ROSH REVIEW EXAM FULL QUESTIONS AND
CORRECT ANSWERS 2026 EXAM PREP WITH
SOLUTIONS GRADED A+
◍ 57-year-old man presents to the ED with severe dyspnea and frothy
sputum. His wife notes he has a "blood problem" that his doctor is
monitoring. On physical exam, you note bilateral pulmonary rales to
the mid-thorax. Vital signs are BP 124/78 mm Hg, HR 140 beats per
minute, RR 35 breaths per minute, and T 99.5°F. Which of the
following is the most common etiology of this disease process?
Acute myeloid leukemia
Multiple myeloma
Polycythemia vera
Waldenstrom macroglobulinemia. Answer: Correct Answer ( D )
Explanation:
This patient is exhibiting signs and symptoms associated with
hyperviscosity syndrome. Hyperviscosity syndrome is defined as
elevated serum viscosity that causes sludging, decreased
microvascular perfusion, and vascular stasis. The most common cause
of hyperviscosity syndrome is elevated serum protein, most often
secondary to Waldenstrom macroglobulinemia or less often due to
,multiple myeloma. It can also be caused by marked leukocytosis with
> 100,0000 cells/mm3 or erythrocytosis from diseases such as
leukemias, polycythemia vera, or hemoglobinopathies like sickle cell
disease, respectively. Signs and symptoms of hyperviscosity
syndrome are primarily secondary to end-organ ischemia creating
mimics of disease processes such as myocardial ischemia, stroke,
pulmonary infarction, congestive heart failure, renal failure, mucosal
hemorrhages, or visual disturbances secondary to retinal ischemia.
Laboratory studies will yield significant leukocytosis or
hyperproteinemia depending upon the etiology. Management of
hyperviscosity syndrome also depends upon the etiology. Supportive
care for any etiology includes intravenous fluid hydration and diuresis
in tandem. Temporizing measures for leukemias include
leukapheresis, patients with elevated proteins require plasmapheresis,
and patients with polycythemia vera require phlebotomy.
While acute myeloid leukemia (A), multiple myeloma (B), and
polycythemia vera (C) are all potential etiologies of hyperviscosity
syndrome, Waldenstrom macroglobulinemia is the most common
etiology of this disease process.
◍ Hyperviscosity Syndrome. Answer:
◍ Question: What blood smear abnormality is associated with
Waldenstrom macroglobulinemia?. Answer: Rouleaux formation.
◍ Correct Answer ( D )
Explanation:
,This patient has a spontaneous simple pneumothorax. A
pneumothorax is a collection of air in the pleural space. A simple
pneumothorax has no communication with the atmosphere and does
not show any signs of a tension. Simple pneumothoraces can be any
size and may be spontaneous or the result of trauma. A
communicating pneumothorax results from a defect in the chest wall
(e.g. from a stabbing or gunshot wound). A tension pneumothorax
occurs when progressive accumulation of air results in compression
and shift of the mediastinal structures. This can lead to rapid onset of
cardiovascular and respiratory distress. The incidence of spontaneous
pneumothorax is greatest in young, healthy men and the majority are
smokers. Patients present with pleuritic chest pain and dyspnea.
Examination findings include decreased breath sounds and
hyperresonance to percussion. Tracheal deviation, hypotensi. Answer:
A 22-year-old healthy man presents with acute onset pleuritic, left-
sided chest pain and mild dyspnea. Vital signs include blood pressure
142/74 mm Hg, heart rate 82 beats/minute, and oxygen saturation
97% on room air. He is in no acute distress. His chest radiograph is
shown above. Which of the following is the next best step in
management?
Discharge home with ibuprofen for pain relief
Order a computed tomography scan of the chest
Perform a chest tube thoracostomy
Place patient on 100% oxygen and repeat chest radiograph in 6 hours
, ◍ Small Pneumothorax. Answer:
◍ Question: What pulmonary infection is associated with
pneumothorax in AIDS patients?. Answer: Pneumocystis jirovecii
pneumonia.
◍ Correct Answer ( A )
Explanation:
The patient has multifocal atrial tachycardia (MAT). MAT occurs
when at least three different atrial ectopic foci depolarize to pace the
heart. These are seen on an ECG as an irregular rhythm with P waves
with at least three distinct morphologies. The QRS complex is narrow,
unless an underlying bundle branch block is present. Because of the
irregular rhythm, MAT is easily confused with atrial fibrillation.
However in MAT, distinct P waves should be visible. MAT is most
commonly seen in elderly patients with chronic lung disease. MAT
can also be seen in heart failure and sepsis. The treatment of MAT is
directed at treating the underlying disorder. In a patient with
symptomatic lung disease, oxygen and bronchodilators improve
pulmonary function and oxygenation and therefore decrease atrial
ectopy. Cardioversion is ineffective for MAT.. Answer: A 79-year-old
man comes to the ED complaining of dyspnea. His rhythm strip is
shown above. What is the most likely underlying process?
Chronic obstructive pulmonary disease
Crohn's disease
CORRECT ANSWERS 2026 EXAM PREP WITH
SOLUTIONS GRADED A+
◍ 57-year-old man presents to the ED with severe dyspnea and frothy
sputum. His wife notes he has a "blood problem" that his doctor is
monitoring. On physical exam, you note bilateral pulmonary rales to
the mid-thorax. Vital signs are BP 124/78 mm Hg, HR 140 beats per
minute, RR 35 breaths per minute, and T 99.5°F. Which of the
following is the most common etiology of this disease process?
Acute myeloid leukemia
Multiple myeloma
Polycythemia vera
Waldenstrom macroglobulinemia. Answer: Correct Answer ( D )
Explanation:
This patient is exhibiting signs and symptoms associated with
hyperviscosity syndrome. Hyperviscosity syndrome is defined as
elevated serum viscosity that causes sludging, decreased
microvascular perfusion, and vascular stasis. The most common cause
of hyperviscosity syndrome is elevated serum protein, most often
secondary to Waldenstrom macroglobulinemia or less often due to
,multiple myeloma. It can also be caused by marked leukocytosis with
> 100,0000 cells/mm3 or erythrocytosis from diseases such as
leukemias, polycythemia vera, or hemoglobinopathies like sickle cell
disease, respectively. Signs and symptoms of hyperviscosity
syndrome are primarily secondary to end-organ ischemia creating
mimics of disease processes such as myocardial ischemia, stroke,
pulmonary infarction, congestive heart failure, renal failure, mucosal
hemorrhages, or visual disturbances secondary to retinal ischemia.
Laboratory studies will yield significant leukocytosis or
hyperproteinemia depending upon the etiology. Management of
hyperviscosity syndrome also depends upon the etiology. Supportive
care for any etiology includes intravenous fluid hydration and diuresis
in tandem. Temporizing measures for leukemias include
leukapheresis, patients with elevated proteins require plasmapheresis,
and patients with polycythemia vera require phlebotomy.
While acute myeloid leukemia (A), multiple myeloma (B), and
polycythemia vera (C) are all potential etiologies of hyperviscosity
syndrome, Waldenstrom macroglobulinemia is the most common
etiology of this disease process.
◍ Hyperviscosity Syndrome. Answer:
◍ Question: What blood smear abnormality is associated with
Waldenstrom macroglobulinemia?. Answer: Rouleaux formation.
◍ Correct Answer ( D )
Explanation:
,This patient has a spontaneous simple pneumothorax. A
pneumothorax is a collection of air in the pleural space. A simple
pneumothorax has no communication with the atmosphere and does
not show any signs of a tension. Simple pneumothoraces can be any
size and may be spontaneous or the result of trauma. A
communicating pneumothorax results from a defect in the chest wall
(e.g. from a stabbing or gunshot wound). A tension pneumothorax
occurs when progressive accumulation of air results in compression
and shift of the mediastinal structures. This can lead to rapid onset of
cardiovascular and respiratory distress. The incidence of spontaneous
pneumothorax is greatest in young, healthy men and the majority are
smokers. Patients present with pleuritic chest pain and dyspnea.
Examination findings include decreased breath sounds and
hyperresonance to percussion. Tracheal deviation, hypotensi. Answer:
A 22-year-old healthy man presents with acute onset pleuritic, left-
sided chest pain and mild dyspnea. Vital signs include blood pressure
142/74 mm Hg, heart rate 82 beats/minute, and oxygen saturation
97% on room air. He is in no acute distress. His chest radiograph is
shown above. Which of the following is the next best step in
management?
Discharge home with ibuprofen for pain relief
Order a computed tomography scan of the chest
Perform a chest tube thoracostomy
Place patient on 100% oxygen and repeat chest radiograph in 6 hours
, ◍ Small Pneumothorax. Answer:
◍ Question: What pulmonary infection is associated with
pneumothorax in AIDS patients?. Answer: Pneumocystis jirovecii
pneumonia.
◍ Correct Answer ( A )
Explanation:
The patient has multifocal atrial tachycardia (MAT). MAT occurs
when at least three different atrial ectopic foci depolarize to pace the
heart. These are seen on an ECG as an irregular rhythm with P waves
with at least three distinct morphologies. The QRS complex is narrow,
unless an underlying bundle branch block is present. Because of the
irregular rhythm, MAT is easily confused with atrial fibrillation.
However in MAT, distinct P waves should be visible. MAT is most
commonly seen in elderly patients with chronic lung disease. MAT
can also be seen in heart failure and sepsis. The treatment of MAT is
directed at treating the underlying disorder. In a patient with
symptomatic lung disease, oxygen and bronchodilators improve
pulmonary function and oxygenation and therefore decrease atrial
ectopy. Cardioversion is ineffective for MAT.. Answer: A 79-year-old
man comes to the ED complaining of dyspnea. His rhythm strip is
shown above. What is the most likely underlying process?
Chronic obstructive pulmonary disease
Crohn's disease
