent infections.
Question 85
B) Test A is more accurate in the high sensitivity range (Correct Answer)
Explanation: Based on ROC curves, if Test A's curve is closer to the upper left corner of the graph in the
high sensitivity range, it indicates that Test A is more accurate in the high sensitivity range compared to
Test B. This means Test A has a better ability to correctly identify true positive cases when set to high
sensitivity, which is particularly useful for screening tests where minimizing false negatives is crucial.
Question 86
B) Large deletion in the gene encoding dystrophin (Correct Answer)
Explanation: A boy presenting with muscle weakness and increased calf circumference is most likely to
have a large deletion in the gene encoding dystrophin. These are classic symptoms of Duchenne muscular
dystrophy (DMD), which is caused by mutations in the dystrophin gene. Large deletions are the most
common type of mutation in DMD, accounting for about 65% of cases. The absence of functional
dystrophin leads to progressive muscle weakness and characteristic pseudohypertrophy of calf muscles.
Question 87
B) Convene a representative focus group to discuss enrollment reluctance (Correct Answer)
Explanation: When researchers notice low enrollment of African American patients in a study, the best
course of action is to convene a representative focus group to discuss enrollment reluctance. This
approach directly engages with the community to understand barriers to participation, cultural concerns,
and potential solutions. It demonstrates respect for the community's perspectives and can provide
valuable insights to improve recruitment strategies and study design, potentially leading to more equitable
representation in research.
Question 88
B) Discuss her treatment goals and expectations (Correct Answer)
Explanation: For a woman presenting with persistent abdominal pain and requesting an endoscopy, the
most appropriate next step is to discuss her treatment goals and expectations. This patient-centered
approach allows the physician to understand the patient's concerns, provide education about the condition
and available diagnostic options, and ensure that the patient's expectations align with medical
recommendations. It also helps in shared decision-making regarding the appropriateness of endoscopy or
alternative approaches.
Question 89
C) Destruction of alveolar walls and air space enlargement (Correct Answer)
Explanation: In an elderly woman presenting with worsening shortness of breath and cough, the most
likely underlying cause is destruction of alveolar walls and air space enlargement, characteristic of
emphysema. This condition, often part of COPD, is common in older individuals and leads to progressive
breathlessness and chronic cough. The destruction of alveolar walls reduces the surface area for gas
exchange and decreases lung elasticity, resulting in air trapping and difficulty breathing.
Question 90
B) Decreased production of adrenocorticotropic hormone (ACTH) (Correct Answer)
Explanation: A young boy experiencing weight loss and fatigue after using oral prednisone is most likely
suffering from decreased production of adrenocorticotropic hormone (ACTH). Prolonged use of
exogenous glucocorticoids like prednisone suppresses the hypothalamic-pituitary-adrenal axis, leading to
decreased ACTH production. When prednisone is stopped or reduced, the body may not produce enough
cortisol due to this suppression, resulting in symptoms of adrenal insufficiency such as fatigue and weight
loss.
Question 91
D) Ultrasonography of the neck (Correct Answer)
Explanation: The patient's symptoms suggest a transient ischemic attack (TIA) affecting the retinal artery.
Given his age and history of hypertension and diabetes, carotid artery stenosis is a likely cause.
Ultrasonography of the neck is the most appropriate initial test to evaluate for carotid artery disease,
which could be the source of emboli causing temporary retinal artery occlusion.
Question 92
A) No seizures 2 years post-op is the best predictor of long-term seizure control (Correct Answer)
Explanation: This conclusion is the most appropriate based on the long-term study of patients who
underwent partial temporal lobectomy. It suggests that patients who remain seizure-free for two years
after the surgery are likely to maintain long-term seizure control, providing valuable prognostic
information for patients considering this procedure.
Question 93
F) Symptom timing (Correct Answer)
Explanation: Given the cyclical nature of the patient's symptoms, gathering information about symptom
timing is crucial. This could help identify if the symptoms are related to her menstrual cycle, potentially
indicating premenstrual dysphoric disorder (PMDD) or another hormone-related condition.
Understanding the timing of symptoms is essential for accurate diagnosis and appropriate treatment.
Question 94
A) Bile ductular proliferation (Correct Answer)
Explanation: The patient's symptoms (jaundice, pale stools) and imaging findings (hypoplastic
gallbladder, small common bile duct) suggest biliary atresia. In this condition, the most characteristic
hepatic change is bile ductular proliferation, which occurs as a compensatory response to the obstruction
of bile flow. This proliferation is an attempt to establish alternative drainage pathways for bile.
Question 95
B) Echocardiography (Correct Answer)
Explanation: Given the patient's history of Graves disease, worsening shortness of breath, irregular
heartbeat, and ECG showing atrial fibrillation, echocardiography is the most appropriate next step. It can
assess cardiac function, valvular abnormalities, and potential complications of hyperthyroidism such as
pulmonary hypertension or cardiomyopathy, which could explain her symptoms.
Question 96
E) Stroke (Correct Answer)
Explanation: The patient's sudden onset of difficulty walking, dizziness, and instability when turning,
combined with his age and history of hypertension, strongly suggest a stroke, particularly in the cerebellar
region. The presence of horizontal nystagmus with position change further supports this diagnosis. Stroke
is a medical emergency requiring immediate evaluation and treatment.
Question 97
A) Adjustment disorder with anxiety (Correct Answer)
Explanation: The patient's symptoms of sudden, severe anxiety episodes occurring shortly after a
significant life stressor (recent divorce) and lasting for a relatively short duration (6 weeks) are most
consistent with adjustment disorder with anxiety. This disorder is characterized by the development of
emotional or behavioral symptoms in response to an identifiable stressor, typically resolving within 6
months of the stressor's cessation.
Question 98
B) Hemoglobin A1c test (Correct Answer)
Explanation: Given the patient's risk factors (obesity, sedentary lifestyle, family history) and elevated
fasting glucose (126 mg/dL), the most appropriate next step is a Hemoglobin A1c test. This test provides
an average of blood glucose levels over the past 2-3 months and is used to diagnose diabetes. It's more
reliable than a single fasting glucose measurement and doesn't require fasting or multiple blood draws
like a glucose tolerance test.
Question 99
A) Chest x-ray (Correct Answer)
Explanation: For a patient with acute pancreatitis developing new respiratory symptoms (labored
breathing, decreased breath sounds at left lung base), a chest x-ray is the most appropriate initial
diagnostic test. It can quickly identify potential complications such as pleural effusion, atelectasis, or
pneumonia, which are common in acute pancreatitis and can cause the described symptoms.
Question 100
F) Cannot be determined from the data provided (Correct Answer)
Explanation: Without specific information about the performance characteristics of the available
screening tests and the patient's individual risk factors, it's impossible to determine which test is most
appropriate. Gestational diabetes screening typically occurs later in pregnancy (24-28 weeks), and the
choice of test depends on various factors including the patient's risk profile and local guidelines. More
information would be needed to make an informed decision.

Practice Tests 2
Question 1: A 75-year-old man presents with symptoms suggestive of pneumonia. After treatment, his
breathing worsens when lying on his left side but improves when rolled to his right. What explains this
improvement?
A) Positionally apparent pulmonary emboli
B) Positionally decreased alveolar-arterial gradient
C) Positionally impeded filling of the left ventricle
D) Positionally impeded movement of the diaphragm
E) Positionally increased left pleural effusion
Question 2: A 21-year-old ballet dancer with amenorrhea seeks help conceiving. What's the most likely
cause of her condition?
A) Addison disease
B) Hypothalamic hypogonadism
C) Partial hypopituitarism
D) Polycystic ovarian syndrome
E) Premature ovarian failure
Question 3: A 66-year-old woman with multiple medical conditions presents with worsening pain when
swallowing. Which structure is most likely to show ulceration on endoscopy?
A) Duodenum
B) Esophagus
C) Gastric cardia
D) Gastric fundus
E) Pylorus
Question 4: A 52-year-old man with diabetes and cirrhosis presents with fever and sudden leg lesions
after returning from a southeastern state. Which microorganism is the most likely cause?
A) Enterobacter aerogenes
B) Enterococcus faecalis
C) Mycobacterium marinum
D) Vibrio vulnificus
Question 5: A 37-year-old woman presents with severe right-sided abdominal pain. What's the most
appropriate next step after initial treatment?
A) Cystoscopy
B) Exploratory laparotomy
C) Helical CT scan of the abdomen
D) X-ray of the kidney, ureter, and bladder
E) No further testing is indicated at this time
Question 6: A 72-year-old man is admitted with abdominal symptoms and proximal colon dilation. What
histopathologic changes are most likely in the colon after surgical resection?
A) Caseating granulomatous inflammation with serosal fibrous adhesions
B) Coagulative necrosis involving mucosa and submucosa
C) Neutrophilic infiltrates in the mucosa with venous congestion and edema
D) Patchy mucopurulent exudate with exploding glandular crypts
E) Transmural chronic inflammation with ulcerations extending into submucosa
Question 7: A 67-year-old veteran undergoes left transfemoral amputation revision. Which physical exam
finding is most likely to hinder his long-term ability to use a prosthesis?
A) A 3-cm-diameter blackened eschar on the right heel
B) A 5-degree left hip flexion contracture
C) An irregular pulse
D) Loss of proprioception in the right great toe
Question 8: A 60-year-old man with multiple comorbidities is admitted with sudden shortness of breath,
dizziness, and chest pain. What's the most likely underlying explanation for his condition?
A) External compression of the superior vena cava
B) Helicobacter pylori infection with transmural ulceration and peritoneal leaking
C) Lactic acidosis caused by systemic hypoperfusion
D) Pulmonary vasculature compromise and cor pulmonale
E) Widespread hepatocellular necrosis and parenchymal edema
Question 9: A 71-year-old woman with severe COPD declines reintubation during an exacerbation.
What's the most appropriate next step?
A) State that if she declines intubation again, she'll receive comfort care only
B) Contact her daughter for information on previous intubation feelings
C) Explain that her advance directive is confusing and discuss options
D) Proceed with reintubation
E) Request psychiatric evaluation of her capacity to make healthcare decisions
Question 10: Which inclusion criteria would design the most efficient study for a phase 3 trial
investigating a new type 2 diabetes prevention medication?
A) Patients ≥18 years with BMI <23 kg/m2 and smokers
B) Patients ≥18 years with no significant medical history
C) Patients ≥45 years with hyperlipidemia and central obesity
D) Patients ≥65 years with hemoglobin A1c ≥6.5%
Question 11: A 55-year-old postmenopausal woman presents with monthly vaginal spotting. What's the
most appropriate diagnostic study?
A) Complete blood count
B) CT scan of the pelvis
C) Endometrial biopsy
D) Hysterosalpingography
E) Serum CA 125 concentration
Question 12: A 28-year-old recently divorced woman reports sudden, severe anxiety episodes. What's the
most likely diagnosis?
A) Adjustment disorder with anxiety
B) Agoraphobia
C) Dysthymic disorder
D) Generalized anxiety disorder
E) Posttraumatic stress disorder
Question 13: An 11-year-old boy's parents express reluctance about the HPV vaccine. How should the
healthcare provider respond?
A) Acknowledge vaccine risks but emphasize the HPV vaccine's safety as an inactivated vaccine
B) Advise vaccination to contribute to HPV elimination in the general population
C) Explain potential HPV exposure from a future partner, even if abstinent until marriage
D) Provide vaccine literature and allow deferral, as it can be given until age 26
Question 14: A 19-year-old pregnant woman admits to smoking. Which factor poses the greatest risk for
sudden infant death syndrome (SIDS)?
A) Employment status
B) History of cocaine use
C) Lack of breast-feeding
D) Maternal smoking
Question 15: A hospital receives reports of patients receiving different oxygen amounts than ordered.
Which measure would most effectively reduce discrepancies?
A) Conduct an in-service program on oxygen use and order documentation
B) Create a standard set of oxygen orders with initial dose, titration parameters, and goal dose
C) Encourage nurses to avoid adjusting oxygen dose without a written physician order
D) Require nurses to enter verbal orders electronically with physician signature within 24 hours
E) Require nurses to call a physician before deviating from the original oxygen order
Question 16: A 58-year-old man with persistent high blood pressure comes for follow-up. What specific
additional history should be obtained?
A) Caffeine use
B) Exercise history
C) Frequency of fast food consumption
D) Refill patterns on medications
Question 17: A 65-year-old man with osteoarthritis and a history of myocardial infarction is considering
celecoxib. What process inhibition raises concerns?
A) Both COX-1 and COX-2 decreasing prostanoid production
B) COX-1 decreasing prostacyclin (PGI2) production
C) COX-1 decreasing thromboxane A2 production
D) COX-2 decreasing prostacyclin (PGI2) production
E) COX-2 decreasing thromboxane A2 production
Question 18: A 75-year-old woman faints while standing. What's the most appropriate next step in
evaluation?
A) Electroencephalography
B) Outpatient ambulatory ECG monitoring (24-hour)
C) Outpatient echocardiography
D) Telemetry observation
E) Tilt test
Question 19: A 39-year-old man with psoriasis presents with worsening itchiness and urinary symptoms.
What's the most likely cause of his pruritus?
A) Exacerbation of psoriasis
B) Obstruction of the common bile duct
C) Oxycodone therapy
D) Tamsulosin therapy
E) Ureteral obstruction
Question 20: Researchers plan to study the relationship between dental x-rays and thyroid cancer risk.
What's the most appropriate IRB response to liability concerns?
A) Approve the study as submitted
B) Do not approve the study
C) Require informed consent language about the right to sue if a positive association is found
D) Require informed consent language releasing the institution from liability
Question 21: What is the most common cause of restrictive cardiomyopathy?
A) Endomyocardial fibrosis
B) Idiopathic
C) Hemachromatosis
D) Amyloidosis
Question 22: Which of the following is not typically seen in a patient with tricuspid incompetence?
A) Normal cardiac output
B) Hepatic pulsation
C) Mid diastolic murmur
D) A wave in JVP
Question 23: What is the minimum amount of air required to produce an air embolism?
A) 200 ml
B) 100 ml
C) 50 ml
D) 150 ml
Question 24: Which of the following is not a characteristic of Hurler syndrome?
A) X-linked inheritance
B) Joint stiffness
C) Coarse facial features
D) Mental retardation
Question 25: In which phase are chromosomal studies typically performed?
A) Anaphase
B) Prophase
C) Telophase
D) Metaphase
Question 26: What is the IQ of a 15-year-old male with a mental age of 9 years?
A) 60
B) 50
C) 80
D) 70
Question 27: Which of the following conditions is associated with absent Y descent and prominent X
wave in jugular venous pulse?
A) Constrictive pericarditis
B) Right ventricular failure
C) Restrictive cardiomyopathy
D) Cardiac tamponade
Question 28: What is the most appropriate prophylaxis for asthma?
A) None of the above
B) Inhaler steroids
C) Oral steroids
D) Inhaler bronchodilator B agonists
Question 29: Which part of the intestine is primarily involved in celiac disease?
A) Distal part of large intestine
B) Distal part of small intestine
C) Proximal part of small intestine
D) Proximal part of large intestine
Question 30: What is the most likely diagnosis for a homeless alcoholic man with foot numbness and
burning pain after exposure to cold and wet conditions?
A) Frostbite
B) Trench foot
C) Chilblains
D) Cold urticaria
Question 31: Which of the following is the histological feature of pemphigus?
A) Colloid bodies
B) Acanthosis
C) Acantholysis
D) Basal cell degeneration
Question 32: What is the most common type of incontinence in elderly men and women?
A) Overflow incontinence
B) Stress incontinence
C) Functional incontinence
D) Urge incontinence
Question 33: Which of the following is a constituent of molybdenum?
A) Xanthine oxidase
B) Carbonic anhydrase
C) Phosphofructokinase
D) Cytochrome oxidase
Question 34: What is the best approach to breaking bad news to a cancer patient?
A) Inform the patient's family
B) Let social services inform the patient
C) Find out how much the patient knows about their condition
D) Don't tell the patient
Question 35: Which of the following is not associated with obstructive sleep apnea?
A) Obesity
B) Acromegaly
C) Protruding jaw
D) Male gender
Question 36: What is the most appropriate management for a patient with aseptic meningitis who has
improved after initial treatment?
A) Discharge home
B) Continue antibiotics until cultures are negative
C) Discontinue current medications and observe
D) Observe for 48 hours
Question 37: Which of the following is the most likely cause of acute kidney injury in a patient who has
ingested "bath salts"?
A) Rhabdomyolysis
B) Acute renal venous thrombosis
C) Crystal-induced tubular obstruction
D) Renal arterial vasospasm
Question 38: What is the best next step in management for a patient with post-infectious thrombocytopenia
without spontaneous bleeding?
A) Splenectomy
B) Initiate steroids
C) Conservative management with follow-up and repeat complete blood cell count
D) Transfuse fresh frozen plasma
Question 39: Which of the following is not a true statement about Crohn's disease?
A) Lymph nodes invasion
B) Can involve stomach and duodenum
C) Transmural involvement
D) Skip lesions
Question 40: What is the most appropriate treatment for a patient with advanced heart failure and frequent
AICD firings?
A) Initiation of a milrinone infusion
B) Angiography for possible percutaneous intervention
C) Insertion of an intra-aortic balloon pump
D) Deactivation of the AICD
Question 41: Which of the following is the best post-exposure management strategy for a healthcare
worker exposed to HIV-positive blood?
A) Tenofovir and emtricitabine
B) Tenofovir, emtricitabine, and raltegravir
C) No post-exposure prophylaxis
D) Tenofovir, emtricitabine, and nevirapine
Question 42: What is the most likely acid-base disorder in an elderly patient with persistent vomiting and
specific blood gas values?
A) Metabolic alkalosis/respiratory alkalosis
B) Respiratory alkalosis
C) Metabolic alkalosis/respiratory acidosis
D) Metabolic alkalosis
Question 43: Which of the following surgeries would pose the greatest risk for post-surgical
complications in the elderly?
A) Non-emergent repair of a thoracic aortic aneurysm
B) Resection of a 5-cm lung cancer
C) Carotid endarterectomy
D) Total colectomy for colon cancer
Question 44: What is the most appropriate pre-ERCP prophylaxis for a patient with primary sclerosing
cholangitis?
A) Ciprofloxacin given once, one hour before the procedure
B) No antibiotics needed
C) Ciprofloxacin starting before the procedure and continuing for 7 days
D) Hold the procedure until the patient receives a full course of ciprofloxacin
Question 45: Which of the following is the most likely cause of a patient's condition after abdominal
aneurysm repair with decreased urine output and tense, distended abdomen?
A) Aminoglycoside toxicity
B) Urinary obstruction
C) Abdominal compartment syndrome
D) Prerenal acute injury
Question 46: What is the best step in treating a patient with Heyde's syndrome?
A) Colon resection
B) Mesenteric artery embolization
C) Aortic valve replacement
D) Mechanical hemostasis using endoscopic clips
Question 47: Which of the following is the most appropriate management for a patient with E. coli urinary
tract infection after initial broad-spectrum antibiotic treatment?
A) Discontinue piperacillin/tazobactam and begin ampicillin
B) Discontinue piperacillin/tazobactam and begin ciprofloxacin
C) Discontinue piperacillin/tazobactam and begin ceftriaxone
D) Continue piperacillin/tazobactam
Question 48: What term best describes the condition of a patient with spontaneous eye opening, visual
tracking, but no purposeful movement after severe head trauma?
A) Vegetative state
B) Coma
C) Minimally conscious state
D) Locked-in syndrome
Question 49: Which area of the GI tract, when inflamed, best explains increased maximal acid output,
decreased serum calcium and iron concentrations, and microcytic anemia?
A) Jejunum
B) Stomach
C) Duodenum
D) Ileum
Question 50: To which deep cerebellar nucleus do neurons from the spinocerebellar cortical region
primarily project?
A) Globose nucleus
B) Fastigial nucleus
C) Dentate nucleus
D) Emboliform nucleus
Question 51: What is the most important factor to consider when evaluating the ill-effects of smoking?
A) Filter of cigarette
B) Duration of smoking
C) Brand of cigarette
D) Number of times smoking in a day
Question 52: Which of the following lacks the Glucose-6-phosphatase enzyme?
A) Brain
B) Kidney
C) Liver
D) Muscles
Question 53: What is the incidence of Bell's palsy in the general population?
A) 1/100 women per lifetime, 1/1000 men per lifetime
B) 1/1000 people per year
C) 1/250 people per lifetime
D) 1/65 people per lifetime
Question 54: Which of the following is not true regarding Kala-azar in India?
A) It is essentially a parasite of reticulo-endothelial system
B) It is endemic in Bihar
C) Dog is the reservoir of infection
D) It is transmitted by sand flies
Question 55: What are the limiting amino acids in wheat?
A) Lysine, methionine
B) Lysine, threonine
C) Threonine, methionine
D) Lysine, arginine
Question 56: Which of the following is associated with microangiopathic hemolytic anemia?
A) Hemolytic uremic syndrome
B) Vitamin B12 deficiency
C) Diabetes Mellitus
D) All of the above
Question 57: What is the most likely diagnosis for a female with hair growth on different body sites, food
intake refusal, BMI < 18, and perception of being fat?
A) Bulimia nervosa
B) Body dysmorphic syndrome
C) Anxiety
D) Anorexia nervosa
Question 58: Which of the following vaccines should not be given to a household contact of an
immunodeficient child?
A) DPT
B) Oral polio
C) Hepatitis
D) BCG
Question 59: What is the most likely diagnosis for a patient presenting with fever and an anterior lymph
node swelling that is warm, tender, and fluctuant?
A) Viral infection
B) Hodgkin's lymphoma
C) Bacterial lymphadenitis
D) All of the above
Question 60: Which test of significance is appropriate for discrete variables?
A) Standard error of difference between two means
B) Chi-square test
C) None of the above
D) T-test
Question 61: What is the next appropriate investigation for a patient with hypertension, small left kidney
on KUB, and renal artery stenosis on arteriography?
A) Renal CT scan
B) Renal biopsy
C) Renal barium study
D) Retrograde pyelography
Question 62: Which of the following conditions is associated with accumulation of increased amounts of
sphingomyelin in the spleen and liver?
A) Obstructive jaundice
B) Gaucher's disease
C) Niemann-Pick disease
D) Von Gierke's disease
Question 63: In which disease is secondary prevention least useful?
A) Breast cancer
B) Diabetes mellitus
C) Leukemia
D) Malnutrition in children
Question 64: What sugar is contained in cerebrosides?
A) Galactose
B) Ribose
C) Fructose
D) Pentose
Question 65: Which of the following is a delusion associated with Othello syndrome?
A) Grandeur
B) Doubles
C) Persecution
D) Infidelity
Question 66: Which amino acid is involved in urea synthesis?
A) Glutamine
B) Valine
C) Aspartic acid
D) Phenylalanine
Question 67: What can an 18-month-old baby typically not do?
A) Feed himself with a spoon
B) Have a vocabulary of 10 words
C) Build a ten-brick tower
D) Drink from a cup
Question 68: Which of the following drugs is administered orally?
A) Gentamycin
B) Amikacin
C) Neomycin
D) Streptomycin
Question 69: What is the most likely location of a lesion in a patient with paresthesias, difficulty walking,
and unsteadiness with eyes closed?
A) Basal ganglia
B) Cerebral cortex
C) Posterior column of the spinal cord
D) Cerebellum
Question 70: Which of the following best describes hallucinations and paranoia?
A) Mood disorder
B) Phobia
C) Schizophrenia
D) Mania
Question 71
A 65-year-old patient presents with hemoptysis and stage III clubbing. What is a probable diagnosis?
A) Tuberculosis
B) Small cell carcinoma of lung
C) Sarcoidosis
D) Non-small cell carcinoma of lung
Question 72
What is the basis for the Working formulation in staging non-Hodgkin's lymphoma?
A) Cellular genetics
B) Morphology of cells
C) Survival characteristics of cells
D) Cell surface markers
Question 73
Which of the following is not a feature of delirium?
A) Impairment of consciousness
B) Immediate memory retention and recall is normal
C) Hyperactivity
D) Disorientation
Question 74
A patient presents with symptoms of anxiety including palpitation, agitation, and worry. What is the first-
line treatment?
A) Monoamine oxidase inhibitors (MAOI)
B) Tricyclic antidepressants (TCA)
C) Selective serotonin reuptake inhibitors (SSRI)
D) Beta-blockers
Question 75
Which of the following is the most appropriate treatment for a patient with methicillin-resistant
Staphylococcus aureus (MRSA) bacteremia and endocarditis?
A) Nafcillin
B) Daptomycin
C) Clindamycin
D) Cefazolin
Question 76
What is the most common causative agent for lobar pneumonia?
A) Streptococcus pneumoniae
B) Staphylococcus aureus
C) Streptococcus pyogenes
D) Haemophilus influenzae
Question 77
Which of the following may enter the body by penetrating exposed skin?
A) Schistosoma
B) Giardia
C) Guinea worm
D) Naegleria
Question 78
Atherosclerosis is inversely related to which of the following?
A) Chylomicrons
B) Triglycerides
C) Low-density lipoprotein (LDL)
D) High-density lipoprotein (HDL)
Question 79
Which of the following is not a symptom of narcolepsy?
A) Daytime sleepiness
B) Cataplexy
C) Hypnagogic hallucinations
D) Catalepsy
Question 80
What represents the 'filaria endemicity rate'?
A) Mosquito infestation rate
B) Filaria disease rate
C) Microfilaria rate
D) Combination of microfilaria and disease rate
Question 81
An 8-year-old child has an itchy rash all over the body, and all family members are experiencing the same
problem. Which drug is preferred?
A) Fluconazole
B) Antibiotics
C) Steroid
D) Topical Permethrin
Question 82
A patient with a history of schizophrenia develops fever, tremors, rigidity, and agitation after escalating
doses of haloperidol. What is the most likely diagnosis?
A) Malignant hyperthermia
B) Neuroleptic malignant syndrome
C) Lithium toxicity
D) Serotonin syndrome
Question 83
Which study design is best for investigating a rare disease?
A) Randomized controlled trial
B) Case-control study
C) Cross-sectional study
D) Cohort study
Question 84
A 77-year-old man presents with progressive memory loss and difficulty managing finances. What is the
most likely diagnosis?
A) Alzheimer's disease
B) Delirium
C) Dementia with Lewy bodies
D) Progressive supranuclear palsy
Question 85
What is the best time to administer long-term nitrates for nocturnal angina?
A) Early morning
B) Evening
C) Noon
D) Late night
Question 86
A breast biopsy reveals ducts filled with atypical cells and central necrosis, without invasion into
surrounding tissue. What is the most likely diagnosis?
A) Colloid carcinoma
B) Comedocarcinoma
C) Infiltrating ductal carcinoma
D) Lobular carcinoma in situ
Question 87
Which of the following is not considered normal flora and should be treated?
A) Candida
B) Fragmented bacteria
C) E. coli
D) Trichomonas
Question 88
What is the characteristic of Leishman-Donovan (LD) bodies?
A) Associated with malaria
B) Associated with larva migrans
C) Associated with Loa loa
D) Associated with Kala-azar
Question 89
Which of the following is associated with the Shine-Dalgarno sequence in prokaryotes?
A) Replication
B) Translation
C) Transcription
D) Translocation
Question 90
Which enzyme is inhibited by fluoride ion?
A) Enolase
B) Pyruvate kinase
C) Phosphofructokinase
D) Lactate dehydrogenase
Question 91
What is Paragonimus westermani commonly called?
A) Lung fluke
B) Tapeworm
C) Liver fluke
D) Intestinal fluke
Question 92
A patient with upper extremity deep vein thrombosis (DVT) requires treatment. Which option is most
appropriate?
A) Warfarin alone
B) Rivaroxaban
C) Warfarin plus Enoxaparin
D) Either A or B
Question 93
What is the likely result of increasing a septic shock patient's mean arterial pressure (MAP) to 75 mmHg
instead of 65 mmHg?
A) Reduced need for renal replacement therapy
B) Decreased risk of cardiac arrhythmia
C) Increased need for renal replacement therapy
D) Improved mortality
Question 94
Which of the following is a characteristic radiological feature of miliary tuberculosis?
A) Presence of a small cavity
B) Septal lines
C) Pleural effusion
D) Sparing of the lung apices
Question 95
A knife wound destroys the right half of the spinal cord at the lower cervical level. What deficit would
most likely result?
A) Impaired movements of the lower limb only
B) Impaired bladder functions only
C) Loss of sensory and motor functions of upper and lower limbs
D) Impaired movements of the upper limb only
Question 96
What is the most likely cause of infection in a child with enlarged axillary lymph nodes and a small,
inflamed lesion on the forearm?
A) Brucella canis
B) Mycobacterium scrofulaceum
C) Yersinia enterocolitica
D) Bartonella henselae
Question 97
In a patient with myocardial infarction, which statement about lactate dehydrogenase (LDH) is correct?
A) LDH isozymes are composed of different subunit combinations, some released during inflammation
following heart attacks
B) LDH is mainly localized in the liver, and its elevation in cardiac disease occurs because of heart
failure
C) LDH isozymes are composed of different subunit combinations, some specific for heart and released
with myocardial damage
D) LDH is an enzyme specific to the endocardium
Question 98
What is the most likely diagnosis for a 3-month-old girl with feeding difficulty, failure to thrive, and
cardiac enlargement on chest x-ray, who dies of severe cardiac failure?
A) Dilated cardiomyopathy
B) Infective endocarditis
C) Hypertrophic cardiomyopathy
D) Endocardial fibroelastosis
Question 99
Regarding postpartum psychosis, which statement is correct?
A) It often progresses to frank schizophrenia
B) Recurrences are common in subsequent pregnancies
C) It has a good prognosis
D) It has an insidious onset
Question 100
A female patient 8 weeks postpartum with poorly controlled asthma presents with wheezing, shortness of
breath, and edema. What is the most likely diagnosis?
A) Angioedema
B) Pulmonary embolism
C) Acute asthma attack
D) Chronic obstructive pulmonary disease (COPD)

Correct Answers & Explanations

Question 1
E) Positionally increased left pleural effusion (Correct Answer)
Explanation: The improvement in breathing when the patient is rolled to his right side suggests a left-
sided pleural effusion. In this position, the effusion pools away from the functioning lung tissue, allowing
for better ventilation and oxygenation. This positional change in symptoms is characteristic of pleural
effusions.
Question 2
B) Hypothalamic hypogonadism (Correct Answer)
Explanation: The combination of amenorrhea in a young ballet dancer suggests hypothalamic
hypogonadism, often called functional hypothalamic amenorrhea. This condition is common in athletes,
especially those in sports emphasizing leanness, due to low body fat, intense exercise, and psychological
stress, which suppress the hypothalamic-pituitary-gonadal axis.
Question 3
B) Esophagus (Correct Answer)
Explanation: The patient's symptoms of worsening pain when swallowing (odynophagia) strongly suggest
esophageal involvement. Given her age and multiple medical conditions, esophageal ulceration is the
most likely finding on endoscopy, which could be due to conditions such as gastroesophageal reflux
disease (GERD) or medication-induced esophagitis.
Question 4
D) Vibrio vulnificus (Correct Answer)
Explanation: The combination of diabetes, cirrhosis, recent travel to a southeastern state, and sudden
onset of leg lesions with fever strongly suggests Vibrio vulnificus infection. This organism is found in
warm coastal waters, particularly in the southeastern United States, and can cause severe, rapidly
progressing skin infections in immunocompromised individuals.
Question 5
C) Helical CT scan of the abdomen (Correct Answer)
Explanation: For a 37-year-old woman with severe right-sided abdominal pain, a helical CT scan of the
abdomen is the most appropriate next step after initial treatment. It provides detailed imaging of the
abdominal organs and can help diagnose conditions such as appendicitis, kidney stones, or ovarian
pathologies, which are common causes of right-sided abdominal pain in this age group.
Question 6
C) Neutrophilic infiltrates in the mucosa with venous congestion and edema (Correct Answer)
Explanation: The patient's symptoms of abdominal discomfort and proximal colon dilation suggest acute
colonic pseudo-obstruction (Ogilvie's syndrome). The histopathologic changes most likely to be seen in
this condition include neutrophilic infiltrates in the mucosa, along with venous congestion and edema,
reflecting the acute inflammatory process and vascular changes associated with this condition.
Question 7
B) A 5-degree left hip flexion contracture (Correct Answer)
Explanation: A hip flexion contracture, even as small as 5 degrees, can significantly impact a patient's
ability to use a prosthesis effectively. It affects gait mechanics and energy expenditure during walking,
making it the most likely factor to hinder long-term prosthesis use among the given options.
Question 8
D) Pulmonary vasculature compromise and cor pulmonale (Correct Answer)
Explanation: The patient's symptoms of sudden shortness of breath, dizziness, and chest pain, along with
multiple comorbidities, suggest a pulmonary embolism leading to pulmonary vasculature compromise and
cor pulmonale. This condition can cause acute right heart strain, explaining the constellation of symptoms
presented.
Question 9
C) Explain that her advance directive is confusing and discuss options (Correct Answer)
Explanation: The most appropriate next step is to clarify the patient's wishes and ensure she understands
the implications of her decision. Explaining that her advance directive is confusing and discussing options
allows for a patient-centered approach, respecting her autonomy while ensuring she's making an informed
decision about her care.
Question 10
C) Patients ≥45 years with hyperlipidemia and central obesity (Correct Answer)
Explanation: For a phase 3 trial investigating a new type 2 diabetes prevention medication, selecting
patients ≥45 years with hyperlipidemia and central obesity would be most efficient. This group represents
individuals at high risk for developing type 2 diabetes, making them ideal candidates for testing a
preventive medication.
Question 11
C) Endometrial biopsy (Correct Answer)
Explanation: For a postmenopausal woman presenting with monthly vaginal spotting, an endometrial
biopsy is the most appropriate diagnostic study. This procedure can directly assess the endometrial tissue
for potential causes of bleeding, including endometrial hyperplasia or cancer, which are important
considerations in postmenopausal women with abnormal uterine bleeding.
Question 12
A) Adjustment disorder with anxiety (Correct Answer)
Explanation: Given the patient's recent divorce and sudden onset of severe anxiety episodes, adjustment
disorder with anxiety is the most likely diagnosis. This condition is characterized by the development of
emotional or behavioral symptoms in response to an identifiable stressor, such as divorce, occurring
within 3 months of the onset of the stressor.
Question 13
C) Explain potential HPV exposure from a future partner, even if abstinent until marriage (Correct
Answer)
Explanation: The most appropriate response is to explain the potential for HPV exposure from a future
partner, even if the child remains abstinent until marriage. This approach addresses potential parental
concerns about sexual activity while emphasizing the importance of protection against future exposure,
regardless of current behavior.
Question 14
D) Maternal smoking (Correct Answer)
Explanation: Among the factors listed, maternal smoking poses the greatest risk for sudden infant death
syndrome (SIDS). Smoking during pregnancy increases the risk of SIDS by 2-3 times, and exposure to
secondhand smoke after birth further increases this risk. It's one of the most significant modifiable risk
factors for SIDS.
Question 15
B) Create a standard set of oxygen orders with initial dose, titration parameters, and goal dose (Correct
Answer)
Explanation: Creating a standard set of oxygen orders with initial dose, titration parameters, and goal
dose would most effectively reduce discrepancies in oxygen administration. This approach provides clear
guidelines for all staff, reducing confusion and allowing for appropriate adjustments within set
parameters.
Question 16
D) Refill patterns on medications (Correct Answer)
Explanation: For a patient with persistent high blood pressure, obtaining information about refill patterns
on medications is crucial. This information can reveal adherence issues, which are a common cause of
uncontrolled hypertension. Understanding medication compliance is essential before considering changes
to the treatment regimen.
Question 17
D) COX-2 decreasing prostacyclin (PGI2) production (Correct Answer)
Explanation: The main concern with celecoxib use in a patient with a history of myocardial infarction is
its inhibition of COX-2, which decreases prostacyclin (PGI2) production. Prostacyclin has
cardioprotective effects, and its reduction can increase the risk of cardiovascular events, especially in
patients with pre-existing cardiovascular disease.
Question 18
E) Tilt test (Correct Answer)
Explanation: For an elderly patient who faints while standing, a tilt test is the most appropriate next step
in evaluation. This test can help diagnose orthostatic hypotension or vasovagal syncope, which are
common causes of fainting in the elderly, especially when associated with positional changes.
Question 19
D) Tamsulosin therapy (Correct Answer)
Explanation: The most likely cause of pruritus in this patient is tamsulosin therapy. Tamsulosin, commonly
used to treat urinary symptoms associated with benign prostatic hyperplasia, can cause pruritus as a side
effect. The combination of worsening itchiness and urinary symptoms suggests that the patient may have
recently started or increased the dose of tamsulosin.
Question 20
A) Approve the study as submitted (Correct Answer)
Explanation: The most appropriate IRB response to liability concerns in this case is to approve the study
as submitted. The potential relationship between dental x-rays and thyroid cancer is an important area of
research, and standard informed consent procedures should be sufficient to address liability concerns.
Adding specific language about liability or the right to sue could unduly influence participants or create
unnecessary anxiety.
Question 21
A) Endomyocardial fibrosis (Correct Answer)
Explanation: The most common cause of restrictive cardiomyopathy is cardiac amyloidosis, followed
closely by endomyocardial fibrosis. This condition leads to the thickening and stiffening of the heart
muscle, impairing its ability to fill properly during diastole. Other causes include hemochromatosis and
idiopathic cases, but endomyocardial fibrosis is particularly prevalent in certain regions and populations.
Question 22
C) Mid diastolic murmur (Correct Answer)
Explanation: In tricuspid incompetence, patients typically do not present with a mid-diastolic murmur.
Instead, symptoms may include elevated jugular venous pressure (JVP), which can show a prominent A
wave due to atrial contraction. A mid-diastolic murmur is more characteristic of mitral stenosis or other
left-sided heart issues.
Question 23
B) 100 ml (Correct Answer)
Explanation: Studies suggest that as little as 100 ml of air can lead to significant complications, including
air embolism. The risk increases with larger volumes, and amounts exceeding 200-300 ml can be fatal.
Air embolisms occur when air enters the vascular system and can obstruct blood flow, leading to serious
consequences.
Question 24
A) X-linked inheritance (Correct Answer)
Explanation: Hurler syndrome is an autosomal recessive disorder caused by mutations in the IDUA gene,
not X-linked inheritance. It leads to a deficiency in an enzyme required for glycosaminoglycan
metabolism, resulting in various physical and cognitive symptoms. The other options listed are indeed
characteristics of Hurler syndrome.
Question 25
D) Metaphase (Correct Answer)
Explanation: Chromosomal studies are typically performed during metaphase when chromosomes are
most condensed and easily visualized under a microscope. This allows for accurate karyotyping and
identification of chromosomal abnormalities. Other phases like prophase or anaphase do not provide the
same clarity for chromosomal analysis.
Question 26
A) 60 (Correct Answer)

Explanation: The IQ can be calculated using the formula For a 15-

year-old with a mental age of 9 years, the calculation would be This indicates
significant developmental delay relative to chronological age.
Question 27
A) Constrictive pericarditis (Correct Answer)
Explanation: Absent Y descent and prominent X wave in the jugular venous pulse are indicative of
constrictive pericarditis. In this condition, the heart's filling is impaired due to thickened pericardium,
affecting the normal descent of the JVP waves. Other conditions like cardiac tamponade may show
different JVP patterns.
Question 28
B) Inhaler steroids (Correct Answer)
Explanation: Inhaled corticosteroids are considered the most appropriate prophylaxis for asthma as they
reduce airway inflammation and prevent exacerbations. They should be used regularly even when
symptoms are not present, unlike bronchodilators which are typically used for immediate relief.
Question 29
C) Proximal part of small intestine (Correct Answer)
Explanation: Celiac disease primarily affects the proximal part of the small intestine, particularly the
duodenum. It leads to damage from gluten exposure, resulting in malabsorption and various
gastrointestinal symptoms. The distal parts of the intestine are less affected.
Question 30
B) Trench foot (Correct Answer)
Explanation: The symptoms described—foot numbness and burning pain after exposure to cold and wet
conditions—are characteristic of trench foot, also known as immersion foot. This condition results from
prolonged exposure to cold water or dampness, leading to tissue damage without freezing.
Question 31
C) Acantholysis (Correct Answer)
Explanation: Pemphigus is characterized histologically by acantholysis, which is the loss of connections
between keratinocytes in the epidermis. This results in blister formation and is a key diagnostic feature of
this autoimmune blistering disorder.
Question 32
D) Urge incontinence (Correct Answer)
Explanation: Urge incontinence is commonly seen in elderly individuals due to age-related changes in
bladder function. It is characterized by a strong urge to urinate followed by involuntary leakage. While
other types of incontinence exist, urge incontinence tends to be the most prevalent among older adults.
Question 33
A) Xanthine oxidase (Correct Answer)
Explanation: Xanthine oxidase is an enzyme that contains molybdenum as a cofactor and plays a crucial
role in purine metabolism. Molybdenum is essential for various enzymatic reactions within the body,
including those involving sulfur-containing amino acids.
Question 34
C) Find out how much the patient knows about their condition (Correct Answer)
Explanation: The best approach to breaking bad news involves assessing the patient's understanding
before providing information. This allows healthcare providers to tailor their communication effectively
and address any misconceptions or concerns that may arise.
Question 35
C) Protruding jaw (Correct Answer)
Explanation: While obesity, acromegaly, and male gender are associated with obstructive sleep apnea, a
protruding jaw is not typically recognized as a direct association. Instead, it may contribute to anatomical
factors leading to airway obstruction but is not a primary risk factor on its own.
Question 36
A) Discharge home (Correct Answer)
Explanation: For patients with aseptic meningitis who have shown improvement after initial treatment,
discharge home with follow-up is appropriate if there are no ongoing symptoms or complications.
Continuous monitoring may be necessary but hospitalization is usually not required once stable.
Question 37
A) Rhabdomyolysis (Correct Answer)
Explanation: Rhabdomyolysis is a common cause of acute kidney injury associated with "bath salts" use
due to muscle breakdown releasing myoglobin into circulation, which can damage renal tubules. This
condition often arises from intense physical activity or drug use that leads to muscle injury.
Question 38
C) Conservative management with follow-up and repeat complete blood cell count (Correct Answer)
Explanation: For post-infectious thrombocytopenia without spontaneous bleeding, conservative
management with monitoring is typically sufficient unless bleeding occurs or platelet counts remain
critically low over time.
Question 39
A) Lymph nodes invasion (Correct Answer)
Explanation: Crohn's disease does not typically involve lymph node invasion; rather it presents with
transmural inflammation affecting any part of the gastrointestinal tract with skip lesions being
characteristic. The other options accurately describe aspects of Crohn's disease pathology.
Question 40
D) Deactivation of the AICD (Correct Answer)
Explanation: In patients with advanced heart failure experiencing frequent automatic implantable
cardioverter-defibrillator (AICD) firings, deactivation may be appropriate if these shocks are deemed
inappropriate or if quality of life considerations outweigh potential benefits from defibrillation.
Question 41
B) Tenofovir, emtricitabine, and raltegravir (Correct Answer)
Explanation: The best post-exposure prophylaxis for healthcare workers exposed to HIV-positive blood
involves a combination therapy that includes Tenofovir and Emtricitabine along with Raltegravir for
optimal efficacy against potential HIV infection.
Question 42
D) Metabolic alkalosis (Correct Answer)
Explanation: Persistent vomiting typically leads to metabolic alkalosis due to loss of gastric acid (HCl),
resulting in increased bicarbonate levels relative to carbon dioxide levels in arterial blood gas
measurements. This condition often manifests in elderly patients experiencing prolonged vomiting
episodes.
Question 43
A) Non-emergent repair of a thoracic aortic aneurysm (Correct Answer)
Explanation: Among the options listed, non-emergent repair of a thoracic aortic aneurysm poses the
greatest risk for post-surgical complications in the elderly. This is due to the complexity of the procedure
and the high incidence of comorbid conditions in older patients, which can lead to higher rates of
complications such as respiratory issues, renal failure, and even mortality. Studies have shown that age is
a significant predictor of adverse outcomes in such surgeries, making it particularly risky for elderly
patients.
Question 44
A) Ciprofloxacin given once, one hour before the procedure (Correct Answer)
Explanation: Prophylactic antibiotics, such as ciprofloxacin administered shortly before an endoscopic
retrograde cholangiopancreatography (ERCP), are recommended for patients with primary sclerosing
cholangitis to reduce the risk of infectious complications. This approach has been shown to significantly
decrease the incidence of post-procedural infections like cholangitis, which can be severe in this patient
population.
Question 45
C) Abdominal compartment syndrome (Correct Answer)
Explanation: After abdominal aneurysm repair, decreased urine output and tense, distended abdomen can
indicate abdominal compartment syndrome. This condition arises from increased intra-abdominal
pressure, which can compress vital organs and impair blood flow. It is critical to recognize and treat this
syndrome promptly to prevent further complications such as renal failure and bowel ischemia.
Question 46
C) Aortic valve replacement (Correct Answer)
Explanation: The best step in treating a patient with Heyde's syndrome, characterized by gastrointestinal
bleeding related to aortic stenosis, is aortic valve replacement. This surgical intervention addresses both
the aortic stenosis and the associated bleeding by restoring normal hemodynamics. Studies have shown
that this approach effectively reduces recurrent gastrointestinal bleeding in affected patients.
Question 47
B) Discontinue piperacillin/tazobactam and begin ciprofloxacin (Correct Answer)
Explanation: For a urinary tract infection caused by E. coli after initial broad-spectrum antibiotic
treatment with piperacillin/tazobactam, it is appropriate to switch to ciprofloxacin if there are concerns
about antibiotic resistance or treatment failure. Ciprofloxacin is often effective against E. coli strains that
may be resistant to other antibiotics, making it a suitable choice for subsequent therapy.
Question 48
A) Vegetative state (Correct Answer)
Explanation: The condition described—spontaneous eye opening and visual tracking without purposeful
movement—best fits the definition of a vegetative state. In this state, patients may exhibit wakefulness but
lack awareness or purposeful interaction with their environment. They do not respond meaningfully to
stimuli despite some preserved brainstem reflexes.
Question 49
C) Duodenum (Correct Answer)
Explanation: Inflammation of the duodenum is associated with increased maximal acid output and can
lead to decreased serum calcium and iron concentrations, resulting in microcytic anemia. Conditions like
celiac disease primarily affect the duodenum, causing malabsorption that contributes to these biochemical
abnormalities.
Question 50
B) Fastigial nucleus (Correct Answer)
Explanation: Neurons from the spinocerebellar cortical region primarily project to the fastigial nucleus
within the cerebellum. This nucleus plays an important role in regulating balance and coordinating
movements by integrating sensory information from the spinal cord.
Question 51
B) Duration of smoking (Correct Answer)
Explanation: When evaluating the ill-effects of smoking, duration of smoking is considered the most
important factor. Longer exposure increases the risk of developing various smoking-related diseases such
as lung cancer, chronic obstructive pulmonary disease (COPD), and cardiovascular diseases. While other
factors like brand or filter may have some influence, duration remains paramount.
Question 52
A) Brain (Correct Answer)
Explanation: The brain lacks glucose-6-phosphatase enzyme, which is crucial for gluconeogenesis and
glycogenolysis processes that occur in organs like the liver and kidneys. As a result, glucose cannot be
released into circulation from glycogen stores in the brain, making it dependent on continuous glucose
supply from blood.
Question 53
C) 1/250 people per lifetime (Correct Answer)
Explanation: The incidence of Bell's palsy is approximately 1/250 people per lifetime. This condition
results from unilateral facial nerve paralysis and can occur at any age but is more common in individuals
aged between 15 and 60 years. The exact cause remains unclear but is thought to be related to viral
infections.
Question 54
C) Dog is the reservoir of infection (Correct Answer)
Explanation: It is not true that dogs are reservoirs for Kala-azar (visceral leishmaniasis). The primary
reservoir hosts are rodents and humans; dogs can be infected but do not serve as significant reservoirs for
transmission in India. Kala-azar is transmitted through sandfly bites.
Question 55
A) Lysine, methionine (Correct Answer)
Explanation: Wheat protein has limiting amino acids primarily lysine and methionine. These amino acids
are essential for human nutrition but are present in lower amounts in wheat compared to other proteins
like animal-based sources or legumes.
Question 56
A) Hemolytic uremic syndrome (Correct Answer)
Explanation: Microangiopathic hemolytic anemia is commonly associated with hemolytic uremic
syndrome (HUS), which involves hemolysis due to small vessel occlusion leading to organ damage.
Vitamin B12 deficiency does not typically cause this type of anemia; thus HUS stands out as a clear
association.
Question 57
D) Anorexia nervosa (Correct Answer)
Explanation: The symptoms described—hair growth on different body sites (hirsutism), food intake
refusal, low BMI (<18), and perception of being fat—are indicative of anorexia nervosa. This eating
disorder involves severe restriction of food intake due to an intense fear of gaining weight despite being
underweight.
Question 58
B) Oral polio (Correct Answer)
Explanation: The oral polio vaccine should not be given to household contacts of immunodeficient
children because it contains live attenuated virus which could potentially cause disease in
immunocompromised individuals. Other vaccines like DPT or Hepatitis vaccines do not pose this risk.
Question 59
C) Bacterial lymphadenitis (Correct Answer)
Explanation: The presentation of fever with warm, tender, and fluctuant anterior lymph node swelling
strongly suggests bacterial lymphadenitis. While viral infections can cause lymphadenopathy, they
typically do not produce such localized tenderness or fluctuation indicative of an abscess or significant
bacterial infection.
Question 60
B) Chi-square test (Correct Answer)
Explanation: The chi-square test is appropriate for analyzing discrete variables or categorical data. It
assesses whether there are significant differences between observed frequencies in different categories
compared to expected frequencies under a null hypothesis.
Question 61
A) Renal CT scan (Correct Answer)
Explanation: In a patient with hypertension and renal artery stenosis indicated on arteriography alongside
a small left kidney on KUB imaging, a renal CT scan would be appropriate next step investigation. It
helps assess renal perfusion and any further anatomical abnormalities contributing to hypertension.
Question 62
C) Niemann-Pick disease (Correct Answer)
Explanation: Niemann-Pick disease is characterized by sphingomyelin accumulation due to
sphingomyelinase deficiency affecting organs like the spleen and liver. This lipid storage disorder leads
to various symptoms including hepatosplenomegaly due to excess sphingomyelin deposits.
Question 63
D) Malnutrition in children (Correct Answer)
Explanation: Secondary prevention strategies are least useful for malnutrition in children because
malnutrition often results from broader socioeconomic factors rather than preventable diseases where
early detection could change outcomes significantly. Addressing underlying causes often requires
comprehensive interventions beyond mere screening.
Question 64
A) Galactose (Correct Answer)
Explanation: Cerebrosides contain galactose as part of their structure; they are glycosphingolipids
composed of ceramide linked to sugar residues including galactose or glucose depending on their type.
This sugar plays an essential role in cellular recognition processes within tissues.
Question 65
D) Infidelity (Correct Answer)
Explanation: Othello syndrome refers specifically to delusions concerning infidelity or unfaithfulness in a
partner. It falls under the category of psychotic disorders where individuals may exhibit strong beliefs
without evidence supporting them; this delusion can severely impact relationships.
Question 66
A) Glutamine (Correct Answer)
Explanation: Glutamine plays a crucial role in urea synthesis as it provides nitrogen atoms necessary for
forming urea during amino acid metabolism in the liver through the urea cycle. It serves as one of the
primary amino acids involved in detoxifying ammonia produced from protein catabolism.
Question 67
C) Build a ten-brick tower (Correct Answer)
Explanation: An 18-month-old child typically cannot build a ten-brick tower due to developmental
milestones; at this age, children generally can stack only two or three blocks together confidently.
Building more complex structures requires further fine motor skill development seen at older ages.
Question 68
C) Neomycin (Correct Answer)
Explanation: Neomycin can be administered orally; it is used primarily for bowel sterilization before
surgical procedures or treating localized infections affecting the gastrointestinal tract. Other options listed
are typically given via injection due to poor oral bioavailability.
Question 69
C) Posterior column of the spinal cord (Correct Answer)
Explanation: Lesions causing paresthesias, difficulty walking, and unsteadiness with eyes closed suggest
involvement of the posterior column pathways responsible for proprioception and fine touch sensation;
damage here would lead to balance difficulties when visual input is removed.
Question 70
C) Schizophrenia (Correct Answer)
Explanation: Hallucinations and paranoia are hallmark symptoms associated with schizophrenia—a
chronic mental disorder characterized by distortions in thinking, perception, emotions, language, sense of
self, and behavior; these features significantly impair functioning and social interactions.
Question 71
B) Small cell carcinoma of lung (Correct Answer)
Explanation: Hemoptysis (coughing up blood) and stage III clubbing are significant clinical findings. In a
65-year-old patient, these symptoms raise suspicion for lung cancer, particularly small cell carcinoma,
which is known for causing paraneoplastic syndromes and can lead to clubbing. Other conditions like
tuberculosis can also cause hemoptysis, but clubbing is more closely associated with malignancies.
Question 72
B) Morphology of cells (Correct Answer)
Explanation: The Working Formulation for staging non-Hodgkin's lymphoma is based primarily on the
morphology of the lymphoma cells. It classifies lymphomas into various categories based on their
histological appearance, which helps in predicting the behavior and prognosis of the disease.
Question 73
B) Immediate memory retention and recall is normal (Correct Answer)
Explanation: Delirium is characterized by acute changes in attention and awareness, often accompanied
by disorientation and confusion. Immediate memory retention and recall are typically impaired in
delirium, making option B the correct answer as it does not align with the features of delirium.
Question 74
C) Selective serotonin reuptake inhibitors (SSRI) (Correct Answer)
Explanation: SSRIs are considered first-line treatment for anxiety disorders due to their efficacy and
favorable side effect profile. They work by increasing serotonin levels in the brain, which helps improve
mood and reduce anxiety symptoms.
Question 75
B) Daptomycin (Correct Answer)
Explanation: Daptomycin is an effective treatment for MRSA bacteremia and endocarditis, especially
when vancomycin is not suitable due to resistance or patient intolerance. It works by disrupting bacterial
cell membrane function, making it a strong alternative in treating resistant infections.
Question 76
A) Streptococcus pneumoniae (Correct Answer)
Explanation: Streptococcus pneumoniae is the most common causative agent of lobar pneumonia. It is a
gram-positive bacterium that can cause severe respiratory infections, particularly in vulnerable
populations like the elderly or immunocompromised.
Question 77
A) Schistosoma (Correct Answer)
Explanation: Schistosoma is a parasitic worm that can enter the body through exposed skin when
individuals come into contact with contaminated water. This mode of entry distinguishes it from other
listed organisms, which do not penetrate through the skin.
Question 78
D) High-density lipoprotein (HDL) (Correct Answer)
Explanation: Atherosclerosis is inversely related to HDL levels; higher HDL levels are associated with a
lower risk of developing atherosclerosis. HDL helps transport cholesterol away from arteries to the liver
for excretion, thus playing a protective role against heart disease.
Question 79
D) Catalepsy (Correct Answer)
Explanation: Catalepsy is not a symptom of narcolepsy; rather, it is a condition characterized by muscle
rigidity and lack of response to external stimuli. Narcolepsy primarily involves excessive daytime
sleepiness, cataplexy (sudden loss of muscle tone), and hypnagogic hallucinations.
Question 80
D) Combination of microfilaria and disease rate (Correct Answer)
Explanation: The 'filaria endemicity rate' represents both the presence of microfilariae in the population
and the incidence of filarial disease. This combined measure helps assess the public health impact of
filarial infections in specific regions.
Question 81
D) Topical Permethrin (Correct Answer)
Explanation: Topical Permethrin is preferred for treating scabies, especially when multiple family
members are affected. It effectively kills scabies mites and their eggs, providing relief from itching and
preventing further spread within households.
Question 82
B) Neuroleptic malignant syndrome (Correct Answer)
Explanation: Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotic medications
like haloperidol. Symptoms include fever, muscle rigidity, altered mental status, and autonomic
dysfunction, which align with the patient's presentation after medication escalation.
Question 83
B) Case-control study (Correct Answer)
Explanation: A case-control study design is best suited for investigating rare diseases as it starts with
identifying individuals with the disease (cases) and compares them to those without it (controls). This
method allows researchers to look back at exposures or risk factors that may have contributed to the
disease's development.
Question 84
A) Alzheimer's disease (Correct Answer)
Explanation: The symptoms described—progressive memory loss and difficulty managing finances—are
characteristic of Alzheimer's disease, a common form of dementia that typically affects older adults. The
gradual decline in cognitive function aligns with this diagnosis.
Question 85
B) Evening (Correct Answer)
Explanation: Administering long-term nitrates in the evening helps prevent nocturnal angina by allowing
for therapeutic effects during nighttime when angina episodes are more likely to occur due to increased
myocardial oxygen demand during sleep.
Question 86
B) Comedocarcinoma (Correct Answer)
Explanation: Comedocarcinoma is a type of ductal carcinoma in situ characterized by necrotic debris
within ducts leading to central necrosis without invasion into surrounding tissues. The biopsy findings
described fit this diagnosis well.
Question 87
A) Candida (Correct Answer)
Explanation: Candida is not considered normal flora in healthy individuals; its overgrowth can lead to
infections such as candidiasis. Other listed organisms are typically part of normal flora unless they cause
opportunistic infections under certain conditions.
Question 88
D) Associated with Kala-azar (Correct Answer)
Explanation: Leishman-Donovan bodies are associated with Kala-azar, also known as visceral
leishmaniasis. These bodies represent amastigotes found within macrophages during infection caused by
Leishmania species.
Question 89
B) Translation (Correct Answer)
Explanation: The Shine-Dalgarno sequence is involved in translation as it helps ribosomes recognize the
start codon on mRNA by base-pairing with complementary sequences on ribosomal RNA. This
interaction facilitates proper initiation of protein synthesis in prokaryotes.
Question 90
A) Enolase (Correct Answer)
Explanation: Fluoride ions inhibit enolase, an enzyme involved in glycolysis. This inhibition disrupts
energy production in cells and has implications for both dental health and metabolic processes.
Question 91
A) Lung fluke (Correct Answer)
Explanation: Paragonimus westermani is commonly known as the lung fluke because it primarily infects
the lungs after being ingested through contaminated food sources or water containing its larvae.
Question 92
C) Warfarin plus Enoxaparin (Correct Answer)
Explanation: For treating upper extremity deep vein thrombosis (DVT), initiating therapy with both
Warfarin and Enoxaparin ensures rapid anticoagulation while Warfarin takes time to reach therapeutic
levels through its anticoagulant effects.
Question 93
A) Reduced need for renal replacement therapy (Correct Answer)
Explanation: Increasing mean arterial pressure (MAP) from 65 mmHg to 75 mmHg improves renal
perfusion during septic shock, potentially reducing the need for renal replacement therapy due to better
kidney function under improved hemodynamics.
Question 94
B) Septal lines (Correct Answer)
Explanation: Septal lines are characteristic radiological features seen in miliary tuberculosis due to
widespread dissemination of small lesions throughout the lungs, often presenting as tiny nodules on
imaging studies.
Question 95
C) Loss of sensory and motor functions of upper and lower limbs (Correct Answer)
Explanation: Damage to one side of the spinal cord results in Brown-Séquard syndrome, characterized by
ipsilateral motor loss due to corticospinal tract damage and contralateral loss of pain and temperature
sensation due to damage to spinothalamic pathways.
Question 96
D) Bartonella henselae (Correct Answer)
Explanation: Bartonella henselae is commonly associated with cat scratch fever, which can present with
lymphadenopathy such as enlarged axillary lymph nodes following exposure or scratch from an infected
cat.
Question 97
C) LDH isozymes are composed of different subunit combinations, some specific for heart and released
with myocardial damage (Correct Answer)
Explanation: Lactate dehydrogenase exists in several isoforms that can be released into circulation during
myocardial infarction due to tissue damage. Elevated LDH levels can indicate myocardial injury among
other conditions.
Question 98
D) Endocardial fibroelastosis (Correct Answer)
Explanation: Endocardial fibroelastosis typically presents in infants with cardiac enlargement due to
abnormal fibrous tissue growth within heart chambers leading to heart failure symptoms like feeding
difficulties and failure to thrive.
Question 99
B) Recurrences are common in subsequent pregnancies (Correct Answer)
Explanation: Postpartum psychosis has a high recurrence risk in future pregnancies; women who
experience this condition should be monitored closely during subsequent pregnancies due to potential
reoccurrence of symptoms.
Question 100
C) Acute asthma attack (Correct Answer)
Explanation: The presentation of wheezing, shortness of breath, and edema in a postpartum patient with
poorly controlled asthma suggests an acute exacerbation of asthma rather than other potential diagnoses
like angioedema or pulmonary embolism.
Conclusion
As you approach the end of your preparation for the USMLE Step 2 CK, it is essential to reflect on the
journey you have undertaken. This chapter serves as a conclusion to your studies, offering insights from
those who have successfully navigated this challenging process, practical mnemonic techniques for last-
minute review, and words of encouragement to help you on exam day. The experiences shared by recent
test-takers can provide motivation and reassurance that success is achievable. Their stories highlight the
diverse paths individuals take to prepare for the exam and the strategies that work best for them.
In addition to success stories, practical mnemonic techniques can be invaluable as you enter the final
stretch of your preparation. These memory aids can help reinforce key concepts and facilitate quick recall
during the exam. The mnemonics provided will be tailored specifically for both Step 2 CK and Step 3,
ensuring that you have targeted tools at your disposal.
Finally, as exam day approaches, it is natural to feel a mix of excitement and anxiety. This chapter will
provide motivational words to bolster your confidence and remind you of your capabilities. Emphasizing
the importance of self-belief and resilience, these messages will serve as a source of strength as you step
into the testing center.
By synthesizing these elements—success stories, mnemonic techniques, and motivational messages—you
will be well-equipped to tackle the USMLE Step 2 CK with confidence and clarity.

Success stories and anecdotes from recent test-takers

Many individuals have faced the challenges of preparing for the USMLE and emerged victorious, each
with their own unique story. These success stories serve not only as inspiration but also as valuable
lessons learned through personal experiences.
One test-taker recalls his journey beginning in medical school, where he struggled with balancing
coursework and clinical rotations while preparing for exams. He found that creating a structured study
schedule was essential. By allocating specific times each week for dedicated study sessions focused on
high-yield topics, he was able to manage his time effectively. He emphasized the importance of utilizing
practice questions regularly to gauge his understanding and identify weak areas. This approach allowed
him to build confidence leading up to the exam.
Another candidates shared how they overcame test anxiety by implementing mindfulness techniques into
their routine. They practiced deep breathing exercises before study sessions and visualized themselves
succeeding during practice exams. On exam day, they used these techniques to remain calm and focused,
which ultimately contributed to their success.
A third individual highlighted the value of study groups in their preparation. They found that discussing
challenging topics with peers not only reinforced their understanding but also provided different
perspectives on complex subjects. This collaborative learning environment fostered a sense of
accountability and motivation among group members.
Several test-takers also reported the importance of self-care during their preparation period. They made it
a priority to engage in physical activity, maintain a balanced diet, and ensure adequate sleep. By taking
care of their physical health, they felt more energized and mentally sharp when studying.
Lastly, many candidates emphasized the significance of believing in oneself throughout the preparation
process. They shared how positive affirmations helped them combat self-doubt and maintain a growth
mindset. Reminding themselves that they had put in the effort and were capable of success was a common
theme among these stories.
These anecdotes illustrate that while each individual's path may differ, there are common strategies that
can lead to success on the USMLE. By learning from these experiences and applying similar principles in
your own preparation, you can enhance your chances of achieving your desired outcome.

Practical mnemonic techniques for last-minute review

Mnemonic Techniques for Step 2 CK

1. Cardiology:
"MONA": Management for acute coronary syndrome – Morphine, Oxygen,
Nitroglycerin, Aspirin.
"ABCDE": Approach to heart failure – A (ACE inhibitors), B (Beta-blockers),
C (Cardiac output), D (Diuretics), E (Education).
2. Pulmonology:
"COPD": Management steps – C (Corticosteroids), O (Oxygen therapy), P
(Pulmonary rehabilitation), D (Drugs - bronchodilators).
"ASTHMA": Management – A (Assess severity), S (SABA - short-acting beta-
agonist), T (Treat with corticosteroids), H (Hospitalize if needed), M (Monitor
response), A (Avoid triggers).
3. Gastroenterology:
"ABCDE": Approach to liver disease – A (Ascites), B (Bleeding varices), C
(Cirrhosis), D (Drug-induced liver injury), E (Encephalopathy).
"PUD": Causes of peptic ulcer disease – P (Peptic ulcer disease), U (Use of
NSAIDs), D (Duodenal ulcers).
4. Endocrinology:
"T4 vs TSH": Remember T4 is produced by thyroid; TSH stimulates thyroid
function.
"Dawn Phenomenon": Increased morning blood sugar levels due to increased
insulin resistance overnight.
5. Nephrology:
"RIFLE": Classification for acute kidney injury – R (Risk), I (Injury), F
(Failure), L (Loss), E (End-stage renal disease).
"A WET BED": Symptoms of nephrotic syndrome – A (Albuminuria), W
(Weight gain due to edema), E (Edema), T (Thromboembolism risk), B (Blood
pressure changes), E (Elevated lipids), D (Diminished protein).
6. Hematology/Oncology:
"CAUTION": Warning signs of cancer – C (Change in bowel/bladder habits),
A (A sore that does not heal), U (Unusual bleeding/discharge), T
(Thickening/lump in breast or elsewhere), I (Indigestion or difficulty
swallowing), O (Obvious change in wart/mole), N (Nagging cough or
hoarseness).
“ABCDE”: Skin cancer assessment – A (Asymmetry), B (Border irregularity),
C (Color variation), D (Diameter >6mm), E (Evolving).
7. Infectious Diseases:
“SIRS”: Criteria for sepsis – Systolic BP <90 mmHg or MAP <65 mmHg;
Increased heart rate; Increased respiratory rate; Abnormal temperature.
“Fever Patterns”: Remember "FUO" – Fever of Unknown Origin often requires
thorough investigation including infections, malignancies, or autoimmune
diseases.
8. Psychiatry:
“SIGECAPS”: Symptoms of depression – S(leep changes), I(nterest
loss/anhedonia), G(uilt/worthlessness), E(nergy loss/fatigue), C(oncentration
difficulties), A(petite changes/weight loss/gain), P(yschomotor
agitation/retardation), S(uicidal ideation).
“CAGE”: Screening tool for alcohol use disorder – C(ut down on drinking?),
A(nnoyed by criticism?), G(uilty about drinking?), E(ye-opener needed?).
9. Pediatrics:
“APGAR”: Assessment at birth – A(ppearance/color); P(ulse/heart rate);
G(rimace/reflexes); A(ctivity/muscle tone); R(eactivity/breathing effort).
“FACES”: Pain scale for children – Use faces ranging from happy to sad to
assess pain levels in younger patients.
10. General Medicine:
“ABCDE”: General assessment approach – A(irway management);
B(reathing); C(irculation); D(isability assessment); E(xposure/environmental
control).
Mnemonic Techniques for Step 3

1. Cardiology:
Use "MONA" again but emphasize its application in acute coronary syndrome
management.
2. Pulmonology:
Adapt "ABCDE" for heart failure management focusing on chronic management
strategies rather than acute interventions.
3. Gastroenterology:
Focus on "ABCDE" for liver disease with an emphasis on long-term
management strategies rather than just acute presentations.
4. Endocrinology:
Reinforce "Dawn Phenomenon," emphasizing lifestyle modifications alongside
pharmacotherapy options available.
5. Nephrology:
Highlight "RIFLE," focusing on prevention strategies for acute kidney injury in
high-risk patients rather than just classification.
6. Hematology/Oncology:
Use “CAUTION” again but emphasize follow-up protocols after initial
diagnosis based on warning signs observed.
7. Infectious Diseases:
Reinforce “SIRS” criteria but focus on treatment algorithms based on severity
assessment rather than just identification.
8. Psychiatry:
Use “SIGECAPS” again but discuss treatment options available once diagnosis
is established focusing on psychotherapy alongside pharmacotherapy.
9. Pediatrics:
Emphasize “APGAR” but discuss long-term developmental milestones
following initial assessment at birth.
10. General Medicine:
Reinforce “ABCDE” approach but focus on its application across various
medical emergencies encountered during clinical practice.
By utilizing these mnemonics effectively during your last-minute review sessions leading up to exams, you
can enhance your retention of critical information while reinforcing your clinical reasoning skills
necessary for both Step 2 CK and Step 3 exams.

Words of encouragement and motivation for exam day

As you prepare for exam day, it's natural to feel a mix of excitement and anxiety about what lies ahead.
Remember that this is a culmination of all your hard work, dedication, and commitment throughout
medical school and beyond. You have put in countless hours studying complex material, honing your
clinical skills, and preparing yourself for this momentous occasion.
Take a moment to reflect on how far you've come in your journey as a medical professional. Each
challenge you've faced has contributed to your growth and resilience as a future physician. Trust in
yourself; you've prepared thoroughly using all available resources—review books, practice questions,
study groups—everything has led you here today.
On exam day, approach each question with confidence in your knowledge base and clinical reasoning
abilities. Remember that it's okay not to know everything; focus instead on what you've learned and apply
that knowledge thoughtfully to each scenario presented before you.
If anxiety begins to creep in during the exam, take deep breaths and remind yourself that feeling nervous is
perfectly normal—it means you care about doing well! Use relaxation techniques you've practiced leading
up to this moment—whether it's visualization or grounding exercises—to bring yourself back into focus if
needed.
Stay positive throughout this process; visualize yourself successfully completing each section with clarity
and calmness as you tackle each question one at a time without rushing through them unnecessarily—
quality over quantity always matters!
Remember that this exam does not define who you are as a physician or what kind of doctor you will
become—it’s simply one step along an incredible journey filled with opportunities ahead!
After completing each section successfully take pride knowing you’ve done everything possible leading
up until now—allow yourself moments of gratitude amidst any stressors present during this time!
Regardless of outcomes achieved today remember there’s always room for growth moving forward—
embrace every experience along this path towards becoming an exceptional healthcare provider
dedicated towards improving lives!
As you step into the testing center today carry with you all those who have supported you along this
journey—family members friends mentors—and let their encouragement propel you forward! You are
ready; believe in yourself!

Bonus
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