, Question 1
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
B. Reduced oxygen delivery from anemia
C. Excessive lactate clearance by the liver
D. Primary respiratory alkalosis causing compensatory metabolic acidosis
Correct Answer: A - Increased anaerobic metabolism due to
impaired mitochondrial oxygen utilization
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.
Question 2
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
C. Administer intravenous thrombolytics
D. Obtain MRI of the brain
Correct Answer: B - Start nimodipine and consult neurosurgery
Page 2
, 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.
Question 3
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
B. Low-molecular-weight heparin for 3 months
C. Direct oral anticoagulant (DOAC) for 6 months
D. Aspirin 81 mg daily indefinitely
Correct Answer: A - Warfarin with target INR 2-3 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.
Question 4
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
C. Benign paroxysmal positional vertigo (BPPV)
Page 3
, D. Acoustic neuroma
Correct Answer: B - Meniere's disease
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.
Question 5
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
C. Emergent ERCP
D. Nasogastric tube decompression
Correct Answer: B - Aggressive intravenous fluid resuscitation
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.
Question 6
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?
Page 4
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
B. Reduced oxygen delivery from anemia
C. Excessive lactate clearance by the liver
D. Primary respiratory alkalosis causing compensatory metabolic acidosis
Correct Answer: A - Increased anaerobic metabolism due to
impaired mitochondrial oxygen utilization
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.
Question 2
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
C. Administer intravenous thrombolytics
D. Obtain MRI of the brain
Correct Answer: B - Start nimodipine and consult neurosurgery
Page 2
, 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.
Question 3
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
B. Low-molecular-weight heparin for 3 months
C. Direct oral anticoagulant (DOAC) for 6 months
D. Aspirin 81 mg daily indefinitely
Correct Answer: A - Warfarin with target INR 2-3 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.
Question 4
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
C. Benign paroxysmal positional vertigo (BPPV)
Page 3
, D. Acoustic neuroma
Correct Answer: B - Meniere's disease
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.
Question 5
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
C. Emergent ERCP
D. Nasogastric tube decompression
Correct Answer: B - Aggressive intravenous fluid resuscitation
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.
Question 6
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?
Page 4
