MSN 621 MAIN EXAMINATION 2026 SET QUESTIONS AND
SOLUTIONS RATED A+
✔✔A 65-year-old male patient presents with the complaint of increasing shortness of
breath and nocturnal cough. His condition has been progressively worsening over the
past three months. He is a smoker and works in a cotton factory. He has one son and
one daughter with asthma. On examination, there is a wheeze and coarse end-
inspiratory crackles in the chest. A chest radiograph reveals diffuse non-specific
changes consistent with lung disease. Spirometry is performed on him. Which of the
following would indicate asthma? - ✔✔68%
✔✔A 44-year-old woman presents with sudden shortness of breath and 10/10 left-sided
chest pain, which began two hours ago while she was at work. She has had two
episodes of frank hemoptysis en route to the emergency department. She reports a
history of deep venous thrombosis three years ago, diagnosed during a prolonged
hospital admission after a cholecystectomy. She completed three months of apixaban at
that time. She smokes one pack of cigarettes per day, and her medications include a
multivitamin and an oral contraceptive pill. Her blood pressure is 70/45 mmHg, heart
rate 140 beats per minute, and respiratory rate 40 breaths per minute. Chest
auscultation demonstrates clear lung sounds in all fields. The patient's left-sided chest
pain is not reproducible, and there is no left chest deformity. An electrocardiogram
shows sinus tachycardia without ST-T wave changes, and the initial D-dimer level is
elevated. After rec - ✔✔IV tPa
✔✔A 45-year-old man presents to the hospital with complaints of dull aching chest pain,
exacerbated upon inhalation. The pain worsens and becomes unbearable while
coughing and sneezing. He further states that he had a fever two days ago, which
responded to acetaminophen. Which of the following is the most likely source of pain in
this patient? - ✔✔Respiratory system
✔✔A 26-year-old male comes to the emergency department complaining of fatigue,
dyspnea, chest pain, and syncope, especially when playing soccer. This has been going
on for the past 2 weeks. He has no significant past medical history. He denies smoking,
caffeine intake, tinnitus, vomiting, or coughing. He has been taking NSAIDs regularly for
the past year due to headaches that he attributes to "being stressed out from my new
job." On examination, BP: 120/81 mmHg, HR: 55 bpm, RR: 18/min, and O2: 99% on
room air. Skin examination: no rashes, abdominal examination: mild epigastric
tenderness but no organomegaly, chest examination: equal air entry bilaterally with no
abnormal sounds. ECG shows P waves and QRS complexes that are independent of
each other. Blood tests show antibodies to the organism in the picture. Which of the
following is the most appropriate treatment for this patient's case? - ✔✔Hospitalization
for IV ceftrax and telemetry monitoring
✔✔A 49-year-old female presents for an annual physical exam. Her medical history is
significant for diabetes mellitus that is well controlled on metformin 500 mg twice a day.
,She otherwise has no complaints except for pain during intercourse. She also has been
moody recently. She has been married for 15 years and has no trouble in the marriage.
Which of the following most accurately describes the hormonal events associated with
menopause? - ✔✔decreased esterdoil
✔✔Which of the following is the best modality for diagnosing a 1x1 cm cystic breast
mass in a 35-year-old female presenting with a painful mobile lump of fewer than 6
months duration? - ✔✔U/S
✔✔A 41-year-old female patient presented to the clinician for contraception. She had 3
children, all born through standard vaginal delivery. She stated that her family was
complete, and was sure that she does not want another child. Her blood pressure was
150/90, and her pulse was at 89 beats/minute. She smoked half a pack of cigarettes
daily. What would be an ideal contraceptive in this case? - ✔✔IUD
✔✔A 17-year-old female sex worker presents to the hospital with a complaint of vaginal
discharge that started two months ago. She also complains of intermenstrual bleeding
and lower abdominal pain. On further questioning, she reveals that she has been active
with multiple partners lately. Her vital signs show blood pressure 100/80 mmHg,
respiratory rate 18 breaths/min, heart rate 88 beats/min, and temperature 101 F (38.3
C). A pelvic examination shows cervical discharge, cervical motion tenderness, and
uterine tenderness. A blood test is ordered, which shows a white cell count of 17,500
per microliter of blood. What is the most likely mechanism leading to the spread of the
causative organism? - ✔✔Thinning of cervical mucous
✔✔A 30-year-old female patient presents with complaints of abdominal pain and
diarrhea for six months. She describes her pain as abdominal cramps. She is unable to
localize her pain. She states it is intermittent, rated 8/10 at its worst and 0/10 currently.
She states her pain is worse right before she has a bowel movement and relieves after
having a bowel movement. She describes her bowel movements as loose, unformed
stools. - ✔✔
✔✔A 12-year-old male is brought to the clinic with complaints of fever and abdominal
cramps. He has also been having bloody diarrhea since yesterday. The detailed history
reveals him to have consumed smoked chicken two days ago. On presentation, he has
a temperature of 100.5 F (37.8 C), a pulse rate of 96 beats per minute, a blood pressure
of 100/70 mmHg, and a respiratory rate of 19 breaths per minute. The physical
examination does not reveal any significant findings, except for hyperactive bowel
sounds. He has a hemoglobin level of 10.5 g/dl, a white cell count of 11500/mm3, and a
platelet count of 350,000/mm3. The treatment is initiated to rehydrate the patient. Which
of the following investigations would help best in establishing the diagnosis? - ✔✔Stool
eval
✔✔A 35-year-old woman presents with sneezing, rhinorrhea, nasal congestion, fatigue,
and myalgias. She developed these complaints one day back and decided to seek
,immediate care. A review of symptoms reveals mild itching in the eyes and a frontal
headache. She admits to smoking two packs of cigarettes daily - ✔✔
✔✔however, she denies alcohol and illicit drug use. The patient's medical history is
significant for gastroesophageal reflux disease and irritable bowel syndrome. The
patient cannot recall her last vaccination and says that she prefers "natural immunity."
Her blood pressure is 130/75 mmHg, pulse is 105/min, temperature 100 F (37.7 C), and
respiratory rate is 19/min. Examination shows red eyes, erythema over the pharynx, and
dry mucous membranes. Which of the following is the next best step in the
management of this patient? - ✔✔Oseltamivir
✔✔A healthy 17-year-old male presents with three days of worsening fatigue,
rhinorrhea, nasal congestion, myalgias, and subjective fever. He is severely allergic to
eggs and therefore does not receive the annual influenza vaccine. His blood pressure is
125/75 mmHg, pulse 100 beats per minute, temperature 100 F (37.7 C), and respiratory
rate 18 breaths per minute. Examination demonstrates conjunctivitis, oropharyngeal
erythema, and clear breath sounds. Given the likely diagnosis, what is the most
appropriate treatment? - ✔✔Symptomatic tx only
✔✔A 6-month-old girl is brought to the office for a routine check-up. The patient has no
health issues and has met all her developmental milestones. The patient has started to
stand up with help, can say the words "mama" and "dada," smile socially, and hold a
spoon with two fingers. She also recognizes her name. Her past medical history is
significant for an urticarial reaction to egg white. She was born at 36 weeks of gestation
and had an uneventful delivery. She has been given the 3rd dose diphtheria, tetanus, &
acellular pertussis vaccine (DTaP), pneumococcal conjugate vaccine (PCV 13), and
inactivated polio vaccine. What is the next best step in the management of this patient?
- ✔✔Give IM
✔✔A 40-year-old woman from the New England area of the United States presents with
complaints of malaise, headache, rash, and fever. She went hiking in a local park with
her family seven days ago. She has a history of depression and hypothyroidism, for
which she takes paroxetine and levothyroxine. She was an occasional smoker but quit
five years ago. On examination, her temperature is 99 F (37.2 C), heart rate is 80/min,
respiratory rate is 16/min, and blood pressure is 125/75 mmHg. A rash is noted on her
right upper extremity (see image). The rest of her physical exam is unremarkable. What
is the recommended treatment for this patient's condition? - ✔✔10 days of doxy
✔✔A patient is diagnosed with Lyme disease and started on doxycycline 100 mg PO
BID for 4 weeks. After the first dose, the patient is worse with dizziness, shaking, and
fever. What is the cause of the change in the patient's condition? - ✔✔Jarisch
herxheimer rxn
✔✔A 34-year-old forest ranger, previously healthy, presents with dizziness, syncope,
and increasing fatigue for 2 weeks. Vital signs are the temperature of 98°F (36.7°C),
, blood pressure of 110/80 mm Hg, and a heart rate of 38 beats per minute with a regular
pulse. No murmur is noted. The neurological exam reveals a Bell palsy. An
electrocardiogram (EKG) shows a complete heart block. Which joint is most likely
painful? - ✔✔Knee
✔✔A patient presents because she believes she is bitten by a tick a few days ago while
hiking in the woods. She mentions swelling in her right ear and general malaise. On
exam, she has a 1 x 2 cm bluish-red nodule located on the right ear lobe. What is the
next best step in management for this patient? - ✔✔Lyme serology
✔✔A female presents with progressive confusion over weeks with memory loss. She
has a slight fever at 100.4 F. Prior to cognitive changes, she had been complaining of
arthralgias. History is otherwise unremarkable except for the fact she is an avid camper.
Which of the following is the initial diagnostic test that should be ordered? - ✔✔Serology
✔✔A 7-year-old boy presents with a pronounced limp secondary to pain in his leg. The
pain is around his left knee, and on physical examination, the left knee is swollen. Two
weeks earlier, he had a painful right ankle with limping. His mother reports he has had
an elevated temperature, but she has not measured it. He lives in a rural area that has a
stream running through the back of the property. Prior to aggressive-invasive therapy,
what infective process should be considered that may not need surgical intervention as
the primary mode of treatment? - ✔✔Lyme disease
✔✔A 17-year-old presents with tonsil hypertrophy, new-onset snoring, bilateral cervical
lymphadenopathy, low-grade fever, and general malaise. Two days ago, the patient
developed severe abdominal pain and anorexia, unaffected by eating or drinking. He
has had a recent bowel movement. Which of the following is the gold standard test in
diagnosing his condition? - ✔✔Heterophil antibody test
✔✔A 17-year-old female presents with a severe sore throat. She has been sick with a
fever for four days. The patient's voice is muffled, and she prefers not to speak
secondary to pain. She has not been able to eat solids for 2 days and has refused to
drink for 1 day. Vital signs show a temperature of 39.8 C, heart rate 140 beats/min,
respiratory rate 20, and blood pressure 110/70 mmHg. The exam shows the tonsils to
be four-plus enlarged with partial airway obstruction and grey-white exudates. It is
associated with cervical lymphadenopathy and splenomegaly. A rapid strep screen is
negative. A CBC shows atypical lymphocytes. What is the most appropriate
management? - ✔✔Admission for hydration and corticosteroids
✔✔A 3-year-old boy presented with a 3-day history of mild headache and decreased
activity. The child later developed a fever of 39.4 C (102.9 F), associated with a mild
cough and sore throat. On physical examination, he has anterior and posterior cervical
lymphadenopathy with mild splenomegaly. The white blood cell count is 5000/mm3 with
an average differential count. The alanine aminotransferase level is increased to 280
SOLUTIONS RATED A+
✔✔A 65-year-old male patient presents with the complaint of increasing shortness of
breath and nocturnal cough. His condition has been progressively worsening over the
past three months. He is a smoker and works in a cotton factory. He has one son and
one daughter with asthma. On examination, there is a wheeze and coarse end-
inspiratory crackles in the chest. A chest radiograph reveals diffuse non-specific
changes consistent with lung disease. Spirometry is performed on him. Which of the
following would indicate asthma? - ✔✔68%
✔✔A 44-year-old woman presents with sudden shortness of breath and 10/10 left-sided
chest pain, which began two hours ago while she was at work. She has had two
episodes of frank hemoptysis en route to the emergency department. She reports a
history of deep venous thrombosis three years ago, diagnosed during a prolonged
hospital admission after a cholecystectomy. She completed three months of apixaban at
that time. She smokes one pack of cigarettes per day, and her medications include a
multivitamin and an oral contraceptive pill. Her blood pressure is 70/45 mmHg, heart
rate 140 beats per minute, and respiratory rate 40 breaths per minute. Chest
auscultation demonstrates clear lung sounds in all fields. The patient's left-sided chest
pain is not reproducible, and there is no left chest deformity. An electrocardiogram
shows sinus tachycardia without ST-T wave changes, and the initial D-dimer level is
elevated. After rec - ✔✔IV tPa
✔✔A 45-year-old man presents to the hospital with complaints of dull aching chest pain,
exacerbated upon inhalation. The pain worsens and becomes unbearable while
coughing and sneezing. He further states that he had a fever two days ago, which
responded to acetaminophen. Which of the following is the most likely source of pain in
this patient? - ✔✔Respiratory system
✔✔A 26-year-old male comes to the emergency department complaining of fatigue,
dyspnea, chest pain, and syncope, especially when playing soccer. This has been going
on for the past 2 weeks. He has no significant past medical history. He denies smoking,
caffeine intake, tinnitus, vomiting, or coughing. He has been taking NSAIDs regularly for
the past year due to headaches that he attributes to "being stressed out from my new
job." On examination, BP: 120/81 mmHg, HR: 55 bpm, RR: 18/min, and O2: 99% on
room air. Skin examination: no rashes, abdominal examination: mild epigastric
tenderness but no organomegaly, chest examination: equal air entry bilaterally with no
abnormal sounds. ECG shows P waves and QRS complexes that are independent of
each other. Blood tests show antibodies to the organism in the picture. Which of the
following is the most appropriate treatment for this patient's case? - ✔✔Hospitalization
for IV ceftrax and telemetry monitoring
✔✔A 49-year-old female presents for an annual physical exam. Her medical history is
significant for diabetes mellitus that is well controlled on metformin 500 mg twice a day.
,She otherwise has no complaints except for pain during intercourse. She also has been
moody recently. She has been married for 15 years and has no trouble in the marriage.
Which of the following most accurately describes the hormonal events associated with
menopause? - ✔✔decreased esterdoil
✔✔Which of the following is the best modality for diagnosing a 1x1 cm cystic breast
mass in a 35-year-old female presenting with a painful mobile lump of fewer than 6
months duration? - ✔✔U/S
✔✔A 41-year-old female patient presented to the clinician for contraception. She had 3
children, all born through standard vaginal delivery. She stated that her family was
complete, and was sure that she does not want another child. Her blood pressure was
150/90, and her pulse was at 89 beats/minute. She smoked half a pack of cigarettes
daily. What would be an ideal contraceptive in this case? - ✔✔IUD
✔✔A 17-year-old female sex worker presents to the hospital with a complaint of vaginal
discharge that started two months ago. She also complains of intermenstrual bleeding
and lower abdominal pain. On further questioning, she reveals that she has been active
with multiple partners lately. Her vital signs show blood pressure 100/80 mmHg,
respiratory rate 18 breaths/min, heart rate 88 beats/min, and temperature 101 F (38.3
C). A pelvic examination shows cervical discharge, cervical motion tenderness, and
uterine tenderness. A blood test is ordered, which shows a white cell count of 17,500
per microliter of blood. What is the most likely mechanism leading to the spread of the
causative organism? - ✔✔Thinning of cervical mucous
✔✔A 30-year-old female patient presents with complaints of abdominal pain and
diarrhea for six months. She describes her pain as abdominal cramps. She is unable to
localize her pain. She states it is intermittent, rated 8/10 at its worst and 0/10 currently.
She states her pain is worse right before she has a bowel movement and relieves after
having a bowel movement. She describes her bowel movements as loose, unformed
stools. - ✔✔
✔✔A 12-year-old male is brought to the clinic with complaints of fever and abdominal
cramps. He has also been having bloody diarrhea since yesterday. The detailed history
reveals him to have consumed smoked chicken two days ago. On presentation, he has
a temperature of 100.5 F (37.8 C), a pulse rate of 96 beats per minute, a blood pressure
of 100/70 mmHg, and a respiratory rate of 19 breaths per minute. The physical
examination does not reveal any significant findings, except for hyperactive bowel
sounds. He has a hemoglobin level of 10.5 g/dl, a white cell count of 11500/mm3, and a
platelet count of 350,000/mm3. The treatment is initiated to rehydrate the patient. Which
of the following investigations would help best in establishing the diagnosis? - ✔✔Stool
eval
✔✔A 35-year-old woman presents with sneezing, rhinorrhea, nasal congestion, fatigue,
and myalgias. She developed these complaints one day back and decided to seek
,immediate care. A review of symptoms reveals mild itching in the eyes and a frontal
headache. She admits to smoking two packs of cigarettes daily - ✔✔
✔✔however, she denies alcohol and illicit drug use. The patient's medical history is
significant for gastroesophageal reflux disease and irritable bowel syndrome. The
patient cannot recall her last vaccination and says that she prefers "natural immunity."
Her blood pressure is 130/75 mmHg, pulse is 105/min, temperature 100 F (37.7 C), and
respiratory rate is 19/min. Examination shows red eyes, erythema over the pharynx, and
dry mucous membranes. Which of the following is the next best step in the
management of this patient? - ✔✔Oseltamivir
✔✔A healthy 17-year-old male presents with three days of worsening fatigue,
rhinorrhea, nasal congestion, myalgias, and subjective fever. He is severely allergic to
eggs and therefore does not receive the annual influenza vaccine. His blood pressure is
125/75 mmHg, pulse 100 beats per minute, temperature 100 F (37.7 C), and respiratory
rate 18 breaths per minute. Examination demonstrates conjunctivitis, oropharyngeal
erythema, and clear breath sounds. Given the likely diagnosis, what is the most
appropriate treatment? - ✔✔Symptomatic tx only
✔✔A 6-month-old girl is brought to the office for a routine check-up. The patient has no
health issues and has met all her developmental milestones. The patient has started to
stand up with help, can say the words "mama" and "dada," smile socially, and hold a
spoon with two fingers. She also recognizes her name. Her past medical history is
significant for an urticarial reaction to egg white. She was born at 36 weeks of gestation
and had an uneventful delivery. She has been given the 3rd dose diphtheria, tetanus, &
acellular pertussis vaccine (DTaP), pneumococcal conjugate vaccine (PCV 13), and
inactivated polio vaccine. What is the next best step in the management of this patient?
- ✔✔Give IM
✔✔A 40-year-old woman from the New England area of the United States presents with
complaints of malaise, headache, rash, and fever. She went hiking in a local park with
her family seven days ago. She has a history of depression and hypothyroidism, for
which she takes paroxetine and levothyroxine. She was an occasional smoker but quit
five years ago. On examination, her temperature is 99 F (37.2 C), heart rate is 80/min,
respiratory rate is 16/min, and blood pressure is 125/75 mmHg. A rash is noted on her
right upper extremity (see image). The rest of her physical exam is unremarkable. What
is the recommended treatment for this patient's condition? - ✔✔10 days of doxy
✔✔A patient is diagnosed with Lyme disease and started on doxycycline 100 mg PO
BID for 4 weeks. After the first dose, the patient is worse with dizziness, shaking, and
fever. What is the cause of the change in the patient's condition? - ✔✔Jarisch
herxheimer rxn
✔✔A 34-year-old forest ranger, previously healthy, presents with dizziness, syncope,
and increasing fatigue for 2 weeks. Vital signs are the temperature of 98°F (36.7°C),
, blood pressure of 110/80 mm Hg, and a heart rate of 38 beats per minute with a regular
pulse. No murmur is noted. The neurological exam reveals a Bell palsy. An
electrocardiogram (EKG) shows a complete heart block. Which joint is most likely
painful? - ✔✔Knee
✔✔A patient presents because she believes she is bitten by a tick a few days ago while
hiking in the woods. She mentions swelling in her right ear and general malaise. On
exam, she has a 1 x 2 cm bluish-red nodule located on the right ear lobe. What is the
next best step in management for this patient? - ✔✔Lyme serology
✔✔A female presents with progressive confusion over weeks with memory loss. She
has a slight fever at 100.4 F. Prior to cognitive changes, she had been complaining of
arthralgias. History is otherwise unremarkable except for the fact she is an avid camper.
Which of the following is the initial diagnostic test that should be ordered? - ✔✔Serology
✔✔A 7-year-old boy presents with a pronounced limp secondary to pain in his leg. The
pain is around his left knee, and on physical examination, the left knee is swollen. Two
weeks earlier, he had a painful right ankle with limping. His mother reports he has had
an elevated temperature, but she has not measured it. He lives in a rural area that has a
stream running through the back of the property. Prior to aggressive-invasive therapy,
what infective process should be considered that may not need surgical intervention as
the primary mode of treatment? - ✔✔Lyme disease
✔✔A 17-year-old presents with tonsil hypertrophy, new-onset snoring, bilateral cervical
lymphadenopathy, low-grade fever, and general malaise. Two days ago, the patient
developed severe abdominal pain and anorexia, unaffected by eating or drinking. He
has had a recent bowel movement. Which of the following is the gold standard test in
diagnosing his condition? - ✔✔Heterophil antibody test
✔✔A 17-year-old female presents with a severe sore throat. She has been sick with a
fever for four days. The patient's voice is muffled, and she prefers not to speak
secondary to pain. She has not been able to eat solids for 2 days and has refused to
drink for 1 day. Vital signs show a temperature of 39.8 C, heart rate 140 beats/min,
respiratory rate 20, and blood pressure 110/70 mmHg. The exam shows the tonsils to
be four-plus enlarged with partial airway obstruction and grey-white exudates. It is
associated with cervical lymphadenopathy and splenomegaly. A rapid strep screen is
negative. A CBC shows atypical lymphocytes. What is the most appropriate
management? - ✔✔Admission for hydration and corticosteroids
✔✔A 3-year-old boy presented with a 3-day history of mild headache and decreased
activity. The child later developed a fever of 39.4 C (102.9 F), associated with a mild
cough and sore throat. On physical examination, he has anterior and posterior cervical
lymphadenopathy with mild splenomegaly. The white blood cell count is 5000/mm3 with
an average differential count. The alanine aminotransferase level is increased to 280
