118A (2024)

118A1
Which of the following diseases is often discovered without symptoms?

a. Aortic dissection
b. Abdominal aortic aneurysm
c. Infective endocarditis
d. Coronary spasm-induced angina
e. Takotsubo cardiomyopathy

The correct answer is b. Abdominal aortic aneurysm (AAA).

• AAA presents as a bulge or dilation in the wall of the aorta in the abdominal portion. Although it is asymptomatic and without clinical signs in the early stages, it can suddenly rupture, which is life-threatening. It is often discovered during routine exams, such as ultrasound and CT scans.

118A2
Which of the following is correct for preventing accidents in the elderly while bathing?

a. Bathe after meals.
b. Bathe late at night.
c. Cool the body after getting out of the bathtub.
d. Avoid bathing during periods of high temperatures.
e. Eliminate the temperature difference between the living room and the dressing room.

The correct answer is e. Eliminate the temperature difference between the living room and the dressing room. 

• Sudden temperature fluctuations are dangerous for elderly people. A large temperature difference between two rooms can lead to thermal shock due to a sudden drop (vasoconstriction) or rise (vasodilation) in body temperature, which can also be responsible for accidents, heart attacks, or strokes.

118A3
Which condition causes both hypocalcemia and hypophosphatemia simultaneously?

a. Tumor-induced osteomalacia
b. Hyperthyroidism
c. Vitamin D deficiency
d. Hypoparathyroidism
e. Mineral and bone disorders associated with chronic kidney disease

The correct answer is c. Vitamin D deficiency.

• Vitamin D facilitates the absorption of calcium and phosphorus from the intestines into the bloodstream. A deficiency in vitamin D leads to hypocalcemia and hypophosphatemia. The release of parathyroid hormone (PTH) in response is usually not sufficient to maintain calcium levels.

118A4
Which of the following is more likely to cause painless ischemic heart disease?

a. Diabetes
b. Osteoporosis
c. Bronchial asthma
d. Parkinson's disease
e. Gastroesophageal reflux disease (GERD)

The correct answer is a. Diabetes. 

• Diabetes is a common cause of ischemic heart disease and diabetic neuropathy, in which the nerves are damaged. As a result, the patient does not experience chest pain (angina), even though the heart muscle is not receiving enough blood and oxygen.

118A5
Which of the following symptoms or physical findings of idiopathic pulmonary fibrosis is incorrect?

a. Clubbing (fingers)
b. Wet cough
c. Weight loss
d. Fine crackles
e. Dyspnea on exertion (shortness of breath during physical activity)

The answer is b. Wet cough. 

• Idiopathic pulmonary fibrosis (IPF) manifests chronically and progressively with scarring (fibrosis) of lung tissue, which causes a dry cough, dyspnea (difficulty breathing), and fine crackles. Digital clubbing and weight loss are also observed in the advanced stage.
• A productive cough is associated with infections or excessive mucus production, as seen in pneumonia, bronchitis, or chronic obstructive pulmonary disease (COPD).

118A6
Which of the following disease and cause combinations is incorrect?

a. Hepatocellular carcinoma – Liver cirrhosis
b. Esophageal adenocarcinoma – Barrett's esophagus
c. Biliary tract cancer – Congenital biliary dilatation
d. Pancreatic ductal carcinoma – Pancreaticobiliary maljunction
e. Gastric cancer – Helicobacter pylori infection

The answer is d. Pancreatic ductal carcinoma – Pancreaticobiliary maljunction. 

• Pancreaticobiliary maljunction or malformation (PBM) is a congenital anomaly of the junction between the pancreatic duct and the bile duct outside the duodenal wall, where pancreatic enzymes flow back into the bile duct, causing bile duct carcinomas but not pancreatic duct carcinomas.
• The other pairs show correct relationships.

118A8
Which of the following statements about anal fistulas in adults is incorrect?

a. They heal spontaneously.
b. They can be associated with Crohn's disease.
c. They can lead to anal cancer.
d. They can develop from a perianal abscess.
e. They discharge pus independent of defecation.

The answer is a. They heal spontaneously. 

• Anal fistulas refer to an abnormal channel between the inside of the anus or rectum and the skin around the anus. Discharge of pus is observed regardless of defecation.
• Without medical or surgical intervention, fistulas can lead to chronic inflammation, which is associated with perineal abscesses, Crohn's disease, and, rarely, anal cancer.

118A9
Which of the following is correct regarding bulimia nervosa?

a. They have high self-esteem.
b. They often become hyperactive.
c. They do not have a fear of obesity.
d. They frequently engage in self-induced vomiting and laxative abuse.
e. They maintain a sense of control over their eating.

The correct answer is d. They frequently engage in self-induced vomiting and laxative abuse. 

• Bulimia nervosa is an eating disorder in which a patient experiences recurrent episodes of binge eating without feeling in control of their food intake.
• These episodes are followed by compensatory behaviors, such as self-induced vomiting, abuse of laxatives, and hyperactivity (not often), due to a fear of gaining weight.

118A11
What is the cause of stress urinary incontinence?

a. Urinary retention
b. Cerebral infarction (stroke)
c. Overactive bladder
d. Interstitial cystitis
e. Radical prostatectomy (prostate removal surgery)

The correct answer is e. Radical prostatectomy (prostate removal surgery).

• Stress urinary incontinence (SUI) occurs when abdominal pressure increases, such as during coughing, sneezing, laughing, or physical exercise, due to weakening or damage to the muscles that control the flow of urine. A total prostatectomy can damage the pelvic floor and the sphincter.

118A12
Which virus causes acquired sensorineural hearing loss?

a. Adenovirus
b. Epstein-Barr (EB) virus
c. Herpes simplex virus
d. Rubella virus
e. Mumps virus

The correct answer is e. Mumps virus. 

• The mumps virus primarily affects the salivary glands but can also damage the inner ear (cochlea) or the auditory nerve, which contribute to the transmission of sound signals to the brain. Therefore, an infection with the mumps virus can lead to acquired sensorineural hearing loss. The hearing loss is typically in one ear (unilateral).
• An infection with the rubella virus during pregnancy can cause congenital hearing loss in the child.

118A13
Which diseases should be considered for emergency surgery? Select two.

a. Cancerous peritonitis
b. Strangulated intestinal obstruction
c. Radiation enteritis
d. Paralytic ileus
e. Perforated generalized peritonitis

The correct answers are b. Strangulated intestinal obstruction and e. Perforated generalized peritonitis.

• Strangulated intestinal obstruction cuts off the blood supply and can cause intestinal necrosis. Perforated generalized peritonitis refers to a hole in the gastrointestinal tract and can lead to a life-threatening infection. Both require emergency surgery.
• In contrast, cancerous peritonitis, radiation enteritis, and paralytic ileus are generally treated with chemotherapy, medication, and conservatively, respectively.

 118A14

118A15

A 3-year-old boy was brought to the hospital by his parents with complaints of fever and leg pain. A month ago, he twisted his left foot and felt pain. Later, he also complained of pain in the right leg. Two weeks ago, he developed a fever around 38°C, and the pain in both legs worsened. He visited his regular doctor and was prescribed antibiotics, but the fever persisted. His height is 103 cm, weight 17 kg. Temperature 37.5°C. Pulse 128/min, regular. Blood pressure 106/70 mmHg. Several purpura were observed on both lower legs. The palpebral conjunctiva appeared anemic. No abnormalities were noted in the ocular conjunctiva. No redness in the throat. Heart sounds and breath sounds were normal. The abdomen was flat, soft, and the liver and spleen were not palpable. No palpable superficial lymph nodes. There was no joint swelling or range-of-motion limitation in the lower limbs.

Blood tests: RBC 2.98 million, Hb 7.2 g/dL, Ht 23%, reticulocytes 1.8%, WBC 15,400 (bands 3%, segmented neutrophils 8%, eosinophils 1%, monocytes 4%, lymphocytes 84%), platelets 20,000.
Blood chemistry: Total protein 7.5 g/dL, albumin 4.4 g/dL, total bilirubin 0.3 mg/dL, direct bilirubin 0.1 mg/dL, AST 45 U/L, ALT 19 U/L, LDH 520 U/L (reference 190-365), ALP 180 U/L (reference 115-359), CK 60 U/L (reference 43-270), BUN 10 mg/dL, creatinine 0.3 mg/dL, uric acid 6.2 mg/dL, Na 140 mEq/L, K 4.0 mEq/L, Cl 101 mEq/L, Ca 11.0 mg/dL, P 6.0 mg/dL, CRP 1.2 mg/dL.
X-rays of both lower legs showed no abnormalities. The following bone marrow smear sample stained with May-Giemsa is shown.

What is the most likely diagnosis?

a. Osteomyelitis
b. Osteosarcoma
c. Acute leukemia
d. Aplastic anemia
e. Hemophagocytic lymphohistiocytosis (HLH)

The correct answer is c. Acute leukemia.

• The characteristics of acute leukemia are uncontrolled proliferation of immature white blood cells (blasts) in the bone marrow and suppression of normal blood cell production. As a result, the child presents with fever (due to abnormal leukemic cells), leg pain, pale conjunctiva (anemia), and purpura (thrombocytopenia).

118A16
A 32-year-old man presented with swelling of the right scrotum. He noticed painless swelling of his right scrotum 3 months ago and came for consultation. There is no notable medical or family history. Height is 170 cm, weight 69 kg. Temperature is 36.1°C. Pulse is 72/min, regular. Blood pressure is 122/66 mmHg. A hard mass was palpated in the right testicle without tenderness.
Blood test results: RBC 4.4 million, Hb 13.7 g/dL, Ht 42%, WBC 6,000, platelets 300,000.
Blood biochemistry: LDH 302 U/L (reference 124–222), hCG 0.1 mIU/mL (reference ≤0.7), α-fetoprotein (AFP) 5.2 ng/mL (reference ≤20).
Scrotal ultrasound showed a 5 cm solid mass with heterogeneous echotexture in the right testicle. A contrast-enhanced CT of the chest and abdomen revealed retroperitoneal lymph node enlargement, with the largest node measuring 3 cm.

What is the first course of action?

a. Observation
b. Radiation therapy
c. Testicular needle biopsy
d. High inguinal orchiectomy
e. Cytotoxic chemotherapy

The correct answer is d. High inguinal orchiectomy.

• A painless swelling in the right scrotum, a 5 cm solid, heterogeneous mass on ultrasound, and elevated LDH levels indicate testicular cancer. Enlarged retroperitoneal lymph nodes on a CT scan suggest metastasis. A high inguinal orchiectomy is both diagnostically and therapeutically useful.
• Observation is inappropriate. Radiation therapy and chemotherapy are not the first steps. A fine needle biopsy increases the risk of spreading cancer cells.

118A17
A 1-year-old girl was brought to the clinic by her mother due to the spread of a rash all over her body. The rash first appeared on her upper limbs three days ago. Two days ago, it spread to her face, trunk, and upper limbs. Yesterday, she developed a fever. She has a history of atopic dermatitis. All routine vaccinations, including the MMR vaccine, have been administered. The rash is itchy, and some areas have blisters and crusts. There is no strawberry tongue. A photo of the skin is shown.

What is the diagnosis?

a. Measles
b. Scarlet fever
c. Hand, foot, and mouth disease
d. Roseola
e. Kaposi varicelliform eruption (eczema herpeticum)

The most likely diagnosis is e. Kaposi varicelliform eruption (eczema herpeticum). 

• A history of atopic dermatitis favors viral infections. Infection with the herpes simplex virus (HSV) causes fever as well as vesicles and crusts in the rash, which spreads rapidly.
• Measles typically presents with a maculopapular rash, Koplik spots in the mouth, and a history of high fever.
• Scarlet fever is characterized by a rough, sandpaper-like rash, a strawberry tongue, and is caused by a group A streptococcal infection.
• Hand-foot-and-mouth disease presents with a rash localized to the hands, feet, and mouth.
• Roseola presents with a high fever followed by a sudden rash.

118A18
A 72-year-old man came to the clinic complaining of sudden vision loss in his left eye. He was watching TV when he suddenly lost vision in his left eye, and since it did not improve, he sought medical attention. He has been smoking 20 cigarettes a day for 50 years and has a blood pressure of 170/96 mmHg. His visual acuity is 0.3 (1.0) in the right eye and only hand motion in the left eye (uncorrectable). The fundus photograph of the left eye is shown.

What is the diagnosis?

a. Vitreous hemorrhage
b. Age-related macular degeneration
c. Vogt-Koyanagi-Harada disease
d. Branch retinal vein occlusion
e. Central retinal artery occlusion

The most likely diagnosis is e. Central retinal artery occlusion (CRAO). 

• Central retinal artery occlusion (CRAO) presents with sudden and painless vision loss in one eye due to an interruption of blood flow to the retina. Fundus photography shows a pale retina with a cherry-red spot at the macula. Hypertension and smoking are risk factors. Immediate treatment is necessary to prevent permanent vision loss.
• A vitreous hemorrhage would present with visual disturbances such as floaters or blurred vision.
• Age-related macular degeneration generally affects central vision progressively.
• Vogt-Koyanagi-Harada disease is a systemic inflammatory disorder affecting the eyes, ears, and skin, often associated with bilateral uveitis.
• Branch retinal vein occlusion would show a different pattern, with retinal hemorrhages and venous dilation.

118A19
A 20-year-old man came to the clinic with complaints of chest discomfort and difficulty breathing. He had felt chest discomfort several times in the past but did not seek medical attention. Since yesterday, he has had persistent shortness of breath, which prompted him to visit the clinic. His medical history is unremarkable. His father had cerebral venous sinus thrombosis in his 20s. The patient is alert. Temperature is 36.2°C. Pulse is 96/min, regular. Blood pressure is 104/68 mmHg. Respiratory rate is 24/min. SpO2 is 94% (room air). Heart and breath sounds are normal. The abdomen is flat and soft, and the liver and spleen are not palpable. Mild edema is noted in the lower limbs.

Blood test results: RBC 4.5 million, Hb 14.5 g/dL, Ht 42%, WBC 6,200 (neutrophils 62%, eosinophils 1%, monocytes 5%, lymphocytes 32%), platelets 220,000, PT-INR 1.0 (reference 0.9–1.1), APTT 30 seconds (control 32.2), plasma fibrinogen 288 mg/dL (reference 186–355), D-dimer 10 μg/mL (reference ≤1.0).
Blood biochemistry: Total bilirubin 1.1 mg/dL, LDH 208 U/L (reference 124–222), BUN 22 mg/dL, creatinine 0.6 mg/dL. CRP 0.3 mg/dL.
Chest X-ray shows no abnormalities.

What is the most appropriate test to perform immediately?

a. Bronchoscopy
b. Pulmonary function test
c. Cervical ultrasound
d. Contrast-enhanced CT from chest to lower limbs
e. Ankle-brachial index (ABI)

The most appropriate test is d. Contrast-enhanced CT from chest to lower limbs. 

• Chest discomfort, shortness of breath, and mild edema in the lower extremities, along with an elevated D-dimer level, suggest a pulmonary embolism (PE). A PE often originates from a deep vein thrombosis (DVT) in the legs. The father's history of sinus vein thrombosis also supports the suspicion of a PE. A contrast-enhanced CT scan is necessary for diagnosing a PE and assessing a deep DVT.

118A20
A 36-year-old woman presented with a rash on her right upper arm. About 10 years ago, she developed a flat rash measuring approximately 3 mm in diameter on her right upper arm. About 3 months ago, it gradually began to enlarge and become raised. Two weeks ago, it started to bleed. A brown nodule measuring 18×16 mm was observed on her right upper arm. One lymph node, 1 cm in diameter, was palpable in her right axilla. A photo of the right upper arm and the dermoscopic image are shown.

What is the diagnosis?

a. Bowen's disease
b. Malignant melanoma
c. Pigmented nevus
d. Actinic keratosis
e. Seborrheic keratosis

The most likely diagnosis is b. Malignant melanoma. 

• Irregular pigmentation in the dermoscopic image, recent enlargement, and bleeding suggest malignant melanoma. A palpable lymph node in the axilla indicates potential metastasis.
• Bowen's disease typically presents as a scaly patch or plaque.
• A pigmented nevus is a benign mole without sudden growth.
• Actinic keratosis is generally a precursor to squamous cell carcinoma, presenting as a rough and scaly patch.
• Seborrheic keratosis usually presents as a waxy, stuck-on lesion.

118A22
A 57-year-old man presented with fever. He had experienced a fever around 38°C with chills for the past two weeks and visited a local clinic. Antipyretics were prescribed, but the fever persisted, and he began to experience shortness of breath with exertion, leading to a referral to the emergency department. He has been on oral medication for diabetes for the past 10 years. He has been undergoing treatment for dental caries for about one month. He has no history of allergies. He is alert. His temperature is 38.2°C. Pulse is 104/min, regular. Blood pressure is 136/82 mmHg. Respiratory rate is 26/min. SpO2 is 94% (room air). A Levine grade 3/6 holosystolic murmur, strongest at the apex, was heard. There were no abnormal breath sounds. The abdomen was flat and soft, with no palpable liver or spleen. Edema was noted in the lower limbs. A painful rash was observed on the right palm.

Blood tests: RBC 4.78 million, Hb 14.0 g/dL, Ht 41%, WBC 13,400, platelets 150,000.
Blood chemistry: BUN 32 mg/dL, creatinine 1.3 mg/dL, blood glucose 175 mg/dL, HbA1c 8.1% (reference 4.9–6.0), Na 134 mEq/L, K 4.2 mEq/L. CRP 12 mg/dL.
A chest X-ray showed a cardiothoracic ratio of 56% and increased pulmonary vascular markings. The ECG showed sinus tachycardia. Echocardiogram in the parasternal long-axis view and color Doppler echocardiogram in the parasternal long-axis view are shown. Blood cultures from two sets both detected viridans streptococci.

What is the appropriate antibiotic to administer while awaiting the results of the drug susceptibility test?

a. Minocycline
b. Rifampicin
c. Levofloxacin
d. Clarithromycin
e. Benzylpenicillin

The most appropriate antibiotic to administer is e. Benzylpenicillin.

• Viridans streptococci detected in the blood culture are a common cause of infective endocarditis (IE), whose symptoms include fever, a holosystolic heart murmur, and a painful rash on the hand (possibly Osler's nodes). The first-line therapy is Benzylpenicillin.

118A23
A 52-year-old woman presented with a history of recurrent ureteral stones. She has been on medication for hypertension for five years. Two years ago, she underwent extracorporeal shock wave lithotripsy (ESWL) for kidney stones. Two weeks ago, she experienced lower back pain, leading to a diagnosis of urolithiasis. Her pulse is 80/min, regular. Blood pressure is 154/90 mmHg. The thyroid gland is not palpable. Heart and breath sounds are normal. There is mild abdominal distension but no edema in the lower extremities.

Blood biochemistry results: Albumin 3.6 g/dL, Ca 13.2 mg/dL, P 2.4 mg/dL, PTH 120 pg/mL (reference range 10–60). Neck ultrasound revealed a 3 cm mass near the lower pole of the right thyroid lobe. The 99mTc-MIBI parathyroid scintigraphy is shown.

Which of the following findings is correct for this patient?

a. Decreased bone density
b. Low serum ALP
c. Metabolic alkalosis
d. Decreased active vitamin D
e. Increased tubular phosphate reabsorption

The correct answer is a. Decreased bone density. 

• Primary hyperparathyroidism (PHPT) refers to elevated PTH levels caused by a parathyroid adenoma, which leads to elevated calcium levels (hypercalcemia) and recurrent kidney stones, as observed in this patient.
• PTH stimulates osteoclast activity in the bones, leading to the release of calcium and phosphate into the bloodstream. This also results in an increase in alkaline phosphatase (ALP) as part of the bone turnover process.
• PTH contributes to metabolic acidosis by promoting the excretion of bicarbonate in the kidneys. Additionally, PTH stimulates the production of active vitamin D in the kidneys, which enhances the absorption of calcium and phosphate from the intestines into the blood. At the same time, PTH decreases the reabsorption of phosphate in the kidneys, causing more phosphate to be excreted in the urine.

118A24
A 52-year-old woman was referred for further evaluation after an abdominal ultrasound during a health checkup two weeks ago showed an abnormality in the gallbladder. She has no subjective symptoms. Her medical history is unremarkable. She is 158 cm tall and weighs 64 kg, with a BMI of 25.6. Her temperature is 36.2°C. The abdomen is flat, soft, and non-tender.

Blood test results: RBC 4.58 million, Hb 13.7 g/dL, Ht 41%, WBC 7,300.
Blood biochemistry: Total bilirubin 0.9 mg/dL, AST 20 U/L, ALT 18 U/L, LDH 148 U/L (reference 124–222), ALP 86 U/L (reference 38–113), γ-GT 28 U/L (reference 9–32), CEA 1.1 ng/mL (reference ≤5), CA19-9 14 U/mL (reference ≤37), CRP 0.1 mg/dL.
The abdominal ultrasound image is shown.

What is the appropriate treatment plan for this patient?

a. Observation
b. Antibiotic treatment
c. Laparoscopic cholecystectomy
d. Anticancer drug treatment
e. Percutaneous transhepatic gallbladder drainage

The most appropriate treatment plan is a. Observation. 

• The ultrasound image shows gallbladder polyps or sludge. However, it is asymptomatic, with no signs of infection, inflammation, or malignancy, and the lab results, including liver function tests, tumor markers, and CRP, are normal. Therefore, observation and regular follow-up are appropriate.

118A25
A 28-year-old woman (gravida 2, para 1) was referred for consultation after being diagnosed with fetal growth restriction at 32 weeks of pregnancy. Her initial prenatal tests at 10 weeks of pregnancy showed blood type O, RhD (+), indirect Coombs test negative, HBs antigen negative, HCV antibody negative, rubella HI antibody titer 1:128, RPR less than 1:1, TPHA negative, and HIV antigen/antibody negative. At 15 weeks of pregnancy, she experienced flu-like symptoms that lasted for a few days but resolved on their own, so no further action was taken. On fetal ultrasound at the time of the consultation, the biparietal diameter (BPD) was 73 mm (-2SD), abdominal circumference (AC) was 23 cm, femur length (FL) was 24 mm, and the estimated fetal weight (EFW) was 1,368 g (-2SD). Fetal ascites was observed.

Which maternal-fetal infection is most likely?

a. Varicella (chickenpox)
b. Syphilis
c. Rubella
d. Hepatitis B
e. Cytomegalovirus infection

The most likely answer is e. Cytomegalovirus (CMV) infection. 

• Flu-like symptoms at 15 weeks of pregnancy, along with fetal growth retardation and fetal ascites, indicate a cytomegalovirus (CMV) infection, which can also lead to hepatosplenomegaly and neurological complications.

118A26
A 33-year-old woman (gravida 1, para 0) presented with complaints of lower abdominal pain and menorrhagia. Her menstrual cycle is regular, occurring every 28 days, lasting for 7 days. She has had dysmenorrhea for the past two years and has been taking over-the-counter painkillers. Four months ago, she began to notice an increase in menstrual blood volume and a dull pain in the lower abdomen, prompting her to seek medical attention. Three years ago, she had a miscarriage and underwent uterine curettage. She is 168 cm tall, weighs 60 kg, and has a temperature of 36.0°C. Her pulse is 76/min, regular, and her blood pressure is 110/74 mmHg. On pelvic examination, the uterus is enlarged to approximately 10 cm, and both adnexa are non-palpable. No induration is felt in the pouch of Douglas.

Blood test results: RBC 3.4 million, Hb 9.4 g/dL, Ht 32%, WBC 6,400, platelets 250,000.
Blood biochemistry: Total protein 6.2 g/dL, AST 20 U/L, ALT 18 U/L, LDH 186 U/L (reference 124–222), CA125 106 U/mL (reference ≤35).
A T2-weighted sagittal MRI of the pelvis is shown.

What is the diagnosis?

a. Uterine fibroid
b. Uterine sarcoma
c. Adenomyosis
d. Endometrial hyperplasia
e. Endometrial polyp

The most likely diagnosis is c. Adenomyosis. 

118A27
A 59-year-old man presented with left shoulder pain. He had been experiencing this pain for the past month. His pulse is 80/min, regular. Blood pressure is 130/70 mmHg. Respiratory rate is 16/min. SpO2 is 99% (room air). Left eyelid ptosis is observed. There is no jugular vein distention. Heart sounds are normal. Breath sounds are diminished in the left lung apex. Muscle strength in the limbs is normal.

Blood biochemistry: Blood glucose 90 mg/dL, HbA1c 5.0% (reference 4.9–6.0), Na 140 mEq/L, K 3.8 mEq/L, Cl 104 mEq/L, CEA 3.2 ng/mL (reference ≤5), SCC 7.0 ng/mL (reference ≤1.5). A diagnosis of squamous cell carcinoma was made through bronchoscopic biopsy. A chest X-ray and contrast-enhanced CT scan of the chest are shown.

Which condition is observed in this patient?

a. Horner syndrome
b. Superior vena cava syndrome
c. Cushing syndrome
d. Lambert-Eaton syndrome
e. Syndrome of inappropriate ADH secretion (SIADH)

The correct answer is a. Horner syndrome. 

118A28
A 10-month-old boy was brought in by his parents with complaints of vomiting. He was born at 39 weeks of gestation with a birth weight of 2,980 g. The parents reported that he vomits after eating solid food. His weight is 6,840 g. His temperature is 36.9°C, heart rate 92/min, blood pressure 90/56 mmHg, and respiratory rate 20/min. Esophageal 24-hour pH monitoring was performed, revealing severe gastroesophageal reflux disease. Frontal and lateral views of an upper gastrointestinal contrast study are shown.

What is the diagnosis for this patient?

a. Gastric volvulus
b. Esophageal diverticulum
c. Esophageal achalasia
d. Hiatal hernia
e. Congenital diaphragmatic hernia

The correct diagnosis is d. Hiatal hernia. 

118A29
A 25-year-old woman (gravida 2, para 0) began experiencing lower abdominal pain four days ago, prompting her to visit an obstetrics clinic. She had her first menstruation at age 12. Her menstrual cycle is regular, occurring every 28 days, and her last menstruation started 10 days ago and lasted for five days. She has had two surgical abortions in the past two years. She is 160 cm tall, weighs 53 kg, and has a body temperature of 37.9°C. Her pulse is 100/min, regular. Blood pressure is 116/62 mmHg, and respiratory rate is 20/min. Her abdomen is flat, but there is rebound tenderness in the lower abdomen. On pelvic examination, the uterus is of normal size and tender. The adnexa are not palpable due to pain. A speculum examination reveals yellow purulent discharge from the external cervical os.

Blood test results: RBC 3.2 million, Hb 10.3 g/dL, Ht 30%, WBC 18,300 (band neutrophils 60%, segmented neutrophils 26%, eosinophils 0%, basophils 1%, lymphocytes 13%), platelets 410,000. CRP is 16 mg/dL. Pregnancy test is negative. Transvaginal ultrasound shows sausage-like swelling of the left fallopian tube, with this area being the point of maximum tenderness.

What should be administered first?

a. Antibiotics
b. Probiotics
c. Antiviral drugs
d. GnRH agonist
e. Glucocorticoids

The correct answer is a. Antibiotics. 

• The clinical findings, including purulent cervical discharge, elevated white blood cell count, and swollen fallopian tube seen on ultrasound, suggest pelvic inflammatory disease (PID), likely due to a bacterial infection.
• Antibiotics are the first-line treatment for PID.

118A30
A 67-year-old man was brought to the hospital by his family, who were concerned about his intoxicated state. He has had a habit of drinking alcohol in the evenings since he was young. After retiring a year ago, his alcohol consumption increased, and recently he has been drinking from morning until night without eating meals. According to his family, his hand and finger tremors stop when he is intoxicated. They also mention that even when they tell him to cut back on drinking, he sneaks out to buy alcohol and drinks it. His height is 173 cm, weight 51 kg. His body temperature is 36.8°C, pulse 72/min, regular. His blood pressure is 108/78 mmHg, respiratory rate 18/min, SpO2 98% (room air). He has an alcohol odor, but he is able to have a conversation. His palpebral conjunctiva shows mild signs of anemia. His sclera shows jaundice, but his eye movements are normal. No abnormalities are heard in heart or lung sounds. His abdomen is flat and soft, and neither the liver nor spleen is palpable. He is admitted for abstinence and further evaluation.

Which medication should be administered after admission?

a. Disulfiram (Antabuse)
b. Levodopa (L-dopa)
c. Benzodiazepine
d. Acetylcholinesterase inhibitor
e. Selective serotonin reuptake inhibitor (SSRI)

The correct answer is c. Benzodiazepine. 

• The patient likely has alcohol dependence and is at risk for alcohol withdrawal syndrome, which can cause serious symptoms such as tremors, seizures, and delirium tremens. Benzodiazepines are the first-line treatment for alcohol withdrawal.
• Disulfiram (Antabuse) is used to help patients abstain from alcohol by causing unpleasant effects if alcohol is consumed.
• Levodopa is used in Parkinson's disease to treat tremors.
• Acetylcholinesterase inhibitors are used in Alzheimer's disease.
• SSRIs are used for depression.

118A32
A 70-year-old man presented with general fatigue. He had been experiencing fatigue for two weeks, which did not improve, prompting him to seek medical attention. His palpebral conjunctiva showed signs of anemia, and no jaundice was observed in the sclera. His abdomen was flat and soft, and neither the liver nor the spleen was palpable. Petechiae were noted on both lower limbs.

Blood test results: RBC 1.74 million, Hb 5.4 g/dL, Ht 16%, reticulocytes 1%, WBC 1,800 (segmented neutrophils 20%, eosinophils 1%, monocytes 2%, lymphocytes 77%), platelets 22,000.
Blood chemistry: Total protein 6.2 g/dL, albumin 3.2 g/dL, total bilirubin 0.6 mg/dL, AST 28 U/L, ALT 34 U/L, LDH 140 U/L (reference 124–222), BUN 12 mg/dL, creatinine 0.7 mg/dL.
A peripheral blood smear showed no abnormalities in red blood cells. Bone marrow biopsy revealed marked hypoplasia.

Which treatment is not appropriate?

a. Plasma exchange
b. Red blood cell transfusion
c. Anti-thymocyte globulin (ATG) administration
d. Thrombopoietin receptor agonist administration
e. Granulocyte colony-stimulating factor (G-CSF) administration

The answer is a. Plasma exchange. 

• This patient presents with severe pancytopenia (low levels of red blood cells, white blood cells, and platelets), bone marrow hypoplasia, and clinical signs like anemia and petechiae, which are consistent with aplastic anemia.
• Plasma exchange is not an appropriate treatment for aplastic anemia as it does not target the underlying bone marrow failure.
• Red blood cell transfusion is appropriate to manage symptomatic anemia.
• Anti-thymocyte globulin (ATG) is used as immunosuppressive therapy in aplastic anemia.
• Thrombopoietin receptor agonists are used to stimulate platelet production in bone marrow failure syndromes.
• G-CSF is used to stimulate white blood cell production, particularly in cases of neutropenia.

118A33
A 64-year-old man presented with swelling under his left ear. He had noticed a lump under his left ear 10 years ago and a smaller lump under his right ear 3 years ago. The lumps had been alternating between increasing and decreasing in size over time. A soft, elastic lump measuring 20 mm in diameter was palpated under his right ear, and a 35 mm lump was palpated under his left ear. There was no adhesion to the skin and no tenderness. A fat-suppressed T1-weighted MRI horizontal section of the neck is shown.

What is the diagnosis?

a. Sialolithiasis (salivary stone disease)
b. Thyroglossal duct cyst
c. Warthin tumor
d. Sjögren syndrome
e. Pleomorphic adenoma of the parotid gland

The correct diagnosis is c. Warthin tumor. 

• Warthin tumors are benign salivary gland tumors, commonly found in the parotid gland. They typically present as painless, slow-growing lumps, which can fluctuate in size, as described in this case. Bilateral involvement, as seen here, is also common in Warthin tumors.
• Sialolithiasis is caused by salivary stones and typically presents with pain during meals.
• Thyroglossal duct cyst is typically a midline neck mass, not located under the ear.
• Sjögren syndrome is an autoimmune condition that affects salivary glands, but it would present with dry eyes and dry mouth, not with isolated parotid masses.
• Pleomorphic adenoma is also a benign parotid tumor, but it tends to be unilateral and does not fluctuate in size.

118A34
A 54-year-old man presented with complaints of floaters and photopsia in his left eye. A few days ago, he started seeing something like a black shadow in bright areas in his left eye, and occasionally noticed flashes of light. He has myopia of -8D in both eyes, and his corrected visual acuity is 1.0 in both eyes. A fundus photograph of his left eye is shown.

What is the diagnosis?

a. Vitreous hemorrhage
b. Age-related macular degeneration
c. Retinitis pigmentosa
d. Rhegmatogenous retinal detachment
e. Branch retinal vein occlusion

The correct diagnosis is d. Rhegmatogenous retinal detachment. 

• The symptoms of floaters (black spots) and photopsia (flashes of light), especially in a patient with high myopia, are classic signs of rhegmatogenous retinal detachment. This condition involves a break or tear in the retina, allowing fluid to enter and cause the retina to detach.
• Vitreous hemorrhage can also cause floaters, but it usually occurs with a history of trauma or vascular disease.
• Age-related macular degeneration is more commonly associated with central vision loss.
• Retinitis pigmentosa is a progressive, hereditary condition that leads to peripheral vision loss and night blindness.
• Branch retinal vein occlusion typically presents with sudden vision loss or blurry vision.

118A35
A 71-year-old man was advised to visit the clinic after screening for hepatitis viruses indicated that "there is a very high possibility of current infection with the hepatitis C virus." He is on calcium channel blockers for hypertension. At the age of 12, he received a blood transfusion after a traffic accident. He has no history of smoking and drinks alcohol occasionally. His consciousness is clear, pulse 76/min, regular, blood pressure 132/74 mmHg. There are no abnormalities in the palpebral or scleral conjunctiva. Heart and lung sounds are normal. The abdomen is flat and soft, with no palpable liver or spleen.
Blood test results: RBC 4.85 million, Hb 14.7 g/dL, WBC 6,300, platelets 160,000.
Biochemistry: Total protein 7.3 g/dL, albumin 4.5 g/dL, total bilirubin 0.7 mg/dL, AST 24 U/L, ALT 28 U/L, γ-GT 36 U/L (reference range 13–64), BUN 12 mg/dL, creatinine 0.5 mg/dL, eGFR 82.8 mL/min/1.73 m².
Immunoserology: HBs antigen negative, HBs antibody negative, HBc antibody negative, HCV antibody positive, HCV-RNA positive.
Abdominal ultrasound shows no abnormalities.

What is the first-line treatment?

a. Interferon
b. Nucleoside analogs
c. Glucocorticoids
d. Ursodeoxycholic acid
e. Direct-acting antivirals (DAA)

The correct answer is e. Direct-acting antivirals (DAA). 

• The patient has chronic hepatitis C, confirmed by positive HCV antibody and HCV-RNA. The treatment of choice for hepatitis C infection, especially in recent years, is direct-acting antivirals (DAA), which have a high cure rate and fewer side effects compared to older therapies like interferon.
• Nucleoside analogs are used for hepatitis B. Ursodeoxycholic acid is used to improve bile flow in certain liver diseases.

118A36
A 64-year-old woman presented with complaints of shortness of breath. Fifteen years ago, she had been diagnosed with hypertension and diabetes, but she had not sought medical attention. Two months ago, she visited a local clinic due to fever and was diagnosed with impaired kidney function. Three weeks ago, she lost her appetite and had been eating only fruit. The night before last, she started feeling short of breath, which led her to seek medical care. Her consciousness is clear. She is 166 cm tall and weighs 75 kg (she weighed 70 kg two months ago). Her pulse is 92 beats per minute, regular. Blood pressure is 190/110 mmHg. Respiratory rate is 20 breaths per minute. SpO2 is 90% (room air). Coarse crackles are heard in both lower lung fields. There is severe pitting edema in both lower legs.
Urinalysis: Protein 3+, glucose 2+, occult blood (−). Random urine protein 188 mg/dL, creatinine 87 mg/dL.
Blood test results: RBC 3.35 million, Hb 9.0 g/dL, Ht 31%.
Biochemistry: Total protein 5.3 g/dL, albumin 2.8 g/dL, BUN 56 mg/dL, creatinine 3.9 mg/dL, uric acid 6.8 mg/dL, blood glucose 263 mg/dL, HbA1c 8.6% (reference range 4.9–6.0), Na 140 mEq/L, K 6.7 mEq/L, Cl 106 mEq/L, Ca 7.2 mg/dL, P 5.6 mg/dL.
A chest X-ray shows cardiomegaly and pulmonary congestion. An ECG shows tented T-waves.

What is the first drug that should be administered to this patient?

a. SGLT2 inhibitors
b. Albumin preparation
c. Calcium gluconate
d. Erythropoietin preparation
e. Angiotensin receptor blocker (ARB)

The correct answer is c. Calcium gluconate. 

• This patient has severe hyperkalemia (K 6.7 mEq/L), which is a life-threatening condition that requires urgent management. The presence of tented T-waves on the ECG is a hallmark of hyperkalemia. The first-line treatment for hyperkalemia is calcium gluconate which helps stabilize the cardiac membrane.
• SGLT2 inhibitors are used for diabetes management.
• Albumin may be used for hypoalbuminemia.
• Erythropoietin may be given for anemia related to chronic kidney disease.
• ARBs are used to control blood pressure and manage kidney disease, but they can increase potassium levels.

118A37
A 7-year-old boy was brought to the clinic at night by his mother, complaining of pain in his right forearm and difficulty moving the fingers of his right hand. Earlier that morning, he had fallen from a swing and struck his right elbow hard, prompting a visit to the clinic. According to the medical records, swelling and deformity of the right elbow were observed, and an X-ray revealed a supracondylar fracture of the right humerus. Manual reduction and splint fixation were performed. Eight hours after returning home, the pain worsened, and he could no longer move his right fingers, leading to a second visit. He is 110 cm tall and weighs 19 kg. Upon removing the splint and bandages, significant swelling of the right forearm was noted. The boy was unable to actively flex or extend his fingers, and he complained of severe pain with passive extension. The radial artery pulse was not palpable.

What is the appropriate management for this patient?

a. Fasciotomy
b. Traction treatment
c. Cast immobilization
d. Finger range-of-motion exercises
e. Open reduction and internal fixation of the fracture

The correct answer is a. Fasciotomy. 

• The child is showing signs of compartment syndrome, a serious condition characterized by increased pressure within a muscle compartment, leading to decreased blood flow, nerve damage, and muscle ischemia. The key symptoms include severe pain with passive movement, swelling, and absence of the radial pulse (indicating compromised circulation). Immediate treatment is required to prevent permanent damage.
• Fasciotomy is the surgical procedure used to relieve the pressure in the compartment and restore blood flow.
• Open reduction and internal fixation may be necessary for fractures, but in this case, the immediate priority is to relieve the pressure caused by compartment syndrome.

118A38
A 43-year-old woman noticed redness in her left eye and came to the clinic. She has no history of trauma or surgery and does not have any subjective symptoms. No eye discharge is present. A photo of her left eye is shown.
What is the most likely diagnosis?

a. Chalazion
b. Trichiasis
c. Ectropion
d. Subconjunctival hemorrhage
e. Epidemic keratoconjunctivitis

The most likely diagnosis is d. Subconjunctival hemorrhage. 

• The image shows a red area under the conjunctiva, typical of a subconjunctival hemorrhage, which occurs when small blood vessels break and bleed underneath the conjunctiva. It often appears suddenly and can look alarming, but it is usually painless and self-limiting.
• Chalazion is a lump in the eyelid.
• Trichiasis involves misdirected eyelashes that irritate the eye, causing discomfort.
• Ectropion refers to outward turning of the eyelid.
• Epidemic keratoconjunctivitis is an infection that typically presents with significant symptoms like eye pain, discharge, and irritation.

118A40
A 65-year-old woman (2 pregnancies, 1 birth) came to the clinic complaining of a lump in her breast. She had been aware of a lump in her left breast for about 10 years but had not sought treatment. Recently, she began to experience pain, which prompted her to seek medical attention. There is no family history of breast cancer. Her height is 160 cm, weight 60 kg, body temperature 36.0°C, pulse 80 beats per minute (regular), and blood pressure 146/90 mmHg. On examination, there is dimpling of the skin on the left breast, and a 3 cm mass is palpable. A mammogram showed a high-density mass with spiculated margins and polymorphic microcalcifications.
What is the diagnosis?

a. Breast cancer
b. Mastopathy (Fibrocystic breast disease)
c. Phyllodes tumor
d. Chronic mastitis
e. Fibroadenoma

The correct diagnosis is a. Breast cancer. 

• The spiculated margins and polymorphic microcalcifications seen on the mammogram are characteristic findings associated with breast cancer. The presence of a long-standing lump, new onset of pain, and skin dimpling are also clinical features suggestive of malignancy.
• Other conditions, such as fibroadenoma and mastopathy, are typically benign.

118A41
A 53-year-old woman (2 pregnancies, 1 birth) who entered menopause at 51 years of age came to the clinic complaining of abnormal genital bleeding. She had been experiencing slight abnormal bleeding for about three months, and two weeks ago, the bleeding increased in volume, prompting her to seek medical attention. There is nothing remarkable in her medical or family history. Her height is 161 cm, weight 65 kg, body temperature 36.2°C, pulse 84 beats per minute (regular), and blood pressure 140/78 mmHg. On pelvic examination, the uterus is slightly enlarged but still mobile, and no adnexal masses are palpable. Blood test results: RBC 3.2 million, Hb 9.9 g/dL, Ht 31%, WBC 6,300, platelets 210,000, PT-INR 1.0 (normal range 0.9–1.1). Blood biochemistry: total protein 6.9 g/dL, albumin 3.7 g/dL, total bilirubin 0.9 mg/dL, direct bilirubin 0.2 mg/dL, AST 18 U/L, ALT 16 U/L, LDH 186 U/L (normal range 124–222), γ-GT 32 U/L (normal range 9–32), BUN 14 mg/dL, creatinine 0.7 mg/dL, CEA 3.2 ng/mL (normal < 5), CA19-9 28 U/mL (normal < 37), CA125 52 U/mL (normal < 35), CRP 1.0 mg/dL. Cytology of the endometrium is positive, and a biopsy revealed endometrioid carcinoma. Cervical-to-pelvic contrast-enhanced CT shows no significant lymphadenopathy or distant metastasis. A T2-weighted sagittal MRI of the pelvis is shown.

What is the appropriate treatment for this patient?

a. Surgery
b. Antibiotic therapy
c. Intra-arterial chemotherapy
d. Chemoradiation therapy
e. Brachytherapy

The correct treatment is a. Surgery.

• Given the diagnosis of endometrioid carcinoma and the absence of lymph node enlargement or distant metastasis on imaging, the appropriate initial treatment is surgery. Typically, surgery for endometrial cancer involves a total hysterectomy, bilateral salpingo-oophorectomy, and often a lymphadenectomy to ensure complete removal of the tumor and staging of the disease.
• Other options like chemotherapy, radiation, or brachytherapy may be considered later depending on the stage and histology of the cancer, but surgery is the first-line treatment in this case.

118A42
56-year-old female. She was brought to the hospital by ambulance with a chief complaint of seizures. She had been experiencing headaches for about a month and had been managing the symptoms with over-the-counter pain relievers. However, she experienced her first generalized seizure at home, prompting her family to call for an ambulance. Upon arrival, her level of consciousness was JCS II-10. Her vital signs were as follows: body temperature of 36.7°C, heart rate of 96/min, regular, blood pressure of 136/86 mmHg, respiratory rate of 16/min, and SpO2 of 98% (under oxygen administration at 2 L/min via nasal cannula). The pupils were both 3 mm in diameter, with brisk light reflexes. The generalized seizure lasted for a few minutes, after which she presented with partial right-sided paralysis. A non-contrast head CT (coronal view) and contrast-enhanced T1-weighted MRI (axial view) were performed.

What is the most likely diagnosis?

a. Glioblastoma
b. Meningioma
c. Brain abscess
d. Schwannoma
e. Metastatic brain tumor

The answer is b. Méningiome. 

• A meningioma is a benign, slow-growing tumor that arises from the meninges, the membranes surrounding the brain and spinal cord. It is the most common type of brain tumor and often presents with seizures, headaches, and focal neurological deficits such as weakness or paralysis on one side, as seen in this patient.
• The MRI and CT images show a well-defined, non-invasive appearance of the mass near the meninges (outside the brain tissue).

118A43

A 21-year-old woman presented with complaints of runny nose, nasal congestion, and sneezing that started two weeks ago. She had been experiencing similar symptoms since the spring three years ago. She had been prescribed antihistamines at a nearby clinic, which initially improved her symptoms, but they worsened again in early March. Both sides of the nasal mucosa were swollen, and watery nasal discharge was observed. Eosinophils were detected in her nasal discharge test. She expressed a desire for rapid symptom relief.

What is the appropriate treatment?

a. Oral antibiotics
b. Desensitization therapy
c. Oral immunosuppressants
d. Nasal laser surgery
e. Intranasal corticosteroids

The correct answer is e. Intranasal corticosteroids. 

• The patient's symptoms (nasal congestion, runny nose, and sneezing) that worsen during specific seasons (spring) are suggestive of allergic rhinitis, likely triggered by seasonal allergens like pollen. The presence of eosinophils in the nasal discharge confirms an allergic component.
• Intranasal corticosteroids are considered the first-line treatment for allergic rhinitis.
• Immunosuppressants are too aggressive for allergic rhinitis.
• Desensitization therapy can be considered for long-term management but does not provide rapid symptom relief.
• Laser surgery is not a first-line treatment for allergic rhinitis.

118A44

A 22-year-old woman presented with headaches and edema. She had been experiencing fever and sore throat for the past two weeks and was diagnosed with tonsillitis at a nearby clinic. Two days ago, she developed headaches and leg edema, which gradually worsened, prompting her visit to the hospital. She had no prior abnormalities noted in school or workplace health check-ups. Her height is 156 cm, weight 45 kg, pulse 84/min (regular), and blood pressure 156/76 mmHg. No facial rash was observed. Heart and lung sounds were normal. Edema was present in both lower legs. Neurological examination was normal. Urinalysis showed proteinuria (2+) and hematuria (3+).

What is the most likely finding in this patient?

a. Decreased C3
b. Elevated IgE
c. Positive M protein
d. Positive antinuclear antibodies (ANA)
e. Positive antiphospholipid antibodies

The most likely finding in this patient is a. Decreased C3. 

• The clinical presentation of a sore throat (tonsillitis), followed by edema, proteinuria, and hematuria, along with elevated blood pressure, suggests post-streptococcal glomerulonephritis (PSGN). A hallmark of PSGN is a decrease in complement component C3, which is often observed in the acute phase.

118A45

A 50-year-old woman visited the clinic with complaints of rashes on both palms and soles. The rash had appeared a few years ago and had fluctuated over time. She experienced itching and pain. She frequently had episodes of tonsillitis. She has been smoking 20 cigarettes a day for 30 years. The fungal test on the rash areas was negative. Photos of her right palm and right foot are shown.

Which joint is most likely to develop arthritis in this patient?

a. Temporomandibular joint
b. Sternoclavicular joint
c. Distal interphalangeal joint
d. Sacroiliac joint
e. Ankle joint

The answer is b. sternoclavicular joint. 

• This patient presents with a chronic history of recurrent palmoplantar pustulosis, characterized by recurrent eruptions of pustules on the palms and soles. This condition is often associated with pustulotic arthro-osteitis, a type of inflammatory arthritis that typically affects the sternoclavicular joint.
• Other signs, such as a history of smoking (which is a known risk factor), recurrent tonsillitis, and negative fungal tests (ruling out a fungal infection), all support this diagnosis.

118A46
A 61-year-old man presented with right-sided chest pain. He had been aware of the chest pain for three months, but it worsened a week ago, prompting him to seek medical attention. His temperature was 36.9°C, pulse 84/min and regular, blood pressure 132/80 mmHg, respiratory rate 16/min, and SpO2 95% on room air. No abnormalities were noted in heart sounds, but diminished breath sounds were noted on the right side. Blood test results were as follows: RBC 4.71 million, Hb 11.0 g/dL, Ht 36%, WBC 9,200, and platelets 580,000. Blood biochemistry showed: SCC 0.7 ng/mL (normal range ≤1.5), ProGRP 23.8 pg/mL (normal range ≤81), and CRP 17 mg/dL. A pleural biopsy revealed malignant cells positive for calretinin immunohistochemical staining. Chest X-ray and FDG-PET/CT scan are shown.

Which statement about this disease is incorrect?

a. The epithelial type is the most common.
b. The prognosis is poor.
c. CEA levels are normal.
d. Hyaluronic acid levels in pleural effusion are elevated.
e. It develops around 5 years after asbestos exposure.

The incorrect choice is e. 

• "A pleural biopsy revealed malignant cells positive for calretinin immunohistochemical staining," and the FDG-PET/CT scan suggests malignant pleural mesothelioma.
• This condition typically develops decades after asbestos exposure, usually between 20 and 50 years after exposure. The epithelial type is the most common. The prognosis is poor. CEA (carcinoembryonic antigen) levels are typically normal in mesothelioma, which helps distinguish it from adenocarcinoma. Hyaluronic acid levels in pleural effusion are elevated.

118A47
A 68-year-old man was brought to the clinic by his wife, who was concerned about his behavior during sleep. Several times a week, about an hour and a half after falling asleep, he would shout loudly, suddenly sit up, and act as if he were fighting something. When his wife restrained him, he would snap out of it and say, "I was dreaming," then go back to sleep, and the next morning he would remember that it had happened in a dream. He has no abnormal behavior during the day. Physically, he reports that his body feels stiff and his movements have slowed down, and he is aware of some memory loss. His height is 168 cm, and his weight is 60 kg. Muscular rigidity is observed in all four limbs. On the Mini-Mental State Examination (MMSE), he scores 21 points (out of 30). Blood tests, biochemical tests, an EEG, and a plain head MRI reveal no abnormalities.

Which of the following sleep disorders does this patient likely have?
a. Nocturnal delirium
b. Sleepwalking
c. Narcolepsy
d. Restless legs syndrome
e. REM sleep behavior disorder (RBD)

The correct answer is e. REM sleep behavior disorder (RBD). 

• REM sleep behavior disorder (RBD) is a condition in which individuals act out their dreams during the REM (Rapid Eye Movement) phase of sleep. Normally, the body experiences muscle atonia (temporary paralysis) during REM sleep to prevent movement, but in RBD, this mechanism fails, allowing the person to physically enact their dreams. After these episodes, he recalls having vivid dreams.
• His muscle rigidity and cognitive decline (as indicated by the Mini-Mental State Examination score of 21) could suggest underlying neurological conditions, such as Parkinson’s disease or Lewy body dementia, both of which are commonly associated with RBD.
• Nocturnal delirium typically involves confusion during the night but does not involve acting out dreams.
• Sleepwalking occurs during non-REM sleep and involves unconscious movement, often without memory of the event.
• Narcolepsy causes excessive daytime sleepiness and sleep attacks, not necessarily violent behavior during sleep.
• Restless legs syndrome is characterized by an urge to move the legs, typically not associated with acting out dreams.

118A48

A 33-year-old woman presented with fever. She returned from Africa two weeks ago, where she had been living for two years. A week ago, she began experiencing fever accompanied by chills, headache, and nausea. She has been having high fevers of up to 40°C every other day and was prescribed antipyretic and analgesic medications by a local clinic. However, her fever did not improve, so she returned for further evaluation. She is conscious, with a body temperature of 39.3°C, a pulse of 108 beats per minute (regular), blood pressure of 80/48 mmHg, a respiratory rate of 20 breaths per minute, and SpO2 of 98% (on room air). The image shows a May-Giemsa stained peripheral blood smear of this patient.

Which of the following is correct regarding this condition?

a. It is transmitted through oral infection.
b. Splenomegaly is observed.
c. A vaccine is effective.
d. The incubation period is 3 to 5 days.
e. Quinolone antibiotics are effective.

The correct answer is b. A splenomegaly is observed. 

• This patient is likely suffering from malaria, which is endemic in many parts of Africa and presents with the classic symptoms of periodic high fevers (often every two or three days), chills, headache, and nausea. The May-Giemsa-stained blood smear would show the presence of Plasmodium parasites, confirming malaria.
• Malaria is transmitted by the bite of an infected Anopheles mosquito.
• Malaria often causes enlargement of the spleen (splenomegaly) as the body attempts to clear the infected red blood cells and the malaria parasites.
• While there is now a malaria vaccine (RTS,S/AS01), it is not fully effective and is not widely available in many regions yet.
• The incubation period for malaria is usually ranging from 7 to 30 days.
• Malaria is treated with antimalarial drugs such as chloroquine, artemisinin-based combination therapies (ACTs), and others.

118A49 A 64-year-old male was brought in by ambulance, complaining of chest pain and difficulty breathing. The previous evening, he had been drinking alcohol, and early in the morning, while performing cleaning duties, he experienced nausea and vomiting. Later, he suddenly developed chest pain and difficulty breathing, prompting a colleague to call for an ambulance. The chest pain worsened with deep breaths. He had a history of gastric ulcers at the age of 36. His consciousness was clear, but his facial expression showed distress. He measured 170 cm in height, weighed 62 kg, and had a body temperature of 36.0°C. His heart rate was 98 beats per minute, with a regular rhythm, blood pressure was 152/104 mmHg, respiratory rate was 24 breaths per minute, and SpO2 was 98% (with a 10 L/min oxygen mask). His skin was moist, and he had cold sweats. His eyelid and scleral conjunctiva showed no abnormalities. The oral cavity was dry with traces of vomit. Heart sounds were normal, but his left breath sounds were diminished. There were no abnormalities in his abdomen. Blood tests revealed the following: RBC 4.6 million, Hb 17.6 g/dL, Ht 52%, WBC 19,000, platelets 360,000. Blood biochemistry showed total protein 6.7 g/dL, total bilirubin 0.5 mg/dL, AST 19 U/L, ALT 13 U/L, BUN 13 mg/dL, creatinine 0.6 mg/dL, blood glucose 98 mg/dL, and CRP 1.1 mg/dL. There were no abnormalities on the electrocardiogram. Supine chest X-ray and plain chest CT images are shown.

What is the most likely diagnosis?

a. Gastroesophageal reflux disease
b. Ruptured aortic aneurysm
c. Esophageal achalasia
d. Boerhaave syndrome
e. Mallory-Weiss syndrome

The answer is d. Boerhaave syndrome. 

• Boerhaave syndrome is a spontaneous rupture of the esophagus, typically caused by a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure, often due to severe vomiting or retching, followed by the sudden onset of chest pain and respiratory distress. Radiological findings may show signs of pneumomediastinum (air in the mediastinum), pleural effusion, or mediastinal widening. It requires prompt diagnosis and treatment.
• It is distinct from Mallory-Weiss syndrome, which involves a tear in the mucosa of the esophagus and usually results in bleeding rather than a full-thickness rupture.

118A50

An 85-year-old woman was admitted to the hospital with a left femoral neck fracture and was confined to bed rest. On admission, muscle strength and sensation in the left lower limb were normal, but the next day, she was unable to move her left foot upwards. On examination, she was unable to dorsiflex her left ankle, with decreased sensation on the dorsal aspect of her left foot. The left lower limb was externally rotated. Select the most likely cause of her decreased ankle movement.

a. Cerebral infarction

b. Lumbar disc herniation

c. Peroneal〈Fibular〉nerve palsy

d. Deep vein thrombosis

e. Achilles tendon rupture

The answer is c: Peroneal (Fibular) nerve palsy. 

• The peroneal nerve, a branch of the sciatic nerve, innervates muscles responsible for dorsiflexion of the foot (like the tibialis anterior) and provides sensation to the dorsal (top) side of the foot. Peroneal nerve palsy can occur due to pressure or trauma around the fibular head, which may happen when the leg is externally rotated or if the patient is bedridden with prolonged pressure on this area.
• Cerebral infarction would likely present with other neurological deficits.
• Lumbar disc herniation would typically cause weakness and sensory changes in a different distribution.
• Deep vein thrombosis causes leg pain and swelling.
• Achilles tendon rupture affects plantarflexion (pushing the foot down).

118A51
A 50-year-old woman was brought to the hospital by ambulance, complaining of palpitations. She had experienced palpitations about once a week for the past few months, but they would resolve quickly, so she did not worry about them. At 8 p.m., while having dinner with family, she suddenly developed palpitations and shortness of breath, prompting her family to call an ambulance. Her medical and family history is unremarkable. She is alert, with a height of 160 cm and weight of 54 kg. Her body temperature is 36.6°C, heart rate 136 beats per minute, regular, blood pressure 126/90 mmHg, and respiratory rate 36 breaths per minute. Her oxygen saturation is 98% on room air. No neck bruits are heard, and no jugular venous distention is observed. Heart and lung sounds are normal. A 12-lead electrocardiogram (ECG) is shown next. She is placed on a cardiac monitor, and an intravenous line is established in her left forearm. Despite performing the Valsalva maneuver for 30 seconds, the tachycardia does not improve. After confirming that she has no history of asthma, adenosine triphosphate (ATP) is planned to be administered. The patient is informed that transient chest discomfort may occur after administration.

What is the correct method of administration?
a. Sublingual administration
b. Subcutaneous injection
c. Intramuscular injection
d. Rapid intravenous injection
e. Continuous intravenous infusion

The answer is d. Rapid intravenous injection. 

• Adenosine is administered to reduce electrical conduction at the atrioventricular (AV) node for the treatment of supraventricular tachycardia (SVT), as observed in this patient.
• However, the half-life of adenosine is very short (around 10 seconds), so it must be delivered to the heart without delay before being metabolized to maintain its efficacy.

118A52
A 21-year-old man was brought to the hospital by ambulance due to chest and back pain. He had lost consciousness while taking a shower. His consciousness returned within a few minutes, but chest and back pain followed, prompting the call for an ambulance. He was diagnosed with lens dislocation during childhood and wears glasses. He is a university triathlete. There is no significant family history. He is alert and conscious. His height is 186 cm, weight 65 kg, body temperature 36.3°C, heart rate 64 beats per minute (regular), blood pressure 132/50 mmHg, respiratory rate 20 breaths per minute, and oxygen saturation is 100% on a mask with 5 L/min of oxygen. A Levine 2/6 diastolic murmur is heard at the left sternal border in the fourth intercostal space. He has long limbs. His ECG shows no abnormalities. Contrast-enhanced chest CT horizontal, coronal, and sagittal images are shown. Emergency surgery was performed, and he is scheduled to be discharged 10 days after surgery.

Which of the following explanations to the patient is incorrect?

a. "You will need to take beta-blockers."
b. "It is okay to continue triathlon training."
c. "Regular imaging of your aorta is necessary."
d. "Visit the hospital if you experience chest or back pain."
e. "You can receive genetic counseling."

The answer (incorrect choice) is b. ("It is okay to continue triathlon training."). 

• This patient's symptoms, such as lens dislocation (ectopia lentis), tall stature, long limbs, and emergent aortic surgery, strongly indicate Marfan syndrome, a genetic disorder that adversely affects connective tissue, particularly the aorta.
• He is at a high risk of life-threatening aortic dissection, which is a tear in the wall of the aorta. Therefore, he must refrain from high-intensity sports and needs genetic testing and periodic monitoring while taking beta-blockers.

118A53
A 48-year-old woman was referred for further evaluation after a mass was detected on her mammogram during a breast cancer screening. A 25 mm mass was palpated in the upper outer quadrant of the right breast.
What is the next appropriate test to perform?

a. Brain MRI
b. Breast MRI
c. Contrast-enhanced chest CT
d. Breast ultrasound
e. Bone scintigraphy

The answer is d. Breast ultrasound. 

• A mass in the upper outer quadrant of the breast is a common presentation of breast cancer. Breast ultrasound is the easiest and least invasive option among the five choices and provides more detailed information, including the size, shape, margins, and whether the mass has benign or malignant features, compared to a mammogram.
• The other tests or a biopsy should be conducted at the next stage if needed.

118A54
A 45-year-old woman was brought in by ambulance due to sudden chest pain. After dinner today, she experienced severe pain in the anterior chest. She lay down to rest, but after 30 minutes, the symptoms did not improve, and her family called for an ambulance. She had a history of fever and rash at the age of 3 (details unknown). For the past five years, she has undergone annual health checkups with no abnormalities reported. She has no smoking or alcohol history. She is conscious, with a height of 162 cm, weight of 47 kg, temperature of 36.7°C, heart rate of 96 beats/min, regular rhythm, blood pressure of 146/88 mmHg, and respiratory rate of 24 breaths/min. SpO2 is 95% (room air). There are no abnormal heart or lung sounds. Her abdomen is flat and soft, and neither the liver nor the spleen is palpable. Immunoserological findings: Rapid test for cardiac troponin T is positive. A 12-lead ECG taken at admission shows ST depression in the inferior leads. The right coronary angiography image is shown.
What is the cause of the coronary artery lesion?

a. Kawasaki disease
b. Buerger disease
c. Takayasu arteritis
d. Marfan syndrome
e. Takotsubo cardiomyopathy

The answer is a. Kawasaki disease. 

• Kawasaki disease is an acute vasculitis that primarily affects children and presents with symptoms like fever and rash, as seen in this patient’s history. This disease can cause long-term damage to the coronary arteries, leading to aneurysms and stenosis, which in turn can result in ischemic heart disease or acute coronary syndromes in adulthood. This typical scenario is observed in this patient.

118A55
A 73-year-old man presented with fever and headache as his main complaints. He has been feeling easily fatigued recently and experienced a 3 kg weight loss over the past three months. He has had a low-grade fever and headache for the past month, and the headache worsened five days ago. His family noticed abnormal behavior, such as going to the wrong bathroom and asking for food in the middle of the night. He has an altered level of consciousness. He is 168 cm tall, weighs 59 kg, and has a temperature of 38.2°C, a pulse rate of 92 beats/min, and blood pressure of 140/92 mmHg. Neurological examination reveals nuchal rigidity, right-sided abducens nerve palsy, and right facial motor paralysis. Cerebrospinal fluid (CSF) findings: appearance is clear, opening pressure 200 mmH2O (normal range 70–170), cell count 250/mm³ (all mononuclear cells) (normal range 0–2), glucose 25 mg/dL (normal range 50–75), protein 180 mg/dL (normal range 15–45), adenosine deaminase (ADA) 15 IU/L (normal range ≤8). Head CT shows no ventricular enlargement.
What is the diagnosis?

a. Tuberculous meningitis
b. Myasthenia gravis
c. Normal pressure hydrocephalus
d. Multiple sclerosis
e. Bell's palsy

The answer is a. Tuberculous meningitis. 

• Meningitis typically presents with fever, headache, nuchal rigidity, and cranial nerve palsies. Additionally, tuberculous meningitis has a specific clinical presentation, including a gradual onset of the aforementioned symptoms over weeks, along with altered behavior and confusion.
• The cerebrospinal fluid (CSF) findings are also characteristic: high protein, low glucose, elevated white cell count (particularly mononuclear cells), and elevated adenosine deaminase (ADA), which is a useful marker for diagnosis.

118A56

A 70-year-old man presents with stiffness in his left leg. He is being treated for diabetes and hypertension at a local clinic. About one month ago, he noticed stiffness and cramping in his left leg after walking about 100 meters, prompting him to seek medical attention. He has a smoking history of 20 cigarettes per day for 50 years. His consciousness is clear. Height: 178 cm; Weight: 84 kg; Body temperature: 36.3°C; Pulse: 68/min, regular; Blood pressure: 168/90 mmHg; SpO2: 96% (room air). There is no jugular vein distension. Heart and lung sounds are normal. His abdomen is flat and soft, and neither the liver nor spleen is palpable. There is no edema in his lower limbs, but there is a cool sensation in the left lower limb. The pulses in the left popliteal artery, left dorsalis pedis artery, and left posterior tibial artery are diminished. An ankle-brachial index (ABI) shows a value of 0.67 on the left side and 1.03 on the right side. A vascular angiogram of the left lower limb is shown.
Which of the following instructions is not appropriate for this patient?

a."Please stop smoking."
b. "Please lose weight."
c. "Please cool your left leg."
d. "Please avoid injuring your left leg."
e. "Please continue walking as part of an exercise regimen."

The answer (incorrect choice) is c. ("Please cool your left leg."). 

• This patient is being treated for hypertension and diabetes. He also has symptoms of reduced pulses, coldness, pain, claudication (cramping during walking), and a low ABI (Ankle-Brachial Index) in the left leg, which indicates peripheral artery disease (PAD).
• The image shows narrowing of the arteries, which must be managed by non-smoking, losing weight, warming the leg (not cooling the leg), exercise, and other measures.

118A57

A 74-year-old man was brought in by ambulance, complaining of abdominal pain and vomiting. He had experienced abdominal pain since the previous day and was unable to eat. Early in the morning, he started vomiting, prompting the call for the ambulance. At the age of 28, he had a history of treatment for a duodenal ulcer. His facial expression showed signs of distress. Height: 160 cm, weight: 50 kg. His temperature was 37.2°C, heart rate 144/min, regular, blood pressure 86/60 mmHg, respiratory rate 22/min, and SpO2 99% on 5 L/min of oxygen via mask. His skin was moist with cold sweats. No abnormalities were found in his conjunctivae or sclerae. His oral cavity was dry. Heart sounds were normal. His abdomen was board-like with muscular guarding. Blood test results showed: red blood cells 5.99 million, hemoglobin 19.0 g/dL, hematocrit 55%, white blood cells 12,000 (87% segmented neutrophils, 0% eosinophils, 0% basophils, 2% monocytes, 11% lymphocytes), platelets 190,000, PT-INR 1.2 (normal range 0.9-1.1). Biochemical tests showed: total protein 5.6 g/dL, albumin 3.3 g/dL, total bilirubin 0.7 mg/dL, AST 24 U/L, ALT 18 U/L, LD 204 U/L (normal range 124-222), ALP 46 U/L (normal range 38-113), γ-GT 29 U/L (normal range 13-64), amylase 235 U/L (normal range 44-132), CK 632 U/L (normal range 59-248), BUN 33 mg/dL, creatinine 2.2 mg/dL, uric acid 16.4 mg/dL, glucose 206 mg/dL, HbA1c 6.0% (normal range 4.9-6.0), Na 137 mEq/L, K 4.4 mEq/L, Cl 98 mEq/L, Ca 8.7 mg/dL. CRP was 40 mg/dL. An abdominal CT under lung window settings is shown.

What is the necessary intervention?

a. Gastric lavage
b. Emergency surgery
c. Hemodialysis
d. Insertion of a nasogastric tube
e. Chest drainage

The answer is b. Emergency surgery. 

• The patient has a history of duodenal ulcer treatment and currently presents with peritonitis, which is supported by acute abdominal pain, board-like rigidity of the abdomen, and muscle guarding. Furthermore, he shows signs of shock and hypotension, and the blood test reveals an elevated white blood cell count and CRP. These findings suggest a diagnosis of a perforated peptic ulcer with peritonitis, a life-threatening condition that requires emergency surgery.

118A59

A 62-year-old woman visited the clinic with the chief complaint of bleeding spots. For several months, she had noticed bruising on her limbs. Recently, numerous petechiae had appeared on her anterior chest, prompting her to seek medical attention. She was conscious and alert. Her temperature was 36.2°C, pulse 68/min, regular, and blood pressure 118/72 mmHg. Petechiae were observed on her anterior chest and limbs. There were no abnormalities in her palpebral or bulbar conjunctivae. No cervical lymphadenopathy was palpated. Heart and lung sounds were normal. The abdomen was flat and soft, with no palpable liver or spleen. Blood test results showed: red blood cells 3.6 million, hemoglobin 11.0 g/dL, hematocrit 33%, white blood cells 5,100 (53% neutrophils, 2% eosinophils, 6% monocytes, 39% lymphocytes), platelets 26,000. PT-INR 1.0 (normal range 0.9–1.1), activated partial thromboplastin time (APTT) 30 seconds (control 32.2 seconds), serum FDP 5 µg/mL (normal ≤10). Biochemistry showed: total bilirubin 1.0 mg/dL, direct bilirubin 0.2 mg/dL, LDH 210 U/L (normal 124–222), BUN 20 mg/dL, creatinine 0.7 mg/dL. No abnormalities were observed in the peripheral blood smear for white or red blood cells. A bone marrow smear showed a mild increase in megakaryocytes, with no morphological abnormalities in hematopoietic cells.

Which test would be useful for determining the treatment plan?

a. Urea breath test
b. Platelet aggregation test
c. Antiphospholipid antibody test
d. Human leukocyte antigen (HLA) test
e. Anti-ADAMTS-13 antibody test

The answer is a. Urea breath test. 

• This patient presents with thrombocytopenia (low platelet count) and petechiae, but other findings, including APTT and FDP, are normal, which indicates immune thrombocytopenic purpura (ITP). ITP can be induced by H. pylori infection, which can be detected by the urea breath test. In ITP, the abnormal immune system destroys platelets.

118A60

A 29-year-old man visited the clinic complaining of shortness of breath during exertion. For several years, he had been told about high blood pressure and abnormal urine tests during workplace health checkups, but he had not visited a medical institution. One week ago, he started experiencing shortness of breath while climbing stairs, which prompted his visit. He was conscious and alert. Height: 172 cm, weight: 82 kg. Temperature: 36.4°C, pulse: 104/min, regular, blood pressure: 228/132 mmHg, respiratory rate: 20/min, SpO2: 96% (room air). There was no jugular vein distension. Heart and lung sounds were normal. Pitting edema was observed on both shins. Neurological examination was normal. Urinalysis showed specific gravity 1.020, protein 3+, blood 3+, with many deformed red blood cells in the sediment. Blood test results: red blood cells 4.22 million, Hb 13.7 g/dL, Ht 40%, white blood cells 9,800, platelets 170,000. Biochemical findings: total protein 6.9 g/dL, albumin 3.8 g/dL, blood urea nitrogen 52 mg/dL, creatinine 4.0 mg/dL, Na 138 mEq/L, K 2.9 mEq/L, Cl 106 mEq/L.

Which test should be performed first while preparing for antihypertensive treatment?

a. Head CT
b. Fundus examination
c. Carotid artery ultrasound
d. Abdominal X-ray
e. Ankle-brachial index (ABI)

The answer is b. Fundus examination. 

• This patient has not only severe hypertension but also kidney dysfunction, as evidenced by elevated creatinine, blood urea nitrogen, proteinuria, hematuria, etc.
• This condition indicates an advanced stage of hypertension, including hypertensive nephropathy, which carries a high risk of ocular damage, such as hypertensive retinopathy, as a sign of end-organ damage.
• A fundus examination is crucial for detecting ocular damage at an early stage to prevent loss of eyesight.

118A62

A 7-month-old boy was brought to the clinic by his concerned parents due to movements where he flexes his head forward. He was born at 40 weeks gestation, weighing 3,020g, without any birth complications. He demonstrated eye-tracking and fixation at 1 month, responsive smiling at 2 months, and head control at 3 months. Two weeks ago, he began extending and raising both arms and flexing his head forward. These movements occurred more than 10 times, about every 10 seconds, and started happening daily. Around the same time, he stopped smiling responsively and lost the ability to roll over and sit up.

Which is the most likely diagnosis?

a. West syndrome
b. Absence epilepsy
c. Lennox-Gastaut syndrome
d. Congenital myotonic dystrophy
e. Fukuyama congenital muscular dystrophy

The answer is a. West syndrome. 

• West syndrome is characterized by developmental regression and typically presents with infantile spasms between 4 and 8 months of age. During this time, recurrent and sudden flexion of the head, arms, and legs is observed in quick succession.

118A63

A 22-year-old man visited the clinic with a chief complaint of coughing. A week ago, he developed a mild fever and cough that have not improved, prompting him to seek medical attention. He lives with his parents and younger brother. Two weeks ago, his 16-year-old brother was diagnosed with whooping cough (pertussis) after showing similar symptoms. Since yesterday, he has had recurrent, paroxysmal coughing, which is particularly strong at night. He is conscious and alert. His vital signs are as follows: temperature 37.1°C, pulse 108/min (regular), blood pressure 124/68 mmHg, respiratory rate 22/min, and oxygen saturation (SpO2) 98% on room air. Heart and lung sounds are normal.

Which statement about this condition is correct?

a. It spreads via airborne transmission.
b. The incubation period is 2 to 3 days.
c. Expiratory stridor is heard during the paroxysmal coughing stage.
d. Cephalosporin antibiotics are effective.
e. Nucleic acid amplification testing is useful for diagnosis during the catarrhal stage.

The answer is e. Nucleic acid amplification testing is useful for diagnosis during the catarrhal stage. 

• It is strongly suspected that this patient is infected with Bordetella pertussis (whooping cough) from his younger brother.
• Nucleic acid amplification testing (e.g., PCR) is useful for diagnosis during the catarrhal stage. Pertussis is spread through droplet transmission, not airborne.
• Its incubation period is typically 7 to 10 days. Inspiratory whooping is observed during the paroxysmal stage, not expiratory stridor, which is associated with upper airway obstruction.
• Its first-line treatment is macrolide antibiotics, such as azithromycin and clarithromycin.

118A64

A 72-year-old woman presented with (1) decreased urine output as her chief complaint. She had been experiencing vomiting and diarrhea for four days, which had reduced her food intake. Two days ago, she began feeling generalized fatigue, and this morning, she noticed a decrease in urine output, prompting her visit. She had been taking antihypertensive medication for 12 years. She is 154 cm tall, weighs 48 kg (her weight was 51 kg two weeks ago). Her pulse is 108 beats per minute, regular, and her blood pressure is 100/52 mmHg. Her oral cavity is dry. No abnormalities were found on chest and abdominal examination. Urine findings: protein 1+, occult blood (–), sediment shows 1–3 red blood cells per high power field (HPF), 1–2 white blood cells/HPF, no casts. Urine biochemistry: (2) urine sodium 10 mEq/L. Blood tests: red blood cells 3.00 million, (3) hemoglobin 10.0 g/dL, hematocrit 31%, white blood cells 9,200, platelets 350,000. Blood chemistry: blood urea nitrogen 70 mg/dL, (4) creatinine 2.5 mg/dL (it was 0.9 mg/dL one month ago), sodium 138 mEq/L, (5) potassium 5.5 mEq/L, chloride 98 mEq/L.

Which of the underlined values is most useful for the differential diagnosis of acute kidney injury?

a. (1)
b. (2)
c. (3)
d. (4)
e. (5)

The answer is b. Urine sodium level. 

• It is likely that this patient has pre-renal acute kidney injury (AKI) rather than intrinsic kidney damage, due to the low urine sodium level. This indicates that the kidney function is still intact and able to reabsorb sodium in response to dehydration caused by vomiting and diarrhea.

118A65

An 82-year-old male fell and sustained a head injury, resulting in a diagnosis of brain contusion. After the acute phase treatment, he was admitted to a recovery rehabilitation ward. It is now the 30th day after the injury. His consciousness level is JCS I-2. His blood pressure is 120/78 mmHg. He is right-handed. A manual muscle test showed the following results: 4 for the left upper and lower limbs, 1 for right elbow flexion, 1 for right finger flexion, 0 for right finger extension, 1 for right hip flexion, 2 for right knee extension, and 0 for right ankle dorsiflexion. He has moderate sensory impairment in the right upper and lower limbs. He is almost independent in a sitting position. Moderate assistance is required for standing up and maintaining a standing position.

What rehabilitation should be performed at this point?

a. Walking training
b. Sitting training
c. Stair climbing training
d. Writing training with the right hand
e. Standing up and maintaining a standing position training

The answer is e. Standing up and maintaining a standing position training.

• At present, this patient needs moderate assistance to stand up and maintain a standing position; therefore, training for these actions is the most appropriate.
• The other activities are too difficult for him at this time.

118A66

A 55-year-old man visited the hospital with a chief complaint of difficulty swallowing. Two years ago, muscle weakness in the right upper limb appeared. One year ago, his legs became stiff, and he started tripping easily. Three months ago, he began experiencing choking while eating. Over the past year, he has lost 3 kg. His consciousness is clear. He is 168 cm tall and weighs 55 kg. His body temperature is 36.5°C, his pulse is 80 beats per minute and regular, and his blood pressure is 128/72 mmHg. There is no abnormality in his eye movements. He presents with speech difficulties. There is atrophy and fasciculation of the tongue. Muscle weakness and atrophy are observed in the distal muscles of the limbs. Tendon reflexes are heightened in both the upper and lower limbs, and Babinski signs are positive bilaterally. Sensory function is normal.

What is most likely to occur in this patient?

a. Pressure ulcers
b. Diplopia
c. Urinary dysfunction
d. Respiratory muscle paralysis
e. Orthostatic hypotension

The answer is d. Respiratory muscle paralysis. 

• Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder that affects both upper and lower motor neurons. It causes muscle weakness, atrophy, heightened reflexes, fasciculations, speech difficulties, and positive Babinski signs, as observed in this patient. It can also lead to respiratory muscle paralysis.
• On the other hand, ALS does not significantly cause pressure ulcers, diplopia, urinary dysfunction, or orthostatic hypotension, as sensory and autonomic functions are largely unaffected.

118A67

A 34-year-old primigravida (G1P0) was admitted to the hospital at 6:00 AM at 39 weeks and 4 days of gestation due to the onset of labor. The pregnancy had been uneventful until this point. Her height is 148 cm, and her weight is 56 kg (pre-pregnancy weight: 48 kg). On vaginal examination, the cervical dilation was 4 cm with 70% effacement, and the presenting part was the fetal head. The fetal heart rate and uterine contraction patterns on admission showed no abnormalities, with uterine contractions occurring every 5 minutes. At 4:00 PM, the cervix was fully dilated. At 6:50 PM, the membranes ruptured, and a vaginal examination revealed the fetal head at +4 cm station, with the small fontanel palpable at the 12 o'clock position. The fetal heart rate and uterine contraction patterns at this time are shown in the attached image.

What is the appropriate management?

a. Vacuum extraction
b. Cesarean section
c. Antibiotic administration
d. Administration of uterotonic drugs
e. Administration of tocolytics

The answer is a. Vacuum extraction. 

• The fetal head has descended to a station of +4 cm, which indicates that delivery is imminent. There is no indication of fetal distress or infection, and the uterine contractions are normal. Thus, vacuum extraction is appropriate to complete vaginal delivery during the prolonged second stage of labor. A cesarean section is not necessary in this case.

118A68

A 15-year-old boy was brought to the clinic by his father, concerned about the shape of his chest, which has appeared different from others since childhood. The patient does not report any chest pain. His pulse is 64 beats per minute, regular. Blood pressure is 132/72 mmHg. Respiratory rate is 14 breaths per minute. SpO2 is 99% (on room air). A photo of his chest is shown.

Select two findings that are observed in this patient:

a. Deformed costal cartilage
b. Barrel chest
c. Sternum fracture
d. Sternal depression
e. Flail chest

The answer is a. Deformed costal cartilage and d. Sternal depression. 

• The image shows a sunken chest appearance, which is typical of pectus excavatum. This condition is often associated with a deformation of the costal cartilage.

118A69

A 76-year-old male presented with fever and right upper quadrant pain as his chief complaints. The pain began yesterday and persisted until this morning. His body temperature is 38.1°C. Pulse rate is 128 beats per minute, regular. Blood pressure is 124/86 mmHg. Respiratory rate is 18 breaths per minute. Yellow discoloration of the conjunctivae is noted. His abdomen is flat and soft, with tenderness in the right upper quadrant. Laboratory findings are as follows: White blood cell count: 17,600. Biochemical findings: Total bilirubin 6.9 mg/dL, direct bilirubin 4.2 mg/dL, AST 371 U/L, ALT 297 U/L, ALP 231 U/L (reference range: 38–113), γ-GT 237 U/L (reference range: 13–64), amylase 52 U/L (reference range: 44–132). CRP 16 mg/dL. Abdominal ultrasound shows no abnormalities in the gallbladder wall. A plain abdominal CT scan is provided.

Which are the appropriate treatments for this patient? Select two.

a. Antibiotic therapy
b. Oral bile stone dissolution therapy
c. Pancreaticoduodenectomy
d. Endoscopic biliary drainage
e. Protease inhibitor therapy

The answers are a. antibiotic therapy and d. endoscopic biliary drainage. 

• This patient complains of fever and right upper quadrant pain and has symptoms of jaundice (yellowing of the conjunctiva), elevated bilirubin levels, and signs of inflammation in blood tests, such as high CRP and white blood cell count, which indicate acute cholangitis.
• Antibiotic therapy is necessary to control the bacterial infection, and endoscopic biliary drainage must be performed to relieve the obstruction in the bile duct, typically via ERCP (Endoscopic Retrograde Cholangiopancreatography).

118A70

A 27-year-old woman came to the clinic with complaints of palpitations and hand tremors. She hadn’t noticed anything during her pregnancy, but about six months after giving birth, she began to feel palpitations, sweating, and hand tremors during exertion. Although her appetite hasn't changed, she has lost 5 kg in the last three months. Additionally, she has become suddenly intolerant to heat. Since giving birth, she has also experienced amenorrhea. Her height is 160 cm, weight 42 kg. Her temperature is 37.2°C. Pulse is 112 beats per minute, regular. Blood pressure is 116/60 mmHg. Respiration rate is 14 breaths per minute. SpO2 is 99% (on room air). Her thyroid is enlarged but soft and non-tender. Cervical lymph nodes are not palpable. Fine tremors are observed in her fingers. Blood biochemistry shows: Thyroid-Stimulating Hormone (TSH) is less than 0.01 μU/mL (reference range 0.2–4.0), Free Triiodothyronine (FT3) is 21.5 pg/mL (reference range 2.3–4.3), Free Thyroxine (FT4) is 3.7 ng/dL (reference range 0.8–2.2). The image of her neck is shown below.

Which tests are useful for this patient's diagnosis? Choose two.

a. Neck plain CT
b. Thyroid ultrasound
c. Thyroid cytology
d. Thyroglobulin measurement
e. Anti-TSH receptor antibody test

The answers are b. Thyroid ultrasound and e. Anti-TSH receptor antibody test. 

• It is highly likely that the patient suffers from hyperthyroidism because she has palpitations, weight loss, heat intolerance, and hand tremors. Moreover, the blood tests show significantly elevated free T3 (FT3) and free T4 (FT4) with suppressed TSH levels.
• A thyroid ultrasound is necessary to evaluate the size and structure of the thyroid gland. The anti-TSH receptor antibody test must be carried out for the diagnosis of Graves' disease, which is an autoimmune condition.

118A72

A 35-year-old woman visited the hospital because of multiple rashes on both lower limbs that appeared two weeks ago. The rashes are slightly raised from the surface of the skin, feel infiltrative, and are associated with heat and tenderness. A picture of her left lower leg is shown below.

What underlying conditions are likely? Choose three.

a. Diabetes mellitus
b. Crohn's disease
c. Behçet's disease
d. Systemic sclerosis (scleroderma)
e. Sarcoidosis

The correct answers for this case are b. Crohn's disease, c. Behçet's disease, and e. Sarcoidosis. 

• These diseases are often associated with erythema nodosum, which presents as a type of rash with painful nodules on the shins.
• Diabetes often causes skin infections or necrobiosis lipoidica, but not erythema nodosum.
• Systemic sclerosis (scleroderma) primarily causes skin hardening, vascular abnormalities like Raynaud's phenomenon, and fibrosis, and is not typically linked to erythema nodosum.

118A73

A 28-year-old woman came to the clinic with complaints of galactorrhea and amenorrhea. The amenorrhea has persisted for three months, and she noticed galactorrhea two weeks ago. She has been receiving oral treatment for depression at a psychiatric clinic for the past two years. There is no notable family history, and she has no pregnancy history. She is conscious, with a height of 158 cm, weight of 46 kg, body temperature of 36.5°C, pulse rate of 80 beats/min (regular), blood pressure of 116/70 mmHg, respiratory rate of 12 breaths/min, and oxygen saturation (SpO2) of 99% (room air). There is no neck stiffness, no abnormalities in eye movement, no goiter, no abnormal heart sounds, and there is milk discharge. She has no edema in her lower legs. Her blood biochemistry shows a prolactin (PRL) level of 80 ng/mL (normal range below 15 ng/mL).

What are the next appropriate steps? Choose three.

a. Pituitary MRI
b. Cerebrospinal fluid protein measurement
c. Review of medication history
d. Thyroid hormone measurement
e. Parathyroid hormone measurement

The correct answers are a. Pituitary MRI, c. Review of medication history, and d. Thyroid hormone measurement. 

• This patient has hyperprolactinemia, which causes amenorrhea. It can be caused by a prolactinoma (a pituitary adenoma), which should be confirmed by a pituitary MRI, psychiatric medications, especially antipsychotics or selective serotonin reuptake inhibitors (SSRIs), and hypothyroidism via the release of thyrotropin-releasing hormone (TRH).

118A74

A 36-year-old man visited the clinic with a sore throat as his chief complaint. He had a fever of 39–40°C and a sore throat for the past 14 days and visited a local medical facility 7 days ago. The rapid antigen tests for influenza virus and SARS-CoV-2 were negative, and antibiotic treatment was started, but his symptoms did not improve, so he returned for another consultation. His temperature was 38.3°C, pulse 104/min (regular), blood pressure 124/82 mmHg, and respiratory rate 18/min. Pharyngeal redness and tonsillar white patches were observed. Two 2-cm lymph nodes and three 1-cm lymph nodes were palpable on both sides of the posterior cervical region. The liver was palpable 2 cm below the right costal margin, and the spleen was palpable 1 cm below the left costal margin. Blood test results: red blood cells 5.02 million, Hb 14.9 g/dL, Ht 43%, white blood cells 14,000 (3% band neutrophils, 20% segmented neutrophils, 3% monocytes, 57% lymphocytes, 17% atypical lymphocytes), platelets 210,000. Blood biochemistry: total protein 7.5 g/dL, albumin 4.2 g/dL, total bilirubin 0.9 mg/dL, AST 280 U/L, ALT 320 U/L, LD 477 U/L (normal range 124–222), BUN 12 mg/dL, creatinine 0.6 mg/dL, CRP 8.3 mg/dL.

What are the possible causes? Select 3.

a. Rhinovirus
b. Cytomegalovirus
c. Varicella-zoster virus
d. Epstein-Barr (EB) virus
e. Human immunodeficiency virus (HIV)

The correct answers are b. Cytomegalovirus (CMV), d. Epstein-Barr virus (EBV), and e. Human immunodeficiency virus (HIV). 

• EBV (Epstein-Barr virus) is the primary cause of infectious mononucleosis, characterized by fever, pharyngitis, lymphadenopathy, and hepatosplenomegaly, along with atypical lymphocytes.
• CMV (Cytomegalovirus) can also cause mononucleosis-like symptoms, particularly in immunocompetent individuals.
• HIV infection can also present with symptoms similar to mononucleosis during its acute stage, including fever, pharyngitis, lymphadenopathy, and atypical lymphocytosis.
• Rhinovirus typically causes mild upper respiratory infections.
• Varicella-zoster virus causes chickenpox or shingles.

118A75

Calculate the Brinkman Index for a patient who has been smoking 20 cigarettes a day for 30 years.

The answer is 600. 

• The Brinkman index is calculated by multiplying the number of cigarettes smoked per day by the number of years the person has smoked.
• This patient smokes 20 cigarettes per day and has smoked for 30 years. Therefore, the Brinkman index for this patient is 600.