118C (2024)

118C1

Which of the following diseases is associated with an increase in eosinophils?

a. IgA nephropathy
b. Hereditary angioedema
c. Antiphospholipid antibody syndrome
d. Cholesterol embolism
e. Granulomatosis with polyangiitis

The correct answer is d. Cholesterol embolism.

• A cholesterol embolism, also known as a cholesterol crystal embolism, is caused by cholesterol crystals breaking off from atherosclerotic plaques and traveling to small blood vessels. This triggers eosinophilia as an inflammatory response.

118C2
Which of the following is the correct approach to managing depression in a terminal cancer patient?

a. Do not ask about anxiety as a doctor.
b. Tell them to endure because everyone feels this way.
c. Stop them when they start talking about suicidal thoughts.
d. Ignore conversations about pleasant past memories.
e. Prioritize and address the emotional distress they are experiencing.

The correct answer is e. Prioritize and address the emotional distress they are experiencing.

• It is necessary to adopt an empathetic and methodical approach towards a terminal cancer patient to manage their emotional difficulties.

118C3
Which of the following decreases in late pregnancy compared to the non-pregnant state?

a. Heart rate
b. White blood cell count
c. Glomerular filtration rate
d. Insulin resistance
e. Hematocrit value

The correct answer is e. Hematocrit value.

• In late pregnancy, the plasma volume increases, causing a relative dilution of red blood cells. As a result, the heart rate and glomerular filtration rate (GFR) also increase.
• The white blood cell count often rises, preparing the immune system for potential challenges during childbirth.
• Hormones such as human placental lactogen decrease the effectiveness of insulin.

118C7
Which of the following is not a cause of splenomegaly (enlarged spleen)?

a. Liver cirrhosis
b. Rotor syndrome
c. Japanese schistosomiasis
d. Budd-Chiari syndrome
e. Idiopathic portal hypertension

The answer is b. Rotor syndrome.

• Rotor syndrome is a liver disease in which the transport and excretion of bilirubin in the liver do not function properly.
• Splenomegaly is caused by portal hypertension, which is not associated with Rotor syndrome.

118C8
Which of the following is a health disorder associated with local vibration exposure?

a. Gottron's sign
b. Heberden's nodes
c. Osler's nodes
d. Raynaud's phenomenon
e. Romberg's sign

The correct answer is d. Raynaud's phenomenon.

• Raynaud's phenomenon is commonly linked to exposure to vibrations and results in restricted blood flow to fingers or toes, leading to color changes and numbness.
• Gottron's sign refers to red or violet papules found over the knuckles and is associated with dermatomyositis.
• Heberden's nodes are bony enlargements of the joints closest to the fingertips, typically associated with osteoarthritis.
• Osler's nodes are painful, red nodules found on the fingers or toes and are a symptom of infective endocarditis, a heart infection.
• Romberg's sign is a neurological test used to assess balance, indicating potential problems with the proprioception or sensory pathways in the nervous system.

118C12
Which of the following conditions would result in a positive right Babinski sign?

a. Right cerebral hemisphere lesion
b. Left pontine lesion
c. Right cerebellar lesion
d. Left cervical spinal cord lesion
e. Cauda equina syndrome

The correct answer is b. Left pontine lesion.

• A positive Babinski sign is an abnormal reflex indicating dysfunction in the corticospinal tract, which is a major pathway in the central nervous system responsible for voluntary motor control.
• The Babinski sign is characterized by an upward movement of the big toe when the sole of the foot is stimulated, suggesting damage to the upper motor neurons.
• The pons is a part of the brainstem that contains fibers of the corticospinal tract.
• Lesions in the left pons can affect the corticospinal tract fibers that are destined to control the right side of the body because most corticospinal fibers cross (decussate) to the opposite side in the lower brainstem (specifically at the medulla).
• A lesion in the left pontine region can disrupt these fibers before they cross to the right side, leading to motor symptoms, including a positive Babinski sign, on the right side of the body.

118C13
Which of the following is not a symptom of a disturbance in self-awareness?

a. "My thoughts are being controlled by others."
b. "My thoughts are being taken away."
c. "Thoughts that are not my own are coming to mind on their own."
d. "My thoughts are being transmitted worldwide through radio waves."
e. "My thoughts are insignificant and worthless."

The answer is e. ("My thoughts are insignificant and worthless.").

• This statement reflects a negative self-evaluation or low self-esteem, rather than a disturbance in self-awareness.

• A disturbance in self-awareness involves changes in how a person experiences their own thoughts, sense of control, or boundaries between self and others.

• Such disturbances are often seen in psychiatric conditions like schizophrenia or other psychotic disorders and involve specific types of thought disturbances, including:

  1. Thought Insertion: Believing that thoughts are being put into one's mind by an external source (related to options a and c).
  2. Thought Withdrawal: Believing that one's thoughts are being taken away or extracted by an outside force (related to option b).
  3. Thought Broadcasting: Believing that one's thoughts are being broadcast to others, often through electronic means or other strange mechanisms (related to option d).

118C14
Which of the following statements is incorrect regarding the neurological developmental stages of a child?

a. The Moro reflex is observed at 1 month.
b. The child rolls over at 3 months.
c. At 7 months, the child quickly removes a towel placed over their face.
d. The parachute reflex is observed at 10 months.
e. At 12 months, when the child is held upright and tilted forward, backward, or to the sides, they extend their legs to try to maintain balance.

The answer is b. The child rolls over at 3 months.

• Rolling over is a developmental milestone where a baby transitions from lying on their back to their stomach or vice versa. It typically occurs around 4 to 6 months of age.
• The Moro reflex, also known as the startle reflex, is a primitive reflex present at birth. It is normally observed in the first few months of life and is still present at 1 month. The reflex usually fades around 4 to 6 months of age.
• At 7 months, babies typically have developed enough motor skills and coordination to remove an object, like a towel, from their face. This action indicates better hand-eye coordination and awareness of their surroundings.
• The parachute reflex, a protective response where a baby extends their arms forward when they are tilted downwards, usually appears around 8 to 9 months and is clearly present by 10 months. It is a sign of developing motor and balance skills.
• By 12 months, babies usually start to stand and take steps. When held upright and tilted in different directions, they will extend their legs to try to keep balance, demonstrating the development of postural reflexes needed for walking and standing.

118C16
Which of the following cancers can be prevented through vaccination?

a. Stomach cancer
b. Lung cancer
c. Leukemia
d. Bladder cancer
e. Cervical cancer

The correct answer is likely e. Cervical cancer.

• Cervical cancer can be prevented through the HPV (Human Papillomavirus) vaccine.

118C17
The findings from laparoscopy are shown below.
Which of the following is not visible in the image?

a. Stomach
b. Liver
c. Spleen
d. Diaphragm
e. Round ligament of the liver

The answer is c. Spleen.

• In the laparoscopic image, the visible structures include the liver, parts of the diaphragm, and likely the round ligament of the liver (ligamentum teres). However, the spleen is not visible in this view.
• The spleen is located in the upper left quadrant of the abdomen, near the stomach and lateral to the liver. Laparoscopic views focused on the liver and diaphragm generally do not capture the spleen.

118C18
Which of the following is not included in the items of the simplified version of the Comprehensive Geriatric Assessment (CGA7)?

a. Motivation
b. Financial situation
c. Cognitive function
d. Basic ADL (Activities of Daily Living)
e. Instrumental ADL

The answer is b. Financial situation.

• The Comprehensive Geriatric Assessment (CGA) is a multidimensional tool used to evaluate the functional, mental, and social aspects of elderly patients to optimize their care and improve their quality of life.

• The simplified version, CGA7, primarily focuses on health, mental status, and functional independence rather than economic factors.

• These areas generally include:

  • Motivation: Assessing the individual's willingness or drive to engage in activities.
  • Cognitive function: Evaluating memory, decision-making, and overall mental capacity.
  • Basic Activities of Daily Living (ADL): Measuring basic self-care abilities like dressing, bathing, and eating.
  • Instrumental Activities of Daily Living (IADL): Assessing more complex daily tasks, such as managing medication, cooking, and handling finances.

118C20
Which of the following workplaces is associated with occupational cataracts?

a. Hospital
b. Printing factory
c. Sewing factory
d. Dry cleaning factory
e. Convenience store

The correct answer is a. Hospital.

• Occupational cataracts can develop in environments where workers are exposed to ionizing radiation, such as X-rays, which is common in hospitals.

118C21
Which of the following can be functionally evaluated by caloric testing (temperature-induced nystagmus)?

a. Lateral semicircular canal
b. Outer hair cells
c. Saccule
d. Posterior semicircular canal
e. Utricle

The correct answer is a. Lateral semicircular canal.

• The caloric test primarily assesses the function of the lateral (horizontal) semicircular canal by inducing nystagmus through temperature changes.

118C25
Which of the following suppresses milk secretion?

a. Sulpiride
b. Paroxetine
c. Prednisolone
d. Bromocriptine
e. Metoclopramide

The correct answer is d. Bromocriptine.

• Bromocriptine is known to inhibit prolactin, the hormone responsible for milk production.

118C26
Which of the following diseases is caused by a decrease in chromosome number?

a. Down syndrome
b. Klinefelter syndrome
c. Marfan syndrome
d. Prader-Willi syndrome
e. Turner syndrome

The correct answer is e. Turner syndrome.

• Turner syndrome is characterized by a reduction in chromosome number, specifically the loss of one X chromosome (45,X).
• Down syndrome is caused by an extra chromosome 21, resulting in a trisomy (47 chromosomes instead of the usual 46).
• Klinefelter syndrome is caused by an additional X chromosome in males (47,XXY).
• Marfan syndrome is a genetic disorder caused by mutations in the FBN1 gene on chromosome 15.
• Prader-Willi syndrome results from a deletion or dysfunction of specific genes on chromosome 15.

118C27
Which of the following approaches by healthcare providers is incorrect in reducing prejudice and stigma toward a particular disease?

a. Listen to the patient's story.
b. Research the latest knowledge about the disease.
c. Classify the patient's characteristics according to social stereotypes.
d. Pay attention to any potential biases you may hold.
e. Consider ways to support the patient in participating in society without being excluded.

118C29
Which of the following has a reference range that varies by sex?

a. Serum calcium level (Ca)
b. Serum CRP level
c. Arterial blood PaO2
d. Serum albumin level
e. Blood hemoglobin level

The correct answer is e. Blood hemoglobin level.

• Hemoglobin levels in men are generally 12% higher than in women.

118C30
Which of the following vaccinations do not need to be postponed after high-dose immunoglobulin therapy in children? Select two.

a. MR vaccine (measles-rubella)
b. Varicella vaccine (chickenpox)
c. DTaP-IPV vaccine (diphtheria, tetanus, pertussis, polio)
d. Mumps vaccine
e. Hib vaccine (Haemophilus influenzae type b)

The correct answers are c. DTaP-IPV vaccine and e. Hib vaccine.

• Inactivated vaccines, such as the DTaP-IPV and Hib vaccines, do not generally require postponement after immunoglobulin therapy, unlike live vaccines such as MR, varicella, and mumps.

118C32
Which of the following prenatal tests are non-invasive? Select two.

a. Chorionic villus sampling (CVS)
b. Amniocentesis
c. Ultrasound examination
d. Maternal serum marker test
e. Umbilical cord blood sampling (fetal blood sampling)

The correct answers are likely c. Ultrasound examination and d. Maternal serum marker test.

• Non-invasive refers to medical procedures or tests that do not require entering the body or breaking the skin, meaning there is no need to insert instruments into the body or draw samples from internal organs or tissues.
• Ultrasound examination and maternal serum marker test are non-invasive methods for prenatal diagnosis, unlike invasive tests such as CVS, amniocentesis, and umbilical cord blood sampling.

118C33
The images are shown below.
Which of these is used for sample collection in newborn mass screening? Select two.

a. ①
b. ②
c. ③
d. ④
e. ⑤

The correct answers are d (④) and e (⑤).

• ④ is a lancet used to puncture the skin to draw blood. In newborn mass screening, this is used to collect blood from the outer part of the heel.
• ⑤ is a piece of dried filter paper. In newborn mass screening, the collected blood is applied within the circular dotted areas.
• ① is a urine collection bag.
• ② is a tube (specimen container) for holding urine or other samples.
• ③ is a micro blood collection tube, used when only a small amount of blood is needed, such as in newborns.

118C34
Which of the following can cause wheezing? Select three.

a. Pneumothorax
b. Atelectasis
c. Left heart failure
d. Bronchial asthma
e. Chronic obstructive pulmonary disease (COPD)

The correct answers are c. Left heart failure, d. Bronchial asthma, and e. Chronic obstructive pulmonary disease (COPD).

•  Wheezing sounds are often associated with airway obstruction or fluid accumulation in the lungs.

118C35
A 51-year-old man presented with pain in the left lower abdomen extending to the flank. He experienced mild left back pain yesterday while at work, which resolved within 30 minutes. This morning, around 8 a.m., he felt sudden, severe pain extending from the left lower abdomen to the flank while commuting by train, prompting him to seek medical attention. He experienced nausea and vomiting on the way to the clinic. He is alert, with a body temperature of 36.3°C, pulse of 80 bpm (regular), blood pressure of 158/94 mmHg, and respiratory rate of 20 breaths per minute. His face is pale with cold sweats, and there is no rebound tenderness in the abdomen. Percussion tenderness is present in the left costovertebral angle. Urine findings: protein 1+, glucose (-), occult blood 3+, with 15-30 red blood cells and 1-4 white blood cells per field in the sediment. Blood biochemistry results: blood urea nitrogen 23 mg/dL, creatinine 1.2 mg/dL, uric acid 8.6 mg/dL, Na 136 mEq/L, K 4.0 mEq/L, Cl 109 mEq/L, Ca 9.2 mg/dL. Abdominal ultrasound shows left hydronephrosis, a left kidney stone, and a left ureter stone, although no calcification shadow is visible on the abdominal X-ray.

What is the likely composition of the stone in this patient?

a. Uric acid
b. Calcium carbonate
c. Calcium phosphate
d. Calcium oxalate
e. Magnesium ammonium phosphate

The correct answer is a. Uric acid.

• In general, uric acid stones are radiolucent and are not visible on X-rays, although the ultrasound showed left hydronephrosis, which is different from calcium-based compounds.
• Additionally, the elevated uric acid level (8.6 mg/dL) and the sudden, intense pain in the lower left abdominal region are consistent with this condition.

118C36
A 69-year-old man presented with gross hematuria. Hematuria appeared one month ago. He is alert, with a height of 176 cm and weight of 86 kg. His temperature is 36.5°C, pulse is 68 bpm (regular), and blood pressure is 118/72 mmHg. His abdomen is flat, and no masses are palpable. Urinalysis results: protein (-), glucose (-), ketones (-), occult blood 3+, with numerous red blood cells in the sediment. The cystoscopic image and pelvic contrast-enhanced CT taken upon arrival are shown below. No abnormalities were found on chest/abdominal CT or bone scintigraphy.

What is the appropriate initial treatment?

a. Cytotoxic anticancer drugs
b. Radical nephroureterectomy
c. Intravesical BCG therapy
d. Transurethral resection of the bladder tumor (TURBT)
e. Immune checkpoint inhibitors

The correct answer is d. Transurethral resection of the bladder tumor (TURBT).

• The patient's presentation of gross hematuria (visible blood in urine) and the cystoscopic and CT findings indicate a bladder tumor. In such cases, the initial approach is usually to perform a transurethral resection of the bladder tumor (TURBT).
• TURBT is both a diagnostic and therapeutic procedure; it allows for the removal of the tumor and provides tissue samples for pathological examination.
• Systemic chemotherapy is generally not the first line for localized bladder tumors and is usually reserved for more advanced or metastatic cases.
• Radical nephroureterectomy is typically used for upper tract urothelial cancers (in the renal pelvis or ureter).
• BCG therapy is used after TURBT for high-risk, non-muscle-invasive bladder cancer to prevent recurrence.
• Immune checkpoint inhibitors are used in advanced or metastatic bladder cancer, especially when there is resistance to chemotherapy.

118C38
A 28-day-old girl was brought to an obstetrics clinic by her parents for a one-month health check-up. She was born at 39 weeks of gestation with a birth weight of 2,850 g. She developed jaundice from day 1, so phototherapy was administered for 3 days. On day 6, her total bilirubin level was 7.3 mg/dL, and her direct bilirubin was 0.1 mg/dL, showing improvement, so she was discharged. She is exclusively breastfed. At the time of the visit, her weight was 3,450 g. Vital signs: temperature 36.8°C, pulse 120 bpm (regular), blood pressure 80/42 mmHg, respiratory rate 32/min, SpO2 99% (room air). Mild jaundice is observed on the skin and slight jaundice in the conjunctiva. Heart and lung sounds are normal. The liver is palpable 2 cm below the costal margin.

Blood test results: RBC 4.2 million, Hb 13.6 g/dL, WBC 9,600, platelets 240,000, PT-INR 1.0 (reference 0.9–1.1), APTT 30 seconds (reference 32.2 seconds). Blood biochemistry results: total protein 5.7 g/dL, albumin 3.8 g/dL, total bilirubin 6.6 mg/dL, direct bilirubin 0.1 mg/dL, AST 35 U/L, ALT 32 U/L, BUN 4.1 mg/dL, creatinine 0.2 mg/dL.

What is the appropriate course of action?

a. Observation
b. Exchange transfusion
c. Phototherapy
d. Biliary drainage
e. Switching from breastfeeding to formula

The correct answer is a. Observation.

• This 28-day-old infant has mild jaundice, as indicated by the elevated total bilirubin level of 6.6 mg/dL, but her direct bilirubin remains low (0.1 mg/dL). This suggests that the jaundice is likely physiologic or related to breastfeeding rather than a more serious condition like biliary atresia, which would typically show an elevated direct (conjugated) bilirubin level.
• The physical exam is generally normal, with no concerning findings in heart or lung sounds, and only mild hepatomegaly (liver palpable 2 cm below the rib cage), which is common in infants. Since her jaundice is mild, her vital signs are stable, and her other lab results (such as liver enzymes, AST and ALT) are within normal limits, no immediate invasive intervention is necessary.

118C40
An unidentified middle-aged man was rescued 30 minutes ago from under a collapsed building following a magnitude 7 earthquake. He does not respond to voice, has a respiratory rate of 32 breaths per minute, and shallow breathing. Capillary refill time is 3 seconds. Both lower legs show extensive bleeding from crush injuries. His extremities are notably cold. The disaster area is widespread, and there are many other injured individuals trapped under buildings.

What is the appropriate color of the triage tag for this patient?

a. Green
b. Yellow
c. Red
d. White
e. Black

The correct answer is c. Red.

1. Red (Immediate)

• Definition: Patients with life-threatening injuries who have a chance of survival if treated immediately.
• Priority: Highest. These patients require immediate intervention to stabilize them, as their injuries could be fatal without prompt treatment.
• Example: Severe bleeding, respiratory distress, or shock, where immediate care can make a critical difference.

2. Yellow (Delayed)

• Definition: Patients with serious but not immediately life-threatening injuries.
• Priority: Second-highest. These patients need care soon, but their condition is stable enough to wait until red-tagged patients are treated.
• Example: Fractures or large wounds without severe bleeding that can wait a few hours without risk of deterioration.

3. Green (Minor)

• Definition: Patients with minor injuries who can wait for extended periods before receiving medical attention.
• Priority: Low. These individuals are often referred to as “walking wounded” and are able to move or tend to themselves to some extent.
• Example: Minor cuts, bruises, or sprains.

4. Black (Deceased or Expectant)

• Definition: Patients who are either deceased or have injuries so severe that they are unlikely to survive, even with extensive medical intervention.
• Priority: Lowest. In a mass casualty situation where resources are limited, care is focused on those with a reasonable chance of survival.
• Example: Traumatic cardiac arrest or massive head injuries in an unresponsive patient with no signs of breathing or circulation.

118C42
A 14-year-old girl is hospitalized for emaciation and amenorrhea. She had good grades in elementary school but struggled with relationships with her teachers and friends. After entering junior high school, she began to restrict her food intake after friends commented on her weight gain. Since then, she has spent much of her time standing, even indoors, in addition to restricting her diet. She developed secondary amenorrhea five months ago and began experiencing severe fatigue about a month ago. She has no history of self-induced vomiting or laxative abuse. Even after hospitalization, her food intake remains low, and she expresses a strong desire not to gain weight. Her height is 148 cm, and her weight is 28 kg.

What findings are likely in this patient?

a. Hyperglycemia
b. Hypothermia
c. Increased bone density
d. Hyperkalemia
e. Hypernatremia

The correct answer is b. Hypothermia.

• Hypothermia is a common symptom in severely malnourished individuals due to a lack of sufficient body fat and energy reserves.
• Hyperglycemia is generally associated with diabetes.
• Malnutrition actually leads to decreased bone density due to calcium and vitamin D deficiencies.
• Hyperkalemia and Hypernatremia are electrolyte imbalances often associated with kidney dysfunction or other metabolic disturbances.

118C43

118C44
A 10-year-old boy was brought to the clinic by his parents with complaints of fever and headache. He began experiencing joint pain and chills this morning. In the afternoon, he developed a headache and fatigue, and his temperature reached 39°C, prompting a visit to the clinic. His joint pain and headache have persisted. He is alert. Height: 158 cm, weight: 48 kg. Temperature: 39.2°C, pulse: 96 bpm (regular), blood pressure: 128/74 mmHg, respiratory rate: 22 breaths/min, SpO₂: 98% (room air). He does not exhibit neck stiffness. Heart and lung sounds are normal. A rapid influenza antigen test was positive.

What is the appropriate explanation to provide to the patient and family?

a. He can return to school the day after his fever subsides.
b. Monitor for abnormal behavior for 2 days.
c. Masks are not necessary when interacting with family members.
d. Fluid intake is not necessary if he does not feel thirsty.
e. Antiviral medication shortens the duration of symptoms by 3 days.

The correct answer is b. Monitor for abnormal behavior for 2 days.

• In cases of influenza in children, particularly with a high fever, there is a risk of developing neurological symptoms or abnormal behavior, which can include confusion, agitation, or even hallucinations.
• It is generally advised to wait until the child is fever-free for at least 24 hours before returning to school to avoid spreading the virus.
• Wearing a mask can still be helpful to prevent spreading influenza to family members.
• Even if the child does not feel thirsty, maintaining hydration is important during a fever to prevent dehydration.
• While antiviral medications can reduce the duration of symptoms, the reduction is typically about 1-2 days rather than 3 days.

118C45
A 38-year-old primigravida (first pregnancy, no previous deliveries) at 34 weeks of gestation came for a prenatal checkup. Until 32 weeks of pregnancy, no abnormalities had been noted. She has no significant medical history. Her vital signs are as follows: temperature 36.9°C, pulse 80 bpm (regular), blood pressure 152/100 mmHg. Her abdomen is soft with no uterine tenderness. Edema is observed in both lower limbs. Urinalysis shows proteinuria of 3+, with a urine protein/creatinine ratio of 2.4 g/gCr. Blood test results: Hb 11.0 g/dL, platelets 180,000. Blood biochemistry: AST 15 U/L, ALT 10 U/L, LD 180 U/L (reference 124–222). Fetal heart monitoring shows a reassuring status, with no uterine contractions. The estimated fetal weight is 1,730 g (−1.5 SD), and umbilical blood flow is normal.

What is the diagnosis?

a. Gestational hypertension
b. HELLP syndrome
c. Chronic hypertension with pregnancy
d. Preeclampsia
e. Superimposed preeclampsia

The correct answer is d. Preeclampsia.

• This patient is in her third trimester (34 weeks of gestation) and presents with elevated blood pressure (152/100 mmHg), significant proteinuria (3+ and urine protein/creatinine ratio of 2.4 g/gCr), and edema. These findings meet the diagnostic criteria for preeclampsia, which typically includes:

  1. New-onset hypertension after 20 weeks of gestation (systolic ≥140 mmHg or diastolic ≥90 mmHg) in a previously normotensive patient.
  2. Proteinuria, defined as either ≥300 mg per 24-hour urine collection or a protein/creatinine ratio ≥0.3, or a dipstick reading of 1+ or more.
• Gestational hypertension involves hypertension without proteinuria or other signs of organ involvement.
• HELLP includes hemolysis, elevated liver enzymes, and low platelet count.
• Chronic hypertension with pregnancy would require a history of hypertension before pregnancy or before 20 weeks of gestation.
• Superimposed preeclampsia is preeclampsia on top of pre-existing hypertension.

118C46
A 43-year-old man presented with snoring as his chief complaint. For the past two years, his snoring during sleep has been loud, and his family has noticed that he occasionally stops breathing. He experiences daytime sleepiness. His height is 172 cm, weight is 95 kg, and his blood pressure is 152/110 mmHg. During a visual examination of the pharynx, only the soft palate was visible.

What is the most useful test for diagnosis?

a. Swallowing function test
b. Bronchoscopy
c. Head X-ray
d. Voice function test
e. Polysomnography

The correct answer is e. Polysomnography.

• Snoring during sleep, daytime sleepiness, and obesity indicate sleep apnea. Polysomnography measures breathing patterns, oxygen levels, and other variables during sleep, which would help determine the presence and severity of sleep apnea.

118C47
A 76-year-old man presented with right-sided chest pain. He had been experiencing pain in the right anterior chest area for one month, and for the past eight days, he also developed swelling of the right side of his face and right upper limb. He is alert. Height: 159 cm, weight: 52 kg. Temperature: 35.9°C, pulse: 96 bpm (regular), blood pressure: 138/78 mmHg, respiratory rate: 20 breaths/min, SpO₂: 95% (room air). On inspection and palpation, edema and swelling were noted from the right chest to the neck and upper limb. Blood biochemistry results show CEA 75 ng/mL (reference ≤5). A chest X-ray revealed a mass on the right upper lung field near the mediastinum. Contrast-enhanced CT of the chest and abdomen showed compression of the superior vena cava due to the tumor, along with liver and left adrenal metastases. He was diagnosed with lung cancer, and radiation therapy was planned for the mass in the right upper lung field near the mediastinum.

What effect is expected from this radiation therapy for this patient?

a. Cure
b. Symptom relief
c. Reduction of distant metastases
d. Enhancement of cytotoxic drug effects
e. Decrease in PD-L1 protein expression

The correct answer is b. Symptom relief.

• Given the presence of superior vena cava compression, the primary goal of radiation therapy in this context is often to alleviate symptoms (such as pain and swelling) caused by the mass pressing on local structures, rather than to achieve a cure.

118C48
A 53-year-old man, employed at a residential unit manufacturing plant, suffered a cerebrovascular disease 6 months ago. After completing outpatient rehabilitation following discharge, he is left with residual hemiplegia, and a return to work is being considered.

What should the occupational physician take into consideration to facilitate his return to work?

a. Limitation on business trips
b. Limitation on night shifts
c. Limitation on working hours
d. Limitation on work at heights
e. Limitation on customer service tasks

The correct answer is d. Limitation of work at heights.

• Work at heights is dangerous for a worker with residual hemiplegia.

118C49
A 48-year-old man presented with high blood sugar. He works in an office and has undergone an annual company health checkup every year, with no abnormalities previously noted. This year, high blood sugar was detected for the first time. He is alert. Height: 170 cm, weight: 76 kg, pulse: 64 bpm (regular), blood pressure: 134/86 mmHg. Skin appears normal. No abnormalities were found in the head, neck, chest, or abdomen. There is no edema in the limbs. Urinalysis results: protein (-), glucose (-), ketones (-). Blood biochemistry results: AST 28 U/L, ALT 42 U/L, fasting blood glucose 128 mg/dL, HbA1c 6.7% (reference 4.9–6.0), total cholesterol 280 mg/dL, triglycerides 220 mg/dL, HDL cholesterol 34 mg/dL, blood urea nitrogen 18 mg/dL, creatinine 0.7 mg/dL, Na 138 mEq/L, K 4.6 mEq/L, Cl 98 mEq/L.

Which test value would be useful in evaluating this patient’s condition?

a. Insulin
b. Glucagon
c. Cortisol
d. Growth hormone (GH)
e. Free thyroxine (FT4)

The correct answer is a. Insulin.

• Testing insulin levels could help evaluate whether the high blood sugar is due to insulin resistance, a common feature in prediabetes and type 2 diabetes, especially given the elevated HbA1c and lipid profile abnormalities (high total cholesterol, high triglycerides, and low HDL).

118C50
A 19-year-old man was brought in by ambulance following a traffic accident. He was riding a motorcycle when he fell, hitting his right flank hard on the asphalt. During transport, he was alert with a heart rate of 100 bpm (regular) and a blood pressure of 120/80 mmHg. Transport time to the hospital was approximately 45 minutes from the time of the accident. Upon arrival, he was responsive to verbal stimuli but occasionally lost consciousness. His heart rate was 112 bpm (regular), blood pressure 90/60 mmHg, respiratory rate 18 breaths/min, and SpO₂ 96% (with 10L/min oxygen via reservoir mask). Heart and lung sounds were normal. His right abdomen was distended and tender. Blood tests showed: RBC 3.3 million, Hb 11.4 g/dL, Ht 33%, WBC 12,800 (2% band neutrophils, 78% segmented neutrophils, 2% eosinophils, 1% basophils, 3% monocytes, 14% lymphocytes), platelets 170,000. Biochemistry: total protein 6.0 g/dL, albumin 3.9 g/dL, AST 40 U/L, ALT 42 U/L, LDH 189 U/L (reference 124-222), BUN 23 mg/dL, creatinine 0.8 mg/dL, Na 141 mEq/L, K 3.7 mEq/L, Cl 107 mEq/L, CRP 0.4 mg/dL. Lactated Ringer's solution was immediately administered. A urinary catheter showed hematuria. The coronal section of an abdominal contrast-enhanced CT scan is shown. Despite blood transfusions and selective right renal artery embolization, his blood pressure remained low at 84/52 mmHg.

What is the appropriate next treatment?

a. Right nephrectomy
b. Autotransplantation of the kidney
c. Right renal vein embolization
d. Percutaneous right nephrostomy
e. Placement of a right ureteral stent

The correct answer is a. Right nephrectomy.

• The patient sustained a significant trauma to the right flank, resulting in hematuria (blood in the urine) and a drop in blood pressure despite receiving blood transfusions and selective embolization of the right renal artery.
• A right nephrectomy (surgical removal of the right kidney) is necessary to stop the bleeding and stabilize the patient.

118C51
An 11-year-old boy was brought to the clinic by his father because he is unable to attend school. His early childhood development was normal. Since starting school, he struggled with writing letters, but he could write hiragana and katakana, and his grades remained average. Starting in third grade, he began making noticeable mistakes in writing kanji, and no matter how much he studied, he could not master them. It took him a long time to copy from the blackboard, and recently he has been unable to keep up with his classes, leading to an increasing number of days when he cannot attend school. He has no issues with friendships.

What is the diagnosis?

a. Intellectual developmental disorder
b. Specific learning disorder
c. Autism spectrum disorder
d. Attention-deficit hyperactivity disorder
e. Developmental coordination disorder

The correct answer is b. Specific learning disorder.

• Specific learning disorder (SLD) involves persistent difficulties in reading, writing, or mathematics that are not explained by intellectual disabilities or other mental health disorders.
• Intellectual developmental disorder would imply a broader cognitive delay affecting various areas, not just writing.
• Autism spectrum disorder typically involves difficulties with social interaction and communication.
• Attention-deficit hyperactivity disorder (ADHD) could cause general inattention or hyperactivity.
• Developmental coordination disorder involves motor coordination difficulties affecting physical activities.

118C52
A 56-year-old man is currently undergoing treatment for hypertension and diabetes. A year ago, he was promoted to a management position at work, which has led to increased stress. Gradually, his alcohol consumption and smoking have increased, and he has gained weight. His home blood pressure readings show a systolic blood pressure around 140 mmHg. He is scheduled to receive an influenza vaccine. He smokes 30 cigarettes per day and consumes two servings of sake per day. His height is 168 cm, weight 86 kg. Urinalysis results: proteinuria 2+, glucose +. Blood biochemistry: HbA1c 7.8% (reference 4.9–6.0), eGFR 40 mL/min/1.73m².

Which of the following is not considered tertiary prevention for this patient?

a. Smoking cessation
b. Alcohol cessation
c. Exercise therapy
d. Nutritional therapy
e. Vaccination

The correct answer is e. Vaccination.

• Tertiary prevention aims to manage existing diseases and prevent complications or further deterioration in patients with chronic conditions.
• Smoking cessation, alcohol cessation, exercise therapy, and nutritional therapy are all aimed at managing his hypertension and diabetes to prevent complications, making them part of tertiary prevention.
• Vaccination, on the other hand, is generally considered primary prevention as it aims to prevent infectious diseases, not specifically manage or control his chronic conditions.

118C53
An occupational physician received a report that there is a high incidence of hepatic angiosarcoma among employees working on the X process in a factory with 500 employees. Since the factory opened 10 years ago, employees have remained in the same positions without transfers. A liver angiosarcoma screening was immediately conducted for all employees, and based on personnel records, two groups were identified: (A) 50 employees assigned to the X process and (B) 450 employees who have never been assigned to the X process. Past health check results and medical records were reviewed. It was found that 6 people in group (A) had developed hepatic angiosarcoma, compared to 1 person in group (B).

What is the research design of this investigation?

a. Case-control study
b. Retrospective cohort study
c. Case series study
d. Randomized controlled trial
e. Meta-analysis

The correct answer is b. Retrospective cohort study.

• In a retrospective cohort study, researchers examine past records to study the outcomes of groups that were exposed to a specific factor compared to those that were not.
• In this case, the factory’s personnel records allowed researchers to identify two groups: those assigned to the X process (exposed group) and those who were not (unexposed group).
• By reviewing past health data, they found a higher incidence of hepatic angiosarcoma in the exposed group.
• Case-control study starts with cases (those with the disease) and controls (those without) and looks backward for past exposures.
• Case series study involves describing characteristics of patients with a specific disease but does not include a comparison group.
• Randomized controlled trial would require randomly assigning participants to exposure groups.
• Meta-analysis combines data from multiple studies.

118C54
A 40-year-old woman presented with increased vaginal discharge as her main complaint. Her menstrual cycle is regular, lasting 30 days with menstruation lasting 5 days. She started living with a new partner one month ago. Her height is 160 cm, weight 60 kg. Her temperature is 36.2°C, and her pulse is 72 bpm (regular). A pelvic examination revealed a uterus of normal size with no abnormalities in the adnexa. A speculum examination showed yellow, frothy discharge and redness of the vaginal walls.

Which test would be useful for diagnosis?

a. Serum TPHA
b. Vaginal secretion microscopy
c. Colposcopy
d. Vaginal wall scraping cytology
e. Gram stain of vaginal secretions

The correct answer is b. Vaginal secretion microscopy.

• The presence of yellow, frothy discharge and redness of the vaginal walls are typical signs of Trichomonas vaginalis infection, which is best diagnosed using microscopy of vaginal secretions.

118C55
A 34-year-old multiparous woman (2 pregnancies, 1 birth) presented at 41 weeks and 2 days of gestation, complaining of a sensation of water breaking. She had been attending regular prenatal checkups since early pregnancy, with no abnormalities noted. At 41 weeks and 2 days, she felt a sensation of water breaking at 7:00 a.m., prompting her to come to the clinic at 8:00 a.m. She had not felt any uterine contractions. A speculum examination showed a small amount of amniotic fluid leakage. On internal examination, her cervix was 3 cm dilated, 60% effaced, with moderate firmness, and the fetal head was at station SP -2 cm. She was admitted for management, and the following observations were made:

1. At 2:00 p.m., regular uterine contractions began, occurring every 8 minutes.
2. At 7:00 p.m., the cervix was fully dilated at 10 cm, 100% effaced.
3. The fetal head rotated so that the face was directed toward the mother's abdominal wall.
4. After three pushes, the fetal head was delivered, followed by the shoulder on the mother’s abdominal side, and then the shoulder on the mother’s back side.
5. The placenta was delivered 9 minutes after the baby.

Which of the underlined observations indicates an abnormal labor progression?

a. ①
b. ②
c. ③
d. ④
e. ⑤

The answer is c. ③.

• In normal labor, the fetal head typically rotates so that the back of the head (occiput) faces the mother's abdomen (anterior position) or back (posterior position) rather than the face.
• The fetal head rotating so that the face is directed toward the mother’s abdominal wall indicates a face presentation, which is an abnormal position for delivery.

118C58
A 68-year-old man presented with extensive bruising on his back. He began noticing purpura on his limbs about a week ago. Yesterday, he noticed extensive bruising on his back while bathing, which prompted him to seek medical attention. He has a history of hypertension and atrial fibrillation, for which he takes antihypertensive medication and warfarin. Blood test results showed: PT-INR 4.0 (reference 0.9–1.1) and activated partial thromboplastin time (APTT) 60 seconds (control 32.2). In a mixing test, adding normal plasma to the patient’s plasma corrected the prolonged clotting time.

Which treatments are appropriate? Choose two.

a. Vitamin K administration
b. Factor VIII administration
c. Discontinuation of warfarin
d. Gamma globulin administration
e. Glucocorticoid administration

The correct answers are a. Vitamin K administration and c. Discontinuation of warfarin.

• The patient is on warfarin, which can lead to excessive anticoagulation, as indicated by the high PT-INR (4.0). The presence of extensive bruising and purpura suggests over-anticoagulation, putting him at risk of bleeding.
• Vitamin K can help reverse the effects of warfarin, reducing the PT-INR and helping restore normal coagulation.
• Stopping warfarin is essential to avoid further anticoagulation and reduce bleeding risk.
• The other options are less appropriate because they do not directly address the effects of warfarin.

118C59
An 83-year-old man was brought to the hospital by ambulance due to altered consciousness. During a prolonged grass-cutting job on a hot day, he had complained of dizziness. Later, co-workers noticed he was semi-conscious and called for an ambulance. He has a history of type 2 diabetes and hypertension, for which he is on medication. His level of consciousness is JCS III-100. His temperature is 38.3°C, heart rate 120 bpm (regular), blood pressure 92/50 mmHg, respiratory rate 24/min, and SpO₂ is 98% (on 5L/min oxygen via mask). His mouth is dry, and he has sweat all over his body. Blood test results: Hb 15.2 g/dL, Hct 53%. Blood biochemistry: BUN 30 mg/dL, creatinine 1.2 mg/dL, blood glucose 98 mg/dL, Na 148 mEq/L, K 4.6 mEq/L, Cl 104 mEq/L.

Which infusion solutions are appropriate for initial treatment? Choose two.

a. Normal saline
b. Amino acid solution
c. High-calorie infusion
d. 5% glucose solution
e. Lactated Ringer’s solution

The correct answers are a. Normal saline and e. Lactated Ringer’s solution.

• The patient shows signs of dehydration and heat exhaustion, likely due to prolonged outdoor activity in the heat. His elevated heart rate, low blood pressure, dry mouth, and high hematocrit indicate a need for fluid resuscitation to restore blood volume.
• Normal saline is a balanced isotonic solution suitable for initial rehydration and stabilizing blood pressure.
• Lactated Ringer’s solution also helps with rehydration and provides electrolytes, which is beneficial given his condition.
• The other options are less suitable as initial treatments because they do not provide the necessary volume or electrolytes for rehydration in a case of heat exhaustion and dehydration.

118C60-62
A 78-year-old man presented with hoarseness.

Present Illness: Hoarseness appeared one month ago. Two weeks ago, he began experiencing coughing while drinking water and was prescribed a cough suppressant at a nearby clinic. The cough did not improve, and three days ago, he started noticing blood in his sputum.

Past Medical History: Three years ago, he underwent right lower lobectomy for primary lung cancer and had been under follow-up observation. He discontinued regular visits a year ago based on his own decision.

Social History: Worked as an office employee until age 65. Lives with his wife. Smoked 20 cigarettes/day for 50 years until age 70. Drinks 350 mL of beer per day.

Family History: Younger brother had stomach cancer in his 70s.

Current Examination: Alert and oriented. Height 162 cm, weight 54 kg, temperature 36.2°C, pulse 72 bpm (regular), blood pressure 124/72 mmHg, respiratory rate 16/min, SpO₂ 98% (room air). No abnormalities in conjunctiva or sclera. No jugular vein distension. Heart and lung sounds normal. Abdomen flat and soft, no palpable liver or spleen.

Test Results: Urinalysis showed no protein, glucose, or blood. Blood tests showed RBC 3.8 million, Hb 13.8 g/dL, Hct 35%, WBC 7,600, platelets 240,000. Blood biochemistry showed total protein 6.0 g/dL, albumin 3.0 g/dL, total bilirubin 0.7 mg/dL, AST 25 U/L, ALT 19 U/L, LDH 343 U/L (reference 124–222), BUN 24 mg/dL, and creatinine 0.8 mg/dL. Imaging revealed a bulging right first arch on the chest X-ray. Contrast-enhanced chest CT showed enlarged mediastinal lymph nodes, while abdominal contrast-enhanced CT and bone scintigraphy showed no abnormalities. An ultrasound-guided biopsy of the enlarged mediastinal lymph node confirmed lymph node recurrence of post-surgical lung adenocarcinoma.

Next Test to Perform:
a. Brain MRI with contrast
b. Abdominal MRI with contrast
c. Neck ultrasound
d. Pulmonary angiography
e. Lung perfusion scintigraphy

The patient underwent chemoradiotherapy for localized mediastinal lymph node recurrence. Later, he developed drug-induced lung injury, leading to respiratory failure and requiring mechanical ventilation via tracheal intubation. Despite ongoing treatment for the drug-induced lung injury, his respiratory condition showed no improvement. After 14 days, he continued to require prolonged mechanical ventilation.

Appropriate Respiratory Management at This Point:
a. Tracheostomy
b. Initiate ECMO
c. Insert a supraglottic airway device
d. Insert a nasopharyngeal airway
e. Initiate non-invasive positive pressure ventilation (NPPV)

Following improvement of the drug-induced lung injury, he was weaned from the ventilator and transferred to the general ward. Rehabilitation began, his physical function and food intake improved, and he was discharged home two months after admission. One month after discharge, he returned to the outpatient clinic with his family. He was barely able to walk on his own, and his weight had decreased by 10 kg over the past three months. A comprehensive examination revealed further enlargement of the mediastinal lymph nodes and new multiple metastases in the liver and lungs. The patient and his family did not wish for aggressive treatment. Although he had no pain, he was diagnosed with progressing cancer cachexia.

Appropriate Actions at This Point (Select Two):
a. Recommend radiation therapy.
b. Explain palliative care options.
c. Discuss the patient’s preferences for home care.
d. Recommend treatment with a different cytotoxic agent.
e. Recommend treatment with immune checkpoint inhibitors.

The next test to perform is a. Brain MRI with contrast.

• Given the history of lung cancer and mediastinal lymph node recurrence, a brain MRI is useful to rule out brain metastasis, which is common in lung cancer patients and could explain neurological symptoms such as hoarseness.

Appropriate respiratory management in the case of prolonged mechanical ventilation is a. Tracheostomy.

• Tracheostomy is typically performed for patients requiring long-term ventilation to improve comfort, facilitate respiratory management, and reduce complications associated with prolonged intubation.

The appropriate actions are b. Explain palliative care options and c. Discuss the patient’s preferences for home care.

• This approach respects his and his family's wishes to avoid aggressive interventions and focuses on comfort and quality of life.

118C63-65

A 55-year-old man presented with constipation.

Present Illness: He was recently transferred to a new position at work three months ago, which made it difficult for him to use the restroom during working hours. He has a history of constipation, and his stools became harder. Two weeks ago, he began experiencing abdominal bloating, prompting him to seek medical attention. His bowel movements occurred once every three days, without straining, but the stools were pellet-like.

Medical History: He has been taking antihypertensive medication since age 45 for hypertension and has never undergone colorectal cancer screening.

Social History: No history of smoking. Occasional alcohol use. He works as an accountant and has no history of overseas travel.

Family History: His father underwent surgery for colorectal cancer at age 74.

Current Findings: The patient is alert and oriented. Height: 165 cm, Weight: 68 kg (no recent weight changes). Temperature: 36.4°C, Pulse: 72/min (regular), Blood Pressure: 136/80 mmHg, Respiratory Rate: 10/min, SpO₂: 97% (room air). No abnormalities of the conjunctiva or sclera, no oral aphthae, thyroid and cervical lymph nodes are not palpable. Heart and breath sounds are normal. The abdomen is flat and soft, with no increase or decrease in bowel sounds. Digital rectal examination revealed no blood or palpable masses. No edema in the lower legs.

Test Results:

Urine Analysis: No protein, glucose, or blood.
Blood Tests: RBC 4.68 million, Hb 13.9 g/dL, Ht 42%, WBC 8,300, Platelets 210,000.
Biochemistry: Total protein 7.5 g/dL, Albumin 3.9 g/dL, Total bilirubin 0.9 mg/dL, Direct bilirubin 0.4 mg/dL, AST 22 U/L, ALT 18 U/L, LD 172 U/L (reference 124–222), ALP 83 U/L (reference 38–113), γ-GT 32 U/L (reference 13–64), Amylase 95 U/L (reference 44–132), BUN 12 mg/dL, Creatinine 0.8 mg/dL, Blood glucose 98 mg/dL, CRP 0.2 mg/dL.
Imaging: Chest X-ray shows a cardiothoracic ratio of 46%, with no abnormalities in the lung fields. Abdominal X-ray reveals no gas or air-fluid levels in the small intestine. A fecal occult blood test was planned.

Given a pre-test probability of 20% for a colorectal lesion in this patient, what is the post-test probability if the fecal occult blood test is positive? Assume the test sensitivity is 80% and specificity is 90%.

a. 33%
b. 53%
c. 57%
d. 67%
e. 97%

Since the fecal occult blood test was positive, a lower gastrointestinal endoscopy was scheduled. What is an appropriate preparatory step on the day of this examination?

a. Shave the lower body.
b. Disinfect around the anus.
c. Ingest a bowel cleansing solution.
d. Ingest barium.
e. Administer formalin enema.

The following images show the sigmoid colon observed during lower gastrointestinal endoscopy. What endoscopic treatment was performed on this patient?

a. Foreign body removal
b. Stent placement
c. Variceal sclerotherapy
d. Polypectomy
e. Endoscopic submucosal dissection (ESD)

The answer is d. 67%.

• Post-test probability=(Sensitivity×Pre-test probability)/{Sensitivity×Pre-test probability+(1−Specificity)×(1−Pre-test probability)}

The answer is c. Ingest a bowel cleansing solution.

• Before a colonoscopy, it is essential to clear the intestines for optimal visualization. Ingesting a bowel cleansing solution is standard preparation to ensure that the colon is free of stool and debris, allowing the endoscopist to examine the mucosa thoroughly.

The answer is d. Polypectomy.

• The images provided show a polyp within the sigmoid colon. Polypectomy is the removal of a polyp during colonoscopy, a common procedure used to prevent potential progression to colorectal cancer.
• Other treatments listed, such as stenting or variceal sclerotherapy, are not appropriate for the appearance of this polypoid lesion.
• Endoscopic submucosal dissection (ESD) is typically reserved for larger lesions or suspected early cancers requiring more extensive removal than a standard polypectomy.

118C66-68

A 61-year-old man was brought to the hospital by ambulance due to a traffic accident.

Present Illness: While driving his car, he collided with a wall, hitting his abdomen hard and was unable to move. He was wearing a seatbelt, and the airbags deployed. A witness called the ambulance.

Past Medical History: He has ischemic heart disease and is on antiplatelet medication.

Social History: Occasional alcohol use.

Family History: His father and brother are being treated for hypertension.

Current Findings: The patient is alert and oriented. Height: 162 cm, Weight: 54 kg, Temperature: 37.0°C, Heart Rate: 112/min (regular), Blood Pressure: 80/44 mmHg, Respiratory Rate: 26/min, SpO₂: 98% (with a reservoir mask at 10 L/min oxygen). His skin shows cold sweat and moisture on his limbs. No abnormalities in the conjunctiva or sclera. His mouth is dry. No jugular venous distension. Heart and lung sounds are normal. The abdomen is distended, with no palpable liver or spleen, and bowel sounds are decreased.

Test Results:

Blood Tests: RBC 4.10 million, Hb 10.1 g/dL, Hct 40%, WBC 10,300 (neutrophils 75%, eosinophils 1%, basophils 1%, monocytes 6%, lymphocytes 17%), Platelets 320,000.
Biochemistry: Total Protein 7.2 g/dL, Albumin 4.0 g/dL, Total Bilirubin 0.9 mg/dL, Direct Bilirubin 0.2 mg/dL, AST 65 U/L, ALT 34 U/L, LDH 177 U/L (reference 124–222), ALP 55 U/L (reference 38–113), γ-GT 32 U/L (reference 13–64), Amylase 130 U/L (reference 44–132), CK 382 U/L (reference 59–248), BUN 22 mg/dL, Creatinine 0.6 mg/dL, Uric Acid 6.2 mg/dL, Blood Glucose 228 mg/dL, HbA1c 5.8% (reference 4.9–6.0), Na 142 mEq/L, K 4.4 mEq/L, Cl 97 mEq/L.

At this point, what are the appropriate actions to take? Select two.

a. Perform platelet transfusion.
b. Administer a sedative intravenously.
c. Rapidly administer lactated Ringer's solution.
d. Place the patient in reverse Trendelenburg position.
e. Perform a Focused Assessment with Sonography for Trauma (FAST).

Subsequently, a non-contrast CT scan of the head and neck showed no abnormalities. Contrast-enhanced CT of the chest and abdomen revealed splenic injury, extravasation of contrast around and within the spleen, free air in the peritoneal cavity, and intra-abdominal fluid accumulation. The patient was intubated, and emergency surgery was planned.

Which of the following is incorrect as part of preoperative management?

a. Induce hypothermia.
b. Prepare for blood transfusion.
c. Administer antibiotics.
d. Perform coagulation tests.
e. Conduct arterial blood gas analysis.

For injuries to the small intestine, mesentery, and spleen, resection of the small intestine and splenectomy were performed. The small intestine showed edema, but abdominal closure was feasible. After admission to the ICU, his heart rate improved to 68/min, and his blood pressure to 132/76 mmHg. Arterial blood gas analysis (on ventilated settings, FIO₂ 0.3) was as follows: pH 7.40, PaCO₂ 35 Torr, PaO₂ 180 Torr, HCO₃⁻ 21 mEq/L, BE -6 mEq/L.

At this stage, what is the most useful site for measuring intra-abdominal pressure to assess for abdominal compartment syndrome?

a. Thoracic cavity
b. Esophagus
c. Intracranial space
d. Artery
e. Bladder

The correct answers are c. Rapidly administer lactated Ringer's solution and e. Perform a FAST (Focused Assessment with Sonography for Trauma).

• Lactated Ringer's solution is used to stabilize blood pressure and prevent shock in trauma patients with signs of hypovolemia (low blood pressure and rapid heart rate here).
• A FAST scan is an ultrasound performed in trauma cases to detect internal bleeding or fluid in the abdominal and thoracic cavities, which helps guide urgent management decisions.
• In this case, the patient’s platelet count is 320,000, which is within the normal range.
• Sedatives are generally avoided in trauma patients with signs of shock or low blood pressure (80/44 mmHg in this case).
• The reverse Trendelenburg position, where the head is elevated and feet are lowered, can reduce blood flow to the brain and vital organs in patients with low blood pressure. 

The answer is a. Induce hypothermia.

• Hypothermia is not appropriate in this case. Trauma patients are at high risk for hypothermia due to blood loss and the effects of anesthesia, and maintaining normal body temperature (normothermia) is essential. Hypothermia can impair blood coagulation and worsen outcomes.
• Other steps, such as preparing for a blood transfusion, administering antibiotics to prevent infection, checking coagulation status, and assessing blood gases, are standard preoperative procedures in trauma cases.

The correct answer is e. Bladder.

• The bladder is commonly used to measure intra-abdominal pressure indirectly in patients suspected of having abdominal compartment syndrome.

118C69-71

A 72-year-old woman visited the clinic, accompanied by her husband, who was concerned about her memory loss.

Current Illness: A year ago, she occasionally complained that the amount of money in her wallet did not match her records. Six months ago, she started repeatedly saying, "A child I don't know is coming to play at our house, but they don’t greet me." Her memory has been gradually worsening, prompting this visit. She has no signs of depression and continues to enjoy her gardening hobby. She does not experience sleep disturbances or abnormal behavior during sleep. According to her husband, no unknown child has come to their home.

Past Medical History: Ectopic pregnancy with surgery at age 25.

Social History: No history of smoking; occasional drinking. Lives with her husband. Her eldest daughter and her family live a 30-minute drive away.

Family History: Her father died of pneumonia, and her mother of a cerebral infarction.

Current Findings: The patient is alert, able to communicate, and maintains politeness. Height: 157 cm, Weight: 52 kg, Temperature: 36.2°C, Pulse: 88/min (regular), Blood Pressure: 132/76 mmHg, Respiratory Rate: 12/min. Heart and lung sounds are normal. Abdominal examination is unremarkable. She walks with a forward-leaning posture and takes small, shuffling steps. There are no abnormalities in cranial nerves. Her limb muscle strength is normal, but there is cogwheel rigidity in all limbs. Tendon reflexes are normal, and there are no signs of ataxia or sensory impairment.

Test Results:

Urine: No protein or glucose detected.
Blood Tests: RBC 4.38 million, Hb 13.2 g/dL, Hct 40%, WBC 5,800, Platelets 180,000.
Blood Chemistry: AST 26 U/L, ALT 18 U/L, LDH 162 U/L (reference 124–222), γ-GT 16 U/L (reference 9–32), Ammonia 22 μg/dL (reference 18–48), BUN 16 mg/dL, Creatinine 0.7 mg/dL, Blood Glucose 96 mg/dL, Na 142 mEq/L, K 4.2 mEq/L, Cl 98 mEq/L, CRP 0.1 mg/dL.
Brain MRI: Shows cerebral cortical atrophy.

What is the most appropriate test for this patient?

a. Rorschach test
b. Standard Language Test of Aphasia (SLTA)
c. Revised Hasegawa Dementia Scale
d. Japanese Denver Developmental Screening Test
e. Hamilton Rating Scale for Depression

What is the appropriate medication for this patient?

a. Donepezil
b. Melatonin
c. Clonazepam
d. Paroxetine
e. Haloperidol

Regarding this patient’s future, an Advance Care Planning (ACP) process has been decided upon. Which of the following is incorrect?

a. Support with a multidisciplinary approach.
b. Prioritize the husband’s wishes over the patient’s.
c. Record the contents of the discussions.
d. Ensure a comfortable environment for the patient to speak.
e. Repeatedly confirm the patient’s wishes.

The correct answer is c. Revised Hasegawa Dementia Scale.

• The Revised Hasegawa Dementia Scale is a cognitive assessment tool specifically used to evaluate dementia and cognitive decline in elderly patients. Given her memory issues, suspected delusions, and progressive symptoms, this scale is suitable for assessing her cognitive state.
• Other options, such as the Rorschach test (a projective psychological test) or the Hamilton Rating Scale for Depression, are not specifically designed to assess dementia or cognitive function.

The correct answer is a. Donepezil.

• Donepezil is a cholinesterase inhibitor commonly prescribed to manage symptoms of Alzheimer's disease and other dementias by improving cognitive function. This medication is appropriate for her suspected dementia symptoms.
• Other medications, such as melatonin (for sleep disturbances), clonazepam (for anxiety or certain sleep disorders), paroxetine (an antidepressant), and haloperidol (an antipsychotic), are not typically used as primary treatments for dementia-related cognitive impairment.

The answer is b. Prioritize the husband’s wishes over the patient’s.

• In Advance Care Planning (ACP), the patient’s wishes are always prioritized, as ACP focuses on respecting and fulfilling the patient’s own preferences for future medical care and quality of life.
• Actions such as involving a multidisciplinary team, recording the discussions, providing a comfortable environment, and continually confirming the patient’s wishes are correct and align with the ACP process.

118C75

Calculate the creatinine clearance (mL/min) without adjusting for body surface area, given the following values: serum creatinine of 1.0 mg/dL, a 24-hour urine volume of 1,200 mL, and a creatinine concentration in the collected urine of 48 mg/dL. Round the result to one decimal place if needed.

The correct answer (the creatinine clearance) is 40 mL/min.

• Creatinine Clearance (Ccr)=(Urine creatinine concentration×Urine volume)/(Serum creatinine×Time (minutes))
• =48×1200/1.0×1440