167 lines
10 KiB
JSON
167 lines
10 KiB
JSON
[
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{
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"id": "sample-001",
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"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.",
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"lead_in": "Which of the following findings would most strongly suggest right ventricular infarction?",
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"choices": [
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{ "id": "A", "text": "Diffuse wheezing and pulsus paradoxus" },
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{ "id": "B", "text": "Hypotension with clear lung fields and elevated jugular venous pressure" },
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{ "id": "C", "text": "New holosystolic murmur radiating to the axilla" },
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{ "id": "D", "text": "Pulmonary edema with severe hypertension" },
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{ "id": "E", "text": "Wide pulse pressure and bounding peripheral pulses" }
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],
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"correct_choice_id": "B",
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"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.",
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"choice_explanations": {
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"A": "This pattern suggests obstructive airway disease or tamponade physiology, not the classic right ventricular infarction triad.",
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"B": "Correct. Hypotension, jugular venous distention, and clear lungs are classic for right ventricular infarction.",
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"C": "A new holosystolic murmur radiating to the axilla suggests acute mitral regurgitation.",
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"D": "Pulmonary edema with hypertension suggests left-sided heart failure or hypertensive emergency.",
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"E": "A wide pulse pressure suggests aortic regurgitation or high-output states."
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},
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"discipline": "Medicine",
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"system": "Cardiovascular",
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"difficulty": 2,
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"labs": [],
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"media": [],
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"tags": ["acute coronary syndrome", "inferior MI", "shock"]
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},
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{
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"id": "sample-002",
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"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.",
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"lead_in": "Which of the following is the most appropriate immediate treatment?",
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"choices": [
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{ "id": "A", "text": "Diazepam infusion" },
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{ "id": "B", "text": "Immediate cesarean delivery before medication" },
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{ "id": "C", "text": "Intravenous magnesium sulfate" },
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{ "id": "D", "text": "Oral labetalol and outpatient follow-up" },
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{ "id": "E", "text": "Warfarin anticoagulation" }
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],
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"correct_choice_id": "C",
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"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.",
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"choice_explanations": {
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"A": "Benzodiazepines are not first-line for eclamptic seizures unless seizures persist despite magnesium.",
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"B": "Delivery is definitive, but maternal stabilization comes first.",
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"C": "Correct. Magnesium sulfate is first-line therapy for eclampsia.",
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"D": "This patient has eclampsia and severe-range blood pressure requiring inpatient emergency treatment.",
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"E": "Warfarin has no role and is generally avoided in pregnancy."
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},
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"discipline": "Obstetrics/Gynecology",
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"system": "Pregnancy",
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"difficulty": 1,
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"labs": [],
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"media": [],
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"tags": ["eclampsia", "hypertension", "pregnancy"]
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},
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{
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"id": "sample-003",
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"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.",
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"lead_in": "Which of the following adverse effects is most important to report immediately?",
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"choices": [
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{ "id": "A", "text": "Mild hair thinning" },
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{ "id": "B", "text": "Metallic taste during infusion" },
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{ "id": "C", "text": "New chest pain or shortness of breath" },
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{ "id": "D", "text": "Transient darkening of the nails" },
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{ "id": "E", "text": "Warmth at the infusion site lasting 5 minutes" }
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],
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"correct_choice_id": "C",
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"explanation": "Fluoropyrimidines can cause coronary vasospasm and cardiotoxicity. New chest pain or shortness of breath during treatment warrants urgent evaluation.",
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"choice_explanations": {
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"A": "Mild alopecia can occur but is not typically urgent.",
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"B": "Taste changes can occur with chemotherapy and are usually not emergent.",
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"C": "Correct. Chest pain or dyspnea can indicate fluoropyrimidine cardiotoxicity.",
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"D": "Nail changes may occur with chemotherapy but are not the highest-risk symptom listed.",
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"E": "Brief warmth can be benign, though persistent pain or swelling should be reported."
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},
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"discipline": "Medicine",
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"system": "Oncology",
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"difficulty": 3,
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"labs": [],
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"media": [],
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"tags": ["colon cancer", "chemotherapy", "toxicity"]
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},
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{
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"id": "sample-004",
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"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.",
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"lead_in": "Which of the following is the most likely cardiac finding?",
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"choices": [
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{ "id": "A", "text": "Aortic valve vegetation with splenic infarcts" },
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{ "id": "B", "text": "Mitral stenosis with opening snap" },
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{ "id": "C", "text": "Tricuspid valve vegetation with septic pulmonary emboli" },
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{ "id": "D", "text": "Ventricular septal rupture after myocardial infarction" },
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{ "id": "E", "text": "Viral myocarditis with global hypokinesis" }
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],
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"correct_choice_id": "C",
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"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.",
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"choice_explanations": {
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"A": "Left-sided endocarditis more often causes systemic emboli such as splenic or renal infarcts.",
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"B": "Mitral stenosis does not explain bacteremia and septic pulmonary emboli.",
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"C": "Correct. Tricuspid endocarditis causes septic pulmonary emboli.",
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"D": "Ventricular septal rupture causes acute heart failure and a harsh murmur after MI.",
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"E": "Myocarditis does not typically cause cavitary septic pulmonary emboli."
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},
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"discipline": "Medicine",
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"system": "Infectious Disease",
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"difficulty": 2,
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"labs": [],
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"media": [],
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"tags": ["endocarditis", "injection drug use", "staphylococcus aureus"]
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},
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{
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"id": "sample-005",
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"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.",
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"lead_in": "Which of the following is the most appropriate initial management?",
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"choices": [
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{ "id": "A", "text": "Begin haloperidol immediately" },
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{ "id": "B", "text": "Cognitive behavioral intervention for tics and reassurance" },
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{ "id": "C", "text": "Electroencephalography" },
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{ "id": "D", "text": "Emergency psychiatric hospitalization" },
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{ "id": "E", "text": "High-dose corticosteroids" }
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],
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"correct_choice_id": "B",
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"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.",
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"choice_explanations": {
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"A": "Antipsychotics can reduce severe tics but are not first-line for mild symptoms.",
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"B": "Correct. Behavioral therapy and reassurance are appropriate initial management.",
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"C": "The history is typical for tics, not seizures.",
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"D": "There is no indication of acute danger requiring hospitalization.",
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"E": "Steroids are not indicated."
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},
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"discipline": "Pediatrics",
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"system": "Psychiatry/Behavioral Health",
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"difficulty": 1,
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"labs": [],
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"media": [],
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"tags": ["tic disorder", "behavioral therapy", "pediatrics"]
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},
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{
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"id": "sample-006",
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"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.",
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"lead_in": "Which of the following is the most appropriate next step in management?",
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"choices": [
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{ "id": "A", "text": "Cefotaxime and albumin" },
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{ "id": "B", "text": "Colonoscopy" },
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{ "id": "C", "text": "Emergent laparotomy" },
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{ "id": "D", "text": "High-dose prednisone" },
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{ "id": "E", "text": "Therapeutic anticoagulation" }
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],
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"correct_choice_id": "A",
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"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.",
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"choice_explanations": {
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"A": "Correct. This patient has spontaneous bacterial peritonitis.",
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"B": "Colonoscopy is not the acute treatment.",
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"C": "Surgery is considered for secondary peritonitis, especially with peritoneal signs or polymicrobial infection.",
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"D": "Steroids are not indicated for SBP.",
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"E": "Anticoagulation is not the immediate treatment for infected ascites."
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},
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"discipline": "Medicine",
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"system": "Gastroenterology",
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"difficulty": 2,
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"labs": [
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{ "name": "Ascitic fluid neutrophils", "value": "620", "unit": "/mm3", "reference": "<250" }
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],
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"media": [],
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"tags": ["cirrhosis", "ascites", "SBP"]
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}
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]
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