[ { "id": "sample-001", "stem": "A 67-year-old man comes to the emergency department because of 2 hours of substernal chest pressure and diaphoresis. He has hypertension, type 2 diabetes mellitus, and chronic kidney disease. Blood pressure is 88/54 mm Hg and pulse is 112/min. ECG shows ST-segment elevation in leads II, III, and aVF. He receives aspirin and is taken for urgent coronary angiography.", "lead_in": "Which of the following findings would most strongly suggest right ventricular infarction?", "choices": [ { "id": "A", "text": "Diffuse wheezing and pulsus paradoxus" }, { "id": "B", "text": "Hypotension with clear lung fields and elevated jugular venous pressure" }, { "id": "C", "text": "New holosystolic murmur radiating to the axilla" }, { "id": "D", "text": "Pulmonary edema with severe hypertension" }, { "id": "E", "text": "Wide pulse pressure and bounding peripheral pulses" } ], "correct_choice_id": "B", "explanation": "Inferior myocardial infarction can involve the right ventricle. Right ventricular infarction classically causes hypotension, elevated jugular venous pressure, and clear lungs due to impaired right-sided filling without primary left-sided pulmonary congestion.", "choice_explanations": { "A": "This pattern suggests obstructive airway disease or tamponade physiology, not the classic right ventricular infarction triad.", "B": "Correct. Hypotension, jugular venous distention, and clear lungs are classic for right ventricular infarction.", "C": "A new holosystolic murmur radiating to the axilla suggests acute mitral regurgitation.", "D": "Pulmonary edema with hypertension suggests left-sided heart failure or hypertensive emergency.", "E": "A wide pulse pressure suggests aortic regurgitation or high-output states." }, "discipline": "Medicine", "system": "Cardiovascular", "difficulty": 2, "labs": [], "media": [], "tags": ["acute coronary syndrome", "inferior MI", "shock"] }, { "id": "sample-002", "stem": "A 29-year-old woman at 34 weeks' gestation is brought to labor and delivery because of a generalized tonic-clonic seizure. She has had headache and visual spots for 1 day. Blood pressure is 172/112 mm Hg. Urine dipstick shows 3+ protein. Fetal heart tracing is category II.", "lead_in": "Which of the following is the most appropriate immediate treatment?", "choices": [ { "id": "A", "text": "Diazepam infusion" }, { "id": "B", "text": "Immediate cesarean delivery before medication" }, { "id": "C", "text": "Intravenous magnesium sulfate" }, { "id": "D", "text": "Oral labetalol and outpatient follow-up" }, { "id": "E", "text": "Warfarin anticoagulation" } ], "correct_choice_id": "C", "explanation": "Eclampsia is preeclampsia with seizures. Magnesium sulfate is first-line seizure treatment and prevention. Severe hypertension should also be controlled, and delivery is indicated after maternal stabilization.", "choice_explanations": { "A": "Benzodiazepines are not first-line for eclamptic seizures unless seizures persist despite magnesium.", "B": "Delivery is definitive, but maternal stabilization comes first.", "C": "Correct. Magnesium sulfate is first-line therapy for eclampsia.", "D": "This patient has eclampsia and severe-range blood pressure requiring inpatient emergency treatment.", "E": "Warfarin has no role and is generally avoided in pregnancy." }, "discipline": "Obstetrics/Gynecology", "system": "Pregnancy", "difficulty": 1, "labs": [], "media": [], "tags": ["eclampsia", "hypertension", "pregnancy"] }, { "id": "sample-003", "stem": "A 52-year-old man is seen for follow-up after a hemicolectomy for stage III colon cancer. He is starting adjuvant chemotherapy. He asks what symptom should make him call the office urgently while receiving fluorouracil-based therapy.", "lead_in": "Which of the following adverse effects is most important to report immediately?", "choices": [ { "id": "A", "text": "Mild hair thinning" }, { "id": "B", "text": "Metallic taste during infusion" }, { "id": "C", "text": "New chest pain or shortness of breath" }, { "id": "D", "text": "Transient darkening of the nails" }, { "id": "E", "text": "Warmth at the infusion site lasting 5 minutes" } ], "correct_choice_id": "C", "explanation": "Fluoropyrimidines can cause coronary vasospasm and cardiotoxicity. New chest pain or shortness of breath during treatment warrants urgent evaluation.", "choice_explanations": { "A": "Mild alopecia can occur but is not typically urgent.", "B": "Taste changes can occur with chemotherapy and are usually not emergent.", "C": "Correct. Chest pain or dyspnea can indicate fluoropyrimidine cardiotoxicity.", "D": "Nail changes may occur with chemotherapy but are not the highest-risk symptom listed.", "E": "Brief warmth can be benign, though persistent pain or swelling should be reported." }, "discipline": "Medicine", "system": "Oncology", "difficulty": 3, "labs": [], "media": [], "tags": ["colon cancer", "chemotherapy", "toxicity"] }, { "id": "sample-004", "stem": "A 44-year-old woman with opioid use disorder is admitted with fever and pleuritic chest pain. Temperature is 39.1 C, pulse is 118/min, and blood pressure is 104/66 mm Hg. CT chest shows multiple peripheral cavitary nodules. Blood cultures grow methicillin-sensitive Staphylococcus aureus.", "lead_in": "Which of the following is the most likely cardiac finding?", "choices": [ { "id": "A", "text": "Aortic valve vegetation with splenic infarcts" }, { "id": "B", "text": "Mitral stenosis with opening snap" }, { "id": "C", "text": "Tricuspid valve vegetation with septic pulmonary emboli" }, { "id": "D", "text": "Ventricular septal rupture after myocardial infarction" }, { "id": "E", "text": "Viral myocarditis with global hypokinesis" } ], "correct_choice_id": "C", "explanation": "Injection drug use is associated with right-sided infective endocarditis, especially tricuspid valve infection. Septic emboli travel to the lungs and can cause peripheral cavitary nodules.", "choice_explanations": { "A": "Left-sided endocarditis more often causes systemic emboli such as splenic or renal infarcts.", "B": "Mitral stenosis does not explain bacteremia and septic pulmonary emboli.", "C": "Correct. Tricuspid endocarditis causes septic pulmonary emboli.", "D": "Ventricular septal rupture causes acute heart failure and a harsh murmur after MI.", "E": "Myocarditis does not typically cause cavitary septic pulmonary emboli." }, "discipline": "Medicine", "system": "Infectious Disease", "difficulty": 2, "labs": [], "media": [], "tags": ["endocarditis", "injection drug use", "staphylococcus aureus"] }, { "id": "sample-005", "stem": "A 7-year-old boy is brought to the clinic because of repetitive blinking and throat clearing for 8 months. His teacher reports that the behaviors increase during tests and decrease when he is focused on drawing. He is otherwise healthy and doing well in school.", "lead_in": "Which of the following is the most appropriate initial management?", "choices": [ { "id": "A", "text": "Begin haloperidol immediately" }, { "id": "B", "text": "Cognitive behavioral intervention for tics and reassurance" }, { "id": "C", "text": "Electroencephalography" }, { "id": "D", "text": "Emergency psychiatric hospitalization" }, { "id": "E", "text": "High-dose corticosteroids" } ], "correct_choice_id": "B", "explanation": "Persistent motor and vocal tics can be managed initially with education, reassurance, and behavioral therapy when symptoms are not severely impairing. Medication is reserved for more functionally impairing cases.", "choice_explanations": { "A": "Antipsychotics can reduce severe tics but are not first-line for mild symptoms.", "B": "Correct. Behavioral therapy and reassurance are appropriate initial management.", "C": "The history is typical for tics, not seizures.", "D": "There is no indication of acute danger requiring hospitalization.", "E": "Steroids are not indicated." }, "discipline": "Pediatrics", "system": "Psychiatry/Behavioral Health", "difficulty": 1, "labs": [], "media": [], "tags": ["tic disorder", "behavioral therapy", "pediatrics"] }, { "id": "sample-006", "stem": "A 61-year-old man with cirrhosis is admitted for confusion. He has asterixis and a distended abdomen. Diagnostic paracentesis shows 620 neutrophils/mm3. Culture results are pending. He has no abdominal rigidity.", "lead_in": "Which of the following is the most appropriate next step in management?", "choices": [ { "id": "A", "text": "Cefotaxime and albumin" }, { "id": "B", "text": "Colonoscopy" }, { "id": "C", "text": "Emergent laparotomy" }, { "id": "D", "text": "High-dose prednisone" }, { "id": "E", "text": "Therapeutic anticoagulation" } ], "correct_choice_id": "A", "explanation": "Spontaneous bacterial peritonitis is diagnosed when ascitic neutrophils are at least 250/mm3. Treatment includes a third-generation cephalosporin and albumin in selected high-risk patients to reduce renal failure and mortality.", "choice_explanations": { "A": "Correct. This patient has spontaneous bacterial peritonitis.", "B": "Colonoscopy is not the acute treatment.", "C": "Surgery is considered for secondary peritonitis, especially with peritoneal signs or polymicrobial infection.", "D": "Steroids are not indicated for SBP.", "E": "Anticoagulation is not the immediate treatment for infected ascites." }, "discipline": "Medicine", "system": "Gastroenterology", "difficulty": 2, "labs": [ { "name": "Ascitic fluid neutrophils", "value": "620", "unit": "/mm3", "reference": "<250" } ], "media": [], "tags": ["cirrhosis", "ascites", "SBP"] } ]