Internal Medicine42 questions
Q3Internal MedicineHypoglycemia workup, Whipple triad
A non-diabetic woman has recurrent episodes of confusion and diaphoresis with documented low glucose that resolve with dextrose. Examination and routine labs are unremarkable. The study most likely to establish the diagnosis is
Amorning and evening cortisol levels
Adrenal insufficiency is tested with 8 AM cortisol plus cosyntropin stimulation, and she lacks hyperpigmentation, hypotension, and electrolyte abnormalities.
Berythrocyte sedimentation rate
A nonspecific inflammatory marker with no role.
Cserum glucagon level
Glucagon deficiency is vanishingly rare and its level is not part of the workup.
Dhemoglobin A1c
A1c averages months of glycemia and cannot characterize episodic hypoglycemia.
Einsulin levels during a 72-hour fast Correct
Whipple triad with recurrent hypoglycemia gets a supervised 72-hour fast with simultaneous glucose, insulin, C-peptide, proinsulin, and sulfonylurea screen; inappropriately elevated insulin at glucose below 55 confirms hyperinsulinemic hypoglycemia (insulinoma if C-peptide is high, exogenous insulin if suppressed).
Einsulin levels during a 72-hour fast
Test point: Whipple triad → supervised 72-hour fast; C-peptide separates insulinoma from exogenous insulin.
Q10Internal MedicineCentral lung mass, tissue diagnosis
A 65-year-old smoker with hemoptysis has a 5-cm right hilar mass on imaging. The most appropriate next step to establish the diagnosis is
Abronchoscopy Correct
A CENTRAL hilar mass is airway-accessible: flexible bronchoscopy provides direct visualization, biopsy, washings, and EBUS nodal sampling in one sitting.
BCT-guided needle biopsy
CT-guided needle is for PERIPHERAL lesions; crossing lung to reach a hilar mass risks pneumothorax and hilar vessels.
CMRI of the chest
Chest MRI is reserved for Pancoast tumors, chest wall or vertebral invasion; it yields no tissue.
DPET scan
PET is a STAGING study after histologic diagnosis, and inflammatory lesions are FDG-avid too.
Ethoracotomy with resection
Resection is treatment; no one operates without tissue diagnosis and staging, and a 5-cm hilar mass may be unresectable small cell.
Abronchoscopy
Test point: Central lesion → bronchoscopy. Peripheral lesion → CT-guided needle. Tissue always precedes PET and surgery.
Q16Internal MedicineSTEMI lead-to-vessel localization
A man develops crushing chest pain while shoveling snow, with nausea and diaphoresis. ECG shows ST elevation in V2 through V4. Coronary angiography will most likely reveal stenosis of the
Aleft anterior descending artery Correct
V2-V4 is the anteroseptal/anterior territory: the LAD.
Bleft circumflex artery
LCx produces lateral changes in V5-V6, I, aVL.
Cleft main coronary artery
Left main shows diffuse ST depression with aVR elevation and usually cardiogenic shock.
Dposterior descending artery
The PDA supplies inferior and posterior walls: II, III, aVF, or tall R waves with ST depression in V1-V3.
Eright coronary artery
RCA is the inferior MI vessel (II, III, aVF); inferior STEMIs also mandate a right-sided ECG for RV infarct.
Aleft anterior descending artery
Test point: V1-V4 LAD; V5-V6/I/aVL LCx; II-III-aVF RCA; V4R proximal RCA (no nitrates); aVR + diffuse depression left main.
Q23Internal MedicineAcute variceal hemorrhage
A cirrhotic man with ascites, spider angiomata, and caput medusae presents vomiting blood: BP 90/50, pulse 110, obtunded. The most appropriate pharmacologic agent is
Afamotidine
Acid suppression does nothing for portal pressure.
Blosartan
Lowers systemic pressure in a patient already shocked.
Coctreotide Correct
Octreotide causes splanchnic vasoconstriction, lowering portal inflow and variceal pressure while endoscopic banding is arranged. The full bundle: airway, restrictive transfusion (Hgb 7), CEFTRIAXONE prophylaxis, EGD within 12 hours, TIPS if refractory.
Domeprazole
Same; a PPI has never shown mortality benefit in variceal bleeding.
Epropranolol
The trap: nonselective beta blockers are prophylaxis only and are contraindicated DURING the bleed; blunting compensatory tachycardia in hemorrhagic shock is dangerous.
Coctreotide
Test point: Octreotide now, ceftriaxone always, band within 12 hours; propranolol only after the acute episode.
Q24Internal MedicineBehcet disease, initial therapy
A young man has 3 months of recurrent painful oral ulcers, an erythematous eye with cell and flare, non-erosive ankle arthritis, papular skin lesions, and weight loss. The most appropriate initial therapy is
Aazathioprine
A real part of the regimen but as the steroid-sparing maintenance drug; onset takes weeks and cannot control acute uveitis.
Bchlorambucil
An alkylating agent for severe refractory disease only, never initial.
Chydroxychloroquine
Lupus and RA drug with no established Behcet role.
Dprednisone Correct
Behcet disease with anterior uveitis is sight-threatening and demands prompt systemic corticosteroids for rapid control across eye, mucosa, and joints; that is the INITIAL agent.
Esulfasalazine
Addresses only peripheral arthritis.
Dprednisone
Test point: PAINFUL oral ulcers = Behcet; reactive arthritis's ulcers are painless. Ocular involvement = systemic steroids first.
Q25Internal MedicineVancomycin flushing reaction
An 82-year-old receiving vancomycin for MRSA pneumonia (culture sensitive only to vancomycin) develops flushing and pruritus of the face and torso mid-infusion. Vitals are unchanged; no wheeze, stridor, or urticaria. The most appropriate management is to
Aadminister epinephrine
No anaphylaxis criteria: normal pressure, no respiratory compromise, no urticaria; epinephrine in an 82-year-old risks ischemia.
Bswitch to imipenem
Carbapenems have no reliable MRSA activity: the culture says so.
Cswitch to oral vancomycin
Oral vancomycin is unabsorbed: that is why it treats C. difficile and cannot treat pneumonia.
Dinfuse the next dose of vancomycin over at least 1 hour Correct
Vancomycin flushing reaction is direct, non-IgE mast cell degranulation (MRGPRX2) from rapid infusion: slow to at least 60 minutes, pretreat with an antihistamine, and continue the drug.
Estop vancomycin and document an allergy
The consequential error: mislabeling an infusion-rate reaction as allergy strips her of the only active agent, now and forever.
Dinfuse the next dose of vancomycin over at least 1 hour
Test point: Flushing + normal vitals = rate reaction: slow it. Hypotension/airway/hives = anaphylaxis: IM epinephrine and stop the drug.
Q31Internal MedicineDrug-induced bradycardic syncope
A 78-year-old diabetic woman syncopizes on standing from a crouch, recovering fully in 30 seconds. Heart rate is 40. An antihypertensive was started 2 weeks ago. The most likely culprit is
Aamlodipine
A dihydropyridine causes vasodilation with REFLEX tachycardia, plus edema and flushing, never a rate of 40.
Batenolol Correct
Only a beta blocker explains the bradycardia: it slows the sinus node AND disables the compensatory tachycardia that should accompany standing. Atenolol is renally cleared and accumulates in an elderly diabetic.
Cfurosemide
Volume depletion from a loop diuretic produces compensatory TACHYCARDIA.
Dhydrochlorothiazide
Same directionality problem as furosemide.
Elisinopril
ACE inhibitors cause hypotension without chronotropic effect.
Batenolol
Test point: Hypotensive AND inappropriately bradycardic = rate-limiting drug (beta blocker, non-DHP CCB, digoxin, clonidine). Tachycardic = volume or vasodilation.
Q34Internal MedicineACE inhibitor angioedema
A woman on lisinopril for 5 years presents with tongue and lip swelling without urticaria or pruritus. In addition to admission for airway monitoring, the most appropriate step is to
Adiscontinue hydrochlorothiazide
HCTZ causes photosensitivity and electrolyte derangements, not angioedema.
Bdiscontinue the lisinopril Correct
Bradykinin-mediated angioedema from ACE inhibition is NOT dose- or time-dependent: it can appear after a decade. The drug is stopped permanently, class-wide.
Cdiscontinue metoprolol started last month
The recency trap: metoprolol was started a month ago but beta blockers do not cause angioedema.
Dsend a C1 esterase inhibitor level
Hereditary angioedema presents young with recurrent episodes and family history, not a first event at 65 with an obvious drug cause.
Esend a serum IgE level
The reaction is bradykinin-mediated, not IgE: exactly why antihistamines and epinephrine work poorly.
Bdiscontinue the lisinopril
Test point: ACEi angioedema: any time-point, no hives, airway first, stop the class forever. Black patients at 3-5x risk.
Q36Internal MedicineMyxedema coma
A woman on an antidepressant is brought in comatose: temperature 34.4 C, pulse 52, respirations 10, periorbital and hand non-pitting edema, delayed relaxation of deep tendon reflexes, bilateral basilar dullness. After appropriate treatment, the diagnosis is confirmed by
Ablood cultures
Infection is the common precipitant, but cultures find the trigger, not the diagnosis.
Bcreatine kinase
CK is elevated in hypothyroid myopathy but nonspecific.
CCT of the head
The exam localizes the coma to the thyroid; imaging is normal.
Delectrocardiography
Sinus bradycardia and low voltage are suggestive, not confirmatory.
Efree thyroxine level Correct
Hypothermia, bradycardia, hypoventilation, myxedema, and hung-up reflexes are myxedema coma; low free T4 (with high TSH) confirms. 'After appropriate treatment' is the point: treat empirically, hydrocortisone BEFORE levothyroxine, never wait on labs.
Efree thyroxine level
Test point: Opposite-direction vitals kill the serotonin syndrome/NMS distractors: she is cold, slow, and hyporeflexic.
Q39Internal MedicineAcute PE, stable
One week after knee surgery a man develops sudden dyspnea and pleuritic pain, with left calf swelling. BP 145/85, pulse 118, saturation 91 percent. D-dimer is elevated. The most appropriate immediate treatment is
Aclopidogrel
Antiplatelet agents treat platelet-rich ARTERIAL clots; venous thrombi are fibrin-rich and need anticoagulation.
Beptifibatide
Same class error as clopidogrel.
Cheparin Correct
Hemodynamically stable PE gets immediate anticoagulation: heparin acts instantly, is titratable and reversible. It halts propagation while endogenous fibrinolysis clears the clot.
Dstreptokinase
Thrombolysis is for MASSIVE PE (SBP under 90); he is 145/85, and one week post-op is a bleeding contraindication.
Ewarfarin
Warfarin needs 5-7 days and transiently INCREASES coagulability (protein C/S fall first); it is never started alone.
Cheparin
Test point: Arterial clot → antiplatelet. Venous clot → anticoagulant. Lysis only for shock, and always WITH heparin, not instead.
Q40Internal MedicineOutpatient CAP with penicillin allergy
A healthy 29-year-old man with penicillin allergy has three weeks of cough after an upper respiratory prodrome, myalgia, and a right lower lobe opacity. T2-T6 paravertebral tender points are noted. The most appropriate outpatient treatment is a
Aaminoglycoside
Poor lung penetration, parenteral, nephro- and ototoxic: never outpatient CAP.
Brespiratory fluoroquinolone
Would work, but guidelines reserve fluoroquinolones for comorbidity, recent antibiotics, or high macrolide resistance: correct treatment, not MOST appropriate.
Cmacrolide Correct
Healthy outpatient + penicillin allergy = macrolide (or doxycycline): it covers pneumococcus AND atypicals, which is why one drug suffices empirically. The allergy removes amoxicillin, the otherwise-first-line choice.
Dneuraminidase inhibitor
Oseltamivir needs symptom onset within 48 hours; he is three weeks in with a bacterial opacity.
Ethird-generation cephalosporin
Cross-reactivity is low but it is unnecessary, largely parenteral, and a ward regimen.
Cmacrolide
Test point: Macrolides cover typicals AND atypicals; amoxicillin covers typicals only, so the allergy moves you BROADER. T2-T7 is the pulmonary viscerosomatic level.
Q42Internal MedicineMitral stenosis, chamber load
A woman with 20 years of mitral stenosis undergoes preoperative ECG. The most likely finding is
Abifascicular block
Conduction system disease, typically ischemic or infiltrative.
Bfirst-degree heart block
AV nodal delay is unrelated to MS.
Cleft atrial enlargement Correct
MS obstructs LA-to-LV flow, so pressure loads the LEFT ATRIUM: P mitrale (broad notched P in II, deep terminal negativity in V1). The dilated LA is also the substrate for atrial fibrillation and stroke.
Dleft ventricular hypertrophy
The trap: the LV is PROTECTED in MS, underfilled and often small. LVH belongs to mitral regurgitation and aortic stenosis.
Eright bundle-branch block
Advanced MS produces RVH via pulmonary hypertension, which is not RBBB.
Cleft atrial enlargement
Test point: Chamber logic: MS loads LA (LV spared); MR loads LA+LV; AS pressure-loads LV; AR volume-loads LV.
Q52Internal MedicineVasovagal syncope
A 32-year-old man about to present to investors feels warmth, diaphoresis, and light-headedness, then loses consciousness for 10 seconds with immediate full recovery. Exam and vitals are normal. The most likely diagnosis is
Acardiac arrhythmia
The dangerous alternative reads oppositely: sudden, exertional or supine, no prodrome, injury, family history of sudden death.
Bgeneralized seizure
A seizure leaves a postictal state of minutes to hours; he was instantly alert.
Corthostatic hypotension
Requires a postural trigger; he was already standing and the trigger was emotional.
Dpanic disorder
Panic causes presyncope via hyperventilation; true LOC is not a feature.
Evasovagal response Correct
Emotional trigger + autonomic prodrome + brief LOC with instant recovery is neurocardiogenic syncope. The prodrome is the sympathetic surge (cholinergic sweat glands); the faint is the Bezold-Jarisch vagal phase.
Evasovagal response
Test point: Prodrome is the single best discriminator in syncope. Everyone still gets an ECG.
Q57Internal MedicinePrerenal azotemia
A man with uncontrolled diabetes has polyuria, a 9-kg weight loss, dry mucous membranes, and tachycardia. BUN is 88, creatinine 3.1; serum acetone is negative. The most appropriate management is
Aa 2-gram sodium diet
He is volume DEPLETED; sodium restriction is counterproductive.
Bdietary protein restriction
A CKD-progression intervention aimed at a number, in a man who just lost 9 kg.
Ccalcium supplementation
CKD mineral-bone therapy, irrelevant acutely.
Dintravenous crystalloid hydration Correct
BUN/Cr of 28 with volume-depletion signs is prerenal azotemia from osmotic diuresis: volume repletion is both treatment and diagnostic test, fully reversible before ATN sets in. Hold metformin, ACEi, NSAIDs.
Evitamin D supplementation
Same.
Dintravenous crystalloid hydration
Test point: Prerenal: BUN/Cr >20, FENa <1 percent, urine osm >500, bland sediment. ATN: 10-15:1, FENa >2 percent, muddy brown casts.
Q63Internal MedicineImmune thrombocytopenic purpura
A young woman with easy bruising and menorrhagia after a viral illness has platelets of 45,000 with normal hemoglobin, leukocytes, coagulation studies, and examination. The most likely diagnosis is
Afactor VII deficiency
Factor deficiency prolongs PT and bleeds deep (joints, muscles), not mucocutaneous.
BIgA vasculitis
HSP is pediatric palpable purpura with NORMAL platelets.
Cidiopathic (immune) thrombocytopenic purpura Correct
ISOLATED thrombocytopenia with everything else normal in a young woman after a viral illness is ITP: antiplatelet antibodies, splenic clearance. Observe above 30k; steroids or IVIG below or with bleeding.
Dthrombotic thrombocytopenic purpura
TTP demands the rest of the pentad: MAHA with schistocytes, fever, renal, neuro. Her normal hemoglobin excludes it: and TTP needs plasma exchange, never platelets.
Evon Willebrand disease
vWD bleeds with a NORMAL platelet count: the defect is adhesion, lifelong, not two months.
Cidiopathic (immune) thrombocytopenic purpura
Test point: Mucocutaneous bleeding = platelet problem; deep bleeding = factor problem. Isolated low platelets = ITP.
Q65Internal MedicinePresbyopia
A 45-year-old hypertensive man reports progressive difficulty reading the newspaper, holding it at arm's length. No eye pain, scotomas, or field loss; no diabetes. The most likely mechanism is
Adiabetic retinopathy
He has no diabetes.
Bdiminished tear production
Dry eye blurs intermittently with burning and clears on blinking; it is not a progressive near-vision deficit.
Copen-angle glaucoma
Glaucoma takes PERIPHERAL fields first and is asymptomatic centrally until late.
Dloss of accommodation Correct
Presbyopia: the stiffening lens and weakening ciliary muscle (parasympathetic, CN III) can no longer focus near, classically symptomatic in the mid-40s.
Eexudative macular degeneration
AMD destroys CENTRAL vision with scotomas and metamorphopsia, denied here, and belongs to older patients.
Dloss of accommodation
Test point: 40s + reading trouble + clean negatives = presbyopia. Anticholinergics mimic it in younger patients.
Q74Internal MedicinePE with HIT history
A 180-kg woman develops dyspnea and tachycardia midway through a 6-hour car ride. Chest radiograph is normal; CT angiography shows filling defects in right pulmonary arterial branches. She reports an unexplained reaction to heparin 15 years ago. The most likely diagnosis is
Aaortic dissection
Dissection is tearing pain with pressure differentials and an intimal flap; she denies chest pain.
Bpneumothorax
Would show a pleural line on the plain film.
Cpulmonary edema
Would show congestion on radiograph with rales.
Dpulmonary embolism Correct
Immobility + obesity + isolated dyspnea/tachycardia + normal film + arterial filling defects = PE. The heparin 'allergy' flags possible HIT: anticoagulate with argatroban, fondaparinux, or a DOAC, never any heparin.
Esubsegmental atelectasis
A common incidental finding that does not explain acute symptoms.
Dpulmonary embolism
Test point: PE classic: dyspnea + tachycardia + normal CXR. Prior heparin reaction = HIT until proven otherwise: all heparins contraindicated.
Q75Internal MedicineHerpes zoster ophthalmicus
A man has 2 days of burning left forehead pain followed by a vesicular rash of the forehead, upper eyelid, and tip of the nose. The most appropriate next step is
Aoral cephalexin
A dermatomal vesicular eruption with neuropathic prodrome is viral, not cellulitis.
BCT of the head
No neurologic indication, and imaging cannot see the cornea.
Cophthalmologic consultation Correct
V1 zoster with Hutchinson sign (nasociliary branch supplies nose tip AND globe) predicts ocular involvement: urgent slit-lamp exam plus high-dose oral antivirals within 72 hours. Keratitis, uveitis, and retinal necrosis threaten sight.
Dreassurance and follow-up
Wastes the antiviral window on a sight-threatening condition.
Etopical corticosteroids
Dangerous: topical steroids on active herpetic keratitis can melt the cornea; ophthalmology alone prescribes them.
Cophthalmologic consultation
Test point: Hutchinson sign = nose tip vesicles = eye at risk. Ramsay Hunt is the geniculate cousin (ear canal + facial palsy).
Q81Internal MedicineGERD failing medical therapy
A man with more than a year of reflux symptoms on a proton pump inhibitor develops melena. Endoscopy shows esophageal ulcerations and a sliding hiatal hernia, with no gastric or pyloric ulcer. The most appropriate management is
Asupine bed rest after meals
Backwards: lying flat worsens reflux; elevate the head of the bed and avoid late meals.
Bfundoplication Correct
PPI-refractory GERD with a complication (bleeding ulcerative esophagitis) and a hiatal hernia: acid suppression cannot fix the incompetent barrier; Nissen fundoplication restores it and repairs the hiatus.
Ccontinued observation
There is active bleeding; nothing to observe toward.
Dtetracycline for Helicobacter pylori
The EGD showed no gastric/pyloric ulcer, H. pylori does not cause reflux esophagitis, and tetracycline is never monotherapy for it.
Esucralfate
A weak adjunct beneath a failing PPI, with no effect on anatomy.
Bfundoplication
Test point: Surgery indications in GERD: failed/intolerant medical therapy, complications (bleeding, stricture, Barrett), large hiatal hernia. Post-op: dysphagia, gas-bloat.
Q82Internal MedicineCMV retinitis
A man with HIV on zidovudine monotherapy has progressive painless visual loss. Funduscopy shows white opaque retinal patches with hemorrhage along the vessels. The most likely diagnosis is
ACandida retinitis
Candida gives fluffy chorioretinal fluff with 'string of pearls' vitreous extension in candidemia (lines, TPN, IVDU).
Bherpes (acute retinal necrosis) retinitis
ARN is painful, rapidly progressive peripheral necrosis with prominent vitritis, often in the immunocompetent.
CToxoplasma retinitis
Toxo is a focal 'headlight in the fog': dense vitritis over the lesion, often beside an old scar: the vitritis separates it.
Dcytomegalovirus retinitis Correct
'Pizza pie' hemorrhagic necrosis with minimal vitritis in advanced HIV (obsolete monotherapy = effectively untreated, CD4 under 50) is CMV retinitis: valganciclovir plus modern ART; watch for IRIS and retinal detachment.
Esarcoid uveitis
Granulomatous uveitis with mutton-fat KPs and systemic findings, not hemorrhagic necrosis.
Dcytomegalovirus retinitis
Test point: CMV = hemorrhage + necrosis + QUIET vitreous (no CD4s to inflame). Toxo = headlight in fog. CD4 <50 diseases: CMV, MAC.
Q84Internal MedicineCHF: preload reduction
A man with orthopnea, bibasilar rales, pitting edema, and an S3 gallop is treated. The immediate physiologic goal of therapy is
Adecreasing cardiac output
His fatigue reflects INADEQUATE output; the goal is to raise it via afterload reduction.
Bdecreasing coronary blood flow
Nothing in heart failure care aims to reduce perfusion.
Cdecreasing left ventricular filling pressure Correct
Congestive symptoms are elevated LVEDP transmitted back into the lungs; loop diuretics, nitrates, and salt restriction lower preload and relieve them. (Mortality comes separately from the ARNI/BB/MRA/SGLT2i pillars.)
Dincreasing myocardial oxygen consumption
Beta blockade helps precisely by REDUCING oxygen demand.
Eincreasing peripheral vascular resistance
Raising afterload increases the impedance the failing ventricle faces.
Cdecreasing left ventricular filling pressure
Test point: Preload down = symptom relief; afterload down + neurohormonal blockade = survival. Diuretics never extend life.
Q86Internal MedicineHepatitis A transmission
A daycare worker develops fever, anorexia, and jaundice; two coworkers are similarly ill. The most likely mode of acquisition is
Acontact with infected blood
Blood routes belong to hepatitis B and C, which do not cluster acutely in a daycare.
Bcontact with infected saliva
Saliva suggests EBV, which causes pharyngitis and splenomegaly, not frank jaundice clusters.
Ceating undercooked ground beef
Undercooked beef is E. coli O157:H7: bloody diarrhea and HUS. (HAV food outbreaks ride shellfish and produce.)
Dinhalation of aerosolized droplets
No hepatitis virus is airborne.
Epoor handwashing Correct
A jaundice cluster among daycare coworkers is hepatitis A: fecal-oral spread from diapered, often asymptomatic children; shedding peaks in the prodrome before anyone looks ill. PEP: vaccine within 14 days; reportable.
Epoor handwashing
Test point: The vowels hit the bowels: A and E are fecal-oral. HAV never becomes chronic.
Q88Internal MedicineHypothyroid dyslipidemia
A woman with fatigue, BMI 30, a diffuse goiter, delayed relaxation of the Achilles reflexes, xanthelasma, LDL 180, triglycerides 150, and TSH 10 should first be treated with
A17-beta estradiol
Estrogen is not a lipid drug and raises triglycerides and clot risk.
Bgemfibrozil
Fibrates are for triglycerides over ~500; hers are 150.
Clevothyroxine Correct
Her dyslipidemia is SECONDARY to hypothyroidism: thyroid hormone upregulates hepatic LDL receptors, so correcting TSH 10 (with goiter and symptoms, treatment-indicated on its own) often normalizes the lipids. Statins in myxedematous muscle also multiply myopathy risk.
Dniacin
No outcome benefit added to modern therapy; flushing and hyperglycemia.
Esimvastatin
Treats the downstream number while leaving the cause, and adds rhabdomyolysis risk now.
Clevothyroxine
Test point: Screen secondary causes before statins: hypothyroidism, nephrotic syndrome, cholestasis, diabetes, drugs. Delayed reflex relaxation is the most specific hypothyroid sign.
Q89Internal MedicineTTP
A woman has fever, progressive confusion, platelets 37,000, decreasing urine output, and a hemoglobin fall from normal to 9.2 over 3 months. The associated laboratory finding most supportive of the diagnosis is
Adecreased reticulocyte count
Backwards: intact marrow responds with reticulocytosis.
Belevated serum AST
Liver enzymes are not the story (LDH is the hemolysis marker).
Celevated serum ammonia
Ammonia points to liver failure, absent here.
Dpositive direct Coombs test
The key discrimination: TTP hemolysis is MECHANICAL, so Coombs is negative. The disease is autoimmune (anti-ADAMTS13) but no antibody ever touches the red cell.
Eschistocytes on the peripheral smear Correct
The full pentad (fever, thrombocytopenia, MAHA, renal failure, neuro change) is TTP: ADAMTS13 deficiency leaves ultralarge vWF multimers that shear red cells into schistocytes. Plasma exchange is life-saving; platelet transfusion is fuel on the fire.
Eschistocytes on the peripheral smear
Test point: ITP = isolated platelets. TTP = platelets + schistocytes + organs; Coombs-negative; exchange, never platelets. Triggers: idiopathic, clopidogrel/ticlopidine, quinine, pregnancy, HIV.
Q93Internal MedicineMitral valve prolapse
A slender young woman with palpitations and atypical chest pain has a known valvular condition. Auscultation is most likely to reveal
Aa blowing decrescendo diastolic murmur
Aortic regurgitation.
Ba combined systolic and diastolic machinery murmur
Patent ductus arteriosus.
Ca crescendo-decrescendo systolic murmur radiating to the carotids
Aortic stenosis.
Da holosystolic murmur at the apex
Established mitral regurgitation: holosystolic, apex, axillary radiation.
Ea midsystolic click and a late systolic murmur Correct
MVP: the myxomatous leaflet billows until the chordae snap taut (click), then regurgitation begins (late systolic murmur). Standing/Valsalva move the click EARLIER and lengthen the murmur; squatting reverses it.
Ea midsystolic click and a late systolic murmur
Test point: MVP and HCM are the only murmurs that get LOUDER with decreased preload. No endocarditis prophylaxis for MVP.
Q94Internal MedicineHypothyroidism vs anemia Missed in session
A 25-year-old woman has fatigue, weight gain, menometrorrhagia, pallor, and bilateral infraorbital edema. The most likely diagnosis is
Acongenital adrenal hyperplasia
CAH virilizes; nothing fits.
Bhypothyroidism Correct
Weight GAIN + periorbital myxedema + menometrorrhagia (anovulation) is hypothyroidism; the pallor is DOWNSTREAM anemia (low EPO, marrow slowing, iron loss from menorrhagia).
Cpernicious anemia
The anchor trap: B12 deficiency causes weight LOSS and demands neurologic findings (subacute combined degeneration) and glossitis: none present, and it is rare at 25.
Dprolactinoma
Prolactinoma causes AMENORRHEA and galactorrhea, not heavy bleeding.
Eprotein malnutrition
Malnutrition wastes; she is gaining.
Bhypothyroidism
Test point: Reason from the findings the answer must explain ALL of: pallor explained one way; weight gain, edema, and bleeding only the thyroid way.
Session missSession miss: chose pernicious anemia off the pallor. B12 without neuro findings should make you doubt B12.
Q98Internal MedicinePrimary spontaneous pneumothorax findings
A tall thin 25-year-old smoker develops sudden pleuritic left chest pain and dyspnea while smoking. Examination is most likely to reveal
Adecreased lung sounds on the left Correct
The tall-thin-young-smoker phenotype ruptures an apical bleb: decreased breath sounds, HYPERRESONANCE, decreased fremitus on the affected side. Small: observe with oxygen; large: drain; counsel smoking cessation (recurrence 30-50 percent).
Ba holosystolic murmur
No valvular story.
Cchest wall crepitus from contusion
He was smoking, not injured.
Da pericardial friction rub
Pericarditis is positional (better leaning forward) with a viral prodrome and diffuse ST elevation.
Ean S4 gallop
A stiff-ventricle sound of the hypertensive elderly.
Adecreased lung sounds on the left
Test point: Percussion sorts it: hyperresonant = air (pneumothorax); dull = fluid or consolidation.
Q102Internal MedicineB12 deficiency in Crohn disease
A cachectic woman with Crohn disease has confusion, personality change, falls, decreased lower-extremity strength, and loss of proprioception and vibratory sensation. The most likely diagnosis is
AAlzheimer disease
Alzheimer has a normal exam until late: no proprioceptive loss or weakness.
Bfolate deficiency
The classic discrimination: identical anemia, but folate deficiency NEVER causes neurologic disease: and folate given alone masks the anemia while the cord degenerates.
CHashimoto thyroiditis
Hypothyroidism gains weight; she is cachectic, and no dorsal column loss.
Dvascular dementia
Stepwise decline with focal, asymmetric deficits: hers are symmetric tract findings.
Evitamin B12 deficiency Correct
Terminal ileal disease removes the only B12 absorption site; dorsal columns plus corticospinal tracts (subacute combined degeneration) plus neuropsychiatric change is the B12 signature. MMA and homocysteine both rise; treat parenterally.
Evitamin B12 deficiency
Test point: B12 without neuro findings, doubt B12 (Q94); neuro findings + malabsorptive mechanism, it is locked (this one).
Q104Internal MedicineTricuspid regurgitation
A 65-year-old man has a holosystolic murmur at the left sternal border that becomes louder with inspiration. The most likely diagnosis is
Aatrial septal defect
ASD gives a pulmonic flow murmur with FIXED split S2, never holosystolic.
Bmitral regurgitation
Also holosystolic but at the APEX radiating to the axilla, and softer with inspiration.
Cpatent ductus arteriosus
Continuous machinery murmur.
Dtricuspid regurgitation Correct
Inspiratory augmentation (Carvallo sign) marks a RIGHT-sided murmur: holosystolic at the LLSB = TR, usually functional from RV dilation. Look for JVD with v waves and a pulsatile liver.
Eventricular septal defect
Right location, but no inspiratory change: and a new VSD at 65 means septal rupture with decompensation.
Dtricuspid regurgitation
Test point: RIGHT = InspIRation. Location plus maneuver solves most murmurs.
Q105Internal MedicineOral and esophageal candidiasis Missed in session
A 28-year-old man with hemophilia and a remote transfusion reaction has 14 days of sore throat, foul taste, heartburn, and thick white pharyngeal plaques; scraping the exudate causes punctate mucosal bleeding. He is afebrile. The most likely diagnosis is
Abacterial pharyngitis
Strep is febrile with tender nodes, not a 14-day afebrile course.
Boral and esophageal candidiasis Correct
Bleeding after scraping PROVES the plaque came off: pseudomembranous candidiasis. Heartburn signals esophageal extension, an AIDS-defining illness: hemophilia + pre-1985 blood products is the HIV vector. Fluconazole plus HIV testing and ART.
Cleukoplakia
Leukoplakia by definition does NOT scrape off: it is hyperkeratosis, part of the epithelium.
Dsquamous cell carcinoma
An indurated fixed lesion, not a wipeable exudate, and wrong demographics.
Eviral pharyngitis
No virus makes thick scrapable plaques.
Boral and esophageal candidiasis
Test point: Oral white lesion algorithm: scrapes off = candida; fixed + lateral tongue + HIV = hairy leukoplakia (EBV); fixed + tobacco = leukoplakia, biopsy it.
Session missSession miss: read 'scraping causes bleeding' as 'cannot scrape off.' The bleeding base is the evidence of removal.
Q110Internal MedicineHypothyroidism in the elderly
A 62-year-old woman on hydrochlorothiazide has a week of weakness, memory loss, mild dyspnea, and a 2.3-kg weight gain: temperature 35.5 C, pulse 58. Skin is dry; bowel sounds hypoactive; she is alert with poor memory. The laboratory study most likely to confirm the diagnosis is
Acortisol level
Adrenal insufficiency LOSES weight with hypotension and hyperpigmentation.
Bfinger-stick glucose
Hypoglycemia is episodic and adrenergic, not a week of progressive change.
Cpotassium level
Thiazide hypokalemia weakens but does not cool, slow, or fatten.
Dsodium level
The strong runner-up: HCTZ hyponatremia causes weakness and confusion but NOT hypothermia, bradycardia, or dry skin: and hypothyroidism itself causes hyponatremia downstream.
Ethyroid-stimulating hormone level Correct
Hypothermia + bradycardia + weight gain + dry skin + cognitive slowing is hypothyroidism: TSH confirms. The depression family history is the classic reversible-mimic distractor.
Ethyroid-stimulating hormone level
Test point: The 4-question hypothyroid signature this form loves: hypothermia, bradycardia, weight gain, dry skin, delayed reflexes, hyponatremia, high LDL.
Q114Internal MedicineDrug-induced lupus
A 52-year-old woman on enalapril, procainamide, metoprolol, aspirin, and furosemide develops fever, arthralgia, and pleuritic chest pain. The study most likely to confirm the diagnosis is
Aanti-dsDNA antibody
Anti-dsDNA marks IDIOPATHIC SLE and is characteristically ABSENT in DIL: the discriminating pair.
Bantihistone antibody Correct
Procainamide is the highest-risk drug for drug-induced lupus (fever, arthralgia, serositis); antihistone antibodies are positive in over 95 percent. Resolves on stopping the drug.
CBUN and creatinine
Renal disease is RARE in DIL: its sparing is a defining feature.
Dcomplete blood count
Nonspecific.
Eelectrolyte panel
Nonspecific.
Bantihistone antibody
Test point: DIL culprits: procainamide, hydralazine, isoniazid, minocycline, TNF inhibitors. DIL: antihistone+, dsDNA-, kidneys/CNS spared, equal sexes, resolves off drug.
Q115Internal MedicineCentral retinal artery occlusion
A 65-year-old man with hypertension, diabetes, prior MI, and a remote carotid endarterectomy has sudden painless right visual loss with a marked afferent pupillary defect. The fundus shows a pale retina with a cherry-red macular spot. The most likely diagnosis is
Aangle-closure glaucoma
Angle closure is PAINFUL: red eye, halos, fixed mid-dilated pupil, vomiting.
Bcentral retinal artery occlusion Correct
Sudden painless monocular loss + RAPD + pale infarcted retina with a cherry-red spot (the choroid-fed fovea shining through) = CRAO, usually carotid embolism: a stroke equivalent demanding full stroke workup, and ESR/CRP for giant cell arteritis in anyone over 50.
Cexudative macular degeneration
Wet AMD is subacute central loss with metamorphopsia, drusen, and subretinal blood.
Dretinal detachment
Detachment announces with floaters, flashes, and a curtain: an undulating retina, not diffuse pallor.
Evitreous hemorrhage
Hemorrhage obscures the fundus view entirely: you could not have taken this picture.
Bcentral retinal artery occlusion
Test point: Cherry-red spot: CRAO in adults; Tay-Sachs/Niemann-Pick in infants. Retina tolerates ~90 minutes of ischemia.
Q116Internal MedicineSimple spontaneous pneumothorax
A 19-year-old woman smoker develops sharp right chest pain, diaphoresis, and dyspnea while jogging: BP 110/70, pulse 120, respirations 20. Breath sounds are decreased with hyperresonance on the right; the trachea is midline. The most likely diagnosis is
Apericarditis
Positional pain with a rub and diffuse ST elevation.
Bpleurisy
A rub without hyperresonance or absent sounds.
Cpneumonia
Pneumonia percusses DULL with crackles, fever, and cough.
Dpneumothorax Correct
Decreased breath sounds WITH hyperresonance is air in the pleural space; midline trachea and normal pressure make it simple, not tension. Primary spontaneous in a young smoker: bleb rupture.
Epulmonary embolism
The near-neighbor: pleuritic pain, dyspnea, tachycardia: but PE has a NORMAL lung exam, never hyperresonance, and she has no VTE risk factor in the stem.
Dpneumothorax
Test point: The fourth pneumothorax question on this form: percussion is the discriminator the pair (PE vs PTX) turns on.
Q119Internal MedicineLung nodule: characterize first
A 78-year-old woman with a 120 pack-year history has 3 months of cough, 2 weeks of blood-streaked sputum, and a right upper lobe nodular lesion on chest radiograph. The most appropriate next step is
Abronchoscopy
Premature: a peripheral upper-lobe nodule is bronchoscopically unreachable.
BCT scan of the chest Correct
A radiographic 'nodular lesion' is uncharacterized: CT defines size, location (central vs peripheral), borders, calcification, and nodes, and DECIDES the biopsy route. Contrast with the earlier hilar-mass stem, where central location was already known and bronchoscopy followed directly.
CMRI of the chest
Reserved for Pancoast, chest wall, or plexus questions.
DPET scan of the chest
A staging tool after tissue, blind under 8-10 mm, with granulomatous false positives.
Esputum cytology
20-30 percent sensitive; a negative changes nothing.
BCT scan of the chest
Test point: CXR finding → CT → tissue (route by location) → PET-CT + brain MRI staging → PFTs → treatment.
Q120Internal MedicinePsoriatic arthritis clues
A 17-year-old boy has intermittent finger joint swelling and pain, occasional dry skin patches, frequent headaches, an innocent murmur since childhood, and bilateral nail pitting. The most likely diagnosis is
Ajuvenile idiopathic arthritis
JIA needs 6+ weeks of persistent arthritis and never pits nails.
BLyme disease
Lyme is a migratory large-joint (knee) disease with erythema migrans.
Cpsoriasis Correct
Nail pitting (80 percent of psoriatic arthritis) plus understated 'dry patches' (hidden plaques: scalp, gluteal cleft, umbilicus) plus small-joint arthritis = psoriatic disease; arthritis precedes skin findings in 15 percent.
Drheumatic fever
His murmur is INNOCENT and predates any illness; rheumatic carditis makes a NEW murmur after strep pharyngitis, with migratory large-joint arthritis.
Esystemic lupus erythematosus
SLE brings systemic features and is female-predominant; no nail pitting.
Cpsoriasis
Test point: Psoriatic arthritis: DIP involvement, dactylitis, enthesitis, seronegative, HLA-B27 family, pencil-in-cup. RA spares DIPs; OA and PsA love them.
Q124Internal MedicineAllergic rhinitis lab finding
A 24-year-old woman has a month of sneezing, pruritic eyes, and clear rhinorrhea, worse at her new office building, unrelieved by OTC antihistamines. Nasal mucosa is pale and boggy; suboccipital tissues are tense. The laboratory study most likely to be abnormal is
AC-reactive protein
Allergy is not a systemic acute-phase disease.
Berythrocyte sedimentation rate
Same.
Cplatelet count
No relationship.
Dserum IgG level
The isotype trap: allergy is IgE, not IgG.
Etotal eosinophil count Correct
Pale boggy mucosa + itching + environmental trigger = allergic rhinitis: type I IgE hypersensitivity with a late-phase eosinophil response, so blood (and nasal smear) eosinophilia. Intranasal steroids are the most effective therapy.
Etotal eosinophil count
Test point: Mucosa color sorts rhinitis: pale/boggy allergic, erythematous viral, normal-with-triggers vasomotor (no itch, no eosinophils).
Q139Internal MedicineNew HFrEF: find the ischemia
A 62-year-old man with hypertension and well-controlled diabetes has 3 weeks of exertional dyspnea, orthopnea, and ankle edema. ECG and radiograph are normal; echocardiography shows a reduced ejection fraction with no valvular disease. The most appropriate next diagnostic modality is
Aangiography of the lower extremities
His edema is venous congestion from the failing heart, not arterial disease.
BCT scan of the chest
The radiograph is normal and the echo already explained the dyspnea.
Cliver function testing
Hepatic congestion is a consequence, not the cause.
Dnuclear stress testing Correct
New HFrEF without valve disease demands an etiology, and ischemic heart disease causes two-thirds of cases. His DIABETES silences angina, so 'denies chest pain' excludes nothing: perfusion imaging finds ischemia and viable (hibernating) myocardium that revascularization can recover.
Esignal-averaged ECG
A niche arrhythmia-risk tool that answers no etiologic question.
Dnuclear stress testing
Test point: T1-T5 left-sided tissue changes = cardiac viscerosomatic corroboration. Etiology workup: ischemia, thyroid, iron, alcohol, HIV, infiltrative.
Q146Internal MedicinePulseless torsades
A hospitalized alcohol-detox patient with potassium 2.8 becomes unresponsive; the strip shows polymorphic wide-complex tachycardia twisting around the baseline. No vital signs are obtainable. The most appropriate treatment is
Adefibrillation Correct
Pulseless torsades is a cardiac arrest rhythm: immediate unsynchronized defibrillation plus CPR. (Magnesium is the torsades drug WITH a pulse, and hypomagnesemia is also why the oral potassium never corrected.)
Bintravenous adenosine
Stable narrow-complex SVT drug.
Cintravenous amiodarone
Post-shock adjunct at best, and amiodarone PROLONGS QT: relatively contraindicated in torsades.
Dintravenous atropine
Bradycardia drug.
Etranscutaneous pacing
Bradycardia tool: overdrive pacing belongs to RECURRENT torsades, not arrest.
Adefibrillation
Test point: Wide-complex algorithm: pulseless = defibrillate; unstable with pulse = synchronized cardioversion; stable = amiodarone; torsades with pulse = magnesium. Fix Mg before K.
Q149Internal MedicineGonococcal urethritis on Gram stain
A 34-year-old man has 2 days of dysuria and cloudy urethral discharge with inguinal adenopathy. Gram stain of the discharge shows gram-negative intracellular diplococci within neutrophils. This is clinical evidence of infection with
AChlamydia trachomatis
The mirror of the cervicitis question: chlamydia is obligate intracellular and NEVER Gram stains: it is the answer when inflammation shows NO organisms.
Bhuman papillomavirus
Causes warts, not discharge.
CNeisseria gonorrhoeae Correct
Gram-negative intracellular diplococci in urethral exudate is ~95 percent sensitive and highly specific in symptomatic men: gonorrhea. Ceftriaxone 500 mg IM, plus doxycycline unless chlamydia is excluded; report, treat 60-day partners, EPT where legal.
DTrichomonas vaginalis
A flagellated protozoan of wet mounts, not Gram stains.
EUreaplasma urealyticum
Cell-wall-less, also unstainable: an NGU cause when NAATs are negative.
CNeisseria gonorrhoeae
Test point: The stain pair: organisms seen = gonorrhea; sterile inflammation = chlamydia. The 2-day incubation also fits GC (chlamydia runs 7-21).
Q153Internal MedicineAcute hepatitis B
A 62-year-old woman has scleral icterus after 2 weeks of 'viral symptoms' (anorexia, fatigue, nausea, myalgia), with dark urine, clay-colored stools, tender hepatomegaly, and NO splenomegaly. No alcohol or drugs. The most likely diagnosis is
Aacute cholecystitis
Cholecystitis is febrile colicky RUQ pain with Murphy sign after fatty food: she is afebrile, painless, and jaundiced.
Bacute hepatitis B Correct
The two-phase course (prodrome then icterus) with conjugated hyperbilirubinemia (dark urine + acholic stool) and tender hepatomegaly is acute viral hepatitis: hepatitis B is the option. IgM anti-HBc marks acute infection; adults clear it more than 95 percent of the time.
Cacute HIV infection
Acute HIV is a mono-like syndrome with rash and pharyngitis, not cholestatic jaundice.
Dacute pancreatitis
Pancreatitis is severe epigastric-to-back pain: she has none.
Einfectious mononucleosis
Excluded twice: NO splenomegaly (stated) and age 62: EBV is an adolescent disease that rarely causes frank jaundice.
Bacute hepatitis B
Test point: Serology grid: HBsAg active; IgM anti-HBc acute (and the window); anti-HBs immune; HBeAg infectious.
Q158Internal MedicineUncomplicated cystitis
A healthy 62-year-old woman has 2 days of urgency, frequency, and incontinence with 2+ blood and 2+ leukocyte esterase on dipstick, normal vitals, and no CVA tenderness. The most appropriate management is
Aampicillin
E. coli resistance 30-50 percent: retired from empiric use.
Bazithromycin
Chlamydia coverage that misses E. coli entirely.
Cceftriaxone
Parenteral pyelonephritis therapy: overtreatment (and remember nitrofurantoin can NEVER treat pyelo: no tissue levels).
Ddoxycycline
Same wrong target.
Enitrofurantoin Correct
Acute uncomplicated cystitis: nitrofurantoin 100 BID x5 days: urine-concentrated, low resistance, minimal collateral damage. Age alone does not make a UTI complicated. Recurrent postmenopausal UTIs: vaginal estrogen is the preventive that works.
Enitrofurantoin
Test point: Cystitis is a luminal infection (nitrofurantoin, fosfomycin work); pyelonephritis is tissue infection (they never do: FQ or ceftriaxone instead).
OMM21 questions
Q2OMMParasympathetics of the distal colon
A patient presents with bloody diarrhea consistent with ulcerative colitis. Structural examination reveals findings at the thoracolumbar junction and sacrum. Which technique will best normalize parasympathetic tone to the involved bowel?
Ahip articulation
Hip articulation has no autonomic relationship to the colon.
Bbalanced ligamentous tension to the lower extremities
BLT to the legs addresses somatic and lymphatic issues, not pelvic parasympathetic outflow.
Cfacilitated positional release to the thoracolumbar junction
The T11-L2 findings are the SYMPATHETIC viscerosomatic reflex for the distal gut; FPR there treats the wrong division.
Dmuscle energy to T11
Muscle energy to T11 also addresses sympathetic, not parasympathetic, tone: the engineered trap.
Esacral rocking Correct
The descending colon, sigmoid, and rectum receive parasympathetic supply from the pelvic splanchnic nerves (S2-S4) exiting the anterior sacral foramina; sacral rocking normalizes tone there.
Esacral rocking
Test point: Distal to the splenic flexure, parasympathetics are sacral (S2-S4); everything proximal is vagal.
Q12OMMMuscle energy, activating force direction
A patient with an upper respiratory infection has T5 extended, sidebent left, rotated left. During muscle energy treatment the physician positions the segment appropriately; the patient's activating force should be toward
Aextension with left sidebending and left rotation Correct
In postisometric relaxation the physician holds the segment at the restrictive barrier (flexion, right sidebending, right rotation) while the patient contracts back TOWARD the ease of motion: extension, left sidebending, left rotation.
Bneutral positioning with right rotation
Describes neither the barrier nor the freedom.
Cflexion with right sidebending and right rotation
This IS the restrictive barrier: the physician's positioning direction, and the single most common wrong answer.
Dflexion with left sidebending and right rotation
Mixes rotation and sidebending to opposite sides, a type I neutral mechanic; T5 ESlSl is type II.
Epure rotation to the right
Ignores the coupled components.
Aextension with left sidebending and left rotation
Test point: Physician positions INTO the barrier; the patient pushes toward the freedom of motion.
Q13OMMFPR positioning (indirect)
A patient with asthma has an occipitoatlantal joint that is extended, sidebent right, rotated left. After reduction of the normal cervical curve, facilitated positional release requires positioning the OA into
Aflexion with left sidebending and right rotation
The direct-technique mirror (the barrier): the trap for anyone reflexing to 'treat toward the barrier.'
Bextension with right sidebending and left rotation Correct
FPR is an INDIRECT technique: flatten the AP curve, add compression, and position into the ease of motion, which is exactly the dysfunction's own pattern: extension, right sidebending, left rotation.
Cflexion with right sidebending and right rotation
Violates OA coupling: at the OA, sidebending and rotation are ALWAYS opposite, regardless of flexion or extension.
Dextension with left sidebending and left rotation
Also violates OA coupling.
Eneutral with right rotation
Not the ease in all three planes.
Bextension with right sidebending and left rotation
Test point: Direct techniques (ME, HVLA) go into the barrier; indirect (FPR, counterstrain, BLT) go into the ease. OA couples SB and rotation to opposite sides.
Q14OMMChapman point, stomach hyperacidity
A man with heartburn triggered by coffee and spicy food, sour eructation, and epigastric tenderness is evaluated for Chapman reflex points. The anterior point for his condition is located
Abetween ribs 2 and 3 on the right
Upper lung.
Bbetween ribs 3 and 4 on the left
Lung, not gut.
Cbetween ribs 3 and 4 on the right
Also pulmonary.
Dbetween ribs 5 and 6 on the left Correct
Stomach hyperacidity's anterior Chapman point is the left 5th intercostal space; the presentation is classic acid dyspepsia.
Ebetween ribs 5 and 6 on the right
The mirror-image trap: the RIGHT 5th-6th interspace is liver and gallbladder.
Dbetween ribs 5 and 6 on the left
Test point: Chapman laterality follows the organ: stomach and spleen left, liver/gallbladder right. Stomach hyperacidity ICS 5 left, peristalsis ICS 6 left, duodenum ICS 8 right.
Q26OMMStill technique, initial position
L3 is found with the left transverse process posterior, worsening with forward bending. Still technique treatment of this segment begins by positioning it in
Aextension with left sidebending and left rotation Correct
Left TP posterior improving in extension = L3 ESlSl. Still is a COMBINED technique that STARTS indirect at the ease (extension, left, left), adds compression, then carries through the barrier to finish direct.
Bflexion with right sidebending and right rotation
The restrictive barrier: where the technique ends up, not where it begins.
Cneutral with axial compression only
Compression is the activating force, but positioning comes first and in three planes.
Dflexion with left sidebending and left rotation
Flexion is the barrier plane.
Eextension with right sidebending and right rotation
Wrong side in both planes for the ease.
Aextension with left sidebending and left rotation
Test point: Still = indirect first, then through to direct. Same starting position as FPR; the difference is the carry-through.
Q33OMMPatellofemoral pain, OMT target
A 14-year-old new runner has anterior knee pain on stairs and prolonged sitting, weak vastus medialis, restricted patellar motion, and hypertonic tender lateral hamstring and iliotibial tissues. Drawer and McMurray tests are negative. The most appropriate treatment is
Aanterior tibial traction tug
Treats a single secondary articular finding while leaving the myofascial cause untouched.
Blymphatic pedal pump
Her swelling is mechanical, not lymphatic congestion.
Cmultiview knee radiography
PFPS is clinical; no trauma, locking, effusion, or weight-bearing failure, so imaging adds nothing.
Dmyofascial release of the hamstring Correct
Patellofemoral pain is a lateral tracking imbalance: weak VMO with tight lateral restraints. Releasing the hypertonic lateral chain addresses the actual driver; pair with VMO and hip strengthening.
Estraight-leg knee immobilizer
Actively harmful: immobilization accelerates quadriceps atrophy, worsening the imbalance.
Dmyofascial release of the hamstring
Test point: Theater sign + stairs = PFPS. Rehabilitate, never immobilize. Adolescent girls: wider pelvis, bigger Q angle.
Q37OMMGastric sympathetics
A man with an NSAID-induced gastric ulcer and hematemesis has multiple somatic findings. To normalize sympathetic tone in his disease process, the best technique is
Acounterstrain to the pelvic region
Pelvic counterstrain addresses S2-S4 parasympathetics to the DISTAL colon: wrong division and organ.
BHVLA to the lumbar spine
Lumbar HVLA is the wrong level, relates to his incidental disc disease, and thrust techniques are poor choices in an actively bleeding patient.
Cmesenteric release of the sigmoid colon
Sigmoid work targets the wrong organ.
Dmuscle energy to the occipitoatlantal joint
The trap: the OA addresses the VAGUS, parasympathetic to the stomach. Right organ, wrong division.
Emyofascial release of the midthoracic spine Correct
Gastric sympathetic supply is the greater splanchnic nerve, T5-T9: midthoracic myofascial release normalizes the facilitated segments.
Emyofascial release of the midthoracic spine
Test point: Stomach: sympathetic T5-T9, parasympathetic vagus (OA/AA/C2). Every autonomics stem is organ x division.
Q48OMMGallbladder viscerosomatic reflex Missed in session
A woman has recurrent right upper quadrant pain two hours after fatty meals, worse tonight. The somatic dysfunction most consistent with her condition is
AT1-T3 neutral, sidebent left, rotated right
Head/neck/heart level.
BT2 flexed, rotated left, sidebent left
T2 is upper thoracic, and viscerosomatic facilitation is non-neutral: type II, yes, but wrong level and side for the gallbladder is the issue here: T2 belongs to head and neck.
CT4-T6 neutral, sidebent right, rotated left
Fails all three axes: barely overlaps the level, is a type I group curve (postural, not visceral), and rotates LEFT.
DT7 extended, rotated right, sidebent right Correct
Biliary colic reflects to the gallbladder's sympathetic level T5-T9 with T7 dead center, as a TYPE II single-segment dysfunction (rotation and sidebending SAME side), rotated toward the right-sided organ.
ET10-T12 neutral, sidebent left, rotated right
T10-T12 is small intestine/kidney territory and type I.
DT7 extended, rotated right, sidebent right
Test point: Viscerosomatic three-axis check: LEVEL (organ's sympathetic range), TYPE (always type II), SIDE (toward the organ).
Session missSession miss: chose the T4-T6 type I option. Being in the right neighborhood on level alone still loses; run level, type, side explicitly.
Q49OMMRadial head somatic dysfunction
After a fall, a woman has lateral elbow pain without swelling and normal radiographs. The radial head glides freely anteriorly but resists posterior glide. The diagnosis is
Aanterior radial head dysfunction Correct
Somatic dysfunction is named for the direction of EASE: free anterior glide = anterior radial head, paired with free supination and restricted pronation; treat by engaging pronation.
Bflexion dysfunction of the elbow
Describes the ulnohumeral joint, not the radial head glide finding.
Cposterior radial head dysfunction
The mirror: free posterior glide, pronation ease: the nursemaid's elbow pattern.
Dtorn brachioradialis tendon
A palpable defect, ecchymosis, flexion weakness: none present, and the injury is rare.
Evalgus sprain of the elbow
A UCL injury gives MEDIAL pain with valgus laxity and swelling.
Aanterior radial head dysfunction
Test point: Anterior radial head = supination free; posterior = pronation free. Name the dysfunction for its freedom.
Q61OMMCounterstrain: plantaris
A man feels a pop in his calf during forceful push-off and has a tender point in the lateral proximal calf at the plantaris origin. Counterstrain treatment requires positioning the leg in
Adorsiflexion and eversion
Lengthening plus eversion, which is not a plantaris action.
Bdorsiflexion and knee extension
Fully lengthening at both joints.
Cdorsiflexion and knee flexion
Dorsiflexion lengthens it at the ankle.
Dplantar flexion and knee extension
Knee extension lengthens plantaris across the knee.
Eplantar flexion and knee flexion Correct
Counterstrain shortens the involved muscle. Plantaris crosses two joints: origin above the knee, insertion on the calcaneus, so shortening needs BOTH knee flexion and plantar flexion. Hold 90 seconds, return slowly and passively.
Eplantar flexion and knee flexion
Test point: Identify the muscle, then fold the body around it. Slow passive return or the spindle resets.
Q64OMMChronic tissue texture changes
A patient with years of seasonal allergic rhinitis is examined for evidence that the somatic component has become chronic. The expected finding is
Adecreased cervical lordosis
A postural finding without chronicity specificity.
Bedema of the anterior axillary fold
Edema is an ACUTE tissue change.
Cfibrotic changes in the T1-T3 paravertebral tissues Correct
Chronic facilitation remodels tissue: fibrotic, ropy, cool, dry: at the head-and-neck sympathetic levels T1-T4. Fibrosis takes time, which is what marks chronicity.
Drestricted atlantoaxial rotation
AA restriction implicates the vagus (parasympathetic), relevant to treatment but not a marker of chronic transition.
Esoft tissue fullness of the mid-supraclavicular region
Fullness is also acute/congestive.
Cfibrotic changes in the T1-T3 paravertebral tissues
Test point: Acute: boggy, warm, moist, red-reflex persists. Chronic: fibrotic, cool, dry, red-reflex fades.
Q78OMMChapman point: duodenum
A 55-year-old man has epigastric tenderness, hematochezia, and a tender anterior Chapman point at the right 8th intercostal space near the costochondral junction. The most likely source is
Acolonic arteriovenous malformation
A real cause of painless hematochezia, but no epigastric tenderness and the colon's Chapman points live on the iliotibial band.
Bduodenal ulcer Correct
The right ICS 8 costochondral point is the DUODENUM. Brisk duodenal bleeding (posterior ulcer eroding the gastroduodenal artery) can present as hematochezia when transit is fast: it is the most common cause of upper GI bleeding.
Cesophagitis
Esophagus is ICS 2 parasternally, with heartburn, not epigastric tenderness and brisk bleeding.
Dgastritis
Stomach points are LEFT ICS 5-6: wrong side.
Ehemorrhoids
Painless bright streaks without abdominal findings.
Bduodenal ulcer
Test point: Hematochezia + epigastric signs = think brisk UPPER GI bleed. Duodenum: right ICS 8.
Q80OMMThoracic outlet syndrome
Months after a rear-end collision, a 46-year-old woman has left neck pain and generalized, non-dermatomal left arm paresthesia. Motor exam is intact; the left anterior scalene is markedly hypertonic with C3-C7 flexed and left-sidebent. The most likely diagnosis is
AC5-C6 disk herniation
A C5-C6 herniation gives DERMATOMAL C6 findings: thumb-index paresthesia, weak wrist extension, diminished brachioradialis: all absent.
Bhypoglossal nerve injury
CN XII is pure tongue motor.
Coccipital somatic dysfunction
The occiput refers to the scalp, never the arm.
Dcervical spondylosis
Degenerative disease is gradual, axial, and older: not post-traumatic at 46.
Ethoracic outlet syndrome Correct
GENERALIZED paresthesia means the plexus is compressed as a bundle, not a single root: at the interscalene triangle narrowed by the hypertonic scalene. Neurogenic TOS is >90 percent of cases; sensory precedes motor findings.
Ethoracic outlet syndrome
Test point: Non-dermatomal arm symptoms + scalene tension = TOS. Tests: Adson, Wright, costoclavicular, Roos. First rib and scalene OMT respond well.
Q117OMMIBS and the collateral ganglia
A 22-year-old graduate student has abdominal pain and bloating relieved by defecation, worse since school began. The physical finding that would most support the diagnosis is
Ahypertonicity of the upper thoracic paraspinal musculature
T1-T4 is head/neck/heart/lung territory: wrong viscera.
Btender points of the left anterior intercostal spaces 4-7
Left ICS 4-7 holds stomach and spleen Chapman points; the colon's Chapman points are on the ILIOTIBIAL BAND.
Ctenderness of the right costotransverse articulations of T1-T4
Same wrong level.
Dtenderness at the anterior tip of rib 12
Rib 12's tip corresponds to no colonic reflex.
Etension and midline tenderness between the xiphoid process and the umbilicus Correct
Pain relieved by defecation + stress exacerbation = IBS; sympathetic hypertonicity to the gut palpates as midline collateral ganglion tension: celiac (below xiphoid) and superior mesenteric (xiphoid-to-umbilicus). Ganglion inhibition treats it.
Etension and midline tenderness between the xiphoid process and the umbilicus
Test point: Collateral ganglia: celiac = foregut, superior mesenteric = midgut, inferior mesenteric = hindgut. Midline tenderness maps the gut.
Q122OMMGastric parasympathetics (vagus)
A 24-year-old woman vomits black granular material with epigastric and left-upper-quadrant tenderness and a tender nodule at the left 5th intercostal space. Which technique will help normalize parasympathetic tone in her disease process?
Abalanced ligamentous treatment to T4
Sympathetic level, and the wrong one (T1-T5 heart/head).
Bfacilitated positional release to T5-T8
The organ-right trap: T5-T9 is the stomach's SYMPATHETIC level.
Chigh velocity, low amplitude to the occipitoatlantal joint Correct
Coffee-ground emesis + the stomach-hyperacidity Chapman point = upper GI bleeding from gastritis/ulcer; gastric PARASYMPATHETICS are the vagus, addressed at OA/AA/C2: HVLA to the OA is the vagal answer offered.
Dmuscle energy to the sacrum
The division-right trap: sacral parasympathetics serve the DISTAL colon, not the stomach.
Emyofascial release to C4
C4 is phrenic territory, not vagal outflow.
Chigh velocity, low amplitude to the occipitoatlantal joint
Test point: Every wrong option gets exactly one filter right: run organ x division on every autonomics stem.
Q123OMMRenal parasympathetics (vagus)
A 37-year-old woman has 4 days of hematuria with BP 145/98 and periorbital edema. Findings include T10 flexed, rotated right, sidebent right and a left-on-left sacral torsion. Which technique would most likely normalize parasympathetic tone related to her diagnosis?
Abalanced ligamentous tension to the sacrum
The division trap: S2-S4 serves bladder and lower ureter, not the kidney.
Bcircular pressure to the L1 nodule
Chapman point treatment addresses lymphatic/sympathetic reflexes.
Chigh velocity, low amplitude to L5
L5 HVLA treats an unrelated somatic finding.
Dmuscle energy to T10
The sympathetic trap: T10-L1 is the renal sympathetic level, and the stem's T10 finding is that viscerosomatic reflex.
Emyofascial release to the occipitoatlantal joint Correct
Hematuria + hypertension + periorbital edema = glomerulonephritis: a KIDNEY problem, and renal parasympathetics are VAGAL (OA/AA/C2), the organ everyone misfiles as sacral.
Emyofascial release to the occipitoatlantal joint
Test point: Kidney and upper ureter: sympathetic T10-L1, parasympathetic VAGUS. Bladder and lower ureter: T11-L2 and S2-S4.
Q126OMMTOS: elevated first rib
A 34-year-old right-handed construction worker has 3 weeks of right arm pain radiating from shoulder to thumb with dorsal hand swelling and no evidence of proximal nerve root compression. Structural examination is most likely to reveal
Aan anterior tender point at right rib 3
Rib 3's anterior point has no plexus relationship.
BC2 extended, rotated right, sidebent right
C2 maps to occiput and scalp, and roots were excluded.
Cflexor retinaculum restriction on the right
Carpal tunnel gives PALMAR median symptoms without shoulder radiation or dorsal swelling: the plausible foil for a tool worker.
Dan inhalation dysfunction at right rib 1 Correct
'No root compression' pivots the C6-looking pain distally to the thoracic outlet; DORSAL HAND SWELLING means venous/lymphatic outflow obstruction there. An elevated (inhalation-restricted) first rib narrows the interscalene and costoclavicular spaces: the classic TOS structural finding in an overhead laborer.
Ea posterior radial head dysfunction on the right
Radial head disease is lateral elbow, no swelling, no shoulder story.
Dan inhalation dysfunction at right rib 1
Test point: Scalenes attach to rib 1; overhead work elevates it. TOS sites: interscalene triangle, costoclavicular space, subpectoral tunnel.
Q130OMMUpper extremity sympathetics
A 56-year-old woman with prior shoulder surgery has numbness of the palmar first three digits, 4/5 left arm strength, restricted supination, and ease of T2-T6 translation to the right. Which treatment would most likely normalize sympathetic tone?
Acounterstrain to C2
A somatic cervical tender point, not an autonomic level.
Bcounterstrain to the right upper trapezius
Wrong side and muscular.
Cfacilitated positional release to the upper thoracics Correct
Upper extremity sympathetics arise T2-T8; the stem's T2-T6 finding is that facilitation, and FPR there addresses it. The limbs have NO parasympathetic supply, so any autonomic question about an arm is sympathetic by default.
Dmuscle energy to the radial head
Treats the supination restriction, a joint finding with no autonomic role.
Emyofascial release to the occipitoatlantal joint
The vagus serves no somatic limb structure: division impossible here.
Cfacilitated positional release to the upper thoracics
Test point: Extremities: sympathetic only. Upper T2-T8, lower T11-L2.
Q144OMMPostpartum coccydynia
Six months after delivering a 4.1-kg infant vaginally, a woman has aching low back and pelvic pain worse with SITTING, dyspareunia, and painful bowel movements, with discomfort on speculum insertion. Sacral examination shows exquisite tenderness at the apex. The most likely cause is
Aabnormal parasympathetic input to the uterus
Her gynecologic exam is normal and she denies uterine symptoms: the pathology is musculoskeletal.
Babnormal sympathetic input to the uterus
Same.
Cexaggerated lumbar lordosis with pelvic tilt
Real in the stem but SECONDARY: lordosis explains back ache and nothing pelvic: the one-finding trap.
Dsacrococcygeal strain and pelvic floor dysfunction Correct
Sitting-provoked pain + apex tenderness = coccydynia from the macrosomic delivery levering the coccyx; the levator ani attaches there, so a strained hypertonic floor explains dyspareunia, painful defecation, AND speculum intolerance: the option that covers every finding.
Esagittal plane postural decompensation
A vaguer restatement of the same partial answer.
Dsacrococcygeal strain and pelvic floor dysfunction
Test point: Choose the option that explains ALL findings, not the loudest one. Treatment: coccygeal mobilization, pelvic floor release, cushion, pelvic PT.
Q147OMMGERD viscerosomatic level
A 52-year-old woman with nocturnal cough, morning bitter taste, months of heartburn, and a small hematemesis is examined. The somatic dysfunction most consistent with her condition is
AC3 extended, rotated right, sidebent right
Cervical: if the question were PARASYMPATHETIC the region would be OA/AA/C2, and C3 is not that either.
BT2 extended, rotated left, sidebent left
Type II and left, but T2 is proximal-esophagus/head-and-neck territory: fails on level.
CT6 flexed, rotated left, sidebent left Correct
GERD reflects to the distal esophagus/GE junction at T5-T6 as a TYPE II single-segment dysfunction rotated LEFT (the esophagus and stomach are left-sided): level, type, and side all pass.
DT10 flexed, rotated right, sidebent right
T10 is small intestine/kidney and rotated right: fails level and side.
EL1 flexed, rotated left, sidebent left
L1 is descending colon and kidney territory.
CT6 flexed, rotated left, sidebent left
Test point: The gallbladder lesson institutionalized: level, then type (always II), then side (toward the organ).
Q154OMMScoliosis: reversibility first
A 12-year-old girl referred by the school nurse has unlevel shoulders and iliac crests with T3-T10 neutral, sidebent left, rotated right, and asymmetric erector spinae mass. The most appropriate next step is to
Aevaluate for reversibility of the curve Correct
A type I neutral group curve with unlevel crests suggests a COMPENSATORY curve driven from below: the branching question is whether it corrects (forward bending, sidebending, sitting vs standing). Corrects = functional: find the leg-length/pelvic cause. Persists = structural: full-spine films and Cobb staging.
Binitiate heel lift therapy
Treatment before diagnosis: a lift under a structural curve can worsen it.
Corder standing postural radiography
The right film ONCE a functional curve is confirmed and a lift is planned: ordering it first presumes the answer.
Dorder thoracic spine radiography
The wrong film either way: scoliosis needs FULL-SPINE standing radiographs.
Erefer her to a pediatric orthopedist
Referral thresholds (Cobb over ~25 or progression) have not been established.
Aevaluate for reversibility of the curve
Test point: Structural pathway: observe <25, brace 25-45 while immature, surgery >45-50. The QB question was the same test from the interpretation side.
Pediatrics20 questions
Q1PediatricsPersistent asthma, controller therapy
A young boy is brought in for a nightly cough of 3 weeks that disrupts sleep, recurring every fall, with a history of bronchiolitis in infancy. Examination reveals wheezing with a partial response to albuterol. The most appropriate long-term management is
Ainhaled budesonide daily Correct
Nightly symptoms recurring seasonally define persistent asthma, which requires a daily anti-inflammatory controller; low-dose inhaled corticosteroid is first line and prevents the annual fall flare.
Binhaled albuterol on a fixed daily schedule
Albuterol is a rescue bronchodilator with no anti-inflammatory effect; scheduling it does not prevent asthma.
Coral albuterol as needed
Oral albuterol is essentially obsolete: poor efficacy with tremor and tachycardia.
Ddaily oral corticosteroids
Daily systemic steroids are reserved for severe refractory disease; growth suppression, adrenal suppression, and bone loss make them wrong here.
Eoral theophylline
Theophylline is a narrow-therapeutic-index alternative requiring level monitoring, never first-line prevention.
Ainhaled budesonide daily
Test point: Symptoms more than 2 nights a month = persistent asthma = daily inhaled corticosteroid.
Q7PediatricsCongenital diaphragmatic hernia, definitive treatment
A newborn has respiratory distress, a scaphoid abdomen, and a radiograph showing bowel loops in the left hemithorax with mediastinal shift to the right. The definitive treatment is
Achest tube placement
The chest lucencies are bowel, not pleural air: a chest tube perforates intestine. The classic misread.
Bsurfactant administration
These infants have pulmonary hypoplasia and surfactant is sometimes adjunctive, but it does not address the defect.
Cempiric antibiotics
Not pneumonia or sepsis; the film does not fit.
Dpostnatal corticosteroids
Antenatal steroids reduce RDS before delivery; postnatal steroids have no role here.
Esurgical repair Correct
Congenital diaphragmatic hernia (left posterolateral Bochdalek defect) is fixed only by operative reduction of the viscera and closure of the diaphragm once the infant is physiologically stable; everything else is stabilization.
Esurgical repair
Test point: CDH triad: distress at birth + scaphoid abdomen + bowel in the chest. Intubate (never bag-mask), decompress the gut, repair when stable.
Q8PediatricsCongenital diaphragmatic hernia, confirmatory test
A newborn has tachypnea with retractions, a scaphoid abdomen, decreased breath sounds on the left, and heart sounds displaced to the right. The study most likely to confirm the diagnosis is
Aarterial blood gas
An ABG grades hypoxemia but carries no anatomic information.
Bchest radiography Correct
A plain chest radiograph confirms CDH in seconds: bowel loops in the hemithorax, contralateral mediastinal shift, gasless abdomen, and an orogastric tube coiling into the chest.
Cechocardiography
Echo comes AFTER diagnosis, to quantify pulmonary hypertension and screen for associated heart disease.
Dfluoroscopy of the diaphragm
Fluoroscopy assesses diaphragmatic paralysis or eventration, not a hernia in a distressed newborn.
Ehyperoxia (oxygen challenge) test
The hyperoxia test separates cardiac from pulmonary cyanosis; the scaphoid abdomen and shifted heart sounds already localize the problem.
Bchest radiography
Test point: Neonatal respiratory distress of unclear cause starts with a chest radiograph; it sorts CDH, RDS, TTN, meconium aspiration, and pneumothorax in one image.
Q22PediatricsPolymastia
A 12-year-old girl is noted during an examination for bronchitis to have a soft, mobile 4-cm axillary mass with a small papular skin lesion at its center. The most likely diagnosis is
Acat-scratch disease
Cat-scratch gives tender regional nodes proximal to an inoculation site on the limb, with exposure history.
Breactive lymphadenopathy
Bronchitis drains to hilar nodes, not axillary; reactive nodes are small and never carry a central papule.
Clymphoma with cutaneous extension
Lymphoma is firm, fixed, with B symptoms; a well-defined papule is not cutaneous invasion.
Dpectoralis major rupture
Essentially unheard of at 12; would show acute pain, ecchymosis, and a deformed axillary fold.
Epolymastia Correct
A central papule (accessory nipple) atop soft glandular tissue in the axilla is accessory breast tissue on the embryologic milk line, becoming apparent as pubertal estrogen rises. Polymastia = tissue with or without nipple; polythelia = nipple only.
Epolymastia
Test point: Milk line runs axilla to groin; ectopic breast tissue declares itself at puberty.
Q27PediatricsAsplenia vaccination
An 8-year-old girl with sickle cell anemia has received all universally recommended childhood vaccinations. The additional vaccine she should receive because of her disease is
AHaemophilus influenzae type b
Completed in the routine infant series.
Bhuman papillomavirus
Starts at 9-12 regardless; sickle cell does not accelerate it.
Cmeningococcal conjugate (MCV4) Correct
Functional asplenia from splenic autoinfarction removes clearance of encapsulated organisms: MCV4 begins at age 2 in asplenia (two doses, boosters q5y) instead of the routine 11-12; at 8 she is the only child in the stem who needs it early.
Dpneumococcal conjugate (PCV13)
Also completed in infancy; her pneumococcal need is PPSV23, which was not offered.
ETdap
The adolescent booster timing is unchanged.
Cmeningococcal conjugate (MCV4)
Test point: Asplenia moves meningococcal and pneumococcal polysaccharide vaccines EARLY, plus penicillin prophylaxis to age 5. Live vaccines remain fine.
Q43PediatricsAnogenital warts in a child
A 5-year-old girl has anogenital condyloma acuminata first noticed one month ago. The physician should initially report the finding to
Athe Centers for Disease Control and Prevention
Clinicians do not report cases directly to CDC.
Bchild protective services Correct
Anogenital warts at 5 raise concern for sexual abuse (perinatal HPV usually appears by 2-3), and physicians are mandatory reporters of reasonable SUSPICION to CPS, who investigate; you do not prove, interrogate, or wait.
Cthe National Institutes of Health
NIH is a research agency with no reporting function.
Dthe state health department
HPV is not a reportable communicable disease, which is exactly why this option fails cleanly (gonorrhea or syphilis would create a PARALLEL health-department duty).
Estate law enforcement
Police may become involved, but CPS is the universal initial report for suspected child maltreatment.
Bchild protective services
Test point: High-specificity findings for abuse: gonorrhea, syphilis, HIV, chlamydia beyond infancy. Warts and HSV are 'suspicious': report the suspicion.
Q45PediatricsBaby-friendly nursery policy
A hospital revises its newborn nursery policies to support breastfeeding. The change most consistent with evidence-based practice is to
Aallow rooming-in for mothers and neonates Correct
Twenty-four-hour rooming-in (Baby-Friendly Step 7) lets mothers respond to early hunger cues, increases feeding frequency and supply, and reliably extends breastfeeding duration.
Bschedule feedings every 4 hours
Newborns feed on demand, 8-12 times daily; scheduling starves supply.
Cprovide free formula samples to mothers who decline breastfeeding
The WHO Code bars hospitals from distributing formula samples to ANY mother; discharge packs measurably shorten breastfeeding.
Dinitiate breastfeeding within 5 hours of birth
Initiation belongs in the FIRST HOUR, during maximal alertness, with skin-to-skin.
Eoffer glucose water between feedings
Water and glucose water displace feeds and risk hyperbilirubinemia and hyponatremia.
Aallow rooming-in for mothers and neonates
Test point: Exclusive breastfeeding 6 months; first-hour initiation; on-demand; no pacifiers during establishment; no marketing.
Q53PediatricsForeign body aspiration
A 2-year-old playing quietly with his 4-year-old sibling on the deck suddenly begins coughing, drooling, and developing stridor. He is afebrile; skin is dry without erythema; pupils are 5 mm and reactive. The most likely diagnosis is
Aanaphylaxis
The stem's dry, nonerythematous, nonedematous skin is written to close this door: no exposure, no hives.
Bcroup
Croup has a barking cough after a viral prodrome, worse at night: not sudden.
Cepiglottitis
Epiglottitis is febrile, toxic, muffled voice, tripod posture, and progresses over hours: he has none.
Dforeign body aspiration Correct
Instantaneous transition from well to symptomatic mid-play in the 1-3 year peak group is aspiration; siblings mean small parts within reach. Keep him calm; rigid bronchoscopy removes it.
Eorganophosphate toxicity
Organophosphates cause MIOSIS and profuse secretions (SLUDGE); his pupils are 5 mm and skin dry.
Dforeign body aspiration
Test point: Onset decides: sudden mid-play = foreign body. If he can cough and phonate, no blind sweeps or thrusts.
Q66PediatricsMeasles
A recently placed foster child with unknown immunizations has high fever, cough, coryza, exudative conjunctivitis, and a confluent erythematous maculopapular rash prominent on the face and neck. No cervical lymphadenopathy. The most likely diagnosis is
AKawasaki disease
Kawasaki needs 5 days of fever plus nonexudative conjunctivitis, mucosal changes, extremity changes: his conjunctivitis is exudative and he has cough/coryza, which Kawasaki lacks.
BRocky Mountain spotted fever
RMSF starts on wrists and ankles moving centrally with tick exposure.
Crubella
Rubella is milder with a fainter non-confluent rash and PROMINENT posterior auricular/occipital nodes: explicitly absent.
Dmeasles Correct
The three Cs plus high fever and a cephalocaudal confluent morbilliform rash in an unvaccinated child is measles. Manage: report immediately, AIRBORNE isolation, vitamin A; complications include otitis, pneumonia, encephalitis, SSPE.
Escarlet fever
Scarlet fever is sandpaper rash, strawberry tongue, circumoral pallor after pharyngitis: no conjunctivitis or coryza.
Dmeasles
Test point: Koplik spots precede the rash and are often gone at presentation. Measles = airborne + vitamin A + health department.
Q72PediatricsFanconi anemia Missed in session
An 8-year-old girl at the 3rd percentile for height (tall siblings) has supernumerary thumbs, petechiae, cafe au lait macules, strabismus, hepatosplenomegaly, and scoliosis. The most likely diagnosis is
ACooley anemia
Beta-thalassemia major presents in infancy with hemolysis and chipmunk facies.
BFanconi anemia Correct
Radial-ray thumb anomalies + short stature + cafe au lait + PETECHIAE (marrow failure, typically declaring at 7-8) is Fanconi anemia, a DNA-repair chromosomal-instability disorder: diepoxybutane breakage test, transplant definitive, AML/SCC risk.
Ciron deficiency anemia
No dysmorphology, no petechiae, no organomegaly.
DTurner syndrome
Turner is short stature in a girl but with webbed neck, shield chest, coarctation, streak ovaries: no marrow failure or thumb anomalies.
EVACTERL association
The engineered distractor: VACTERL shares limb and vertebral findings but has NO hematologic or cutaneous component: petechiae, cafe au lait, and organomegaly go unexplained.
BFanconi anemia
Test point: When two diagnoses share features, discriminate on the findings only ONE explains, never on the overlap.
Session missSession miss: chose VACTERL off the thumbs+scoliosis overlap. Petechiae had no VACTERL explanation: that was the answer sitting in the stem.
Q99PediatricsGiardiasis
Children and staff at a daycare have 10 days of foul-smelling watery diarrhea with flatulence; stool cultures and rotavirus antigen are negative. No travel. The most likely organism is
AEntamoeba histolytica
Amebiasis is invasive dysentery with travel exposure, explicitly denied.
BEnterobius vermicularis
Pinworm causes nocturnal perianal itch, not diarrhea.
CEscherichia coli O157:H7
O157:H7 is BLOODY diarrhea from undercooked beef and grows on culture.
DGiardia lamblia Correct
Prolonged nonbloody malabsorptive diarrhea in a daycare cluster with NEGATIVE routine cultures (which detect only bacteria) is Giardia: duodenal trophoblasts blunt villi without invasion. Stool antigen/PCR diagnoses; tinidazole treats.
EVibrio cholerae
Rice-water cholera is a travel/shellfish disease.
DGiardia lamblia
Test point: Routine stool culture finds bacteria only: a negative one excludes nothing parasitic. Post-Giardia lactose intolerance mimics treatment failure.
Q100PediatricsVaricella contagious period
An unvaccinated child is exposed to a classmate with chickenpox. The classmate is contagious
Afrom the moment of his own exposure until the rash appears
The incubation period is not contagious.
Bfrom 24 hours before the rash until the rash appears
Ends exactly when infectivity peaks.
Cfrom the appearance of the rash until the last lesion crusts
Misses the pre-rash shedding entirely.
Dfrom 24 hours preceding the rash until crusting of the last lesion Correct
Varicella spreads from 1-2 days BEFORE the rash (the epidemiologically crucial window) until every lesion crusts, ~5 days in. Airborne plus contact, ~90 percent household attack rate.
Efor 10 to 21 days after his exposure
Describes incubation (10-21 days), a different question.
Dfrom 24 hours preceding the rash until crusting of the last lesion
Test point: Exposed and unvaccinated: varicella vaccine within 3-5 days (VZIG for the immunocompromised, pregnant, neonates). School exclusion until crusted.
Q125PediatricsBenign rolandic epilepsy
A 9-year-old boy has nocturnal episodes of facial grimacing and guttural noises; his father outgrew similar episodes. Physical examination is most likely to reveal
Adilated pupils
An ictal transient at most, not an exam finding.
Bfacial tics
The trap: tics are WAKING phenomena, suppressible, urge-driven, and vanish in sleep: the inverse of this story.
Cincreased deep tendon reflexes
UMN findings would demand imaging for structural disease.
Dincreased facial muscle tone
Same.
Eno related abnormalities Correct
Benign childhood epilepsy with centrotemporal spikes: nocturnal facial/oropharyngeal seizures, genetic, remits by adolescence: with a completely NORMAL interictal exam; the abnormality lives only on sleep-activated EEG. Many need no medication.
Eno related abnormalities
Test point: BECTS: rolandic cortex = face/pharynx, sleep-bound, outgrown. Contrast absence epilepsy: daytime stares, 3 Hz spike-wave, ethosuximide.
Q133PediatricsApt test
A well-appearing 4-day-old breastfed neonate born at home has blood in the stool with a normal examination. The most appropriate test to delineate the source of the blood is
Athe Apt test Correct
The Apt test distinguishes fetal from maternal hemoglobin by alkali denaturation: HbF resists (stays pink = infant bleeding); HbA denatures (yellow-brown = swallowed maternal blood from cracked nipples or delivery). A well infant makes swallowed blood the leading cause: nothing in his gut is bleeding.
Ba complete blood count
Grades anemia, silent on origin.
Ca direct antiglobulin (Coombs) test
Immune hemolysis causes jaundice, not bloody stools.
Dpartial thromboplastin time
Intrinsic pathway; vitamin K deficiency prolongs PT first.
Eprothrombin time
The clinically loaded alternative: home birth may mean no vitamin K, and PT is that test: but only AFTER Apt shows the blood is fetal.
Athe Apt test
Test point: 'Delineate the source' = whose blood is it. Fetal → work up (vitamin K, NEC, fissure, allergy); maternal → fix the latch.
Q134PediatricsRocky Mountain spotted fever
A 29-year-old veterinarian presents in August with fever of 40.0 C, headache, myalgia, and a macular petechial rash that began on the wrists and ankles and spread to the trunk. Progression can be prevented by treatment with
Aciprofloxacin
No reliable rickettsial activity.
Bdoxycycline Correct
Centripetal wrist-and-ankle rash + summer + occupational tick exposure = RMSF; doxycycline at ANY age, empirically on suspicion: serology is retrospective and untreated mortality runs 20-25 percent via endothelial vasculitis (ARDS, myocarditis, DIC).
Cmetronidazole
Anaerobes and protozoa.
Dtrimethoprim-sulfamethoxazole
May actually WORSEN rickettsial disease: contraindicated.
Evancomycin
Gram-positive coverage, irrelevant.
Bdoxycycline
Test point: The doxycycline-in-children exception: short courses do not stain teeth and RMSF kills. Rash spreading IN = RMSF; spreading DOWN = measles.
Q136PediatricsStevens-Johnson syndrome
A 3-year-old on an antibiotic for 3 days for otitis media has 1 day of bilateral conjunctivitis, poor intake, and hemorrhagic crusted lip erosions with targetoid perioral lesions. No desquamation, lymphadenopathy, or delayed capillary refill. The most likely diagnosis is
Aprimary herpetic gingivostomatitis
HSV attacks gingiva and tongue with fever and TENDER nodes: explicitly absent, and no conjunctivitis.
Bscarlet fever
Sandpaper rash after pharyngitis, improves ON antibiotics.
Cstaphylococcal scalded skin syndrome
The closest mimic with perioral crusting: but the toxin cleaves superficial desmoglein-1, so SSSS SPARES MUCOSA, and the stem's 'no desquamation' negates its hallmark.
DStevens-Johnson syndrome Correct
Drug exposure + TWO mucosal sites (oral, ocular) + targetoid lesions = SJS. Stop the drug immediately (the single most outcome-changing act), burn-unit care if extensive, urgent ophthalmology.
Etoxic shock syndrome
Requires hypotension and multiorgan involvement; his perfusion is normal.
DStevens-Johnson syndrome
Test point: SJS <10 percent BSA, TEN >30. Triggers: sulfa, anticonvulsants, allopurinol, NSAIDs: and Mycoplasma in children.
Q141PediatricsSalt-wasting CAH Missed in session
A 2-week-old with 4 days of vomiting is dehydrated and tachycardic with ambiguous genitalia. The most likely serum electrolyte findings are
Ahypernatremia and hyperkalemia
No mechanism retains both.
Bhypernatremia and hypokalemia
The vomiting-pattern trap: and the pattern that fits 11-beta and 17-alpha deficiencies, but both cause HYPERTENSION, impossible in this shocked infant.
Chyponatremia and hyperkalemia Correct
Ambiguous genitalia names the disease: 21-hydroxylase deficiency (95 percent of CAH). No aldosterone = the opposite of aldosterone's job: sodium WASTED (hyponatremia), potassium RETAINED (hyperkalemia), plus acidosis. Crisis at 1-3 weeks as maternal steroids wane; 17-OHP confirms; saline + dextrose + hydrocortisone, then fludrocortisone.
Dhyponatremia and hypokalemia
Pure vomiting losses without the adrenal lesion.
Enormal sodium and potassium
A salt-wasting crisis is never electrolyte-neutral.
Chyponatremia and hyperkalemia
Test point: Reason from the finding that names the disease (genitalia), not the loudest symptom (vomiting). BP separates the CAH enzymes.
Session missSession miss: chose hypernatremia/hypokalemia off the vomiting. Aldosterone absence dictates the electrolytes.
Q150PediatricsBronchiolitis
A 4-month-old with 2 days of rhinorrhea and cough now breathes faster and noisier: RR 40, saturation 96 percent, comfortable, no retractions, faint bilateral expiratory wheezes, warm boggy T1-T4 tissues. The most likely diagnosis is
Aasthma
Not diagnosable at 4 months: a first viral wheeze IS bronchiolitis.
Bbronchiolitis Correct
URI prodrome descending to expiratory wheeze in an infant under 2 is bronchiolitis (RSV): a clinical diagnosis, supportive care only: suction, hydration, oxygen below 90. No steroids, bronchodilators, antibiotics, films, or viral panels. He is mild: home.
Ccroup
Croup is INSPIRATORY stridor with a barking cough from the subglottis.
Dinfluenza
Influenza is abrupt and febrile-toxic; he is comfortable at 37.8.
Epertussis
Pertussis paroxysms whoop and vomit, with apnea in infants and clear lungs between fits: and a 1-2 week catarrhal ramp.
Bbronchiolitis
Test point: 'Warm, boggy' T1-T4 = ACUTE viscerosomatic change (contrast the fibrotic chronic rhinitis stem). Admission: hypoxia, apnea, poor feeding, under 2 months, comorbidity.
Q152PediatricsPyloric stenosis
A 5-week-old firstborn boy has 2 weeks of worsening nonbilious postprandial vomiting with poor weight gain, dehydration, a scaphoid nontender abdomen, sodium 133, potassium 2.8, chloride 92, bicarbonate 17. The most appropriate imaging study is
Aabdominal ultrasonography Correct
The 3-6 week firstborn male with NONBILIOUS projectile vomiting and hypochloremic hypokalemia is hypertrophic pyloric stenosis: ultrasound (muscle over 3-4 mm, channel over 15-17 mm) is radiation-free and over 95 percent sensitive. Then: FLUIDS AND POTASSIUM FIRST: pyloromyotomy is never an emergency.
Bair contrast enema
Intussusception's test-and-treatment, a 6-month-to-2-year colicky disease.
CCT scan of the abdomen
Needless radiation.
Dplain film radiography
Shows a distended stomach at best, never the muscle.
Eupper gastrointestinal series with small-bowel follow-through
The old test (string sign) and the right one for BILIOUS vomiting (malrotation): but his vomit is formula.
Aabdominal ultrasonography
Test point: Classic alkalosis may be masked by dehydration acidosis (his bicarb is 17): the chloride and potassium still tell the gastric story.
Q160PediatricsAutism: early intervention
An 18-month-old girl repeats phrases from the room's conversation, does not respond to 'come here' or her name, inspects the stethoscope rather than people, and interacts little with her exhausted mother. The most appropriate initial referral is to
Aan audiologist
Normally the reflex first step for language concerns: but she repeats phrases just heard, demonstrating intact hearing: the stem defused it deliberately.
Ban early intervention program Correct
Echolalia + no name response + object-over-people preference at the 18-month M-CHAT visit flags autism spectrum disorder: IDEA Part C early intervention is referred on SUSPICION, before and in parallel with diagnostic confirmation, because earlier behavioral intervention changes trajectory.
Ca geneticist
After diagnosis (fragile X, microarray), not initially.
Da neurologist
For seizures, regression, or focal findings: none present.
Ea pediatric psychologist
Performs the formal diagnostic evaluation (ADOS): in parallel, never as a services-delaying prerequisite.
Ban early intervention program
Test point: Refer on suspicion; services do not wait for the label. M-CHAT at 18 and 24 months; echolalia without communicative language is a red flag, not a variant.
Neuro / MSK16 questions
Q11Neuro / MSKC6 radiculopathy, dermatome
After an acceleration-deceleration injury, a patient has neck pain, weak wrist extension, and a diminished brachioradialis reflex. Sensory testing should be directed to the
Afourth and fifth fingers and medial palm
C8 territory (ulnar), paired with weak finger flexion and intrinsics.
Blateral humerus
C5, the axillary region over the deltoid, paired with weak abduction and a diminished biceps reflex.
Cmedial forearm
T1 (medial antebrachial cutaneous).
Dmiddle finger
C7, the closest trap: that pairs with weak elbow extension and wrist FLEXION and a diminished triceps reflex.
Ethumb, index finger, and lateral palm Correct
Brachioradialis reflex and wrist extension both localize to C6, whose dermatome is the lateral forearm, thumb, and index finger; a whiplash mechanism suggests C5-C6 disc or foraminal disease.
Ethumb, index finger, and lateral palm
Test point: Reflex map: biceps C5, brachioradialis C6, triceps C7, patellar L4, Achilles S1.
Q17Neuro / MSKSpondylolysis / spondylolisthesis
A 21-year-old figure skater has 6 months of progressive low back pain after a fall, midline tenderness at the lumbosacral junction, and a normal neurologic examination. A lateral radiograph shows anterior displacement of L5 on S1. The injury she sustained is
Aan acute lumbosacral somatic dysfunction
Somatic dysfunctions produce no bony step-off on film and do not explain 6 months of progression.
Ba lumbar type II somatic dysfunction
Same: not a radiographic lesion.
Cfracture of the L5 pars interarticularis Correct
Anterolisthesis of L5 on S1 in a young hyperextension athlete means bilateral spondylolysis, a pars interarticularis stress fracture, by far most common at L5 ('Scotty dog with a collar' on obliques).
Dan L5 compression fracture
A compression fracture shows anterior body height loss and wedging, not anterior translation of an intact body, and does not occur from a fall on ice in a healthy 21-year-old.
Equadratus lumborum strain
A QL strain is lateral, not midline, and would not last 6 months or show on radiograph.
Cfracture of the L5 pars interarticularis
Test point: Hyperextension athlete + midline lumbosacral pain = pars defect; MRI if films are negative.
Q46Neuro / MSKACA stroke localization
A patient has left-sided weakness with the LEG far weaker than the arm, gait apraxia, grasp and suck reflexes, and altered mentation. The occluded vessel is the
Aanterior cerebral artery Correct
Leg-predominant weakness maps to the medial hemisphere motor strip: ACA territory, corroborated by frontal release signs, abulia, and gait apraxia (add urinary incontinence to the list).
Binternal carotid artery
ICA occlusion combines ACA+MCA territories, so the leg would not be selectively worse; look for amaurosis fugax.
Cmiddle cerebral artery
The most common stroke but the opposite pattern: face and arm worse than leg, plus aphasia or neglect.
Dposterior cerebral artery
PCA gives homonymous hemianopia with macular sparing and minimal weakness.
Evertebrobasilar system
Posterior circulation gives crossed signs, cranial nerves, ataxia, vertigo.
Aanterior cerebral artery
Test point: ACA leg > arm; MCA face/arm > leg; PCA vision; brainstem crossed findings.
Q55Neuro / MSKFacet-mediated back pain
A 60-year-old man has 6 months of low back pain with morning stiffness that improves with movement, returns with prolonged standing, and is reproduced by lumbar extension. Neurologic examination is normal; L2-L4 are neutral, sidebent right, rotated left. The most likely diagnosis is
Adegenerative spondylosis Correct
Extension-provoked pain loads the posterior elements: facet arthropathy of degenerative spondylosis, with the gel phenomenon of osteoarthritic stiffness. The type I curve is compensatory.
Blumbar radiculopathy
No dermatomal radiation, sensory change, weakness, or reflex loss.
Clumbar strain
A strain is an acute event resolving in weeks, not 6 progressive months at 60.
Dpiriformis syndrome
Buttock pain with sciatic radiation, provoked by hip internal rotation, not axial extension pain.
Esomatoform disorder
A diagnosis of exclusion; he has a coherent mechanical syndrome.
Adegenerative spondylosis
Test point: Extension-provoked = facets; flexion-provoked = discogenic. If neurogenic claudication appears, it has become stenosis.
Q70Neuro / MSKAntiepileptic adherence
A 29-year-old woman with 6 years of seizure freedom on valproate and an oral contraceptive begins rotating shift work every 3 days. The most appropriate advice is to
Aavoid shift work entirely
Overreach: counsel sleep protection, do not take her job.
Bswitch contraception to medroxyprogesterone
Rests on a false premise: valproate is an enzyme INHIBITOR and does not reduce OCP efficacy: that problem belongs to carbamazepine, phenytoin, phenobarbital, topiramate.
Cswitch valproate to phenobarbital
Replaces a working regimen with a sedating inducer that WOULD undermine her contraception.
Dtake her medications on waking, regardless of the time of day Correct
Anchoring doses to waking survives rotating schedules and keeps intervals stable; missed doses are the top cause of breakthrough seizures. (Separately, valproate's teratogenicity warrants a preconception conversation.)
Eadd phenytoin
Polytherapy for a controlled patient with a therapeutic level: harm without benefit.
Dtake her medications on waking, regardless of the time of day
Test point: Never switch a drug that is working. Enzyme inducers, not valproate, defeat OCPs; estrogen lowers lamotrigine levels.
Q79Neuro / MSKAcute rotator cuff tear
A 60-year-old man feels a pop reaching to catch a falling object and now has anterolateral shoulder pain, a positive Hawkins sign, and a positive drop arm test. Years ago similar pain resolved with rest. The most likely diagnosis is
Aglenoid labral tear
Labral tears click, catch, and destabilize (O'Brien, crank), typically with overhead athletes.
Blong head of biceps rupture
Biceps rupture gives a Popeye deformity and bicipital groove pain with Speed/Yergason positivity, not a drop arm.
Cacute tear of the rotator cuff Correct
A positive drop arm is relatively specific for full-thickness supraspinatus tear; the acute-on-chronic story (old impingement pain, modest force finishing a degenerated tendon) is the usual biography. MRI confirms; acute tears in active patients go to repair.
Dglenohumeral osteoarthritis
OA is gradual, with crepitus and loss of active AND passive motion, no pop.
Eteres minor strain
Isolated teres minor injury is rare and would impair external rotation (Hornblower), not abduction.
Cacute tear of the rotator cuff
Test point: Cuff map: supraspinatus empty-can/drop-arm; infraspinatus resisted ER; teres minor Hornblower; subscapularis lift-off.
Q85Neuro / MSKSAH with negative CT
A hypertensive woman has a severe headache followed by loss of consciousness and a seizure, with meningismus but no fever. Head CT is negative. Lumbar puncture shows xanthochromia, 950 RBCs, protein 1,500, and 22 WBCs. The most likely diagnosis is
Aencephalitis
HSV encephalitis is febrile with altered mentation and lymphocytic pleocytosis.
Bidiopathic epilepsy
Epilepsy explains neither the stiff neck, the blood, nor a protein of 1,500.
Cbacterial meningitis
Afebrile with a trivial WBC of 22: reactive to blood, not infection.
Dischemic stroke
Ischemic stroke has normal CSF.
Esubarachnoid hemorrhage Correct
Xanthochromia (bilirubin from lysed RBCs, forming 2-12 hours after bleeding) distinguishes true SAH from traumatic tap; CT sensitivity falls steeply after 6 hours, which is why LP follows a negative scan. Next: CTA, secure the aneurysm, nimodipine 21 days.
Esubarachnoid hemorrhage
Test point: Thunderclap + negative CT = LP for xanthochromia. Traumatic tap: RBCs FALL across tubes; SAH: constant.
Q96Neuro / MSKNeurogenic claudication imaging Missed in session
A man has bilateral leg cramping after walking two blocks, relieved by sitting, with no skin or hair changes and normal pulses. Lumbar motion is restricted. The study most likely to identify the diagnosis is
ACT of the abdomen
Aortoiliac disease is already excluded by the normal vascular exam.
Bechocardiography
No cardiac question.
Cintersegmental motion testing
An examination maneuver, not a diagnostic study.
Dlumbar radiography
Plain films show the degenerative SUBSTRATE but cannot image neural elements: the modality must match the structure that defines the diagnosis.
EMRI of the lumbar spine Correct
Relief with sitting (flexion opens the canal) plus normal vascular findings = neurogenic claudication from spinal stenosis. The diagnosis IS neural compression, and only MRI shows the thecal sac, ligamentum flavum, and roots.
EMRI of the lumbar spine
Test point: Neurogenic: variable distance, flexion relief, shopping-cart sign, normal pulses. Vascular: fixed distance, rest relief, skin changes, ABI.
Session missSession miss (chose radiography): match the imaging to the structure that defines the diagnosis, not to the region.
Q97Neuro / MSKBrachioradialis reflex setup
After a snowmobile collision with left neck pain and left arm weakness, the examiner supports the relaxed forearm in neutral and strikes the distal radius. The nerve root primarily tested is
AC4
No standard limb reflex.
BC5
Biceps: thumb in the antecubital fossa.
CC6 Correct
Distal-radius percussion with the forearm supported is the brachioradialis reflex: C5-C6, tested as predominantly C6, fitting her whiplash C5-C6 disc mechanism.
DC7
Triceps: strike above the olecranon with the elbow flexed.
CC6
Test point: Setups identify reflexes on exams: fossa-thumb = C5, distal radius = C6, olecranon = C7.
Q103Neuro / MSKIsolated supraspinatus tear
A 17-year-old falls on an outstretched arm: subacromial tenderness, painful arc above 80 degrees, weak (4/5) flexion and abduction, normal (5/5) internal and external rotation, positive drop arm. No AC joint deformity or tenderness. The most likely diagnosis is
Aacromioclavicular separation
Excluded by the stated negatives: no step-off, no AC tenderness, no deformity.
Bglobal rotator cuff rupture
A global tear would weaken external AND internal rotation: both are 5/5.
Cinfraspinatus tear
Infraspinatus loss shows as weak external rotation, which is normal.
Dbiceps tendon rupture
Popeye deformity, groove tenderness, weak flexion-supination: absent.
Esupraspinatus tear Correct
Selective abduction weakness with a positive drop arm and intact rotations isolates the supraspinatus, which both initiates abduction and depresses the humeral head (why the drop arm fails at 90 despite the 0-15 initiation role).
Esupraspinatus tear
Test point: Abduction 0-15 supraspinatus, 15-90 deltoid, >90 scapular rotation (2:1 rhythm). Selective deficits name the muscle.
Q107Neuro / MSKEpidural hematoma
A 20-year-old struck in the left temporal area responds only to noxious stimuli, with a dilated poorly reactive left pupil, right-sided extensor posturing, and a right Babinski sign. CT of the head will most likely reveal
Aa concave blood collection along the right hemisphere
Concave/crescent = SUBDURAL (bridging veins, crosses sutures, elderly/anticoagulated): and the wrong side.
Ba convex blood collection compressing the left hemisphere Correct
Temporal impact tears the middle meningeal artery: a biconvex (lentiform) epidural hematoma bounded by suture lines, here left-sided: matching the ipsilateral blown pupil (uncal herniation compressing CN III) and contralateral posturing. Emergency craniotomy.
Ccisternal subarachnoid blood
Aneurysmal SAH physiology, not focal herniation after a blow.
Dright inferior temporal and frontal parenchymal hemorrhage
Contusions are plausible in trauma but do not produce this lateralized herniation syndrome, and the side is wrong.
Enormal brain parenchyma
He is herniating.
Ba convex blood collection compressing the left hemisphere
Test point: Epidural: artery, lens, lucid interval, sutures stop it. Subdural: veins, crescent, crosses sutures. Blown pupil = ipsilateral; posturing = contralateral.
Q111Neuro / MSKMultiple sclerosis: bilateral INO
A 26-year-old woman has 1 week of abnormal taste, unsteadiness, vertigo, and diplopia. Examination shows nystagmus, bilateral internuclear ophthalmoplegia, and ataxia. The most likely diagnosis is
Aacute disseminated encephalomyelitis
The demyelinating alternative, but ADEM is post-infectious, pediatric-leaning, and defined by ENCEPHALOPATHY, which she lacks.
Bbrainstem stroke
A single vascular event is abrupt, unilateral for INO, and belongs to older patients with risk factors.
CHuntington disease
Chorea, psychiatric change, and dementia with family history: no ophthalmoplegia.
Dmultiple sclerosis Correct
BILATERAL INO (impaired adduction with abducting nystagmus, convergence spared) requires lesions in both medial longitudinal fasciculi: essentially pathognomonic for demyelination in a young woman. MRI with gadolinium (Dawson fingers), oligoclonal bands; IV steroids for the relapse.
Esystemic lupus erythematosus
Neuropsychiatric lupus comes with systemic disease: rash, arthritis, serositis, cytopenias.
Dmultiple sclerosis
Test point: Bilateral INO = MS until proven otherwise. Uhthoff (heat) and Lhermitte (neck flexion shock) ride along.
Q113Neuro / MSKWernicke aphasia mistaken for delirium
A 65-year-old man has 12 hours of 'delirium': fluent nonsensical speech with no comprehension and decreased blink to threat in the right visual field. The most appropriate diagnostic step is
Aarterial blood gas analysis
Metabolic encephalopathy does not produce focal aphasia plus hemianopia.
Bcarotid ultrasonography
Etiologic workup after the stroke is confirmed, not the diagnostic step.
Celectroencephalography
Nonconvulsive status is a real delirium mimic, but a focal aphasia WITH a matching field cut says structural lesion in one vascular territory.
DMRI of the brain Correct
Fluent speech without comprehension plus a right field cut localizes to the left temporal lobe (inferior division of the left MCA): a stroke misread as delirium. MRI with diffusion-weighted imaging shows acute ischemia within minutes of onset.
EPET scan of the brain
No role in acute stroke.
DMRI of the brain
Test point: Wernicke patients are 'confused' but fluent with paraphasias and no comprehension; Broca patients are frustrated and telegraphic. Field cut = it is not delirium.
Q121Neuro / MSKMallet finger
A 37-year-old woman notices while styling her hair that the tip of her middle finger droops: full passive but no active extension of the distal phalanx. After radiography, the most appropriate management is
BMRI of the hand
A clinical diagnosis; the film answers the only management question.
Copen reduction with internal fixation
Surgery only for a fragment over one-third of the articular surface or volar subluxation: what the radiograph screens for.
Dphysical therapy
Actively harmful now: motion is the enemy; therapy follows the splint.
Estack splint Correct
Mallet finger: terminal extensor tendon avulsion at the DIP, often from trivial force. Continuous extension splinting 6-8 weeks: one lapse into flexion resets the clock; the PIP stays free.
Estack splint
Test point: Untreated mallet → swan neck. Boutonniere = central slip at PIP. RA owns both deformities but spares DIPs; OA and psoriatic own the DIPs.
Q128Neuro / MSKNormal pressure hydrocephalus
A 74-year-old woman has 9 months of confusion, inattention, disorganized speech, urinary incontinence, and a wide-based shuffling gait. CT of the head will most likely show
Aa cerebellar infarct
Cerebellar infarcts are acute with dysmetria and nystagmus.
Ba crescent-shaped hyperdense collection
A subdural is the great mimic but needs trauma or anticoagulation and shows focality.
Cenlarged ventricles Correct
Wet, wobbly, wacky over months = NPH: ventriculomegaly OUT OF PROPORTION to sulcal atrophy from impaired CSF absorption at normal opening pressure. Large-volume tap test, then VP shunt: gait improves most; one of the few reversible dementias.
Dhippocampal atrophy
Alzheimer leads with memory and walks normally until late: the ordering is reversed here (gait first).
Ean intracranial mass
A mass declares with headache, seizures, or focal signs.
Cenlarged ventricles
Test point: Gait-first dementia + incontinence = NPH. Periventricular fibers to legs and bladder stretch first.
Q142Neuro / MSKFunctional thoracic curve
A 19-year-old right-handed college quarterback has a slight right paravertebral hump at T3-T7 on forward bending that DISAPPEARS with right sidebending while forward bent. The most likely cause is
Aa defect in the vertebral ring epiphysis
Scheuermann kyphosis (ring epiphysis defects, wedged vertebrae) is RIGID: it does not correct with sidebending.
Ba developmental response on his dominant hand side Correct
A hump that RESOLVES with positioning is a functional (type I, reversible) curve: the convexity that repetitive dominant-side use builds in a throwing athlete. No restriction, cleared to play.
Can early presentation of spondylolisthesis
Spondylolisthesis is a lumbar (L5-S1) step-off problem, wrong region entirely.
Dgeneralized ligamentous laxity
Laxity is polyarticular, not one positional thoracic finding.
Eiliopsoas spasm
Iliopsoas disease produces lumbar-pelvic patterns and a functional short leg.
Ba developmental response on his dominant hand side
Test point: Adam test logic: persistent hump = structural (scoliometer, Cobb); resolving hump = functional (find the driver: handedness, leg length).
Biostatistics13 questions
Q9BiostatisticsSelection (referral) bias
The only hospital in the state with neonatal and pediatric ICUs reviews its delivery records and finds a cesarean rate far above the state average. The most likely explanation is
Aexpectation bias
Expectation bias is an observer's anticipated result skewing measurement; cesarean is an objective documented event.
Binformation bias
Information bias is error in MEASURING exposure or outcome; the problem here is who entered the sample.
Cobserver bias
Observer bias needs interpretive judgment; a cesarean is binary and recorded.
Drecall bias
Recall bias requires participants reporting from memory, essentially confined to case-control interviews.
Eselection bias Correct
Every high-risk pregnancy in the state is referred there, so the denominator is enriched for exactly the deliveries most likely to end in cesarean: referral (Berkson) bias, a form of selection bias.
Eselection bias
Test point: Distortion from who got INTO the study = selection bias; distortion from how data were collected on those already in = information bias.
Q28BiostatisticsInterpreting p = 0.049
A trial of combination therapy versus hydrochlorothiazide alone reports a 25-mmHg systolic reduction (95% CI 15-35), p = 0.049. The best interpretation is
Athe combination is superior to either medication individually
Overreach: the trial never tested the ARB alone, so no claim about 'either individually' is supported.
Bthe combination reduces hypertension risk by 5 percent
Converts a p value into a risk reduction; the outcome was continuous mmHg, not a proportion.
Cthere is a 95 percent probability the true reduction is 25 mmHg
Attaches probability to the POINT ESTIMATE: a confidence interval never does that.
Dthere is an approximately 5 percent probability the decrease was due to chance Correct
p = 0.049 is the probability of a result this extreme if the null were true, conventionally read as ~5 percent chance-alone probability; the CI excluding zero is concordant.
Ethe result is not statistically significant
False: 0.049 is below 0.05 and the CI excludes zero.
Dthere is an approximately 5 percent probability the decrease was due to chance
Test point: p attaches to the data given the null; a CI never gives the point estimate a probability.
Q38BiostatisticsDesign for a rare disease
Investigators with limited time and funding want to test whether occupational wood dust exposure is associated with nasopharyngeal carcinoma, a rare cancer. The most appropriate design is a
Acase-control study Correct
Rare disease + limited resources = case-control: sample ON the outcome, assemble existing cases, compare prior exposure, report an odds ratio.
Bclinical trial
Randomly assigning wood dust is unethical and impossible.
Ccross-sectional study
A snapshot of a rare, long-latency cancer captures almost no cases and cannot establish temporality.
Decological study
Population-level comparison cannot link exposure and disease in the same person (ecological fallacy).
Eprospective cohort study
The strongest observational design but exactly wrong here: enormous cohorts and years needed for a rare outcome. Cohorts shine for rare EXPOSURES.
Acase-control study
Test point: Rare disease → case-control. Rare exposure → cohort. Watch for recall bias as the price.
Q41BiostatisticsStatistical test selection
A 3-arm parallel trial compares mean cholesterol levels (mg/dL) across three drug groups. The most appropriate statistical test is
A3-sample proportion test
Also requires a categorical outcome (a proportion).
Banalysis of variance Correct
Three or more groups with a CONTINUOUS outcome is ANOVA by definition (between- versus within-group variance, F statistic); a significant result then needs post-hoc testing to find which pair differs.
Cchi-square test
Chi-square compares CATEGORICAL variables, like baseline sex distribution.
Dlogistic regression
Logistic regression models a BINARY outcome; continuous cholesterol would call for linear regression.
Et-test
A t-test compares exactly TWO means; three pairwise t-tests inflate family-wise type I error to ~14 percent.
Banalysis of variance
Test point: Grid: continuous/2 groups t-test; continuous/3+ ANOVA; categorical chi-square; non-normal Mann-Whitney or Kruskal-Wallis.
Q47BiostatisticsHazard ratio significance
A cohort study reports cardiovascular death hazards versus no antibiotic: amoxicillin 0.95 (0.55-1.63), azithromycin 1.87 (1.16-3.01), levofloxacin 1.60 (0.82-2.72), ciprofloxacin 0.86 (0.62-1.73). The drug with significantly increased risk is
Aamoxicillin
Interval spans 1: null.
Bazithromycin Correct
Only azithromycin's interval (1.16-3.01) sits entirely above 1.0: statistically significant increased hazard, the real QT/torsades signal.
Dlevofloxacin
The trap: the 1.60 point estimate looks large but 0.82-2.72 crosses 1: too imprecise to interpret (few events).
Eno antibiotic
The referent, HR fixed at 1 by definition.
Bazithromycin
Test point: Ratio measures are significant iff the CI excludes 1. A big point estimate with a wide crossing interval means nothing.
Q51BiostatisticsConfidence interval interpretation
A cohort study of vitamin A and hip fracture reports a relative risk of 1.5 with a 95% CI of 1.05 to 2.07. The correct interpretation is that
Athe number needed to treat is 5 percent
NNT is the reciprocal of absolute risk reduction, not derivable from a relative risk alone.
Bthe study has 95 percent power
Power is 1 minus beta, a design property never stated here.
Cthere is a 5 percent chance the true relative risk is 1.5
Inverts alpha and misattaches probability to the point estimate.
Dthere is a 95 percent chance the true relative risk lies between 1.05 and 2.07 Correct
The interval excludes 1.0, so the association is significant, and the standard reading of a 95% CI is the range expected to contain the true population value with 95 percent confidence.
Ethe association is not statistically significant
False: 1.05-2.07 sits entirely above 1.
Dthere is a 95 percent chance the true relative risk lies between 1.05 and 2.07
Test point: Attach the 95 percent to the INTERVAL, never to the point estimate; check the null (1 for ratios, 0 for differences) first.
Q56BiostatisticsEmpirical rule
Exam scores are normally distributed with mean 55 and standard deviation 5. The range containing 99.7 percent of students is
B35 to 75
4 SD has no standard meaning.
C40 to 70 Correct
99.7 percent spans 3 standard deviations: 55 plus or minus 15.
D45 to 65
The 2-SD range (95 percent): the off-by-one trap.
E50 to 60
The 1-SD range (68 percent).
C40 to 70
Test point: 68/95/99.7 at 1/2/3 SD. Exact 95 percent CI uses 1.96. SEM = SD/sqrt(n) describes the mean, not individuals.
Q62BiostatisticsStrongest evidence: RCT
Two small conflicting studies exist on yoga for childhood ADHD. With no constraint on time or funding, the design providing the strongest evidence of efficacy is a
Acase-control study
Built for rare diseases, working backward with recall bias.
Bcohort study
The best observational option, but families who choose yoga differ systematically in ways adjustment cannot fully remove.
Ccorrelational study
Association without confounder control at all.
Dcross-sectional study
A snapshot cannot show the yoga preceded the improvement.
Erandomized clinical trial Correct
For an intervention that can be ethically assigned, randomization balances known AND unknown confounders and blinding controls placebo effects: the strongest single-study evidence.
Erandomized clinical trial
Test point: Can you ethically randomize the exposure? Yes = RCT. No = best-fitting observational design. (A meta-analysis of RCTs would outrank one trial.)
Q77BiostatisticsOR table: significance vs magnitude
A study of macular degeneration reports odds ratios: myopia 1.28 (0.96-1.74), Fuchs dystrophy 1.77 (0.82-4.91), contact lens use 0.60 (0.35-1.88), green iris 0.96 (0.84-1.20), prior cataract surgery 1.04 (1.01-1.07). The best predictor of disease is
Adegree of myopia
Crosses 1.
BFuchs endothelial dystrophy
The trap: the biggest point estimate with an enormous crossing interval (0.82-4.91) means too few events to interpret.
Chistory of contact lens use
Crosses 1.
Dgreen iris color
The cleanest true null: point estimate at 1 with a narrow interval.
Eprevious cataract surgery Correct
Only cataract surgery's interval excludes 1.0: the sole statistically defensible predictor, however clinically modest (4 percent odds increase).
Eprevious cataract surgery
Test point: Precision, not magnitude, determines significance; magnitude, not precision, determines clinical importance. Read both.
Q132BiostatisticsInternal validity
In a 500-participant trial of the Mediterranean diet versus a low-calorie diet, participants are randomly allocated to groups. Random allocation is particularly important to ensure which type of validity?
Aconstruct
Whether an instrument measures its concept: irrelevant to allocation.
Bcontent
Test-design coverage of a domain.
Cestimation
Not a recognized validity type.
Dexternal
External validity is generalizability, set by WHO was enrolled, not how they were assigned: the classic paired distractor.
Einternal Correct
Internal validity asks whether the observed effect is truly caused by the intervention WITHIN the sample; randomization balances known and UNKNOWN confounders (baseline weight, motivation, activity), which no statistical adjustment can fully do.
Einternal
Test point: Internal = true for these subjects; external = true for other people. Randomization buys the first, eligibility criteria trade the second.
Q135BiostatisticsObservational causal language
A cohort study reports hip fracture relative risk 1.5 (95% CI 1.05-2.00) for high-dose vitamin A users. The study shows that
Adecreased vitamin A intake will reduce the risk of hip fracture
An interventional claim a cohort cannot make: that requires an RCT.
Bvitamin A supplementation probably resulted in an increased risk of hip fracture Correct
The CI excludes 1 (significant), the RR of 1.5 means increased risk, and 'probably' is the correctly hedged causal language for an OBSERVATIONAL design.
Cvitamin A supplementation results in a 1.5-fold decreased risk
Wrong direction.
Dvitamin A supplementation results in a 2-fold decreased risk
Wrong direction and wrong number.
Evitamin A supplementation results in a 2-fold increased risk
Reads the upper CI BOUND as the effect size; the point estimate is 1.5.
Bvitamin A supplementation probably resulted in an increased risk of hip fracture
Test point: Point estimate = effect size; bounds = precision. Cohorts support 'is associated with / probably,' never 'will.'
Q143BiostatisticsNumber needed to treat
A trial of an Alzheimer drug shows progression in 50 of 120 treated versus 75 of 120 on placebo. The calculation for how many patients must be treated for one to benefit is
A(50 x 45) / (70 x 75)
The cross-product: an odds ratio.
B(50/75) / (70/45)
An odds-style ratio, no NNT meaning.
C1 / |[50/(50+70)] - [75/(75+45)]| Correct
NNT = 1/ARR: one over the absolute difference in event rates (0.417 vs 0.625 → ARR 0.208 → NNT ~5). The '1 over a difference' SHAPE identifies it without arithmetic.
D[50/(50+70)] / [75/(75+45)]
A ratio of rates: relative risk.
E|[50/(50+70)] - [75/(75+45)]| / [75/(75+45)]
Difference over control rate: relative risk reduction.
C1 / |[50/(50+70)] - [75/(75+45)]|
Test point: Shape recognition: 1/difference = NNT; rate ratio = RR; diagonal product = OR; difference/CER = RRR. NNT depends on absolute risk, which is why relative numbers mislead.
Q151BiostatisticsProspective design identification
Researchers assign 150 students by coin flip to take or not take an obstetrics-gynecology rotation, collect sleep histories at baseline, during, and at follow-up, and compare sleep disorder proportions between groups. This is an example of a
Acase series study
No comparison group at all: the presence of a control excludes it instantly.
Bcase control study
Case-control starts from the OUTCOME and looks backward.
Ccross-sectional study
A snapshot without follow-up.
Dprospective cohort study Correct
Exposure defined first, subjects followed FORWARD, outcomes compared between exposed and unexposed: prospective architecture. (The coin flip technically makes it an RCT, which is structurally a randomized prospective cohort: with RCT absent, this is the answer.)
Eretrospective cohort study
Retrospective cohorts mine EXISTING records where both exposure and outcome already happened.
Dprospective cohort study
Test point: Identify designs by their starting point: exposure-forward = cohort; outcome-backward = case-control; neither = cross-sectional; assigned = trial.
OB/GYN13 questions
Q19OB/GYNRefractory late decelerations
A 42-week pregnancy is induced. At 9 cm dilation the tracing shows recurrent symmetric decelerations whose nadir follows the contraction peak, persisting despite repositioning, IV fluids, oxygen, and stopping oxytocin. The most appropriate next step is to
Aadminister terbutaline
Terbutaline treats tachysystole, which is not described, and oxytocin is already off.
Bcontinue expectant monitoring
Watching refractory late decelerations invites hypoxic-ischemic injury.
Cplace the patient in Trendelenburg position
Trendelenburg is a cord-prolapse maneuver; cord compression produces VARIABLE decelerations, not late.
Dprepare for an emergency cesarean section Correct
Late decelerations signal uteroplacental insufficiency (fitting a postterm placenta); when they persist despite the full intrauterine resuscitation bundle, delivery is the treatment.
Eperform a forceps-assisted vaginal delivery
The trap: operative vaginal delivery requires COMPLETE dilation. She is 9 cm, so forceps are contraindicated on that criterion alone.
Dprepare for an emergency cesarean section
Test point: VEAL CHOP. Refractory lates = deliver; forceps demand 10 cm, +2 station, ruptured membranes, known position.
Q29OB/GYNIncontinence: exclude UTI first
A woman with classic urge incontinence, including leakage on arriving home, has urinalysis showing positive nitrites. Before treating her incontinence, the most appropriate next step is to
Ameasure a postvoid residual
PVR is the overflow-incontinence workup; her pattern is urgency with normal voiding.
Bobtain a urine culture Correct
Nitrites (highly specific for Enterobacteriaceae bacteriuria) demand culture confirmation: UTI is a common, fully reversible cause of urgency, and treating it may resolve her symptoms entirely.
Csend urine cytology
Cytology screens for urothelial cancer in HEMATURIA, which she lacks.
Dorder urodynamic testing
Second line for diagnostic uncertainty or pre-surgery, never before infection is excluded.
Estart oxybutynin
Starting an anticholinergic with possible bacteriuria treats the wrong problem and impairs emptying, aggravating infection.
Bobtain a urine culture
Test point: DIAPPERS: clear the reversible causes before labeling incontinence. Positive nitrite → culture before anticholinergics.
Q35OB/GYNInpatient PID
A 17-year-old with pelvic pain, fever, mucopurulent cervicitis, and involuntary guarding with rebound requires treatment. The most appropriate regimen is
Aazithromycin and linezolid
Linezolid is a gram-positive drug; no gonococcal or anaerobic coverage.
Bcefazolin and metronidazole
Cefazolin has poor gonococcal activity and the regimen has zero chlamydia coverage.
Ccefoxitin and doxycycline Correct
Peritoneal signs push PID to PARENTERAL therapy: cefoxitin covers gonococcus and anaerobes, doxycycline covers chlamydia. Admission criteria: pregnancy, TOA, failed orals, severe illness, cannot exclude appendicitis.
Dtigecycline and imipenem
Broad-spectrum intra-abdominal artillery, not first-line PID.
Evancomycin and ciprofloxacin
Vancomycin is gram-positive only, and fluoroquinolones no longer treat gonorrhea (resistance).
Ccefoxitin and doxycycline
Test point: Outpatient PID: ceftriaxone IM + doxy + metronidazole x14d. Inpatient: cefoxitin/cefotetan + doxycycline.
Q54OB/GYNThreatened abortion
A woman at 5 weeks by dates has vaginal bleeding that is decreasing, a closed cervical os, hCG rising from 750 to 1,500 over 48 hours, and an intrauterine gestational sac without a fetal pole. The most appropriate management is
Astrict bed rest
Bed rest does not prevent miscarriage and carries thromboembolic harm: a retired myth.
Bvaginal progesterone
No established benefit in threatened abortion.
Cdilatation and curettage
D&C would terminate a potentially viable pregnancy; it is for incomplete, missed, or septic abortion.
Drepeat ultrasonography in 1 week Correct
Closed os + appropriately doubling hCG (over 53 percent per 48h) + intrauterine sac = threatened abortion with a likely viable pregnancy; at 5 weeks a fetal pole is not yet expected, so re-image in a week when cardiac activity should appear.
Eintramuscular medroxyprogesterone
A synthetic progestin with teratogenic concern, doubly wrong.
Drepeat ultrasonography in 1 week
Test point: The cervical os classifies abortion. Rh-negative bleeders get anti-D. hCG should double every ~48 hours early on.
Q58OB/GYNCervicitis: chlamydia Missed in session
A pregnant woman has mucopurulent cervical discharge from a friable cervix, more than 15 leukocytes per high-power field, no organisms on Gram stain, no vaginal wall inflammation, and no organisms on wet mount. Her partner had urethral discharge. The most likely organism is
AChlamydia trachomatis Correct
Inflammation with NO visible organism points at the obligate intracellular chlamydia, which never Gram stains; the leukorrhea is itself a sensitive sign of chlamydial cervicitis. Diagnose by NAAT; treat with azithromycin in pregnancy, test of cure, treat the partner.
BGardnerella vaginalis
BV is non-inflammatory (few WBCs), thin gray discharge, clue cells: not cervicitis.
CMycoplasma genitalium
A legitimate unstainable cervicitis agent but far less common: the runner-up.
DNeisseria gonorrhoeae
Gonorrhea shows gram-negative intracellular diplococci; treat empirically anyway in practice, but the stain argues against it as the answer.
ETrichomonas vaginalis
Trichomonas is a VAGINITIS (stem: no vaginal wall inflammation) and is diagnosed BY the wet mount: motile flagellates, whose absence excludes it.
AChlamydia trachomatis
Test point: Localize cervix vs vagina first; then read the stain as an INCLUSION criterion: no organisms + inflammation = chlamydia.
Session missSession miss: anchored on 'wet mount' and chose Trichomonas. A wet mount reports leukocytes (host) and organisms (pathogen); only organisms name a diagnosis.
Q67OB/GYNOvarian cancer risk
A 32-year-old woman with months of bloating, abnormal bleeding, dyspareunia, and a hard fixed adnexal mass has a new dry cough. The element of her history that most increases her risk for this condition is
Aalcohol use disorder
Alcohol tracks with breast, liver, esophageal, colorectal cancers, not ovarian.
Bfamily history Correct
Ovarian cancer at 32 strongly suggests hereditary disease: BRCA1/2 or Lynch; family history is the strongest identifiable risk factor, and every epithelial ovarian cancer patient is offered germline testing.
Ca low-fat diet
No evidence base.
Doral contraceptive use
The trap: OCPs are PROTECTIVE (30-50 percent, persisting decades) by suppressing ovulation: the incessant-ovulation hypothesis.
Bfamily history
Test point: Risk = more ovulation (nulliparity, early menarche, late menopause); protection = less (parity, breastfeeding, OCPs, tubal ligation).
Q68OB/GYNPreventing pyelonephritis in pregnancy
A woman at 24 weeks with no prenatal care presents with fever, vomiting, and bilateral costovertebral angle tenderness with pyuria. Her current condition could most likely have been prevented by
Ascreening for and treating asymptomatic bacteriuria Correct
Pregnancy is the one setting where asymptomatic bacteriuria is treated: untreated ASB progresses to pyelonephritis in 20-30 percent (progesterone-dilated ureters, mechanical compression). Universal first-visit culture is the standard she never received.
Bdaily prophylactic ciprofloxacin
Fluoroquinolones are contraindicated in pregnancy, and prophylaxis is reserved for recurrent disease.
Cincreased daily water intake
Reasonable advice that does not prevent ascending infection in bacteriuric pregnancy.
Ddaily cranberry juice
Weak evidence even outside pregnancy.
Eprenatal vitamins with folic acid
Prevents neural tube defects; right advice, wrong question.
Ascreening for and treating asymptomatic bacteriuria
Test point: Pyelo in pregnancy = admit + IV ceftriaxone + suppression after. Screen everyone at 12-16 weeks.
Q71OB/GYNASB in pregnancy, drug choice
A woman at 32 weeks' gestation has positive leukocyte esterase and leukocytes on routine dipstick without symptoms. T10-L1 paravertebral spasm is noted. The most appropriate treatment is
Aciprofloxacin
Fluoroquinolones: fetal cartilage toxicity.
Bclindamycin
Clindamycin has essentially no gram-negative urinary coverage: it is a BV and GBS-allergy drug.
Cnitrofurantoin Correct
Asymptomatic bacteriuria in pregnancy is treated; nitrofurantoin concentrates in urine with excellent E. coli coverage and is safe at 32 weeks (avoided at or beyond 38 weeks for neonatal G6PD hemolysis).
Dpenicillin
Penicillin G/V has inadequate E. coli activity; amoxicillin would have been legitimate, which is the distractor's engine.
Etetracycline
Tetracyclines: tooth discoloration, bone inhibition, maternal hepatotoxicity.
Cnitrofurantoin
Test point: Pregnancy UTI-safe: nitrofurantoin (<38w), cephalexin, amoxicillin, fosfomycin. Avoid FQ, tetracycline, TMP-SMX at the edges. T10-L1 = renal viscerosomatic level.
Q91OB/GYNBack labor
A laboring woman with membranes ruptured 16 hours ago has severe low back pain with each contraction, out of proportion to her abdominal discomfort. The most effective relief measure is
Acounterstrain to the thoracic paravertebral muscles
Wrong region and impractical: 90-second holds during contractions.
Bdirect pressure to the lumbosacral region Correct
Back labor, usually occiput posterior, drives the fetal occiput into the maternal sacrum: firm sacral counterpressure counters the force mechanically and gates nociception (T10-L1 afferents). Hands-and-knees positioning encourages rotation.
Cshoulder massage
Comfort without addressing the mechanism.
Dcervical traction
No relationship to labor pain.
ETrendelenburg positioning
A cord-prolapse and hypotension maneuver, not analgesia.
Bdirect pressure to the lumbosacral region
Test point: Occiput posterior = back labor = sacral counterpressure, double hip squeeze, position changes. ROM >18h: GBS prophylaxis and chorioamnionitis watch.
Q106OB/GYNPrimary dysmenorrhea
A 15-year-old nulliparous girl who reached menarche 3 months ago has severe crampy pain with her regular menses. Pelvic examination is unremarkable; she is not sexually active. In addition to OMT, the most appropriate initial step is to
Ainitiate nonsteroidal antiinflammatory drugs Correct
Primary dysmenorrhea (normal exam, onset near menarche) is prostaglandin-driven myometrial ischemia: NSAIDs block synthesis at the source, best started a day before menses and scheduled. Next step if failing: combined hormonal contraception.
Binitiate oral antibiotics
PID needs sexual activity and cervical motion tenderness: neither exists.
Corder pelvic ultrasonography
Imaging is for SECONDARY features: onset after 25, progression, abnormal exam, treatment failure.
Dperform an MRI of the pelvis
Same, and never first.
Eschedule an immediate laparoscopy
The endometriosis endgame after NSAIDs plus hormones fail, never initial at 15.
Ainitiate nonsteroidal antiinflammatory drugs
Test point: Primary: young, normal exam, first-line NSAIDs. Secondary: older onset, progressive, abnormal exam: find the cause.
Q129OB/GYNBacterial vaginosis in pregnancy
A 22-year-old primigravida at 13 weeks has thin white malodorous discharge, vaginal pH 5.5, and epithelial cells covered with coccobacilli on microscopy. She is at greatest risk of developing
Aabruptio placentae
Abruption belongs to hypertension, cocaine, trauma, smoking.
Ba future ectopic pregnancy
Ectopics follow TUBAL scarring from PID (chlamydia/gonorrhea); BV is a dysbiosis, not a tubal infection: her partner count baits this.
Cgestational diabetes
Metabolic risk factors, unrelated.
Dgestational hypertension
Nulliparity and obesity territory, no BV link.
Epreterm labor Correct
Clue cells + pH over 4.5 + fishy thin discharge = bacterial vaginosis (Amsel criteria); in pregnancy BV associates with PRETERM LABOR, PPROM, chorioamnionitis, and low birth weight. Symptomatic: metronidazole, safe in pregnancy.
Epreterm labor
Test point: Vaginitis grid: BV clue cells/pH>4.5/no inflammation; Trich frothy green/motile; Candida curdy/normal pH. Don't screen asymptomatic pregnancies for BV.
Q138OB/GYNPemphigoid gestationis
A 31-year-old at 28 weeks has a rapidly spreading eruption of erythematous patches with VESICLES AT THE MARGINS on the arms, abdomen, and legs, plus fever, malaise, nausea, and diarrhea. Labs show mild physiologic elevations only. The most likely diagnosis is
Aatopic eruption of pregnancy
Early-pregnancy eczema in atopics, no systemic illness.
Bintrahepatic cholestasis of pregnancy
ICP itches without a primary rash: bile acids make it.
Cpemphigoid gestationis Correct
Marginal VESICLES + periumbilical spread + a flu-like prodrome = pemphigoid gestationis: anti-BP180 autoimmune blistering (linear C3 on DIF), third-trimester, recurs in later pregnancies, and carries SGA/prematurity risk: steroids plus fetal surveillance.
Dpruritic urticarial papules and plaques of pregnancy
PUPPP starts in STRIAE, SPARES the umbilicus, never blisters, has no systemic symptoms, and favors primigravidas with multiples.
Epustular psoriasis of pregnancy
The hard competitor (fever, diarrhea, leukocytosis) but its marginal lesions are sterile PUSTULES in FLEXURES, with hypocalcemia.
Cpemphigoid gestationis
Test point: Vesicles at margins + umbilicus involved = pemphigoid; striae + spared umbilicus = PUPPP; itch without rash = cholestasis.
Q157OB/GYNDMPA counseling
An 18-year-old choosing depot medroxyprogesterone because she does not want a daily method should be counseled that the most likely side effect is
Aanorexia
Backwards: DMPA is the contraceptive most associated with weight GAIN.
Bdepression
Reported but neither most common nor causally solid.
Cirregular bleeding Correct
Unscheduled bleeding and spotting is DMPA's most common effect and its leading discontinuation reason: front-loaded counseling doubles persistence. It settles by 3-6 months; half to two-thirds are amenorrheic at a year, which many prefer.
Ethromboembolism
The trap: VTE risk rides on ESTROGEN: progestin-only DMPA is precisely the choice for smokers over 35, migraine with aura, and VTE history.
Cirregular bleeding
Test point: Also counsel: reversible BMD loss (black box) and ~10-month fertility delay. For 'nothing daily,' LARCs outperform everything.
Ethics / Legal11 questions
Q6Ethics / LegalMedical futility
A 94-year-old comatose woman with traumatic brain injury, cervical fracture, and bacterial meningitis failing antibiotics has no advance directive. The physician recommends supportive care because further therapies are unlikely to change her outcome. This recommendation reflects the principle of
Aautonomy
She is comatose without a directive; this is surrogate decision-making, not self-determination.
Bbeneficence
Beneficence operates in the background, but the stem's justification is ineffectiveness, not benefit.
Cfutility Correct
The stated rationale, therapies 'unlikely to change her outcome,' is the definition of medical futility: interventions that cannot achieve their physiologic goal need not be offered.
Dnonmaleficence
The close distractor: continuing burdensome care does harm, but nonmaleficence is about avoiding harm; the stem argues futility.
Epaternalism
The physician is recommending and discussing, not overriding the family.
Cfutility
Test point: 'Unlikely to change the outcome' is the exam's flag phrase for futility.
Q21Ethics / LegalAutonomy: the informed refusal
A 60 pack-year smoker with a lateral tongue lesion receives extensive counseling on the risks and benefits of biopsy. He declines all evaluation, saying he does not want doctors interfering, and asks only for symptom care. Honoring his decision reflects
Aautonomy Correct
A competent, fully informed adult may refuse any evaluation even when refusal is likely fatal; capacity is about understanding and communicating a choice, not agreeing with the physician. 'Extensive counseling' marks the refusal as informed.
Bbeneficence
Beneficence is what pushed the biopsy recommendation; autonomy is what governs the refusal.
Cdignity
Real but not one of the four classical principles the exam tests.
Djustice
Justice concerns fair allocation across populations; no resource question exists.
Enonmaleficence
Nonmaleficence is harm avoidance and could argue either direction, the sign it is not intended.
Aautonomy
Test point: Counseling already happened + settled preference = respect autonomy. Contrast: a fear-based, unexplored refusal gets a conference, not acquiescence.
Q44Ethics / LegalMalpractice: proximate cause
A patient suffers a hemorrhagic stroke shortly after an injection and sues. At trial, the plaintiff cannot prove the injection was the prevailing factor that precipitated the stroke. The element of malpractice that fails is
Awrongful act
Dereliction is not stated to have failed; only the causal link did.
Bdamages
Damages are established: stroke and paralysis.
Cduty
The physician-patient relationship creates duty.
Dproximate cause Correct
'Prevailing factor' is causation language: proximate cause requires that the harm was a foreseeable result of the breach and would not have occurred but for it. Temporal association is not causation.
Estatute of limitations
A procedural filing bar, not an element, and the case is already in court.
Dproximate cause
Test point: The 4 Ds all must hold: duty, dereliction, damages, direct cause. Stems are built by deleting exactly one.
Q60Ethics / LegalAnti-Kickback Statute
A surgeon rents office space from a laboratory at a rate that varies with the number of referrals he sends. This arrangement violates a criminal law established by the
AConsolidated Omnibus Budget Reconciliation Act
COBRA is insurance continuation (and EMTALA's vehicle), not referral payments.
BInternational Anti-Bribery and Fair Competition Act
Extends the FCPA to foreign officials: no domestic healthcare application.
CSherman Antitrust Act
Sherman governs restraint of trade and monopolization.
DSocial Security Amendments of 1972 Correct
Remuneration tied to referral volume is a kickback under the Anti-Kickback Statute, enacted in the Social Security Amendments of 1972: a CRIMINAL statute requiring knowing and willful intent.
EEthics in Patient Referrals (Stark) Act
Stark is CIVIL and strict-liability, covering physician self-referral; the word 'criminal' excludes it by definition.
DSocial Security Amendments of 1972
Test point: AKS: criminal, intent, anyone, safe harbors voluntary. Stark: civil, strict liability, physicians, exceptions mandatory.
Q73Ethics / LegalEMTALA screening
A woman with 3 weeks of back pain presents to an emergency department. Her HMO prefers she be seen in its office. Under federal law she is entitled to
Areferral to a specialist
Not an EMTALA element.
BHMO authorization before evaluation
The practice EMTALA was written to prohibit: delaying screening for authorization.
Creceive a screening examination Correct
EMTALA obligates a medical screening examination for anyone who presents, before any payment or authorization discussion; insurer preference is irrelevant until it is done.
Da notice of privacy practices
That is HIPAA.
Ereceive treatment
Overstates it: treatment (stabilization) is owed only if screening finds an emergency condition; 3 weeks of back pain will likely screen negative and be referred.
Creceive a screening examination
Test point: EMTALA (via COBRA 1986): screen, stabilize, transfer appropriately. Penalties are personal and not malpractice-insurable.
Q90Ethics / LegalThe unexplored refusal Missed in session
A 53-year-old woman with a hard 2-cm breast mass with skin dimpling refuses excisional biopsy because she is afraid of the procedure, asking to return in 6 months. The most appropriate response is to
Aarrange a conference with her to further discuss management options Correct
'Afraid' marks a modifiable barrier, not an informed refusal: no counseling is described and the less invasive options (core needle, FNA) were never offered. The conversation is the next step; if she still refuses after full counseling, THEN autonomy governs.
Bdocument her wishes and repeat mammography in 6 months
Abandonment dressed as autonomy: the mammogram will show the same mass and the delay costs stage.
Cprescribe an anxiolytic
Medicalizes a rational fear without closing the information gap.
Dproceed with biopsy despite her objection
Battery: never in a competent adult.
Erefer her for psychiatric evaluation
Declining surgery out of fear is not psychopathology.
Aarrange a conference with her to further discuss management options
Test point: Autonomy protects an INFORMED refusal; an unexplored, fear-based one gets a conference. Scan the stem for whether counseling already happened.
Session missSession miss: chose observation. The paired question (tongue lesion, 'after extensive counseling') is the autonomy side of the same axis.
Q108Ethics / LegalMass casualty triage
After a chemical plant explosion, 30 patients are en route. As triage officer with resources stressed to the limit, your responsibility is to
Aevaluate all patients for treatment after registration
Registration never gates emergency care (and EMTALA agrees).
Bevaluate each patient once
Triage is DYNAMIC: patients are re-sorted as they evolve.
Csort patients by time of presentation
First-come-first-served is the opposite of triage.
Dsort patients to ensure treatment for anyone injured
Describes normal operations, impossible by the stem's premise.
Esort patients to focus treatment on doing the most good for the largest number Correct
Mass casualty triage is utilitarian: greatest number of survivors, which means an EXPECTANT category exists and the sickest may be deprioritized. START: red immediate, yellow delayed, green walking, black expectant.
Esort patients to focus treatment on doing the most good for the largest number
Test point: Chemical event: DECONTAMINATE before entry or the ED becomes casualty 31. Triage decisions take ~30 seconds each.
Q131Ethics / LegalSTI reporting and partner notification
A married 40-year-old man with a generalized rash, fever, and penile lesions a month ago has a positive VDRL. He asks, 'Who has to know about this?' The most appropriate response is
A'I have to report this to the health department, and they will notify your sexual partners.' Correct
Secondary syphilis is nationally notifiable: reporting is a legal duty, and the health department performs confidential partner notification (partners are told of exposure, never the index name). Honesty now beats a surprise later.
B'Our conversations are protected under HIPAA.'
A false reassurance: HIPAA explicitly PERMITS mandatory public health reporting.
C'Provide me a list of your partners and I will contact them anonymously.'
Contact tracing is the health department's function, not the physician's.
D'The only person I am required to tell is your spouse.'
Wrong twice: no direct spousal duty, and the health department must be told.
E'You will need to contact your partners and urge them to receive treatment.'
Good counseling but incomplete: it omits the mandatory report he asked about.
A'I have to report this to the health department, and they will notify your sexual partners.'
Test point: Reportable STIs: syphilis, gonorrhea, chlamydia, HIV, chancroid. Treatment: benzathine penicillin G 2.4M units IM x1; expect Jarisch-Herxheimer.
Q145Ethics / LegalRefusal to treat: liability
An on-call physician refuses to respond to a gunshot victim because she is HIV positive, demanding another provider be found; the patient dies during the delay. The physician will likely be found
Aliable, because he engaged in an act of commission
Terminology: commission is doing harm; this was failing to act.
Bliable, because he failed to provide care Correct
All four Ds hold: on-call status creates DUTY, refusal is DERELICTION, death is DAMAGES, the delay is DIRECT CAUSE: liability by an act of OMISSION.
Cnot liable, because another provider was available
A substitute not available IN TIME discharges nothing.
Dnot liable, because providers may protect themselves from infection
No recognized right to refuse for HIV status: universal precautions exist, needlestick risk is ~0.3 percent with PEP available: and the ADA makes the refusal discrimination besides.
Enot liable, because there was no duty to treat
On-call IS the duty, and EMTALA compounds it.
Bliable, because he failed to provide care
Test point: The 4-Ds triptych on this form: causation missing (injection/stroke), damages missing (bupropion), all present (this one).
Q148Ethics / LegalElder abuse reporting
A cognitively intact 78-year-old man living with his son's family has bruises in various stages of healing on the back and abdomen and tearfully discloses that his daughter-in-law beats him. The most appropriate next step is to
Aask his permission to notify the police
The respectful-sounding trap: mandatory reporting does not require consent: autonomy governs his medical choices, not your legal duty.
Bcontact adult protective services to report the injuries Correct
Multi-stage bruising in protected areas + a changed story + direct disclosure from an intact patient: mandatory elder-abuse report to APS. Inform him you must report; assess whether going home tonight is safe; document verbatim with photographs.
Ccontact the patient's son to inform him
Routes the information into the abuser's household: the son may be complicit or unable to protect.
Dorder a CT of the abdomen and pelvis
Normal vitals, no acute abdomen: imaging defers the actual emergency, his safety.
Equestion the daughter-in-law privately
Never confront the suspected abuser: retaliation and rehearsed cover stories.
Bcontact adult protective services to report the injuries
Test point: CPS for children, APS for vulnerable adults; both report SUSPICION, neither asks permission, neither confronts.
Q156Ethics / LegalMalpractice: no damages
A primary care physician prescribes a tobacco-cessation drug contraindicated in a patient's seizure disorder; her cardiologist has her stop it and she threatens to sue. The case has no merit if the patient
Asuccessfully quit smoking
A good outcome does not preclude harm: she could quit AND have seized.
Bsuffered no damages Correct
Prescribing bupropion into a seizure disorder is a genuine breach: but malpractice requires all four Ds, and a breach WITHOUT HARM is not actionable. No seizure, no injury, no case.
Cused additional over-the-counter medications
Complicates causation without defeating the case.
Dused the modality incorrectly
Contributory negligence reduces damages proportionally; it does not erase the claim.
Ewas nonadherent with her follow-up visit
Same.
Bsuffered no damages
Test point: Bupropion contraindications: seizure disorder, eating disorders, abrupt alcohol/benzo withdrawal. Varenicline or NRT instead.
Surgery / EM10 questions
Q5Surgery / EMPyogenic flexor tenosynovitis
Two days after a nail-gun puncture of the finger, a man presents with a fusiform swollen digit held in flexion, tenderness along the flexor sheath, and severe pain on passive extension. The most appropriate management is
AIV antibiotics and immobilization with serial examinations
Antibiotics-alone is defensible only in the first ~24 hours of a mild presentation; at 2 days with the full tetrad, withholding drainage costs the finger.
Bbedside incision and drainage with oral antibiotics
Bedside I&D cannot adequately drain a closed tendon sheath and risks tendon injury.
Coral antibiotics and outpatient follow-up
Outpatient oral therapy badly undertreats a closed-space infection.
Dintravenous antibiotics and emergency department consultation with a hand surgeon Correct
All four Kanavel signs after a penetrating inoculation define pyogenic flexor tenosynovitis, a closed-space hand emergency: IV antibiotics with MRSA coverage plus emergent hand surgery for operative sheath irrigation.
Eoral antibiotics with a splint
Same failure: no oral pathway is adequate.
Dintravenous antibiotics and emergency department consultation with a hand surgeon
Test point: Kanavel signs = flexor tenosynovitis = IV antibiotics + OR. Felon and paronychia drain at bedside; the sheath does not.
Q18Surgery / EMSecondary spontaneous pneumothorax
A man with left-sided pneumonia acutely decompensates: saturation 84 percent, respiratory rate 32, heart rate 120, blood pressure 120/70. Breath sounds are markedly diminished on the right; radiograph shows a large right pneumothorax with a left infiltrate. The most appropriate next step is
Aendotracheal intubation
The dangerous distractor: positive pressure ventilation with an undrained pneumothorax creates tension physiology. Decompress first.
Bintravenous antibiotics
Indicated for the pneumonia but does nothing for a collapsed lung in the next minutes.
Cintravenous corticosteroids
He has no obstructive airway disease.
Dpericardiocentesis
Tamponade requires hypotension, JVD, and muffled heart sounds; his pressure is 120/70 and the film shows a lung problem.
Ethoracostomy Correct
A large secondary spontaneous pneumothorax in a decompensating patient needs tube thoracostomy: it is both confirmation and definitive treatment. Normal blood pressure and an obtained film mean this is not tension.
Ethoracostomy
Test point: Stable + film in hand = chest tube. Tension physiology + no film = needle first. Decompress before intubating.
Q50Surgery / EMAAA repair selection
A man with severe COPD has a large abdominal aortic aneurysm above repair threshold on CT. The most appropriate management is
Aopen surgical repair
Open wins for hostile anatomy (short/angled neck, poor access), young patients needing durability, connective tissue disease, infection, or no surveillance compliance: none apply.
Bdigital subtraction aortography
Invasive aortography adds nothing; CTA already characterized it.
Cendovascular repair Correct
Above threshold (5.5 cm men, 5.0 women, rapid growth, or symptoms) means repair; severe COPD is exactly the high-perioperative-risk patient EVAR was built for: no laparotomy, no cross-clamp. Tradeoff: lifelong endoleak surveillance.
Dultrasound surveillance in 6 months
Surveillance intervals are for SMALL aneurysms; his has crossed the threshold.
ECT surveillance in 12 months
Same, and surveillance uses ultrasound, not CT.
Cendovascular repair
Test point: High-risk patient + suitable anatomy = EVAR; young/hostile anatomy = open. Screen: one-time US, men 65-75 who ever smoked.
Q69Surgery / EMRule of nines
A man sustains superficial and deep partial-thickness burns to the entire anterior chest and abdomen and the anterior surface of one upper extremity. The estimated body surface area burned is
A18 percent
Omits the arm.
B22 percent Correct
Anterior trunk 18 plus half of one arm (4.5) = 22.5, approximately 22 percent. Both burn depths are second-degree and count.
C27 percent
Adds a full arm (9) as if both surfaces burned.
D31 percent
No combination yields it.
E36 percent
The entire trunk, front and back.
B22 percent
Test point: Adults: head 9, each arm 9, each leg 18, trunk 18+18, perineum 1. First-degree burns do NOT count. Parkland: 4 mL x kg x %TBSA, half in the first 8 hours from injury.
Q83Surgery / EMPerforated peptic ulcer
A woman with peptic ulcer disease on famotidine has sudden severe upper abdominal pain, worse with movement and breathing, diffuse tenderness, hypoactive bowel sounds, and heart rate 110 with BP 150/90. Upright radiograph shows free air under the diaphragm. The most appropriate next step is
Aa 2-liter crystalloid bolus alone
Supportive but not outcome-determining, and she is not hypotensive.
BCT of the abdomen with contrast
The tempting delay: the plain film already made the diagnosis; CT is for equivocal cases.
Cimmediate surgical consultation and preparation for surgery Correct
Pneumoperitoneum plus peritonitis is a perforated viscus: emergency laparotomy (Graham patch), with fluids, antibiotics, NG decompression, and a PPI running CONCURRENTLY, not instead.
Dtype and crossmatch for 6 units of blood
She is perforated, not hemorrhaging: no melena, no hypotension; a type and screen suffices.
Eemergency upper endoscopy
Contraindicated: insufflating a perforation enlarges it and floods the peritoneum.
Cimmediate surgical consultation and preparation for surgery
Test point: Upright CXR detects 1-2 mL of free air. Free air + peritonitis = OR now. Post-laparoscopy air can persist a week.
Q87Surgery / EMRuptured AAA pathogenesis
A 62-year-old hypertensive man has sudden abdominal and back pain with syncope: BP 88/60, pulse 118, hemoglobin 9.0, negative fecal occult blood, no peritoneal signs, mildly elevated amylase. The underlying cause is
Aatherosclerosis of the superior mesenteric artery
SMA disease is mesenteric ischemia: pain out of proportion, lactate, acidosis: his chemistry is normal.
Bcholelithiasis
Biliary colic causes neither hypotension nor anemia. The amylase bump is a nonspecific red herring.
CHelicobacter pylori infection
A bleeding ulcer would flag occult blood; a perforation would show peritonitis.
DMarfan syndrome
Also medial degeneration, but of the ASCENDING aorta in young marfanoid patients.
Eweakening of the media of the artery wall Correct
Pain + hypotension + acute anemia without a GI source is ruptured AAA, contained retroperitoneally (hence no peritonitis). Pathogenesis is degeneration of the tunica MEDIA: elastin loss, smooth muscle apoptosis; Laplace's law drives rupture with diameter. Management: straight to the OR, permissive hypotension, no CT.
Eweakening of the media of the artery wall
Test point: Unstable + pulsatile abdomen = OR without imaging. Stable + uncertain = CTA.
Q92Surgery / EMTension pneumothorax (classic)
After a motorcycle collision, a man has respiratory distress, distended neck veins, absent left breath sounds with hyperresonance, and hypotension. No imaging has been obtained. The most appropriate next step is
Bchest radiography
Imaging a tension physiology wastes the minutes that matter.
Cpericardiocentesis
Tamponade shares JVD and shock but has CLEAR EQUAL lungs and muffled heart sounds: his unilateral chest findings exclude it.
Dneedle thoracentesis Correct
Tension pneumothorax is a CLINICAL diagnosis: obstructive shock + unilateral absent breath sounds with hyperresonance = immediate needle decompression (5th ICS anterior axillary per ATLS), then chest tube. The absent film is itself the tell.
Etube thoracostomy after imaging
The chest tube is definitive but the needle comes first in extremis.
Dneedle thoracentesis
Test point: Film in the stem = stable = tube. No film + shock = needle now. Decompress before any positive-pressure ventilation.
Q109Surgery / EMAppendicitis with appendicolith
A 15-year-old girl has 6 hours of constant abdominal pain worse with walking, anorexia, low-grade fever, and right lower quadrant guarding. LMP was 2 weeks ago. CT shows a calcified right-lower-quadrant density with fat stranding. The most likely diagnosis is
Aacute appendicitis Correct
An appendicolith with periappendiceal stranding plus anorexia, migratory-pattern constant pain, and guarding is appendicitis: and an appendicolith predicts failure of antibiotics-only management, so appendectomy.
Bacute mesenteric lymphadenitis
The mimic in children AFTER a viral illness, with a normal appendix on imaging.
Covarian torsion
The reason the LMP is in the stem: torsion is SUDDEN colicky pain with an adnexal mass on imaging and prominent vomiting: none present. (US with Doppler is its test.)
Dpartial small-bowel obstruction
Obstruction distends, vomits, and tinkles: her abdomen is nondistended without surgical history.
Eureterolithiasis
Stone pain is colicky flank-to-groin with hematuria and a writhing patient: appendicitis patients lie still.
Aacute appendicitis
Test point: US first in children and pregnancy. Pain-worse-with-walking = peritoneal irritation. Alvarado/MANTRELS organizes the features.
Q118Surgery / EMGlasgow Coma Scale
An intoxicated man with a forehead contusion opens his eyes to voice, converses but is disoriented, and obeys commands. His Glasgow Coma Scale score is
B8
The intubation threshold ('less than 8, intubate'), far below him.
C10
Would need further deficits in two domains.
D13 Correct
Eyes to voice = 3; confused conversation = 4; obeys commands = 6. Total 13, mild TBI: but intoxication never explains a subnormal GCS without imaging, so he still gets a CT and serial exams.
E15
Requires spontaneous eye opening and full orientation.
D13
Test point: E4V5M6, minimum 3. Confused-but-conversant is V4; inappropriate words is V3. 13-15 mild, 9-12 moderate, <=8 severe (intubate).
Q155Surgery / EMTension pneumothorax without tracheal deviation Missed in session
An 18-year-old strikes his chest on the steering wheel: BP 86/50, pulse 130, saturation 80 percent. Distended neck veins, MIDLINE trachea, left chest wall bruising, hyperresonance with markedly diminished breath sounds on the left, left upper quadrant tenderness. The most appropriate initial intervention is
Aendotracheal intubation
Positive pressure into an undecompressed tension chest is catastrophic: decompress first.
Bneedle decompression Correct
Obstructive shock + UNILATERAL hyperresonance with absent breath sounds is tension pneumothorax: needle decompression now (5th ICS anterior axillary), tube to follow. The midline trachea excludes nothing: tracheal deviation is a LATE, INSENSITIVE sign absent in most real cases.
Cnormal saline bolus
Fluid cannot fix a mechanical obstruction to venous return.
Dpericardiocentesis
The engineered trap: tamponade shares JVD and hypotension (both are obstructive shock) but has CLEAR, EQUAL breath sounds and muffled heart tones: the lung exam is the only discriminator, and his is unilateral.
Ethoracotomy
For penetrating arrest or massive hemothorax. (The LUQ tenderness earns a spleen workup after the chest.)
Bneedle decompression
Test point: Never let an insensitive sign rule OUT. Shared shock findings can never discriminate; the organ-specific exam does.
Session missSession miss: the midline trachea pulled the answer to pericardiocentesis. Hyperresonance was the finding tamponade cannot produce.
Psychiatry9 questions
Q4PsychiatrySchizophrenia, evidence-based management
A young man has over a year of auditory hallucinations, disorganized behavior, and responding to internal stimuli, with prominent avolition, asociality, and poor self-care on a premorbid schizoid background. He denies sadness. The most appropriate management is
Aa benzodiazepine plus cognitive behavioral therapy
Benzodiazepines have no maintenance role and CBT alone leaves psychosis untreated.
Bpsychodynamic psychotherapy
Psychodynamic therapy is ineffective in schizophrenia and can destabilize.
Cdepot haloperidol
A first-generation depot has worse negative-symptom coverage and more EPS; long-acting injectables are for demonstrated nonadherence, not established here.
Dan SSRI
His flat presentation is negative symptoms, not depression: he explicitly denies sadness, and an SSRI does not treat psychosis.
Eziprasidone and psychosocial treatment Correct
Schizophrenia is treated with a second-generation antipsychotic COMBINED with psychosocial intervention (supported employment, social skills training, family psychoeducation); the psychosocial arm is what moves functional outcomes and negative symptoms.
Eziprasidone and psychosocial treatment
Test point: Atypical antipsychotic PLUS psychosocial treatment; negative symptoms are not depression.
Q20PsychiatryTardive dyskinesia, antipsychotic switch
After 25 years of fluphenazine decanoate for schizophrenia, a man develops a year of choreoathetoid orofacial movements that disappear in sleep and worsen with distraction. He still requires antipsychotic coverage. The best medication change is to
Acarbidopa-levodopa
Increases dopaminergic tone: worsens dyskinesia and risks exacerbating psychosis.
Bclozapine Correct
This is tardive dyskinesia from decades of a high-potency first-generation agent; clozapine has the lowest D2 occupancy and TD risk of any antipsychotic and may improve existing TD, so cross-taper to it (VMAT2 inhibitors are the FDA-approved TD drugs when available).
Cdantrolene
Dantrolene treats NMS and malignant hyperthermia: acute fever, rigidity, autonomic instability, none present.
Dphenytoin
An anticonvulsant; this is a movement disorder, not seizures.
Etizanidine
An alpha-2 agonist for spasticity from upper motor neuron disease.
Bclozapine
Test point: EPS timeline: dystonia hours-days, akathisia days-weeks, parkinsonism weeks-months, TD months-years. Anticholinergics WORSEN TD.
Q32PsychiatryAcute stress disorder timing
Twenty-five days after surviving a bombing, a woman has restlessness, feeling dazed, inability to recall parts of the event, and undistressing rituals of repeating her loved ones' phrases. The most likely diagnosis is
Aacute stress disorder Correct
Twenty-five days sits inside the 3-day-to-1-month window that defines acute stress disorder, and the prominent dissociation (amnesia, derealization) is characteristic.
Badjustment disorder
Adjustment disorder requires a NON-life-threatening stressor; a bombing is Criterion A trauma.
Camnestic disorder
Amnestic disorder needs a medical or substance cause; hers is dissociative and event-selective.
Dobsessive-compulsive disorder
Her rituals are explicitly not distressing, time-consuming, or impairing: not compulsions.
Eposttraumatic stress disorder
PTSD requires MORE than 1 month; at day 40 the same picture converts.
Aacute stress disorder
Test point: The clock decides: <3 days normal reaction, 3 days-1 month ASD, >1 month PTSD. Benzodiazepines worsen trajectory.
Q76PsychiatryHypoactive sexual desire disorder
A 38-year-old woman reports 3 years of absent sexual interest that concerns her; once engaged she enjoys intercourse and reaches orgasm. Cycles are every 26-28 days; exam is normal; she denies anhedonia elsewhere. The most likely diagnosis is
Aandrogen deficiency
No cause exists (no oophorectomy, adrenal or pituitary disease), and no validated female testosterone threshold defines it.
Bfemale sexual arousal disorder
Would mean she wants sex but her body does not respond: the opposite.
Chypoactive sexual desire disorder Correct
Desire is absent while arousal and orgasm are intact, with personal distress and over 6 months' duration: the deficit isolates to the desire phase.
Dperimenopause
Excluded by regular 26-28 day cycles and a normal exam.
Esexual aversion disorder
Requires active avoidance, disgust, or fear: she participates and enjoys.
Chypoactive sexual desire disorder
Test point: Map the complaint to the response-cycle phase; the stem's negatives (cycles, anhedonia denial) are doing the excluding.
Q101PsychiatryDelayed PTSD, pharmacotherapy
A combat veteran with supraventricular tachycardia develops 6 weeks of flashbacks, hearing his friends cry out, uncontrollable crying, and failing concentration after watching a war documentary, 30 years after service. The most appropriate medication is
Abupropion
No PTSD efficacy and can worsen arousal.
Bcitalopram Correct
PTSD with delayed expression: intrusion, negative mood, arousal, over 1 month, functionally impairing. SSRIs are first-line pharmacotherapy and citalopram is the only one offered.
Cclomipramine
The OCD tricyclic: and his SVT makes any TCA (sodium-channel blockade, proarrhythmia) a poor choice.
Dimipramine
Second-line TCA with the same cardiac problem.
Equetiapine
The trap: flashbacks are trauma memories recognized as memories, not psychosis; antipsychotics are late adjuncts only.
Bcitalopram
Test point: Trauma-focused psychotherapy is first-line overall; SSRIs for drugs; prazosin for nightmares; benzodiazepines contraindicated.
Q112PsychiatryDelirium tremens
A 45-year-old man is brought in confused and hallucinating; his daughter found glyburide and empty vodka bottles at home. Temperature 39.3 C, pulse 182, pupils 8 mm, reflexes 3+, dehydrated. Glucose is 123. The most likely diagnosis is
Aacute psychosis
Primary psychosis never produces fever of 39.3 and a pulse of 182.
Bdelirium tremens Correct
A hyperadrenergic delirium (fever, extreme tachycardia, mydriasis, hyperreflexia) in a chronic drinker who stopped is DT, typically 48-96 hours after the last drink. ICU, benzodiazepines by scale, thiamine before glucose, replete magnesium.
Cdiabetic ketoacidosis
DKA requires hyperglycemia with ketoacidosis: 123 excludes it.
Dneuroleptic malignant syndrome
NMS needs an antipsychotic and shows lead-pipe rigidity with HYPOreflexia, not clonus-adjacent hyperreflexia.
Esulfonylurea overdose
The glucose of 123 refutes it: glyburide overdose means profound hypoglycemia. The bottle is bait.
Bdelirium tremens
Test point: Timeline: tremor 6-12h, hallucinosis 12-24h (CLEAR sensorium), seizures 24-48h, DT 48-96h (clouded + autonomic storm).
Q127PsychiatryInterrupted suicide attempt
A 36-year-old man put a gun to his head during an argument until a relative wrestled it away. An hour later he reports the ideation is gone, he was 'just angry,' and he agrees to admission: but his insurer will not approve hospitalization and the family promises to watch him at home. The most ethical course is to
Aadmit him to the psychiatric unit Correct
An interrupted FIREARM attempt is maximal lethality; calm at one hour is expected, not reassuring, and he consents: voluntary admission. Insurance denial is ethically irrelevant, and a psychiatric emergency is an EMTALA condition regardless of payment.
Bdischarge him with a short-term prescription for sedatives
Hands an acutely suicidal man an overdose vehicle.
Cnotify law enforcement for the family's safety
He threatened himself, not others: no Tarasoff duty; police matter only for removing the gun.
Dobserve him in the emergency department for 24 hours
A hedge that is neither treatment nor the right level of care.
Eschedule an outpatient psychiatric visit for the next day
Leaves the highest-risk window (hours to days) uncovered.
Aadmit him to the psychiatric unit
Test point: Family supervision never substitutes for admission after a high-lethality attempt. Means restriction counseling regardless of disposition.
Q140PsychiatryDepression screening instrument
A 21-year-old woman has 3 weeks of fatigue, 4.5-kg weight loss, insomnia, anhedonia, and poor concentration with normal examination and labs. The most appropriate screening tool is the
ABeck Anxiety Inventory
Anxiety instrument: note the near-miss with the Beck DEPRESSION Inventory, which is not what this option says.
BHamilton Depression Rating Scale Correct
Five SIG E CAPS symptoms over 2+ weeks with normal medical workup = major depression; the Hamilton is the only depression-specific instrument offered (in practice, PHQ-9 screens; Hamilton grades severity).
CMinnesota Multiphasic Personality Inventory
A 567-item personality profile: wrong tool and scale.
DRorschach test
A projective test with poor psychometrics, obsolete diagnostically.
EYale-Brown Obsessive-Compulsive Scale
OCD severity scale; no obsessions or compulsions.
BHamilton Depression Rating Scale
Test point: Two mandatory follow-ons at this visit: ask about suicidality directly, and screen for mania before starting an antidepressant.
Q159PsychiatryAnorexia nervosa endocrinology
A 19-year-old woman (BMI 14.9) with amenorrhea for 6 months, twice-daily gym visits, lanugo, yellow-tinged skin, ankle edema, and a syncopal episode is evaluated. The laboratory abnormality most consistent with her presentation is
Adecreased follicle-stimulating hormone Correct
Starvation suppresses hypothalamic GnRH pulsatility: LOW FSH and LH (hypogonadotropic hypogonadism), low estrogen, amenorrhea. Admission is met (BMI under 15, syncope); refeed slowly watching PHOSPHATE.
Bdecreased cortisol
Backwards: starvation stress RAISES cortisol.
Cincreased luteinizing hormone
High LH would mean PRIMARY ovarian failure: her ovaries are fine, the signal is off.
Dincreased prolactin
Normal prolactin distinguishes this from prolactinoma amenorrhea.
Eincreased thyroid-stimulating hormone
Euthyroid sick: low T3 with normal-to-LOW TSH, not high.
Adecreased follicle-stimulating hormone
Test point: Anorexia panel: low FSH/LH, high cortisol and GH (low IGF-1), low T3, normal prolactin. Weight restoration, not OCPs, treats the bone loss.