,Q1 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
Which of the following best explains why a patient with severe sepsis develops
lactic acidosis despite adequate arterial oxygen saturation?
A. Increased anaerobic metabolism due to impaired mitochondrial oxygen utilization CORRECT
B. Reduced oxygen delivery from anemia
C. Excessive lactate clearance by the liver
D. Primary respiratory alkalosis causing compensatory metabolic acidosis
RATIONALE: In sepsis, microcirculatory dysfunction and mitochondrial impairment lead to
anaerobic metabolism and lactate production even with normal PaO2. Anemia (B) reduces
oxygen delivery but is not the primary cause here; lactate clearance (C) is decreased, not
increased; and respiratory alkalosis (D) does not cause lactic acidosis.
Q2 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
A previously healthy individual presents with sudden-onset severe headache,
neck stiffness, and photophobia. CT shows diffuse subarachnoid hemorrhage.
Which of the following is the most appropriate next step in management?
A. Immediate lumbar puncture
B. Start nimodipine and consult neurosurgery CORRECT
C. Administer intravenous thrombolytics
D. Obtain MRI of the brain
RATIONALE: Nimodipine improves outcomes in aneurysmal subarachnoid hemorrhage by
preventing vasospasm, and neurosurgical evaluation is critical for possible aneurysm
clipping/coiling. Lumbar puncture (A) is contraindicated with mass effect; thrombolytics (C) would
worsen bleeding; MRI (D) is not the immediate priority.
Page 2
,Q3 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
A 32-year-old woman with a history of recurrent venous thromboembolism is
found to have a homozygous factor V Leiden mutation. Which of the following is
the most appropriate long-term anticoagulation strategy?
A. Warfarin with target INR 2-3 indefinitely CORRECT
B. Low-molecular-weight heparin for 3 months
C. Direct oral anticoagulant (DOAC) for 6 months
D. Aspirin 81 mg daily indefinitely
RATIONALE: For unprovoked VTE with homozygous factor V Leiden, indefinite anticoagulation is
recommended. Warfarin is preferred over DOACs in antiphospholipid syndrome but not
necessarily here; however, DOACs are also acceptable. The best answer among options is
warfarin for indefinite therapy. LMWH for 3 months (B) is inadequate; DOAC for 6 months (C) is
too short; aspirin (D) is insufficient.
Q4 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
Which of the following is the most likely diagnosis in a patient presenting with
episodic vertigo, tinnitus, and hearing loss, where symptoms last hours and
resolve completely?
A. Vestibular neuritis
B. Meniere's disease CORRECT
C. Benign paroxysmal positional vertigo (BPPV)
D. Acoustic neuroma
RATIONALE: Meniere's disease is characterized by the triad of episodic vertigo, tinnitus, and
fluctuating hearing loss, with attacks lasting 20 minutes to 12 hours. Vestibular neuritis (A)
presents with acute prolonged vertigo without hearing loss; BPPV (C) is positional and brief;
acoustic neuroma (D) causes progressive unilateral hearing loss and imbalance, not episodic
vertigo.
Page 3
, Q5 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
A 45-year-old man presents with sudden severe epigastric pain radiating to the
back, nausea, and vomiting. Serum lipase is elevated >3 times the upper limit of
normal. Which of the following is the most appropriate initial management?
A. Immediate CT scan of the abdomen
B. Aggressive intravenous fluid resuscitation CORRECT
C. Emergent ERCP
D. Nasogastric tube decompression
RATIONALE: Initial management of acute pancreatitis includes aggressive IV fluid resuscitation
to maintain organ perfusion and prevent necrosis. CT (A) is not immediately necessary unless
complications suspected; ERCP (C) is indicated for concurrent cholangitis or biliary obstruction;
NG tube (D) is not routinely recommended.
Q6 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
A 55-year-old man with a 30-pack-year smoking history presents with hemoptysis
and weight loss. Chest X-ray shows a right hilar mass. Which of the following is
the most appropriate next step to establish a diagnosis?
A. Sputum cytology
B. CT-guided percutaneous biopsy
C. Bronchoscopy with biopsy CORRECT
D. PET-CT scan
RATIONALE: Bronchoscopy with biopsy is the preferred initial diagnostic procedure for a central
hilar mass, allowing direct visualization and tissue sampling. Sputum cytology (A) has lower
sensitivity; percutaneous biopsy (B) is better for peripheral lesions; PET-CT (D) is for staging, not
diagnosis.
Page 4
MAJOR CLINICAL DISCIPLINES
Which of the following best explains why a patient with severe sepsis develops
lactic acidosis despite adequate arterial oxygen saturation?
A. Increased anaerobic metabolism due to impaired mitochondrial oxygen utilization CORRECT
B. Reduced oxygen delivery from anemia
C. Excessive lactate clearance by the liver
D. Primary respiratory alkalosis causing compensatory metabolic acidosis
RATIONALE: In sepsis, microcirculatory dysfunction and mitochondrial impairment lead to
anaerobic metabolism and lactate production even with normal PaO2. Anemia (B) reduces
oxygen delivery but is not the primary cause here; lactate clearance (C) is decreased, not
increased; and respiratory alkalosis (D) does not cause lactic acidosis.
Q2 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
A previously healthy individual presents with sudden-onset severe headache,
neck stiffness, and photophobia. CT shows diffuse subarachnoid hemorrhage.
Which of the following is the most appropriate next step in management?
A. Immediate lumbar puncture
B. Start nimodipine and consult neurosurgery CORRECT
C. Administer intravenous thrombolytics
D. Obtain MRI of the brain
RATIONALE: Nimodipine improves outcomes in aneurysmal subarachnoid hemorrhage by
preventing vasospasm, and neurosurgical evaluation is critical for possible aneurysm
clipping/coiling. Lumbar puncture (A) is contraindicated with mass effect; thrombolytics (C) would
worsen bleeding; MRI (D) is not the immediate priority.
Page 2
,Q3 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
A 32-year-old woman with a history of recurrent venous thromboembolism is
found to have a homozygous factor V Leiden mutation. Which of the following is
the most appropriate long-term anticoagulation strategy?
A. Warfarin with target INR 2-3 indefinitely CORRECT
B. Low-molecular-weight heparin for 3 months
C. Direct oral anticoagulant (DOAC) for 6 months
D. Aspirin 81 mg daily indefinitely
RATIONALE: For unprovoked VTE with homozygous factor V Leiden, indefinite anticoagulation is
recommended. Warfarin is preferred over DOACs in antiphospholipid syndrome but not
necessarily here; however, DOACs are also acceptable. The best answer among options is
warfarin for indefinite therapy. LMWH for 3 months (B) is inadequate; DOAC for 6 months (C) is
too short; aspirin (D) is insufficient.
Q4 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
Which of the following is the most likely diagnosis in a patient presenting with
episodic vertigo, tinnitus, and hearing loss, where symptoms last hours and
resolve completely?
A. Vestibular neuritis
B. Meniere's disease CORRECT
C. Benign paroxysmal positional vertigo (BPPV)
D. Acoustic neuroma
RATIONALE: Meniere's disease is characterized by the triad of episodic vertigo, tinnitus, and
fluctuating hearing loss, with attacks lasting 20 minutes to 12 hours. Vestibular neuritis (A)
presents with acute prolonged vertigo without hearing loss; BPPV (C) is positional and brief;
acoustic neuroma (D) causes progressive unilateral hearing loss and imbalance, not episodic
vertigo.
Page 3
, Q5 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
A 45-year-old man presents with sudden severe epigastric pain radiating to the
back, nausea, and vomiting. Serum lipase is elevated >3 times the upper limit of
normal. Which of the following is the most appropriate initial management?
A. Immediate CT scan of the abdomen
B. Aggressive intravenous fluid resuscitation CORRECT
C. Emergent ERCP
D. Nasogastric tube decompression
RATIONALE: Initial management of acute pancreatitis includes aggressive IV fluid resuscitation
to maintain organ perfusion and prevent necrosis. CT (A) is not immediately necessary unless
complications suspected; ERCP (C) is indicated for concurrent cholangitis or biliary obstruction;
NG tube (D) is not routinely recommended.
Q6 APPLY EVIDENCE-BASED DIAGNOSTIC AND MANAGEMENT STRATEGIES ACROSS
MAJOR CLINICAL DISCIPLINES
A 55-year-old man with a 30-pack-year smoking history presents with hemoptysis
and weight loss. Chest X-ray shows a right hilar mass. Which of the following is
the most appropriate next step to establish a diagnosis?
A. Sputum cytology
B. CT-guided percutaneous biopsy
C. Bronchoscopy with biopsy CORRECT
D. PET-CT scan
RATIONALE: Bronchoscopy with biopsy is the preferred initial diagnostic procedure for a central
hilar mass, allowing direct visualization and tissue sampling. Sputum cytology (A) has lower
sensitivity; percutaneous biopsy (B) is better for peripheral lesions; PET-CT (D) is for staging, not
diagnosis.
Page 4
