118B (2024)

118B2
Which of the following is correct regarding abdominal and pelvic palpation?

a. The liver is palpated on its posterior surface with bimanual examination.
b. The pancreas is palpable during deep inspiration.
c. The upper pole of the kidney is palpable during deep inspiration.
d. The bladder is palpable dorsally during a rectal examination.
e. The prostate is palpable ventrally during a rectal examination.

The correct answer is e. The prostate is palpable ventrally during a rectal examination.

The prostate gland is located ventrally (toward the front of the body) relative to the rectum.
The liver is typically palpated from the anterior side during an abdominal examination.
The pancreas is located deep in the abdomen and is not palpable under normal conditions
The kidneys may be palpable in some cases, especially the lower pole of the right kidney.
The bladder is located anteriorly (toward the front) relative to the rectum.

118B3
What is the most common cause of seizures in a 2-year-old child?

a. Acute encephalopathy
b. Epilepsy
c. Bacterial meningitis
d. Febrile seizures
e. Anger-induced seizures (breath-holding spell)

The correct answer is d. febrile seizures.

They occur when a child has a sudden fever caused by a viral or bacterial infection. They are generally benign and do not lead to epilepsy or long-term neurological disorders.
The other options can also cause seizures and may sometimes have serious effects, but they are less common than febrile seizures in young children around the age of 2.

118B4
Which of the following is not a finding of peritonitis?

a. Rebound tenderness
b. Guarding (muscle rigidity)
c. Tenderness on percussion
d. Positive heel-drop test
e. Positive Courvoisier's sign

The correct answer is e. positive Courvoisier's sign.

Courvoisier's sign refers to a painless, enlarged gallbladder associated with jaundice, caused by a bile duct obstruction, often due to a malignant condition such as pancreatic cancer.
On the other hand, peritonitis causes several findings, such as rebound tenderness (Blumberg's sign) after applying firm pressure to the abdomen, guarding of the abdominal muscles in response to inflammation, tenderness on percussion due to abdominal irritation, and a positive heel-drop test from the jarring of the abdominal organs.

118B5
Which of the following is incorrect regarding the procedure for securing peripheral venous access with an intravenous catheter?

a. Disinfect the skin before puncture.
b. Puncture the skin at an angle of 15 to 30 degrees.
c. After confirming blood return, advance both the inner needle and the catheter (outer tube) slightly.
d. Remove the tourniquet before withdrawing the inner needle.
e. Re-cap the withdrawn inner needle.

The incorrect answer is e. Re-capping the withdrawn inner needle.

Re-capping a needle can lead to exposure to pathogens. The needle should be discarded immediately without re-capping.
Disinfecting the skin before the puncture is essential for preventing infections.
Puncturing the skin at an angle of 15 to 30 degrees is the correct technique for inserting an intravenous catheter.
Advancing the inner needle and catheter slightly after confirming blood return ensures proper catheter placement in the vein.
Removing the tourniquet before withdrawing the inner needle prevents excessive pressure or blood flow in the vein.

118B7
Which of the following appears as a higher signal intensity than muscle on a T2-weighted MRI of the knee joint?

a. Tendon
b. Ligament
c. Joint fluid
d. Cortical bone
e. Meniscus

The correct answer is c. Joint fluid.

T2-weighted images highlight the differences in water content within tissues, and tissues with more fluid, such as joint fluid or edema, are displayed as high signal intensity (bright).
Other tissues contain less water and appear as low signal intensity (dark).

118B8
Which of the following tissues is difficult to palpate during a normal neck examination?

a. Salivary gland
b. Carotid artery
c. Parathyroid gland
d. Cricoid cartilage
e. Sternocleidomastoid muscle

The correct answer is c. Parathyroid gland.

The parathyroid glands are small and are located deep behind the thyroid gland. They are difficult to palpate.
The salivary gland is located under the jaw.
The carotid artery is easily palpable next to the trachea.
The cricoid cartilage is found below the thyroid cartilage, in the middle of the neck.
The sternocleidomastoid muscle is visible on the side of the neck.

118B9
Which of the following is true about a randomized controlled trial (RCT)?

a. It is an observational study.
b. It is a study with high external validity.
c. It cannot account for unmeasured confounding factors.
d. It is suitable for studying diseases with low prevalence.
e. It provides a higher level of evidence than a case-control study.

The correct answer is e. It provides a higher level of evidence than a case-control study.

Randomized controlled trials (RCTs) randomly assign study subjects to different groups, making the groups similar to each other regarding various factors, except for the specific interventions. This randomization increases the reliability of the results.
An observational study is one without intervention.
External validity refers to generalizability to other populations, which can be limited due to strict inclusion criteria or a controlled environment.
Randomization generally reduces the impact of confounding factors, including unmeasured ones.
A study of rare diseases requires a large number of participants, which makes RCTs more challenging.

118B10
Which of the following is incorrect regarding rehabilitation?

a. It is started early after the onset of the condition.
b. It supports the patient's social participation.
c. It aims to improve the patient's functional abilities.
d. The patient's goals are shared among multiple professions.
e. The goal is to fix the patient's functional impairments.

The correct answer (incorrect choice) is e. The goal is to fix the patient's functional impairments.

Rehabilitation aims to restore, improve, or maximize (not fix) the patient's functional abilities in daily life and social activities through an early start and collaboration among various healthcare professionals.

118B11
Which of the following is incorrect regarding patient and public involvement in clinical research?

a. They participate as partners from the early stages of the research.
b. They have the right to disclose information obtained through the research.
c. They provide advice to reduce the burden on research participants.
d. They participate as members of the research ethics review committee in a public capacity.
e. They provide advice to ensure that documents related to the research are written in clear and understandable language.

The (incorrect) answer is b. They have the right to disclose information obtained through the research.

Patients and the public should participate in the research from the early stages as members of the ethics committee.
They should receive necessary information in clear and understandable language to provide advice in the interest of the study participants.
However, they do not have the right to disclose confidential or sensitive information or data obtained through the research.

118B12
The following diagram shows a schematic representation of the chest. Where would apical impulse be observed in a severe case of chronic obstructive pulmonary disease (COPD)?

a. ①
b. ②
c. ③
d. ④
e. ⑤

The correct answer is e. (⑤).

Chronic obstructive pulmonary disease (COPD) causes hyperinflation of the lungs, which displaces the heart downward and laterally, including the apical impulse (the point of maximal impulse, PMI).

118B13
Which of the following clinical conditions occurs acutely in patients after severe burns?

a. Polyuria
b. Hyperlipidemia
c. Hypovolemic shock
d. Venous thrombosis
e. Compartment syndrome

The correct answer is c. Hypovolemic shock.

Severe burns cause damage to the skin and underlying tissues, leading to significant fluid loss.
Urine output will decrease. Hyperlipidemia, venous thrombosis, or compartment syndrome can occur in chronic conditions or during the recovery phase.

118B14
Which of the following is not a condition for which alcohol is a risk factor?

a. Esophageal cancer
b. Dementia
c. Osteoporosis
d. Wernicke's encephalopathy
e. Chronic obstructive pulmonary disease (COPD)

The correct (incorrect) answer is e. Chronic obstructive pulmonary disease (COPD).

Chronic obstructive pulmonary disease (COPD) is primarily caused by long-term smoking, air pollution, or occupational exposure to dust and chemicals.
Alcohol may damage the esophagus, brain, and bones, and can cause encephalopathy due to a deficiency in thiamine (vitamin B1).

118B15
Which of the following is not a cause of polypharmacy in the elderly?

a. Coexistence of multiple diseases
b. Shortening of prescription durations
c. Prescriptions from multiple healthcare facilities
d. Decreased ability to self-manage medications
e. Lack of coordination between healthcare facilities and pharmacies

The answer is b. shortening of prescription durations.

Shortening prescription durations can actually contribute to the prevention of polypharmacy.
The other options can lead to polypharmacy.

118B16
Which of the following has the highest proportion of extracellular fluid relative to total body fluid?

a. Newborn
b. Infant
c. Toddler
d. School-aged child
e. Adult

The correct answer is a. Newborn.

The proportion of extracellular fluid (ECF) in a newborn is about 40% of body weight. ECF is important for hydration and metabolism.
The proportion of ECF decreases with age to about 20% of body weight in adults.

118B17
Which of the following is useful for ruling out a diagnosis?

a. When a highly sensitive test is positive
b. When a highly sensitive test is negative
c. When a highly specific test is positive
d. When a highly specific test is negative
e. When the sensitivity / (1 - specificity) is greater than 1

The correct answer is b. When a highly sensitive test is negative.

A highly sensitive test means that it can detect the disease with a low rate of false negatives. If this test shows a negative result, the possibility of the disease can be ruled out.
On the other hand, a highly specific test means it has a low rate of false positives. If this test shows a positive result, a diagnosis can be confirmed.

118B19
Which of the following is not an appropriate question for understanding a patient's explanatory model?

a. "Can you list your symptoms?"
b. "What kind of treatment do you think will be necessary?"
c. "How do you think your life will change once the illness is cured?"
d. "Do you have any ideas about what might have caused the illness?"
e. "In what ways has the illness caused difficulties for you?"

The answer (incorrect choice) is a. ("Can you list your symptoms?").

The patient's explanatory model refers to the patient's belief, understanding, or expectation about their illness, its causes, or treatments.
Symptoms are a fact, not a reflection of their belief, understanding, or expectation.

118B20
Which of the following is a delusion?

a. "I see many small bugs on the floor."
b. "I hear my name being called by my mother's voice."
c. "A bugging device has been implanted in my body, and I am being monitored."
d. "I can feel a rubber ball moving around inside my stomach."
e. "Everything I eat feels like I'm chewing sand, and it doesn't taste good."

The answer is c. ("A bugging device has been implanted in my body, and I am being monitored.").

A delusion is a fixed and false belief about reality.
A hallucination is a false sensory experience, such as visual, olfactory, gustatory, auditory, or tactile, as seen in the other choices.

118B21
Which of the following combinations of patient information during the preoperative examination and perioperative risk is incorrect?

a. Smoking – Postoperative atelectasis
b. Limited mouth opening – Difficulty securing the airway
c. Heavy alcohol consumption – Pulmonary embolism
d. Taking anticoagulants – Difficulty with hemostasis
e. Hives after eating bananas – Latex allergy

The (incorrect) answer is c. Heavy alcohol consumption – Pulmonary embolism.

Excessive alcohol consumption can cause bleeding, delayed wound healing, and cardiovascular complications.
Risk factors for pulmonary embolism (PE) include immobility, obesity, and venous thrombosis.
Smoking, limited mouth opening, and anticoagulants can each cause atelectasis, airway management issues, and bleeding, respectively.
Bananas and latex can trigger cross-reactions.

118B22
Which of the following combinations of physical examination findings and conditions is correct?

a. Dimple sign – Gynecomastia
b. Kernig sign – Meningitis
c. Chvostek sign – Pleural effusion
d. Blumberg sign – Undescended testicle
e. Grey-Turner sign – Urolithiasis (kidney stone)

The correct answer is b. Kernig sign – Meningitis.

The Kernig sign is a clinical test used to evaluate for meningitis, an inflammation of the protective membranes covering the brain and spinal cord.
The test is performed by having the patient lie on their back with the hip and knee flexed to 90 degrees.
A positive Kernig sign occurs when there is pain or resistance to knee extension, indicating irritation of the meninges (the protective membranes).
The dimple sign is more commonly associated with conditions like breast cancer.
The Chvostek sign is associated with hypocalcemia (low calcium levels) and involves twitching of facial muscles when the facial nerve is tapped.
The Blumberg sign is associated with peritonitis (inflammation of the abdominal lining) and is elicited by pressing on the abdomen and observing for rebound tenderness.
The Grey-Turner sign, which refers to bruising on the flanks, is typically associated with acute pancreatitis or retroperitoneal hemorrhage.

118B24
Which of the following is a characteristic complaint of social anxiety disorder?

a. "I'm afraid of getting an MRI scan."
b. "I am hated by everyone around me."
c. "Something terrible is going to happen tomorrow."
d. "I feel extremely anxious when meeting strangers."
e. "I check the door lock dozens of times before leaving home."

The correct answer is d. ("I feel extremely anxious when meeting strangers.").

Social anxiety disorder (SAD), also known as social phobia, is characterized by an intense fear of social interactions and the fear of being embarrassed by others.
"I’m afraid of getting an MRI scan." indicates a specific phobia, but not social phobia.
"I am hated by everyone around me." is observed in depressive disorders or paranoid delusions.
"Something terrible is going to happen tomorrow." indicates generalized anxiety disorder (GAD) without a specific event.
"I check the door lock dozens of times before leaving home." is a symptom of obsessive-compulsive disorder (OCD).

118B25
A clinical study is being conducted on individuals under the age of 16. Which of the following involves explaining the study in a way that is understandable to the participants and obtaining their agreement to participate?

a. Opt-out
b. Paternalism
c. Living will
d. Second opinion
e. Informed assent

The correct answer is e. informed assent.

Informed assent is the process of explaining a study in an understandable way to a minor in order to obtain their agreement to participate, though full legal informed consent must be obtained from a parent or guardian.
Opt-out refers to a decision not to participate.
Paternalism means making decisions on behalf of others who lack sufficient capacity.
A living will is a legal document that describes a person's wishes for medical treatment in case they lose mental capacity.
A second opinion is advice or evaluation from another medical professional.

118B26
A 54-year-old woman. She is visiting for a regular check-up for diabetes. Her medical history has no notable features. She is a housewife. She has no smoking history and drinks alcohol occasionally. She experienced menopause at 51. Her family history has no notable features. She is 158 cm tall and weighs 80 kg, with a BMI of 31.3. Her body temperature is 36.2°C, pulse 72/min, regular. Her blood pressure is 126/78 mmHg, and respiratory rate is 18/min. No abnormalities are found in the physical examination. Her fasting blood glucose levels have been between 180–220 mg/dL, and her HbA1c has remained between 8–10% (normal range: 4.9–6.0), with no signs of improvement. She has gained 5 kg over the last two years. The outpatient physician has recommended glucose-lowering medications, but the patient has repeatedly declined, saying, "I will definitely lose weight by the next visit, so I don't want to start the medication." However, she is willing to continue her visits.

Which of the following statements is not appropriate to say to this patient?

a. "What kind of treatment do you think you can realistically follow?"
b. "What do you consider to be your goals for treatment?"
c. "Could you explain again why you don't want to start the medication?"
d. "What do you think will happen if your diabetes continues in its current state?"
e. "If you don't want to start the medication, would you be willing to seek care at another medical facility?"

The (inappropriate) answer is e. ("If you don't want to start the medication, would you be willing to seek care at another medical facility?").

The doctor should not undermine the trust between the patient and the doctor. The doctor must use the conversation to promote collaboration, understanding, and shared decision-making with the patient, as seen in the other statements.

118B27
A 72-year-old man. He presented with a chief complaint of insomnia. He has been receiving treatment for lung cancer for the past year. Six months ago, he was diagnosed with metastasis to the lumbar spine and began experiencing back pain during walking, climbing stairs, and lifting heavy objects. A month ago, he started occasionally experiencing mild back pain while standing. A week ago, he reported having trouble falling asleep due to the pain and is asking for help to alleviate his sleep deprivation.

Which pain should be the primary target for pain relief?

a. Pain during walking
b. Pain while standing
c. Pain during stair climbing
d. Pain that disrupts sleep
e. Pain when lifting heavy objects

The correct answer is d. Pain that disrupts sleep.

The patient is suffering from pain due to the advanced stage of cancer. The priority is to relieve the pain that affects sleep, as this is fundamental to improving quality of life.

118B28
A 75-year-old woman. She was diagnosed with advanced small cell lung cancer with bone metastasis one month ago. According to her wish to live peacefully at home without aggressive treatments like drug-based cancer therapy, she is receiving home care. The patient has bi-monthly home visits from a doctor and is taking several oral medications for cancer-related pain relief. She lives alone but maintains an independent lifestyle at home.

Today, during a routine home visit, the patient strongly expressed a desire to take over-the-counter supplements.

Which of the following responses is incorrect?

a. Listen carefully to the patient's wishes.
b. Share the information with the healthcare team.
c. Confirm the financial cost.
d. Refrain from further medical care for this patient.
e. Gather medical information about the supplements.

The (incorrect) answer is d. Refrain from further medical care for this patient.

The healthcare providers must continue to support the patient, respect her autonomy and preferences as much as possible, and cooperate within the team.

118B29
A 64-year-old man. He presented with complaints of night sweats, low-grade fever, and a persistent cough. He has been receiving treatment for rheumatoid arthritis with disease-modifying antirheumatic drugs (DMARDs) and biologics for the past four years. One month ago, he began experiencing night sweats, low-grade fever, and a cough. Due to persistent symptoms, he visited a nearby clinic. His heart and lung sounds were normal. A chest X-ray revealed a cavitary lesion in the right upper lung field.

Which test is necessary to determine the need for airborne infection precautions in this patient?

a. Acid-fast bacillus (AFB) sputum smear
b. Acid-fast bacillus (AFB) sputum culture
c. Tuberculin skin test
d. Bronchoalveolar lavage (BAL) culture
e. Interferon-gamma release assay (IGRA) specific to tuberculosis bacteria

The correct answer is a. Acid-fast bacillus (AFB) sputum smear.

Tuberculosis (TB) infection presents with night sweats, low-grade fever, a persistent cough, and a cavitary lesion in the lung on the chest X-ray. TB is an airborne infectious disease, so a rapid test is required to identify Mycobacterium tuberculosis. The AFB sputum smear is a quick method to assess for contagiousness.
The AFB sputum culture is more sensitive but takes weeks to provide results.
The tuberculin skin test and IGRA can only indicate prior TB exposure, not active infection or contagiousness.
The BAL culture is more invasive and not the preferred option in this case.

118B30
A 40-year-old man. He visited the clinic after an abnormality was detected during a workplace health screening. The health screening results he brought show a BMI of 31 and HbA1c of 7.0% (normal range: 4.9–6.0). He is 168 cm tall and weighs 90 kg. During the interview, he mentioned that recently his father began receiving hemodialysis due to end-stage renal failure caused by diabetes, which has made him want to lose weight. However, he finds it difficult to exercise because of his busy work schedule and often eats out.

Which approach would be most effective for this patient’s stage of behavior change?

a. "If you continue like this, you will need dialysis in the future."
b. "Come back for a consultation when you're really serious about losing weight."
c. "What do you think you can do to lose weight?"
d. "Let’s aim to lose 5 kg in six months."
e. "Walk for 30 minutes every day."

The correct answer is c. ("What do you think you can do to lose weight?").

When a patient is aware of the need for change in treatment, he is in the contemplation stage of the stages of behavior change model. At this stage, the most effective approach is to let the patient reflect on the change themselves, rather than emphasizing the danger of the disease or forcing them to take action.

118B31
A 1-month-old boy. He was brought to the clinic by his parents with complaints of irritability and poor feeding. Since last night, he has been irritable and his milk intake has decreased by about 50%, prompting a visit to the emergency department during the night. There were no abnormalities during the perinatal period. His consciousness is clear.
① Body temperature: 37.1°C
② Heart rate: 120 beats/min, regular
③ Blood pressure: 80/50 mmHg
④ Respiratory rate: 36 breaths/min
His complexion is slightly poor. The anterior fontanelle is flat. No lymph nodes are palpable in the neck. Heart sounds and breath sounds are normal. The abdomen is soft.
⑤ Capillary refill time: 4 seconds.

Which of the underlined findings requires urgent attention?

a. ①
b. ②
c. ③
d. ④
e. ⑤

The answer is e.⑤ Capillary refill time: 4 seconds.

If the capillary refill time is longer than 2 seconds, it suggests the possibility of poor peripheral perfusion, which could indicate circulatory collapse or shock in infants. This may be caused by dehydration or infections.
Other findings are within the normal range for a 1-month-old baby.

118B33
A 74-year-old man visited the clinic with a chief complaint of difficulty swallowing food. He became aware of this sensation while eating about three months ago, and it gradually worsened to the point where he could barely eat, prompting him to seek medical attention. He is conscious and alert. He is 170 cm tall and weighs 46 kg (a 10 kg loss over 3 months). His temperature is 37.0°C, pulse 64/min, regular. Blood pressure is 100/56 mmHg. Respiratory rate is 14/min, and SpO2 is 96% (room air). His skin is dry. He shows signs of anemia in the palpebral conjunctiva but no jaundice in the scleral conjunctiva. His oral cavity is dry. No lymph nodes are palpable in the neck. Heart sounds and breath sounds are normal. The abdomen is flat, soft, and the liver and spleen are not palpable. Upper gastrointestinal endoscopy revealed a tumor in the mid-esophagus, and pathology from an endoscopic biopsy diagnosed squamous cell carcinoma. Due to difficulty with oral intake, tube feeding was initiated. A nasogastric tube was inserted 55 cm from the nasal wing, and intermittent tube feeding was started. The next day, before resuming tube feeding, a nurse noticed that the tube had retracted 30 cm and reported it to the attending physician.

Which is the appropriate action before resuming tube feeding?

a. Resume feeding as is.
b. Reinsert the tube to 55 cm and resume feeding.
c. Reinsert the tube to 55 cm, listen for air injection sounds at the epigastrium, and then resume feeding.
d. Reinsert the tube to 55 cm, inject water to confirm patency, and then resume feeding.
e. Reinsert the tube to 55 cm, confirm the tube tip is in the stomach with a chest X-ray, and then resume feeding.

The correct answer is e. Reinsert the tube to 55 cm, confirm the tube tip is in the stomach with a chest X-ray, and then resume feeding.

Using a chest X-ray is the most reliable method to confirm the correct positioning of the tube tip in the stomach.

118B34
A 72-year-old woman visited the clinic complaining of headache and eye pain. Since last night, she has experienced pain in her right eye along with a worsening headache. Visual acuity is 0.05 in the right eye (uncorrectable) and 1.0 in the left eye. The right pupil measures 4 mm, and the direct light reflex is absent. When the eyelids are closed and the eyes are palpated, the left eyeball is elastic and soft, while the right eyeball is clearly hard. The slit-lamp microscopy image of the right eye is shown.

What is the appropriate treatment?

a. Observation
b. Antibiotic eye drops
c. Miotic eye drops
d. Ocular massage
e. Oral glucocorticoids

The correct answer is c. Miotic eye drops.

Acute angle-closure glaucoma presents with a hard eye, severe pain, reduced vision, and a fixed, mid-dilated pupil.
Miotic eye drops help relieve intraocular pressure by constricting the pupil.

118B35
A 38-year-old man was brought in by ambulance with right-sided chest pain and shortness of breath following a traffic accident. While driving a car, he collided head-on with a central divider and sustained significant chest trauma. He is conscious and alert. His body temperature is 35.4°C, heart rate is 108 bpm, regular. Blood pressure is 88/60 mmHg. Respiratory rate is 28 breaths/min, and SpO2 is 88% (on 10 L/min oxygen via a reservoir mask). His pupils are 4 mm bilaterally, with a normal light reflex. He is able to speak, and there are no secretions in the oral cavity. Capillary refill time is 3 seconds. His skin is clammy and moist. Jugular venous distension is observed. On examination of the right chest, there is visual bulging of the chest wall, palpable subcutaneous emphysema, tympanic percussion, and diminished breath sounds on auscultation. Heart sounds are normal.

What is the immediate treatment?

a. Thoracentesis
b. Hypothermia therapy
c. Osmotic diuretic administration
d. Massive infusion of lactated Ringer’s solution
e. Non-invasive positive pressure ventilation (NPPV)

The correct answer is a. Thoracentesis.

This patient likely has a tension pneumothorax, based on his chest trauma, decreased breath sounds, tympanic percussion, subcutaneous emphysema, and jugular venous distension.
This condition requires immediate decompression with thoracentesis to relieve the pressure in the pleural space.

118B36
A 54-year-old woman visited the emergency department after falling and hitting her face following alcohol consumption. A simple head CT scan revealed no abnormalities. An open wound on the forehead was sutured. The photo shows the forehead after suturing.

Which is the correct instruction to give to the patient before discharge?

a. "You can wash your face at home."
b. "You will need to be hospitalized for suture removal."
c. "Do not use a pillow when sleeping."
d. "Do not take pain medication."
e. "If you feel nauseous, come for a follow-up the next day."

The correct answer is a. ("You can wash your face at home.").

Washing after the suturing of an open wound is possible as long as it is done carefully and can help prevent infection.
Removing the stitches does not require hospitalization.
Using a pillow or taking pain medication poses no problem.
In case of signs of nausea, an immediate follow-up examination is necessary.

118B37
A 32-year-old woman visited the clinic with a chief complaint of cervical lymph node swelling. She had noticed swelling on the left side of her neck for the past three weeks, and more recently, swelling developed on the right side, prompting her to seek medical attention. She has no fever, weight loss, or night sweats. She has been healthy her whole life, with no history of pet ownership or allergies. Her husband had been treated for a painless ulcer on his penis three months ago. The patient is conscious and alert. She is 168 cm tall and weighs 61 kg. Her temperature is 36.7°C, pulse 78/min, regular, blood pressure 106/68 mmHg, respiratory rate 16/min, and SpO2 100% (room air). Diffuse, partially confluent 3mm red macules and papules are observed on the palms and soles. There are no ulcerative lesions in the oral cavity. The pharynx shows no redness. A 5 cm movable, soft lymph node is palpable in the left cervical region. Similarly, a 3 cm enlarged lymph node is palpable in the right cervical region. Heart and breath sounds are normal, and the liver and spleen are not palpable.

What is the most appropriate treatment?

a. Antifungal drug
b. Antiviral drug
c. Cephalosporin (Cefem)
d. Penicillin
e. Carbapenem

The correct answer is d. Penicillin.

The symptoms, including bilateral cervical lymphadenopathy, a diffuse rash on the palms of the hands and the soles of the feet, as well as the history of her husband’s painless ulcer on the penis, suggest secondary syphilis, which is an STD (sexually transmitted disease) caused by a bacterium (Treponema pallidum).
The most appropriate treatment for syphilis is penicillin.

118B38
A 72-year-old woman was hospitalized for a stroke and, after rehabilitation, was discharged home, where she has now lived alone in her apartment for three months. She currently lives ① alone in her apartment. Mild motor paralysis remains in her right upper and lower limbs, and ② she cannot walk long distances. Before hospitalization, ③ she enjoyed talking and attended a haiku class as a hobby, but she has recently stopped attending because ④ she cannot climb the stairs at the entrance to the haiku class. Since being discharged, ⑤ she has tended to stay home most of the time.

Which of the underlined parts is classified as a participation restriction under the International Classification of Functioning, Disability, and Health (ICF)?

a. ①
b. ②
c. ③
d. ④
e. ⑤

The correct answer is e. ⑤ she has tended to stay home most of the time.

A participation restriction under the International Classification of Functioning, Disability, and Health (ICF) means a limitation in her ability to participate in life activities and her social environment.

118B39
A 25-year-old man visited the clinic complaining of reduced urine output. A week ago, his family noticed swelling in his face. Three days ago, his urine output decreased, prompting him to seek medical attention. He has been healthy throughout his life. He is 177 cm tall and weighs 74 kg. His pulse is 72 beats/min, regular. His blood pressure is 108/64 mmHg. Edema is noted in both eyelids. No abnormalities are observed in the chest or abdomen. There is pitting edema in both lower legs. Urinalysis: protein 4+, glucose (-), occult blood (-), protein quantification 1,540 mg/dL (reference range 15–45), creatinine quantification 70 mg/dL, Na 15 mEq/L. Blood test results: red blood cells 6.32 million, Hb 19.1 g/dL, Ht 55%. Blood biochemistry: total protein 3.6 g/dL, albumin 1.2 g/dL, blood urea nitrogen 40 mg/dL, creatinine 1.9 mg/dL, uric acid 7.6 mg/dL, total cholesterol 521 mg/dL, Na 131 mEq/L, K 4.7 mEq/L, Cl 100 mEq/L.

Which test should be performed next?

a. Cystoscopy
b. Renogram
c. Abdominal contrast-enhanced CT
d. Abdominal ultrasound
e. Abdominal X-ray

The correct answer is d. Abdominal ultrasound.

Nephrotic syndrome, characterized by significant proteinuria, hypoalbuminemia, hyperlipidemia, and edema, necessitates an abdominal ultrasound for the evaluation of the kidneys.
This is a non-invasive test, which may be followed by other tests for further evaluation.

118B40
A 38-year-old primiparous woman (1st pregnancy, no prior deliveries) at 32 weeks of gestation visited the clinic due to upper abdominal pain. Since the day before, she had been experiencing headaches, a flickering sensation in her eyes (scintillating scotoma), discomfort in the epigastric region, finger stiffness, generalized edema, and reduced urine output. Today, she is complaining of pain from the upper abdomen to the right hypochondrium, fatigue, and nausea. Her pulse is 84 beats/min, regular. Her blood pressure is 156/102 mmHg. There are no abnormalities in the fetal heart rate on cardiotocography.

What is expected to be decreased in this patient?

a. LD
b. AST
c. Platelet count
d. Hematocrit
e. Urine protein/creatinine ratio

The correct answer is c. Platelet count.

This patient's symptoms, such as upper abdominal pain, headaches, a flickering sensation in her eyes (scintillating scotoma), discomfort in the epigastric region, finger stiffness, generalized edema, and reduced urine output during the late stage of pregnancy, suggest HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets).

118B41-42

A 65-year-old woman was brought in by ambulance due to abnormal behavior.

Present illness: She has had constipation for the past week. A few days ago, when she returned home from shopping, she displayed unusual behavior, such as throwing away purchased items in the trash and scattering money. This morning, she appeared confused and responded sluggishly to calls, prompting her husband to call for an ambulance.

Medical history: She has been treated for type 2 diabetes and fatty liver at a nearby clinic, where she is taking a DPP-4 inhibitor.

Family history: Nothing noteworthy.
Lifestyle history: No history of smoking or alcohol consumption.

Current symptoms: She is drowsy but can open her eyes and converse when called. Height: 154 cm, Weight: 72 kg, BMI: 30.4. Temperature: 36.4°C. Heart rate: 80/min, regular. Blood pressure: 104/64 mmHg. Respiratory rate: 16/min. SpO2: 98% (room air). There is jaundice in the conjunctiva. No palpable thyroid enlargement or cervical lymph nodes. There are spider angiomas and palmar erythema on the anterior chest. No abnormalities in heart and lung sounds. The abdomen is flat, soft, and the liver is not palpable. The spleen is palpable 1 cm below the left costal margin. There is no edema in the lower legs.

Laboratory findings:
Blood tests: RBC 3.96 million, Hb 12.1 g/dL, WBC 3,800, Platelets 100,000, PT-INR 1.0 (reference 0.9–1.1).
Blood biochemistry: Total protein 7.0 g/dL, Albumin 3.4 g/dL, Total bilirubin 3.7 mg/dL, AST 74 U/L, ALT 52 U/L, γ-GT 63 U/L (reference 9–32), Cholinesterase 150 U/L (reference 201–421), Ammonia 180 μg/dL (reference 18–48), BUN 12 mg/dL, Creatinine 0.6 mg/dL, Blood glucose 148 mg/dL, HbA1c 7.6% (reference 4.9–6.0), Na 142 mEq/L, K 3.8 mEq/L, Ca 8.8 mg/dL. A simple head CT showed no abnormalities.

What neurological finding is present in this patient?

a. Rigidity
b. Intention tremor
c. Neck stiffness
d. Barré sign
e. Difficulty maintaining a fixed posture (asterixis)

What is the appropriate treatment?

a. Transfusion of fresh frozen plasma
b. Intravenous injection of 50% glucose
c. Intravenous infusion of normal saline
d. Intravenous infusion of albumin
e. Intravenous infusion of branched-chain amino acid preparation

The answer is e. Difficulty maintaining a fixed posture (asterixis).

This patient may have a hepatic disorder, such as liver cirrhosis, due to the high ammonia level, jaundice in the conjunctiva, spider angiomas (small, spider-like blood vessels visible on the skin), and palmar erythema (redness of the palms). In addition, the patient exhibits abnormal behaviors. These findings suggest hepatic encephalopathy, which also presents with asterixis.

The answer is e. Intravenous infusion of branched-chain amino acid preparation.

In hepatic encephalopathy, branched-chain amino acids (BCAAs) are used to improve liver function and reduce ammonia levels.
Fresh frozen plasma is for clotting disorders.
50% glucose is used for hypoglycemia.
Normal saline is for dehydration or electrolyte imbalances.
Albumin infusion can be helpful in liver disease, but it does not specifically address ammonia or neurological symptoms.

118B43-44

A 70-year-old man was brought in by ambulance after a fall from a bicycle.

Present illness: The patient fell while riding a bicycle and hit the right temporal region of his head. He was not wearing a helmet. A passerby called emergency services, and an ambulance was requested. Upon contact with the emergency team, his level of consciousness was GCS 14 (E3V5M6).

Medical history: He has been taking antihypertensive medication for hypertension since the age of 58.

Lifestyle history: No smoking history, occasional alcohol consumption. Lives with his wife.
Family history: His father died of acute myocardial infarction at age 80. His mother is 95 years old and has always been healthy.

Current symptoms: 30 minutes after the injury, upon arrival, his level of consciousness was GCS 8 (E2V2M4). Height: 163 cm, Weight: 60 kg. Temperature: 36.7°C. Heart rate: 80/min, regular. Blood pressure: 148/92 mmHg. Respiratory rate: 22/min. SpO2: 93% (with oxygen administered via a reservoir mask at 10 L/min). Heart sounds are normal. There is no difference in breath sounds between sides, but the base of the tongue is sunken, and he exhibits snoring-like breathing. His pupils are 4 mm on the right, 3 mm on the left, with a delayed light reflex on the right side. There are abrasions on the right temporal region and the back of the right hand. No other visible injuries, but left-sided partial hemiparesis is noted.

Test results: A focused assessment with sonography for trauma (FAST) showed no abnormalities.

What is the appropriate immediate action?

a. Tracheal intubation
b. Thoracentesis
c. Emergency pacing
d. Ventricular drainage
e. Central venous catheter placement

A non-contrast head CT scan was performed after the procedure. What is the diagnosis?

a. Brain contusion
b. Subcortical hemorrhage
c. Acute epidural hematoma
d. Acute subdural hematoma
e. Diffuse axonal injury

The answer is a. Tracheal intubation.

The patient's decreased level of consciousness (GCS 8), the sunken tongue, and snoring-like breathing indicate a compromised airway and a potential risk of aspiration. Securing the airway through tracheal intubation is the priority.

The answer is d. Acute subdural hematoma.

The CT scan findings are consistent with an acute subdural hematoma, characterized by a crescent-shaped collection of blood between the dura mater and the brain surface, which can cause midline shift and compression of brain structures. It can occur after a fall from a bicycle, resulting in a head injury.

118B45-46

A 77-year-old woman was brought in by ambulance due to sudden chest and back pain, along with a sense of fatigue.

Present Illness: Early this morning, she woke up with sudden chest and back pain and lay in bed for about 30 minutes, but her unbearable sense of fatigue worsened, so she requested an ambulance.

Medical History: She has a history of diabetes and hypertension, for which she is on medication.

Lifestyle History: She lives with her 80-year-old husband and manages household chores without any problems. No smoking history. Occasional alcohol consumption.

Family History: Nothing significant to note.

Current Symptoms: She is alert and conscious. Height: 150 cm, Weight: 51 kg. Temperature: 36.1°C. Heart rate: 96/min, regular. Blood pressure: 102/70 mmHg in the upper limbs, 114/60 mmHg in the lower limbs. Respiratory rate: 15/min. SpO2: 98% (room air). No abnormal breath sounds. A Levine 2/6 diastolic murmur is heard at the third intercostal space along the left sternal border. The abdomen is flat, soft, with no palpable liver or spleen. No neck pain. She reports pain in both shoulders but shows no tenderness or limitation in the range of motion.

Test Results:
Blood test results: RBC 3.91 million, Hb 11.9 g/dL, Hct 37%, WBC 8,600, Platelets 160,000.
Blood biochemistry: Total protein 6.4 g/dL, Albumin 3.0 g/dL, Total bilirubin 1.7 mg/dL, AST 98 U/L, ALT 134 U/L, LDH 263 U/L (reference 124-222), CK 74 U/L (reference 41-153), BUN 24 mg/dL, Creatinine 0.6 mg/dL, Na 139 mEq/L, K 4.8 mEq/L, Cl 105 mEq/L. CRP 6.8 mg/dL.

The ECG, thoracic spine X-ray, and plain chest CT are shown in the images.

What is the most likely diagnosis?

a. Tension pneumothorax
b. Acute myocardial infarction
c. Thoracic vertebral compression fracture
d. Acute aortic dissection
e. Acute mitral valve insufficiency

After the tests, the pain slightly improved, but fatigue persisted. Following the plain chest CT, heart rate was 108/min, regular. Blood pressure was 92/62 mmHg. SpO2: 98% (room air).

What is the next appropriate action?

a. Observation
b. Emergency surgery
c. Chest tube drainage
d. Cardiac catheterization
e. Intra-aortic balloon pumping (IABP) insertion

The answer is d. Acute aortic dissection.

An acute aortic dissection presents suddenly with chest and back pain.
There is often a noticeable difference in blood pressure between the upper and lower extremities.
A diastolic murmur along the left sternal border indicates aortic insufficiency.
The CT images also clearly show an acute aortic dissection.

The answer is b. Emergency surgery.

An acute aortic dissection requires immediate surgery, especially if severe symptoms are present or if the diameter of the aorta exceeds 5.5 cm.

118B49-50

A 78-year-old woman was brought in by ambulance due to loss of appetite.

Present Illness: About a week ago, her food intake decreased, and she started spending most of the day lying in bed. Since yesterday, it has become difficult for her to eat, prompting her husband to call an ambulance.

Medical History: She was diagnosed with hypertension around 25 years ago, Alzheimer's disease, and osteoporosis about 2 years ago. She underwent surgery 3 months ago for a left subtrochanteric femoral fracture. She is currently taking an angiotensin II receptor blocker (ARB), a calcium channel blocker, active vitamin D, and a cholinesterase inhibitor.

Lifestyle History: Lives with her husband. No smoking history. Occasional alcohol consumption.

Family History: Her father had a stroke, and her mother had a cerebral hemorrhage.

Current Symptoms: Consciousness level is JCS II-10. Height: 151 cm, Weight: 46 kg. Temperature: 36.4°C. Heart rate: 100/min, regular. Blood pressure: 108/78 mmHg. Respiratory rate: 16/min. SpO2: 95% (room air). No abnormalities in the palpebral or bulbar conjunctiva. Heart sounds and breath sounds are normal. The abdomen is flat, soft, with no palpable liver or spleen. No abnormalities in the extremities.

Test Results:
Urine test: Protein (−), Glucose (−), Occult blood (−).
Blood test: RBC 3.20 million, Hb 10.1 g/dL, Hct 30%, WBC 7,200, Platelets 230,000.
Blood biochemistry: Total protein 7.1 g/dL, Albumin 3.6 g/dL, Total bilirubin 0.6 mg/dL, AST 23 U/L, ALT 12 U/L, LDH 184 U/L (reference 124-222), BUN 41 mg/dL, Creatinine 1.0 mg/dL, Blood glucose 110 mg/dL, Na 146 mEq/L, K 3.8 mEq/L, Cl 103 mEq/L, Ca 13.6 mg/dL. CRP 0.2 mg/dL.
A head CT scan showed no abnormalities.

Which finding is most likely to be observed in this patient?

a. Polyuria
b. Tetany
c. Barré's sign
d. Trousseau's sign
e. Difficulty maintaining a fixed posture (asterixis)

What should be used in the initial treatment?

a. Normal saline
b. Distilled water for injection
c. 50% glucose solution
d. Sodium bicarbonate solution
e. Calcium gluconate solution

The answer is a. Polyuria.

The patient's lab results show a high calcium level (13.6 mg/dL), indicating hypercalcemia. Hypercalcemia can lead to several symptoms, one of which is polyuria, or excessive urination.
Tetany is a sign of low calcium (hypocalcemia) and involves muscle spasms.
Barré's sign detects mild muscle weakness, often related to neurological conditions.
Trousseau's sign is a classic indicator of hypocalcemia, showing muscle irritability.
Asterixis is a symptom of metabolic encephalopathy, manifesting as an inability to maintain a steady posture.

The answer is a. Normal saline.

For treating hypercalcemia, normal saline (0.9% sodium chloride) is the initial treatment of choice. It is given intravenously to rehydrate the patient and to increase the excretion of calcium through the kidneys.