118D (2024)

118D1

Which of the following is correct about vestibular neuritis?

a. Recurrence is common.
b. Vertical nystagmus is observed.
c. It is accompanied by headache.
d. It is accompanied by hearing loss.
e. It is accompanied by nausea.

The correct answer is e. It is accompanied by nausea.

Vestibular neuritis is an inner ear disorder that affects the vestibular nerve, which sends balance information from the inner ear to the brain.
The condition typically causes sudden, severe vertigo (a spinning sensation), balance issues, and nausea.
Vestibular neuritis usually happens once, with recurrence being rare.

118D2

Since the discovery of the virus, outbreaks have repeatedly occurred across various parts of Africa. The virus enters the body through wounds or mucous membranes when a person comes into contact with the bodily fluids of an infected individual. Symptoms start with fever, fatigue, headache, muscle pain, and sore throat, followed by vomiting and diarrhea. Even after recovery, the virus may remain in semen. The average fatality rate in past outbreaks is approximately 50%.

Which virus is this?

a. Ebola virus
b. Zika virus
c. Novel coronavirus
d. Dengue virus
e. Poliovirus

The correct answer is a. Ebola virus.

The Ebola virus is known for causing severe, often deadly outbreaks primarily in Africa. It spreads through direct contact with bodily fluids (such as blood, saliva, sweat, semen, breast milk, urine, or feces) of an infected person, particularly through open wounds or mucous membranes.
Ebola's symptoms begin with fever, fatigue, headache, muscle pain, and sore throat, which then progress to more severe symptoms like vomiting, diarrhea, and sometimes internal and external bleeding.
After recovery, the virus can persist in certain bodily fluids, notably semen, posing a risk of transmission even post-recovery.
Ebola has an average case fatality rate of about 50% in past outbreaks.
The Zika virus is primarily spread by the bite of an infected Aedes mosquito, though it can also be transmitted through sexual contact. Symptoms are usually mild and include fever, rash, joint pain, and conjunctivitis (red eyes).
COVID-19, caused by the SARS-CoV-2 virus, spreads mainly through respiratory droplets.
Dengue is also spread by Aedes mosquitoes and typically causes high fever, severe headache, pain behind the eyes, joint and muscle pain, and rash. Severe cases can lead to dengue hemorrhagic fever, which causes bleeding.
Polio is caused by the poliovirus and spreads through fecal-oral transmission, primarily affecting young children. It can lead to symptoms like fever, fatigue, and, in severe cases, paralysis.

118D3
Which ECG finding requires an immediate electric shock?

a. Asystole
b. Atrial fibrillation
c. Pulseless ventricular tachycardia
d. Complete atrioventricular block
e. Pulseless electrical activity (PEA)

The correct answer is c. Pulseless ventricular tachycardia.

Pulseless ventricular tachycardia (VT) is a life-threatening heart rhythm that requires immediate defibrillation (electric shock) because the heart is beating too fast and ineffectively, failing to pump blood. This results in a lack of pulse and blood circulation, making it a form of cardiac arrest. Defibrillation aims to reset the heart's electrical activity, allowing it to potentially resume a normal, organized rhythm.
Asystole, or "flatline," is a complete absence of electrical activity in the heart. Defibrillation is not effective for asystole because there is no underlying electrical rhythm to reset. Instead, CPR and medications are the primary interventions.
Atrial fibrillation is a common irregular rhythm that can be serious but does not require immediate defibrillation unless the patient is hemodynamically unstable. Atrial fibrillation without pulselessness is not considered cardiac arrest.
In complete Complete atrioventricular (AV) block, the electrical signals between the atria and ventricles are disrupted, but the heart often continues beating independently in the ventricles, providing a pulse. Defibrillation is not indicated unless the patient is in cardiac arrest.
In Pulseless electrical activity (PEA), electrical activity is present on the ECG, but the heart is not effectively pumping blood, resulting in no pulse. Defibrillation is not effective for PEA; instead, CPR and treating the underlying causes are the recommended interventions.

118D4

Which of the following is correct regarding tic disorder in children?

a. It is more common in males.
b. It frequently occurs during adolescence.
c. It commonly involves slow movement symptoms.
d. Symptoms are often observed during sleep.
e. Symptoms frequently persist throughout life.

The correct answer is a. It is more common in males.

Tic disorders in children, including conditions like Tourette syndrome, are more commonly observed in boys than in girls with a male-to-female ratio of approximately 3:1.
Tic disorders typically begin in childhood, often between ages 5 and 7, with symptoms usually decreasing or even disappearing by adolescence.
Tic disorders are characterized by rapid, repetitive, and involuntary movements or sounds.
Tics generally decrease or disappear during sleep.

118D5
Which of the following is correct regarding inguinal hernia in adults?

a. It is common in elderly women.
b. It is an external hernia.
c. The frequency of direct inguinal hernia is high.
d. It is caused by incomplete closure of the processus vaginalis.
e. A history of open abdominal surgery is a risk factor.

The correct answer is b. It is an external hernia.

An inguinal hernia in adults is classified as an external hernia because it protrudes through the abdominal wall or inguinal canal, resulting in a visible or palpable bulge.
Inguinal hernias are actually more common in men than in women, regardless of age.
Indirect inguinal hernias are generally more common overall.
Incomplete closure of the processus vaginalis causes indirect inguinal hernias, particularly in children and young adults.
Open abdominal surgery is typically a risk factor for incisional hernias, not inguinal hernias.

118D6
What is the most common cause of acute pyelonephritis in adult men?

a. Sexually transmitted infection
b. Overactive bladder
c. Diabetic nephropathy
d. Interstitial cystitis
e. Ureteral obstructive stone

The correct answer is e. Ureteral obstructive stone.

In adult men, the most common cause of acute pyelonephritis (a kidney infection) is an obstructive stone in the ureter. When a stone obstructs the ureter, it prevents urine from flowing normally from the kidney to the bladder. This obstruction creates a backup of urine, which provides an environment where bacteria can grow and lead to infection.

118D8
Which of the following is correct regarding the pathophysiology of acute respiratory distress syndrome (ARDS)?

a. Decreased airway resistance
b. Decreased pulmonary vascular resistance
c. Decreased intrapulmonary shunt
d. Increased lung compliance
e. Decreased pulmonary surfactant

The correct answer is e. Decreased pulmonary surfactant.

In acute respiratory distress syndrome (ARDS), the level of pulmonary surfactant decreases. Surfactant is a substance produced by cells in the lungs that reduces surface tension, helping keep the alveoli (air sacs) open and preventing their collapse.
In ARDS, lung injury leads to inflammation and damage to the cells that produce surfactant, resulting in surfactant deficiency. This causes the alveoli to collapse or become filled with fluid, reducing the lungs' ability to exchange oxygen and leading to severe hypoxemia (low blood oxygen levels).
In ARDS, airway resistance, pulmonary vascular resistance, and intrapulmonary shunt increase (meaning more blood passes through the lungs without being oxygenated), and lung compliance, or the ability of the lungs to expand, decreases due to the stiffening of lung tissue caused by inflammation, fluid buildup, and loss of surfactant.

118D9
Which condition is commonly associated with primary sclerosing cholangitis?

a. Ischemic colitis
b. Pseudomembranous colitis
c. Diverticulitis of the colon
d. Ulcerative colitis
e. Irritable bowel syndrome

The correct answer is d. Ulcerative colitis.

Primary sclerosing cholangitis (PSC) is a chronic liver disease that causes inflammation and scarring of the bile ducts. It is commonly associated with inflammatory bowel disease (IBD), particularly ulcerative colitis.
The exact cause of PSC is unknown.

118D10
Which of the following is unlikely to occur with an orbital blowout fracture?

a. Diplopia (double vision)
b. Epistaxis (nosebleed)
c. Olfactory disturbance (loss of smell)
d. Impaired upward gaze
e. Sensory disturbance in the cheek

The answer is c. Olfactory disturbance (loss of smell).

An orbital blowout fracture typically occurs when the bones around the eye socket (orbit) are fractured due to trauma, often affecting the thin bones that make up the orbital floor. This type of fracture can lead to several symptoms due to its impact on nearby structures.
However, olfactory disturbance (loss of smell) is unlikely because the olfactory nerve, responsible for the sense of smell, is located higher in the nasal cavity near the cribriform plate of the ethmoid bone, far from the typical site of an orbital blowout fracture.

118D11

Which of the following is correct regarding severe combined immunodeficiency (SCID)?

a. All lymph nodes in the body become enlarged.
b. Immunity to viruses is maintained.
c. It follows a dominant inheritance pattern.
d. Serum immunoglobulin levels are within the normal range.
e. Poor weight gain occurs shortly after birth.

The correct answer is e. Poor weight gain occurs shortly after birth.

Severe combined immunodeficiency (SCID) is a genetic disorder characterized by a severe impairment in both T and B lymphocyte function, resulting in a severely compromised immune system.
SCID often leads to poor weight gain or “failure to thrive” shortly after birth due to frequent infections, gastrointestinal issues, and difficulty absorbing nutrients.
Lymph node enlargement is not typical in SCID.
SCID is generally inherited in an autosomal recessive or X-linked recessive pattern.

118D12
Which of the following are necessary for classifying the severity of chronic kidney disease (CKD)? Select two.

a. Blood pressure
b. Gender
c. Urine specific gravity
d. Age
e. Abdominal circumference

The correct answers are b. Gender and d. Age.

In chronic kidney disease (CKD), the severity classification, often based on the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, takes into account factors such as age and gender.

118D13
Which of the following are mechanical complications after acute myocardial infarction? Select three.

a. Ventricular septal rupture
b. Left ventricular outflow tract obstruction
c. Cardiac tamponade
d. Acute mitral regurgitation
e. Acute aortic regurgitation

The correct answers are a. Ventricular septal rupture, c. Cardiac tamponade, and d. Acute mitral regurgitation.

These are all mechanical complications that can occur following an acute myocardial infarction (MI) due to structural damage to the heart, and they can significantly worsen the patient's condition if not promptly recognized and treated.
Ventricular septal rupture is a tear in the wall (septum) between the left and right ventricles. It is a serious complication resulting from necrosis (death) of the septal tissue after an MI.
Cardiac tamponade occurs when fluid or blood accumulates in the pericardial sac surrounding the heart. This can result from a rupture of the heart wall after MI, allowing blood to leak into the pericardium.
Acute mitral regurgitation can occur if the papillary muscles or the mitral valve apparatus is damaged during an MI, particularly in the case of an infarction affecting the left ventricle.
Left ventricular outflow tract obstruction is usually associated with conditions like hypertrophic cardiomyopathy, where structural abnormalities obstruct blood flow out of the left ventricle.
Acute aortic regurgitation more commonly associated with aortic root diseases, infective endocarditis, or trauma.

118D14
Which of the following treatments are appropriate for prostate cancer? Select three.

a. Orchiectomy (testicle removal)
b. Radiation therapy
c. Administration of α1 blockers
d. Radical prostatectomy (complete removal of the prostate)
e. Transurethral resection of the prostate (TURP)

The correct answers are a. Orchiectomy (testicle removal), b. Radiation therapy, and d. Radical prostatectomy (complete removal of the prostate).

Orchiectomy is a form of androgen deprivation therapy (ADT). Since prostate cancer growth is driven by male hormones (androgens), removing the testes (which produce most of the body’s testosterone) reduces androgen levels, slowing the progression of the cancer.
Radiation therapy is a standard treatment for localized or locally advanced prostate cancer. It involves targeting the prostate gland with high-energy rays to destroy cancer cells.
Radical prostatectomy (complete removal of the prostate) is a surgical procedure to remove the prostate gland and some surrounding tissue. It is typically performed for localized prostate cancer that has not spread beyond the prostate.
α1 blockers, such as tamsulosin, are used to relieve urinary symptoms caused by benign prostatic hyperplasia (BPH), not to treat prostate cancer.
Transurethral resection of the prostate (TURP) is a surgical procedure used to relieve urinary obstruction caused by BPH.

118D15
Which of the following are common fracture sites in elderly individuals with a history of osteoporosis who experience a fall? Select three.

a. Spine
b. Patella
c. Ankle
d. Distal radius
e. Proximal femur

The correct answers are a. Spine, d. Distal radius, and e. Proximal femur.

Vertebral compression fractures are very common in people with osteoporosis, often occurring with minimal trauma or even spontaneously.
A distal radius fracture, commonly known as a Colles' fracture, often results from a fall onto an outstretched hand.
Fractures of the proximal femur, including hip fractures, are a major concern in elderly individuals.
Fractures of the patella are less common in osteoporosis-related falls. They are more likely to result from direct trauma, such as a blow to the knee.
Ankle fractures are not strongly associated with osteoporosis. They are more often the result of twisting injuries or uneven ground.

118D16
A 60-year-old man presented with a chief complaint of headache. He has a history of taking analgesics as needed for tension-type headaches. Four days ago, he experienced a sudden onset of headache and nausea. The pain involves the entire head and is particularly severe in the occipital region extending to the neck. Despite taking analgesics several times, the symptoms did not improve, prompting him to seek medical attention. During a previous health check-up, he was diagnosed with hypertension but left it untreated. His smoking history is about 10 cigarettes/day for 40 years, and he drinks approximately one cup of shochu per day.

On examination, he is alert and oriented, with a height of 165 cm, weight of 70 kg, temperature of 36.8°C, pulse of 84 bpm (regular), blood pressure of 184/96 mmHg, respiratory rate of 16/min, and SpO₂ of 97% (room air).

A horizontal plain CT scan of the head is shown.

Which medication should be administered intravenously after securing venous access?

a. Heparin
b. Atropine
c. Prednisolone
d. Calcium channel blocker
e. Calcium gluconate

The correct answer is d. Calcium channel blocker.

Subarachnoid hemorrhage (SAH) typically presents with Sudden severe headache (described as a "thunderclap headache"), Nausea and vomiting, a history of untreated hypertension, and CT findings of hyperdense blood in the subarachnoid spaces.
Calcium channel blockers, particularly nimodipine, are essential in the management of SAH because they help prevent cerebral vasospasm, a serious complication that can lead to delayed cerebral ischemia and worsen outcomes.
Anticoagulants like heparin are contraindicated in SAH, as they can exacerbate bleeding and increase the risk of worsening the hemorrhage.
Atropine is used for bradycardia or to reduce secretions.
Corticosteroids like prednisolone are not indicated in the treatment of SAH.
Calcium gluconate is used to correct hypocalcemia or treat hyperkalemia.

118D17
An 83-year-old woman presents with a chief complaint of difficulty swallowing during meals. Two years ago, she experienced heartburn, was diagnosed with gastroesophageal reflux disease (GERD) through upper gastrointestinal endoscopy, and was prescribed acid-suppressing medication. She has noticed a sensation of obstruction while eating for the past year, and the symptoms have persisted, prompting her to seek medical attention. She has no history of smoking or alcohol consumption.

On examination, she has a height of 156 cm, weight of 60 kg, temperature of 36.8°C, pulse of 60 bpm (regular), blood pressure of 140/88 mmHg, respiratory rate of 18/min, and SpO₂ of 94% (room air).

There are no abnormalities in the palpebral and bulbar conjunctivae. Heart sounds are normal. Breath sounds are diminished in the left lower anterior chest area. The abdomen is flat and soft, and the liver and spleen are not palpable.

Horizontal and coronal CT images of the chest and abdomen are provided.

What is the diagnosis?

a. Esophageal cancer
b. Esophageal diverticulum
c. Mediastinal tumor
d. Esophageal achalasia
e. Hiatal hernia

The correct answer is e. Hiatal hernia.

A hiatal hernia occurs when part of the stomach protrudes through the diaphragm into the thoracic cavity, often through the esophageal hiatus. This can lead to symptoms like a sensation of obstruction during meals, as the stomach may press against the esophagus or cause reflux.
On CT scans, a hiatal hernia may show the stomach or parts of it located above the diaphragm, within the chest cavity.
The other options would show a mass (cancer or tumor), a pouch-like structure (diverticulum), or a dilated esophagus with narrowing at the lower esophageal sphincter (achalasia) on CT scans.

118D18
A 32-year-old woman (G0P0) presents with a chief complaint of amenorrhea. She had menarche at age 13, and her menstrual cycles were regular until age 29, after which she experienced irregular cycles, leading to amenorrhea since age 31, prompting her to consult a gynecologist. For the past six months, she has been experiencing headaches, with increasing frequency and intensity over the past two months. Physical examination reveals a height of 165 cm, weight of 55 kg, temperature of 36.3°C, pulse of 64 bpm (regular), blood pressure of 120/67 mmHg, and respiratory rate of 18/min. Her breasts are well-developed, and her external genitalia are female in appearance, with pubic and axillary hair present. Laboratory tests show red blood cells at 3.5 million, hemoglobin 12.1 g/dL, hematocrit 33%, white blood cells 3,700, and platelets 310,000. Blood biochemistry results include TSH 2.3 μU/mL (reference range 0.2–4.0), prolactin 125 ng/mL (reference ≤15), and hCG <0.5 IU/L (reference ≤1.0). Transvaginal ultrasound reveals a uterus of normal size but with a thin endometrium; the ovaries are normal in size with visible small follicles.

Which imaging test should be performed next?

a. Abdominal CT
b. FDG-PET
c. Pituitary MRI
d. Mammography
e. Thyroid ultrasound

The correct answer is c. Pituitary MRI.

The patient's elevated prolactin level, amenorrhea, and headaches strongly suggest a pituitary adenoma. Hyperprolactinemia can cause menstrual irregularities and amenorrhea by disrupting the hypothalamic-pituitary-ovarian axis.
Pituitary MRI is the gold standard for evaluating the pituitary gland to confirm the presence of an adenoma, determine its size (microadenoma or macroadenoma), and assess for mass effect on surrounding structures, such as the optic chiasm.
The transvaginal ultrasound reveals normal ovarian size and visible follicles, ruling out primary ovarian dysfunction.
The TSH level is within the normal range, ruling out hypothyroidism as a cause of hyperprolactinemia.
The hCG level is undetectable, ruling out pregnancy as a cause of amenorrhea.
FDG-PET is used to detect metabolically active malignancies. Prolactinomas are benign tumors and do not require FDG-PET for diagnosis.

118D19
A 73-year-old woman presents with complaints of muscle weakness and difficulty swallowing. Two months ago, she began having trouble climbing stairs, and one month ago, she was unable to lift or move her bedding. Two weeks ago, she developed edema of the upper eyelids and erythema across her body, and seven days ago, difficulty swallowing due to choking prompted her to seek medical attention. On examination, she is conscious, with a height of 154 cm, weight of 40 kg, temperature of 37.5°C, pulse of 96 bpm (regular), blood pressure of 134/70 mmHg, respiratory rate of 16/min, and SpO₂ of 97% on room air. Findings include pale erythematous edema of the upper eyelids and reddish papules on the dorsal side of the finger joints. Additional erythema is observed on the auricles, anterior neck, back, extensor surfaces of the upper limbs, and lateral buttocks. No abnormalities are noted in heart sounds, breath sounds, or superficial lymph nodes. There is symmetric proximal muscle weakness in the limbs but no sensory abnormalities. Urinalysis shows no abnormalities. Laboratory findings reveal RBC 3.72 million, Hb 11.3 g/dL, Hct 33%, WBC 5,900 (neutrophils 75%, eosinophils 1%, monocytes 12%, lymphocytes 12%), platelets 260,000, total protein 5.6 g/dL, albumin 3.0 g/dL, AST 108 U/L, ALT 79 U/L, LDH 628 U/L (reference: 124–222), γ-GT 30 U/L (reference: 9–32), CK 1,620 U/L (reference: 41–153), BUN 12 mg/dL, creatinine 0.4 mg/dL, glucose 111 mg/dL, TSH 3.8 μU/mL (reference: 0.2–4.0), FT3 2.7 pg/mL (reference: 2.3–4.3), FT4 1.1 ng/dL (reference: 0.8–2.2), CRP 0.8 mg/dL, and positive anti-TIF1-γ antibody. Chest X-ray reveals no abnormalities.

What is the most important complication to monitor in this patient?
a. Liver failure
b. Malignancy
c. Interstitial pneumonia
d. Acute kidney injury
e. Bladder and rectal dysfunction

The correct answer is b. Malignancy.

This patient presents with symptoms and findings characteristic of dermatomyositis, an idiopathic inflammatory myopathy associated with skin manifestations and muscle weakness. Dermatomyositis is known to have a strong association with malignancy, making it a paraneoplastic syndrome in some cases.
Positive anti-TIF1-γ antibody is strongly associated with cancer-related dermatomyositis. It serves as a marker for malignancy in patients with dermatomyositis.
Elevated AST and ALT levels are due to muscle inflammation, not liver dysfunction. No evidence suggests liver failure.
While interstitial lung disease is a possible complication of dermatomyositis, the chest X-ray is normal, and there are no respiratory symptoms like dyspnea.
Renal function is normal (BUN and creatinine are within reference ranges).
No symptoms or findings suggest neurological involvement affecting the bladder or rectum.

118D20
An 80-year-old woman was hospitalized for aspiration pneumonia following a stroke and treated with antibiotics for 7 days. While her pneumonia is showing improvement, she has developed more than 10 episodes of watery diarrhea per day. On examination, she is conscious, with a height of 154 cm, weight of 43 kg, temperature of 37.3°C, pulse of 72 bpm (regular), blood pressure of 136/80 mmHg, respiratory rate of 18/min, and SpO₂ of 97% on room air. Heart and lung sounds are normal, and the abdomen is flat with mild tenderness in the lower abdomen. Laboratory findings reveal RBC 3.8 million, Hb 11.0 g/dL, WBC 10,100, platelets 210,000, total protein 7.3 g/dL, albumin 3.9 g/dL, total bilirubin 0.8 mg/dL, AST 30 U/L, ALT 35 U/L, LDH 140 U/L (reference: 124–222), γ-GT 30 U/L (reference: 9–32), amylase 100 U/L (reference: 44–132), BUN 12 mg/dL, creatinine 0.8 mg/dL, glucose 98 mg/dL, and CRP 1.2 mg/dL. An abdominal X-ray reveals no abnormalities.

Which test should be performed at this point?
a. Fecal occult blood test
b. Stool culture
c. Urea breath test
d. Fecal Clostridioides difficile toxin test
e. α1-antitrypsin test

The correct answer is d. Fecal Clostridioides difficile toxin test.

Clostridioides difficile infection (CDI) is a common cause of antibiotic-associated diarrhea in hospitalized or recently hospitalized patients. The gold standard for diagnosing CDI involves testing for toxins A and B in the stool.
The abdominal X-ray is normal, ruling out major bowel obstruction or ileus.
Laboratory findings do not indicate severe infection (e.g., WBC is elevated but not critically high, CRP is modestly elevated).
Fecal occult blood test detects hidden blood in the stool, useful for diagnosing gastrointestinal bleeding.
While a stool culture could detect C. difficile, it is not routinely used because it takes longer to process and does not confirm toxin production.
Urea breath test is used to detect Helicobacter pylori.
α1-antitrypsin test is used to evaluate protein-losing enteropathy.

118D21
A 21-year-old woman presents with facial rashes as her chief complaint. She has had recurring facial rashes for the past eight years, with episodes of improvement and worsening. The rash tends to worsen before menstruation. Over the past two months, her condition has deteriorated due to mental stress and an unbalanced diet. She has not used topical corticosteroids. There is no itching, but she reports mild pain. A photograph of her face is shown.

What is the diagnosis?
a. Nodular prurigo
b. Acne vulgaris
c. Lupus vulgaris
d. Rosacea-like dermatitis
e. Seborrheic dermatitis

The correct answer is b. Acne vulgaris.

Acne vulgaris is a common skin condition characterized by the presence of comedones (blackheads and whiteheads), papules, pustules, and sometimes nodules or cysts but not itching. It often occurs in adolescents and young adults due to hormonal changes, but it can persist into adulthood.
Nodular prurigo presents as intensely itchy nodules, often on the extremities.
Lupus vulgaris is a form of cutaneous tuberculosis, presenting as slow-growing reddish-brown plaques or nodules.
Rosacea typically presents with flushing, persistent redness, and sometimes papules or pustules, often in middle-aged adults.
Seborrheic dermatitis usually presents as scaly, greasy patches of erythema in areas rich in sebaceous glands (e.g., scalp, nasolabial folds).

118D22
A 65-year-old man visited the clinic after abnormalities were detected during an abdominal ultrasound as part of a health check-up. Two years ago, liver function abnormalities were identified during a health check, but he did not undergo further evaluation due to a lack of symptoms. His past medical history is unremarkable. He is self-employed, has a smoking history of 20 cigarettes/day for 20 years, and consumes 350 mL of beer weekly for the past 45 years. His mother died of liver cancer. On examination, his height is 170 cm, weight is 70 kg, pulse is 96 bpm (regular), and blood pressure is 144/90 mmHg. Heart and lung sounds are normal. The liver is palpable 2 cm below the right costal margin. Laboratory findings include total bilirubin 0.8 mg/dL, AST 90 U/L, ALT 85 U/L, γ-GT 60 U/L (reference: 13–64), fasting glucose 98 mg/dL, HbA1c 5.6% (reference: 4.9–6.0), triglycerides 160 mg/dL, HDL cholesterol 36 mg/dL, and α-fetoprotein (AFP) 160,000 ng/mL (reference: ≤20). Immunoserological findings reveal HBs antigen negative and ① HCV antibody positive, with an ② ICG test (15-minute retention) of 8% (reference: ≤10). Contrast-enhanced CT of the chest and abdomen shows a ④ 5-cm hepatocellular carcinoma (HCC) in the anterior segment of the right hepatic lobe with ③ one intrahepatic metastasis and ⑤ metastases to both lungs.

What is the reason for determining that this patient is not a candidate for hepatocellular carcinoma resection?
a. ① HCV antibody positive
b. ② ICG test (15-minute retention)
c. ③ Intrahepatic metastasis
d. ④ Tumor diameter of 5 cm
e. ⑤ Pulmonary metastases

The correct answer is e. Pulmonary metastases.

Hepatocellular carcinoma (HCC) is often treated with surgical resection when the tumor is localized to the liver and there are no extrahepatic metastases.
Candidates for resection typically have:
- No extrahepatic metastases.
- No vascular invasion (portal or hepatic veins).
- Good liver function (e.g., no significant cirrhosis or portal hypertension).
However, the presence of pulmonary metastases (extrahepatic spread) makes the patient ineligible for surgical resection, as resection would not cure the disease in such cases.

118D23
A 25-year-old man presents with left cheek pain and nasal discharge. He had cold-like symptoms starting five days ago. Three days ago, he developed pain in the left cheek and noticed purulent nasal discharge from the left nostril. The left cheek pain has intensified, prompting him to seek medical attention.

On examination, his temperature is 37.2°C. There is no redness or swelling of the skin over the cheeks. Nasal examination reveals purulent nasal discharge in the left nostril.

What is the diagnosis?

a. Nasal furuncle
b. Trigeminal neuralgia
c. Acute sinusitis
d. Cheek cellulitis
e. Allergic rhinitis

The correct answer is c. Acute sinusitis.

Acute sinusitis (also known as acute rhinosinusitis) is an inflammation of the paranasal sinuses that commonly occurs following an upper respiratory tract infection (URI).
The combination of localized cheek pain, purulent nasal discharge, and recent upper respiratory symptoms strongly supports the diagnosis of acute sinusitis.
A nasal furuncle (infection of a nasal hair follicle) presents with localized tenderness, swelling, and redness around the nasal vestibule.
Trigeminal neuralgia causes severe, sharp, and intermittent facial pain triggered by specific stimuli (e.g., touch, chewing).
Cheek cellulitis involves redness, swelling, and warmth of the overlying skin.
Allergic rhinitis presents with clear nasal discharge, nasal congestion, and sneezing, often triggered by allergens.

118D24
A 30-year-old woman presents with postprandial fullness as her main complaint. She has been experiencing this symptom since high school, with periods of worsening during times of stress, such as university entrance exams and after starting her job. Over the past three months, the frequency of symptoms has increased to three times a week, leading her to seek medical attention. She denies weight loss or fever. Her medical and family history are unremarkable. On examination, her height is 160 cm, weight is 56 kg, temperature is 36.2°C, pulse is 64 bpm (regular), and blood pressure is 120/70 mmHg. There are no abnormalities in the conjunctiva or sclera. Heart and lung sounds are normal. The abdomen is flat, soft, and non-tender. Laboratory findings show RBC 4.68 million, Hb 13.9 g/dL, Hct 42%, WBC 5,300, platelets 210,000, total protein 7.8 g/dL, albumin 4.3 g/dL, total bilirubin 0.9 mg/dL, AST 22 U/L, ALT 16 U/L, LDH 180 U/L (reference: 124–222), ALP 80 U/L (reference: 38–113), γ-GT 21 U/L (reference: 9–32), amylase 92 U/L (reference: 44–132), BUN 12 mg/dL, creatinine 0.6 mg/dL, and CRP 0.1 mg/dL. A urea breath test is negative, and upper gastrointestinal endoscopy shows no abnormalities.

Which treatment should not be used for this patient?
a. Kampo (traditional Japanese herbal medicine)
b. NSAIDs
c. Antidepressants
d. Acid-suppressing drugs
e. Gastrointestinal motility regulators

The answer is b. NSAIDs.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in patients with dyspepsia because they can irritate the gastric mucosa and worsen symptoms. NSAIDs inhibit cyclooxygenase (COX), reducing prostaglandin synthesis, which is protective for the gastric mucosa.
Certain Kampo medicines, such as Rikkunshito, have been shown to improve symptoms of functional dyspepsia by enhancing gastric motility and reducing discomfort.
Low-dose tricyclic antidepressants or SSRIs can be used to manage functional dyspepsia, especially when there is a strong stress-related component.
Proton pump inhibitors (PPIs) or H2 blockers are commonly used to reduce gastric acid and alleviate symptoms in functional dyspepsia.
Prokinetic agents, such as domperidone or metoclopramide, can be effective in managing postprandial symptoms by improving gastric emptying and reducing bloating.

118D25
A 63-year-old man was brought to the emergency department by ambulance with a chief complaint of dyspnea. He had been experiencing exertional shortness of breath for three days. Today, after returning home, his dyspnea gradually worsened to the point that he could no longer tolerate it, prompting him to call for an ambulance. He had been diagnosed with hypertension at the age of 50 but had not sought medical attention since then. He has a smoking history of 20 cigarettes/day for 43 years and drinks alcohol occasionally.

On examination, he is alert but appears distressed. He is 170 cm tall, weighs 85 kg, has a temperature of 36.8°C, a heart rate of 122 bpm (regular), blood pressure of 190/116 mmHg (no side-to-side difference), a respiratory rate of 26/min, and SpO₂ of 92% while on oxygen via a reservoir mask at 10 L/min. Physical findings include jugular vein distention, an audible S4 heart sound, and coarse crackles throughout both lung fields. There is no leg edema.

Laboratory findings: RBC 4.45 million, Hb 13.7 g/dL, Hct 41%, WBC 8,100, platelets 220,000, total protein 6.9 g/dL, AST 31 U/L, ALT 30 U/L, LDH 164 U/L (reference: 124–222), CK 110 U/L (reference: 59–248), BUN 21 mg/dL, creatinine 1.1 mg/dL, eGFR 60 mL/min/1.73 m², uric acid 8.2 mg/dL, glucose 104 mg/dL, Na 132 mEq/L, K 3.9 mEq/L, Cl 110 mEq/L, BNP 1,820 pg/mL (reference: ≤18.4), and CRP 0.3 mg/dL. A rapid troponin T test is negative.

Echocardiography reveals normal cardiac contractility with no valvular disease. A 12-lead ECG and chest X-ray are shown.

What is the diagnosis?
a. Pericarditis
b. Dilated cardiomyopathy
c. Hypertensive emergency
d. Unstable angina
e. Obstructive hypertrophic cardiomyopathy

The correct answer is c. Hypertensive emergency.

This patient presents with a hypertensive emergency, which is characterized by a severe elevation in blood pressure (≥180/120 mmHg) accompanied by evidence of end-organ damage.
In this case, the elevated blood pressure (190/116 mmHg) is associated with symptoms and findings indicative of acute pulmonary edema, which represents end-organ damage.
Pericarditis typically presents with chest pain, pericardial friction rub, and diffuse ST-segment elevation on ECG.
The echocardiogram shows normal cardiac contractility, ruling out dilated cardiomyopathy.
Unstable angina is unlikely due to the absence of chest pain and a negative troponin test.
There is no evidence of left ventricular outflow tract obstruction or hypertrophic changes on echocardiography (obstructive hypertrophic cardiomyopathy).

118D26

A 72-year-old man presented with complaints of lower abdominal pain and hematuria. He had noticed hematuria starting a month ago and began experiencing lower abdominal pain yesterday, prompting his visit. He is 162 cm tall, weighs 58 kg, and has a body temperature of 36.8°C, a pulse rate of 60 beats per minute (regular), a blood pressure of 148/90 mmHg, and a respiratory rate of 16 breaths per minute. His abdomen is flat, soft, and non-tender, with no palpable liver or spleen. A digital rectal exam reveals a 5-cm elastic hard prostate without tenderness. Urinalysis findings: Protein (±), glucose (−), occult blood (3+), sediment shows more than 100 red blood cells/HPF and more than 100 white blood cells/HPF. An abdominal X-ray and cystoscopic image are shown. Urine culture was submitted, and antibiotic treatment was initiated.

What is the most appropriate next treatment?
a. Stone dissolution therapy
b. Total cystectomy
c. Creation of a bladder fistula
d. Transurethral cystolithotripsy
e. Extracorporeal shock wave lithotripsy

The correct answer is d. Transurethral cystolithotripsy.

The patient presents with classic symptoms of bladder stones: lower abdominal pain, hematuria, and findings on cystoscopy (image B) and abdominal X-ray (image A) that confirm the presence of a large bladder stone.
The most appropriate treatment is transurethral cystolithotripsy, which allows for effective and minimally invasive removal of the bladder stone.
Bladder stones are typically composed of calcium oxalate or phosphate, which do not dissolve with medications.
Removing the bladder is unnecessary unless there is a severe complication, such as malignancy or a non-functioning bladder.
A bladder fistula is used in specific cases, such as severe bladder outlet obstruction or malignancy.
Extracorporeal shock wave lithotripsy (ESWL) is effective for kidney stones smaller than 2 cm.

118D27

A 65-year-old woman presented with a neck mass as the chief complaint. She had been aware of the neck mass for 8 months but did not seek medical attention as it was painless. The size of the mass had not changed, but her family urged her to seek medical advice. She reported no fever, night sweats, or weight loss. Examination of the chest and abdomen revealed no abnormalities. Multiple elastic, mobile, and firm lymph nodes measuring 2–3 cm in diameter were palpable in the bilateral cervical and inguinal regions without tenderness. Laboratory findings include RBC: 4.15 million, Hb: 12.5 g/dL, Ht: 40%, WBC: 5,600, Platelets: 280,000, Total protein: 7.0 g/dL, Albumin: 4.2 g/dL, LDH: 200 U/L (reference: 124–222), CRP: 0.2 mg/dL, and HTLV-1 antibody: negative. Peripheral blood smear and bone marrow biopsy showed no abnormal cells. Contrast-enhanced CT from the neck to the pelvis revealed lymphadenopathy (3 cm in diameter) in the bilateral cervical, inguinal, and para-aortic regions. Histopathological analysis of the right cervical lymph node biopsy, including H&E staining and CD20 immunohistochemical staining, is shown.

What is the most likely diagnosis?

a. Follicular lymphoma
b. Burkitt lymphoma
c. Peripheral T-cell lymphoma
d. Adult T-cell leukemia/lymphoma
e. Diffuse large B-cell lymphoma

The correct answer is a. Follicular lymphoma.

The combination of painless lymphadenopathy, indolent clinical course, histopathological findings (nodular growth pattern and CD20 positivity), and lack of systemic symptoms strongly suggests follicular lymphoma.
Burkitt lymphoma is an aggressive B-cell lymphoma, typically presenting with rapidly growing masses and systemic symptoms.
Peripheral T-cell lymphoma and adult T-cell leukemia/lymphoma would be associated with T-cell markers (not CD20) and often present with systemic symptoms and hypercalcemia.
Diffuse large B-cell lymphoma is aggressive and often presents with rapid progression and systemic symptoms.

118D28
A 19-year-old male presents with shortness of breath. He noticed dyspnea two days ago, and today, he experienced chest pain accompanied by difficulty breathing, prompting him to seek medical attention. On examination, he is alert with a temperature of 37.2°C, heart rate of 104 bpm (regular), blood pressure of 98/62 mmHg, respiratory rate of 22/min, and an SpO₂ of 90% on room air. No breath sounds are heard on the right side. A chest X-ray is shown.

Which complication should be monitored for after chest tube drainage?
a. Chylothorax
b. Pulmonary edema
c. Arrhythmia
d. Thromboembolism
e. Recurrent laryngeal nerve injury

The correct answer is b. Pulmonary edema.

The patient has a pneumothorax, indicated by the absence of breath sounds on the right and the chest X-ray findings. Thoracic drainage is a typical treatment to re-expand the lung in such cases.
After thoracic drainage, re-expansion pulmonary edema is a known and serious complication that can occur. The sudden re-expansion of the lung leads to increased capillary permeability, resulting in leakage of fluid into the alveoli and subsequent pulmonary edema.
Chylothorax refers to lymphatic fluid accumulating in the pleural space, usually from trauma or damage to the thoracic duct.
Arrhythmia or thromboembolism is unrelated to thoracic drainage.
Recurrent nerve injury is usually associated with surgical procedures in the neck or thoracic inlet.

118D29

A 32-year-old multiparous woman (2 pregnancies, 1 delivery), at 35 weeks and 1 day of gestation, was brought in by ambulance due to vaginal bleeding. She had been receiving antenatal care at another medical institution until 33 weeks of pregnancy. She had planned to deliver at this hospital for her hometown delivery but called an ambulance due to vaginal bleeding. She is conscious, with a body temperature of 37.2°C, heart rate of 92 beats/min, regular, blood pressure of 108/72 mmHg, respiratory rate of 20 breaths/min, and SpO₂ of 98% on room air. Speculum examination revealed continuous bleeding from the external cervical os, with an estimated total blood loss of approximately 200 mL. On fetal cardiotocography, the fetal condition is favorable, and uterine contractions occur once every 10 minutes. A transvaginal ultrasound image taken upon admission (arrow pointing to the internal cervical os) is shown.

What is the appropriate management?

a. Blood transfusion
b. Position change
c. Emergency cesarean section
d. Bimanual uterine compression
e. Administration of magnesium sulfate

The correct answer is c. Emergency cesarean section.

Placenta previa is a condition where the placenta is abnormally located near or over the internal cervical os, as indicated by the ultrasound image.
Placenta previa with ongoing bleeding and uterine contractions at 35 weeks necessitates an emergency cesarean section to prevent catastrophic maternal and fetal complications.

118D30

A 73-year-old man visits the hospital for further evaluation of his pancreas after being noted to have pancreatic duct dilation during an abdominal ultrasound at a health checkup two weeks ago. He has been receiving oral treatment for diabetes for 10 years. His consciousness is clear. Height: 160 cm, Weight: 57 kg. Vital signs: Body temperature 36.8°C, Pulse 88/min, regular, Blood pressure 140/94 mmHg, Respiratory rate 12/min. There are no abnormalities noted in the palpebral or bulbar conjunctivae. Heart and lung sounds are normal. The abdomen is flat, soft, and non-tender; the liver and spleen are not palpable. Laboratory findings show: Total protein 7.4 g/dL, Albumin 4.5 g/dL, Total bilirubin 0.7 mg/dL, AST 22 U/L, ALT 19 U/L, LDH 190 U/L (reference: 124–222), ALP 85 U/L (reference: 38–113), γ-GT 18 U/L (reference: 13–64), Amylase 120 U/L (reference: 44–132), BUN 17 mg/dL, Creatinine 0.8 mg/dL, Blood glucose 174 mg/dL, HbA1c 7.2% (reference: 4.9–6.0), CEA 3.2 ng/mL (reference: ≤5), CA19-9 38 U/mL (reference: ≤37), CRP 0.1 mg/dL. MRCP imaging is provided below.

What is the most likely diagnosis?

a. Cholangiocarcinoma
b. Duodenal papillary tumor
c. Pancreaticobiliary maljunction
d. Mucinous cystic neoplasm (MCN)
e. Intraductal papillary mucinous neoplasm (IPMN)

The correct answer is e. Intraductal Papillary Mucinous Neoplasm (IPMN).

The patient is an elderly man (73 years old) with a history of diabetes and a recent finding of pancreatic duct dilation on ultrasound.
The patient has no abdominal pain or jaundice, which reduces the likelihood of other diagnoses such as bile duct cancer or duodenal papillary tumor.
Pancreaticobiliary maljunction anomaly is a congenital abnormality.
Mucinous cystic neoplasm (MCN) typically presents in younger women.

118D31

36-year-old male presenting with palpitations. The patient has experienced exertional palpitations and episodes of near syncope for 10 years. During school health checkups, ECG abnormalities were noted but were followed up with observation only. Recently, he sought medical attention due to concern about his maternal cousin's sudden death at the age of 25. Additionally, a maternal aunt is being treated for a cardiac condition of unspecified nature.

Physical examination reveals a conscious, alert patient with no signs of jugular venous distension, edema, or abnormal heart/lung sounds. His vital signs are as follows: height, 168 cm; weight, 70 kg; temperature, 36.5°C; pulse, 72 bpm (regular); and blood pressure, 124/72 mmHg.

Bloodwork is largely normal except for an elevated BNP level of 178 pg/mL (reference: ≤18.4). Chest X-ray shows a cardiothoracic ratio of 45%, with no signs of pulmonary congestion or pleural effusion. A 12-lead ECG and echocardiogram are provided (images A and B). Echocardiographic findings include a left ventricular septal wall thickness of 22.5 mm, posterior wall thickness of 8.6 mm, diastolic diameter of 38.0 mm, and a left ventricular ejection fraction of 79.6%, with no significant valvular disease or pressure gradient in the left ventricular outflow tract.

Holter ECG reveals episodes of non-sustained ventricular tachycardia, which are accompanied by subjective dizziness. Coronary angiography shows no stenotic lesions, while cardiac MRI reveals delayed enhancement in the mid-wall of the interventricular septum.

What is the most appropriate treatment to prevent sudden cardiac death in this patient?

a. Digoxin therapy
b. Disopyramide therapy
c. Loop diuretic therapy
d. Permanent pacemaker implantation
e. Implantation of an implantable cardioverter-defibrillator (ICD)

The answer is e. Implantation of an implantable cardioverter-defibrillator (ICD).

The patient has a family history of sudden death, hypertrophic septal wall thickening as shown on echocardiogram, non-sustained ventricular tachycardia (NSVT), and delayed enhancement on cardiac MRI, which strongly indicate hypertrophic cardiomyopathy (HCM) with the risk of sudden cardiac death (SCD).
An ICD is the most effective intervention for preventing SCD in high-risk patients with HCM. The device monitors heart rhythm and delivers an electric shock if it detects life-threatening arrhythmias, such as ventricular tachycardia or ventricular fibrillation.
Digoxin is not recommended in HCM as it increases contractility.
Disopyramide is effective for a broad range of supraventricular and ventricular arrhythmias.
Loop diuretics can help manage fluid overload.
A permanent pacemaker is indicated for symptomatic bradycardia or advanced AV block.

118D32

A 64-year-old man presented for a routine visit. He was diagnosed with diabetes 8 years ago and suffered an acute anterior myocardial infarction 1.5 years ago. He is currently diagnosed with chronic heart failure and attends a local clinic near his home. His medications include aspirin, angiotensin-converting enzyme (ACE) inhibitors, carvedilol, spironolactone, a statin, and a proton pump inhibitor. During a regular check-up, edema was observed. The patient is alert and oriented. He has a height of 170 cm and a weight of 80 kg. His body temperature is 36.2°C, pulse rate is 84/min, regular, and blood pressure is 108/76 mmHg. His oxygen saturation is 98% on room air. His skin is moist, and jugular venous distension is present. No abnormalities are noted in heart or lung sounds. The abdomen is flat and soft, with no palpable liver or spleen. Peripheral coldness is not observed, but edema is present in both lower legs. Urinalysis findings include negative protein and glucose 1+. Blood test results show RBC 4.36 million, Hb 13.2 g/dL, WBC 8,000, platelets 280,000, total bilirubin 1.2 mg/dL, AST 48 U/L, ALT 42 U/L, CK 72 U/L (reference: 59–248), blood urea nitrogen 12 mg/dL, creatinine 0.7 mg/dL, blood glucose 124 mg/dL, HbA1c 6.9% (reference: 4.9–6.0), LDL cholesterol 80 mg/dL, Na 132 mEq/L, K 4.8 mEq/L, BNP 216 pg/mL (reference: ≤18.4), and CRP 0.8 mg/dL. The 12-lead ECG is shown below. Chest X-ray reveals cardiomegaly and mild pulmonary congestion. Echocardiography shows an ejection fraction of 42%, thinning of the anterior wall, increased inferior vena cava diameter, and reduced respiratory variation.

Which medication should be added to improve the prognosis?

a. Alpha-blocker
b. Verapamil
c. SGLT2 inhibitor
d. Sulfonylurea
e. Angiotensin II receptor blocker

The correct answer is c. SGLT2 inhibitors.

Heart failure with reduced ejection fraction (HFrEF) is evident from the echocardiogram findings, including an ejection fraction of 42%, and other clinical signs such as jugular vein distension, leg edema, and elevated BNP (216 pg/mL).
Sodium-glucose co-transporter 2 (SGLT2) inhibitors help reduce fluid overload, decrease cardiac workload, and improve heart failure symptoms by promoting natriuresis and osmotic diuresis. They also have favorable effects on cardiac metabolism.
α-blockers are not recommended for heart failure treatment and can worsen outcomes by causing hypotension or fluid retention.
A non-dihydropyridine calcium channel blocker like verapamil can depress myocardial contractility.
Sulfonylureas have no benefit in improving heart failure outcomes.
This patient is already on an ACE inhibitor, which is sufficient to block the renin-angiotensin-aldosterone system. Adding an angiotensin II receptor blocker (ARB) is unnecessary and not recommended in this setting.

118D33

A 23-year-old man visited the clinic with the complaint of being unable to go to work. Two months ago, he received complaints from a client company due to an order mistake and was severely reprimanded by his boss. Since then, he has felt down and unmotivated about work. At night, he found it hard to fall asleep because thoughts about work occupied his mind, but he was still able to enjoy his hobby circle activities on holidays as usual. Starting a week ago, he began experiencing palpitations in the mornings when trying to go to work and took leave.

There is no notable medical or family history. After visiting the clinic, he was advised to rest at home, which relieved his palpitations. Additionally, after receiving an apology from his boss for the reprimand and being assigned a new client company, he was able to return to work three months later.

What is the diagnosis?
a. Major depressive disorder
b. Social anxiety disorder
c. Circadian rhythm sleep disorder
d. Adjustment disorder
e. Post-traumatic stress disorder (PTSD)

The correct answer is d. Adjustment disorder.

The patient’s symptoms and timeline align closely with adjustment disorder, as they were triggered by an identifiable stressor and resolved after the situation improved.
Major depressive disorder (MDD) would involve persistent symptoms such as low mood, loss of interest in almost all activities (not just work), significant weight changes, or suicidal ideation.
Social anxiety disorder involves a pervasive fear of social interactions or performance situations where the person fears judgment or embarrassment.
Circadian rhythm sleep disorder involves a disruption of the sleep-wake cycle that causes insomnia or excessive sleepiness, unrelated to external stressors.
Post-traumatic stress disorder (PTSD) occurs after exposure to a life-threatening event or severe trauma.

118D34

A 51-year-old man presented with low back pain and left lower limb pain. He had been experiencing low back pain and dull pain in the left lower limb for three months, which became more severe in recent days. His gait showed mild forward flexion and claudication. There was tenderness in the lumbar region, and a straight-leg raising test was positive on the left side. T2-weighted sagittal and axial MRI images of the lumbar spine are shown below.

Which of the following is most likely to be observed in this patient?

a. Sensory impairment of the anterior thigh
b. Positive femoral nerve stretch test
c. Weakness of ankle plantar flexion
d. Exaggerated Achilles tendon reflex
e. Positive Babinski sign

The correct answer is c. Weakness of ankle plantar flexion.

The patient has lower back pain radiating to the left leg, which is a classic symptom of lumbar disc herniation. A positive straight leg raise test (Lasègue test) indicates nerve root irritation, likely at the L5 or S1 level.
Compression of the S1 nerve root often causes weakness of plantar flexion (difficulty pressing the foot down, such as when pushing the gas pedal) and diminished Achilles reflex (not reflex hyperactivity as seen in upper motor neuron lesions).
Hypoesthesia of the anterior thigh and positive femoral nerve stretch test correspond to L2-L4 nerve roots.
Hyperreflexia of the Achilles tendon and Babinski sign positive suggest upper motor neuron lesions.

118D36

A 15-year-old girl is brought to the clinic by her mother, who is concerned about her weight loss. She has lost 5 kg over the past three months. Her consciousness is clear. Height is 157 cm, weight 38 kg. Vital signs: body temperature 36.8°C, pulse rate 120/min (regular), blood pressure 126/68 mmHg, respiratory rate 24/min, and SpO2 99% on room air. Her skin is moist, and swelling of the anterior neck is observed. Heart and lung sounds are normal. The abdomen is flat and soft with no palpable liver or spleen. No edema is noted in the lower legs. A mild tremor of the fingers is observed. Laboratory findings reveal: RBC 4.5 million, Hb 12.7 g/dL, Ht 38%, WBC 6,800, platelets 260,000; total protein 6.8 g/dL, albumin 3.6 g/dL, total bilirubin 0.9 mg/dL, AST 26 U/L, ALT 27 U/L, LDH 220 U/L (reference: 124–222), BUN 16 mg/dL, creatinine 0.4 mg/dL, uric acid 4.5 mg/dL, fasting blood glucose 96 mg/dL, HbA1c 5.0% (reference: 4.9–6.0), total cholesterol 122 mg/dL, triglycerides 140 mg/dL, Na 140 mEq/L, K 4.0 mEq/L, Cl 99 mEq/L, and CRP 0.3 mg/dL.

Which test is necessary for the diagnosis?
a. Head MRI
b. Anti-GAD antibody
c. Arginine stimulation test
d. Wrist bone X-ray
e. Free thyroxine (FT4)

The correct answer is e. Free thyroxine (FT4).

The clinical findings, such as weight loss, tachycardia (120 bpm), anterior neck swelling (indicating an enlarged thyroid), and finger tremor, along with the laboratory findings, including a low total cholesterol level (122 mg/dL), strongly indicate hyperthyroidism.
In hyperthyroidism, FT4 is typically elevated, reflecting increased thyroid hormone production.
Anti-GAD antibody is associated with autoimmune diabetes (type 1 diabetes). In this patient, normal HbA1c and fasting glucose levels rule out diabetes mellitus.
The arginine stimulation test evaluates growth hormone secretion.

118D37

A 58-year-old man presents with right shoulder pain. The pain began one month ago after lifting a heavy object. Initially, the pain was present only during movement, but it gradually developed into pain at rest and at night. His height is 173 cm, weight 67 kg, and temperature 36.1°C. Examination reveals pain during abduction of the right shoulder, and the inability to maintain the abducted position. The right shoulder X-ray and T2-weighted coronal MRI images are provided.

What is the most likely diagnosis?

a. Rotator cuff tear
b. Shoulder dislocation
c. Humeral fracture
d. Rheumatoid arthritis
e. Osteoarthritis

The correct answer is a. Rotator cuff tear.

Rotator cuff injuries are commonly caused by trauma, such as lifting heavy weights or repetitive overhead activities. MRI is the gold standard for diagnosing rotator cuff tears, as it shows discontinuity or abnormal fluid signals in the tendon, confirming the diagnosis.
There is no evidence of dislocation or fracture in this case.
Rheumatoid arthritis typically presents with symmetrical joint involvement, morning stiffness, and systemic symptoms.
Shoulder osteoarthritis causes chronic pain and stiffness but not acute post-traumatic symptoms.

118D38

A 56-year-old woman presents with pain in the lower back and limbs. She has experienced pain in the lower back and limbs for the past five years. Six months ago, her husband passed away from lung cancer, and since that time, her pain has worsened. She was prescribed NSAIDs at a nearby clinic, but they did not improve her condition. Recently, she has developed a painful, itchy, and unpleasant sensation in her lower limbs during sleep, which resolves when she moves them. Her weight has been stable. Physical examination reveals tenderness in the distal and proximal interphalangeal joints of the fingers, diffuse tenderness across all joints without swelling, and painful reactions upon palpation of wide areas, including the central upper edges of the trapezius muscles and the upper outer regions of the buttocks. No abnormalities in spinal range of motion, muscle strength, or sensory deficits in the limbs are observed. Laboratory tests show no significant abnormalities except for an ESR of 8 mm/hour and normal CRP. What is the most likely cause of the patient’s generalized pain?

a. Spondyloarthritis
b. Fibromyalgia
c. Rheumatoid arthritis
d. Osteoarthritis
e. Polymyalgia rheumatica

The correct answer is b. Fibromyalgia.

Fibromyalgia is typically characterized by widespread pain and tenderness in specific regions, without any laboratory abnormalities.
Normal inflammatory markers (CRP and ESR) and the absence of joint swelling or muscle weakness rule out inflammatory or systemic conditions such as rheumatoid arthritis, spondyloarthritis, or polymyalgia rheumatica.
Osteoarthritis, on the other hand, causes localized joint pain and is often accompanied by radiographic evidence of joint degeneration.

118D39

A 3-year-old boy was brought to the hospital by ambulance after ingesting a heated tobacco stick left on a table. Upon discovery, his mother induced him to spit out the tobacco leaves from his mouth, and he vomited twice during transport in the ambulance. He is crying but remains alert and conscious. His vital signs are as follows: temperature 36.9°C, heart rate 110/min (regular), blood pressure 100/64 mmHg, and respiratory rate 30/min. What is the appropriate management for this case?

a. Gastric lavage
b. Airway management
c. Observation
d. Drinking large amounts of water
e. Blood purification therapy

The correct answer is c. Observation.

Ingestion of a heated tobacco stick (which is part of devices like e-cigarettes) can expose children to nicotine, a toxic substance in large amounts. However, the situation described does not show signs of severe nicotine toxicity.
The child vomited shortly after ingestion, likely expelling much of the nicotine, and is currently alert with stable vital signs. These observations suggest mild exposure rather than a life-threatening condition.

118D40

A 74-year-old woman presented with proteinuria. She was previously noted to have proteinuria during a specific health check last year, but she left it untreated due to a lack of symptoms. This year, she was again noted to have proteinuria during the specific health check and sought medical consultation. She has no significant medical history. She is asymptomatic, employed, and her blood pressure, which she occasionally measures at home, is around 120/70 mmHg. Her body weight is stable, but she has mild pitting edema in both lower extremities.

Urine findings: Specific gravity 1.015, pH 6.0, protein 3+, glucose (-), occult blood (-). The random urine protein/creatinine ratio is 2.5 g/gCr (normal <0.15). Urine sediment shows 1–4 RBCs/HPF, 1–4 WBCs/HPF, 1–4 hyaline casts/HPF, with a few granular casts and broad casts.

Blood biochemistry findings: Creatinine 0.7 mg/dL, eGFR 61.6 mL/min/1.73 m². Abdominal ultrasound reveals no abnormalities in the kidneys.

What is the most likely diagnosis?

a. IgA nephropathy
b. Membranous nephropathy
c. Polycystic kidney disease
d. Minimal change nephrotic syndrome
e. Idiopathic crescentic glomerulonephritis

The correct answer is b. Membranous nephropathy.

Urine protein is 3+, and the urine protein/creatinine ratio is 2.5 g/gCr, indicating significant protein loss in the urine, which is characteristic of nephrotic-range proteinuria. However, the creatinine level (0.7 mg/dL) and eGFR (61.6 mL/min/1.73 m²) are relatively stable, suggesting that the kidney disease is in an early stage, which is typical of membranous nephropathy.
There is no significant hematuria (only 1–4 RBCs/HPF) and no signs of inflammation like high white blood cell counts or active urinary casts. This rules out many glomerular diseases that cause prominent hematuria, such as IgA nephropath or crescentic glomerulonephritis.
The patient has no systemic signs or symptoms of autoimmune disease, infection, or malignancy, which are often seen in conditions like crescentic glomerulonephritis or minimal change disease in adults with secondary causes.
Polycystic kidney disease has structural abnormalities on ultrasound.

118D41

A 49-year-old man was brought to the hospital by ambulance due to fever and abnormal behavior. A week ago, he had a sore throat and low-grade fever, for which he was prescribed general cold medicine at a local clinic. His low-grade fever persisted, and two days ago, he developed a headache. This morning, his family found him naked in his room, exhibiting incoherent speech and behavior. He has no significant past medical or family history.

On admission, he was conscious but disoriented regarding place and time. He is 170 cm tall and weighs 60 kg. His vital signs included a temperature of 38.5°C, heart rate of 84/min (regular), and blood pressure of 112/70 mmHg. Heart and lung sounds were normal. Nuchal rigidity and a positive Kernig's sign were observed. Cranial nerve examination was unremarkable. There was no motor paralysis in the limbs, and no asymmetry in response to painful stimuli.

Blood test findings: Red blood cell count was 5.2 million/μL, hemoglobin was 15.2 g/dL, and hematocrit was 45%, all within the normal range. White blood cell count was 7,500/μL, and platelet count was 280,000/μL, both normal. Blood glucose level was 100 mg/dL, and CRP was 0.1 mg/dL, indicating no significant systemic inflammation.

Cerebrospinal fluid (CSF) findings: The opening pressure was 180 mmH2O (normal: 70–170 mmH2O), slightly elevated. The CSF appeared xanthochromic. The cell count was 98/mm³ (normal: 0–2/mm³), predominantly mononuclear (98% mononuclear cells, 2% polymorphonuclear cells). Protein was 150 mg/dL (normal: 15–45 mg/dL), significantly elevated. Glucose was 50 mg/dL (normal: 50–75 mg/dL), within the normal range.

A FLAIR MRI of the brain is provided.

What is the most appropriate initial treatment for this patient?

a. Administration of antibiotics
b. Advising rest at home
c. Administration of heparin
d. Administration of diazepam
e. Administration of acyclovir

The correct answer is e. Administration of acyclovir.

After preceding cold-like symptoms, the patient developed headache, abnormal behavior, and impaired consciousness.
Nuchal rigidity and a positive Kernig's sign raise suspicion of meningitis, but the findings on the plain head MRI suggest otherwise.
High-signal areas are observed in the medial temporal lobe, pointing towards herpes simplex virus (HSV) encephalitis.
The cerebrospinal fluid findings show an increase in cell count with a predominance of mononuclear cells, and the glucose level remains within the normal range, further supporting a viral etiology.
HSV encephalitis is a medical emergency with high morbidity and mortality if left untreated. Empirical treatment with acyclovir, a potent antiviral for HSV, must be initiated immediately upon suspicion.

118D44

An 82-year-old woman was brought to the clinic by her son, who was concerned about her memory loss. Five years ago, she began repeatedly asking the same questions. One year ago, she started getting lost and became unable to shop or cook on her own. She has been observed to become angry at her own reflection in the mirror. During the consultation, she appeared anxious, frequently glancing at her son, and answered the date incorrectly when asked. Her score on the Revised Hasegawa's Dementia Scale was 11 points (out of 30). Neurological examination showed no abnormalities. Blood biochemistry and electroencephalography results were normal. FLAIR horizontal MRI and T1-weighted coronal MRI images of the brain are shown.

What is the most appropriate medication for this patient?

a. Diazepam
b. Donepezil
c. Paroxetine
d. Haloperidol
e. Levodopa (L-dopa)

The correct answer is b. Donepezil.

The patient exhibits progressive memory impairment, characterized by repetitive questioning that has worsened over time. Additionally, she has developed disorientation (e.g., getting lost), an inability to perform activities of daily living such as shopping and cooking, and behavioral changes, such as becoming angry at her reflection. These symptoms are consistent with Alzheimer’s disease. Furthermore, a score of 11 out of 30 on the Revised Hasegawa Dementia Scale indicates moderate dementia.
Donepezil is a cholinesterase inhibitor that increases acetylcholine levels in the brain, helping to improve cognitive function or slow cognitive decline in patients with Alzheimer’s disease.
Diazepam is used for anxiety or agitation but can worsen confusion and cognitive impairment in patients with dementia.
Paroxetine is an antidepressant.
Haloperidol is an antipsychotic used for severe agitation or psychosis.
Levodopa (L-dopa) is used for Parkinson’s disease.

118D45

A 69-year-old woman presented with involuntary movements as the chief complaint. Fifteen years ago, she developed tremors in her right hand and slowed movements, leading to a diagnosis of Parkinson’s disease. She began taking anti-Parkinson’s medications, which improved her symptoms. Five years ago, she started experiencing difficulty walking. One year ago, the effectiveness of her anti-Parkinson’s medications began to diminish, and at times, she became unable to walk. When the dosage of her anti-Parkinson’s medications was increased, she developed irregular, repetitive involuntary movements of her trunk and upper and lower limbs, making it impossible for her to maintain a seated position.

What is the involuntary movement described above?

a. Tics
b. Dystonia
c. Resting tremor
d. Dyskinesia
e. Myoclonus

The correct answer is d. Dyskinesia.

Dyskinesia is a hyperkinetic movement disorder caused by excessive dopaminergic stimulation, often seen in patients with advanced Parkinson's disease who have been on levodopa therapy for many years. These movements are typically irregular, involuntary, and choreiform (dance-like), involving the trunk, limbs, or face.
Tics are stereotyped, sudden, repetitive movements or vocalizations, often seen in conditions like Tourette syndrome.
Dystonia involves sustained, twisting muscle contractions, which cause abnormal postures.
A hallmark symptom of Parkinson’s disease, resting tremor is rhythmic and occurs when the muscles are at rest.
Myoclonus refers to sudden, brief, shock-like muscle jerks.

118D46

A 65-year-old man visited the clinic for a regular check-up. He has been receiving treatment for diabetes and hypertension at a local clinic, where he is prescribed a biguanide, a DPP-4 inhibitor, and an angiotensin receptor blocker (ARB). He reports no subjective symptoms. He has no history of smoking or alcohol consumption and walks 7,000 steps daily for exercise.

His height is 164 cm, weight 60 kg, pulse 72/min (regular), and blood pressure 118/72 mmHg. Home blood pressure readings are in the 120s/70s. Chest and abdominal examinations show no abnormalities. Bilateral Achilles tendon reflexes are absent.

Urine findings: Protein 3+, occult blood (-). Sediment shows 1–2 RBCs/HPF, 0–1 WBCs/HPF, and no casts. Spot urine protein is 500 mg/dL, and spot urine creatinine is 250 mg/dL.

Blood test results: RBC 3.0 million/μL, Hb 10.0 g/dL, Ht 33%, WBC 6,200/μL, platelets 310,000/μL.

Biochemical findings: Blood urea nitrogen (BUN) 25 mg/dL, creatinine 1.2 mg/dL, eGFR 48.0 mL/min/1.73 m², uric acid 6.0 mg/dL, blood glucose 120 mg/dL, HbA1c 7.2% (normal: 4.9–6.0%), Na 142 mEq/L, K 5.0 mEq/L, Cl 108 mEq/L.

What medication should be added to slow the progression of this patient’s renal dysfunction?

a. Urate-lowering drug
b. SGLT2 inhibitor
c. Calcium channel blocker
d. Sulfonylurea drug
e. Cation-exchange resin

The correct answer is b. SGLT2 inhibitor.

The patient’s profile, with diabetes, proteinuria, and reduced eGFR, makes an SGLT2 inhibitor the best choice to slow the progression of chronic kidney disease (CKD). This medication complements the benefits of the angiotensin receptor blocker (ARB) already prescribed.
Urate-lowering therapy is not indicated unless there is hyperuricemia or gout.
Calcium channel blockers can help control hypertension.
Sulfonylurea drug lowers blood glucose but offer no renal benefits.
Cation-exchange resin is used to treat hyperkalemia.

118D47

A 34-year-old man was referred to the clinic after a chest abnormality was noted during a health checkup. He has no history of abnormal chest findings and no symptoms of cough or sputum production. His body temperature is 35.9°C, pulse 64/min (regular), blood pressure 132/84 mmHg, respiratory rate 16/min, and SpO2 is 98% (on room air). No abnormalities are found in heart sounds or breath sounds. A contrast-enhanced chest CT is shown.

What is the most likely diagnosis?

a. Thymoma
b. Pleural mesothelioma
c. Mature teratoma
d. Malignant lymphoma
e. Neurogenic tumor

The correct answer is e. Neurogenic tumor.

The location in the posterior mediastinum, the well-circumscribed lesion, and the asymptomatic presentation strongly point toward a neurogenic tumor.
Thymoma and mature teratoma are typically located in the anterior mediastinum, not the posterior mediastinum.
Pleural mesothelioma originates from the pleura and is commonly associated with asbestos exposure.
Lymphomas generally involve multiple mediastinal lymph nodes, causing a more diffuse pattern or large anterior mediastinal masses.

118D48

A 3-year-old girl was brought to the clinic by her parents after a heart murmur was detected for the first time during her 3-year-old health checkup. There are no reported issues with her activities at daycare. Her medical and family histories are unremarkable. On auscultation, a fixed splitting of the second heart sound (S2) is noted. A Levine grade 2/6 systolic murmur is heard at the left sternal border in the 2nd intercostal space, and a Levine grade 2/6 diastolic murmur is heard primarily at the lower left sternal border. The abdomen is flat and soft, with no palpable liver. Echocardiography reveals a 12 mm atrial septal defect (ASD) with enlargement of the right atrium and right ventricle. There are no findings suggestive of pulmonary hypertension.

What is the most appropriate explanation to provide to the parents regarding atrial septal defect?

a. "This is a disease that often has a genetic cause."
b. "She should avoid physical activity at daycare."
c. "It is common for arrhythmias to occur during childhood."
d. "Salt restriction is necessary to reduce the heart's workload."
e. "We need to consider closing the defect at the appropriate time."

The correct answer is e. ("We need to consider closing the defect at the appropriate time.").

While some small ASDs (<5 mm) may close spontaneously in early childhood, larger defects like the 12 mm ASD in this patient are unlikely to close on their own and may require intervention.
While some ASDs are associated with genetic syndromes (e.g., Down syndrome), most isolated ASDs are not inherited.
Children with ASDs are typically asymptomatic and can engage in normal activities.
Arrhythmias are a potential complication of untreated ASD, but they usually occur in adulthood, not childhood.
Salt restriction is only used in cases of heart failure or significant pulmonary hypertension.

118D49

A 28-year-old woman (G0P0) presented with abdominal pain and shortness of breath the day after undergoing embryo transfer. She was diagnosed with polycystic ovary syndrome (PCOS) one year ago and has been receiving infertility treatment. She underwent in vitro fertilization (IVF) with embryo transfer using ovulation-inducing medications.

Her height is 170 cm, weight 71 kg, body temperature 36.6°C, pulse 76/min (regular), and blood pressure 102/60 mmHg. Heart and breath sounds are normal. The abdomen is distended, and a pelvic exam reveals bilateral adnexal enlargement.

Laboratory findings: RBC 4.9 million/μL, Hb 16.6 g/dL, Ht 52%, WBC 14,000/μL, platelets 260,000/μL, otal protein 6.8 g/dL, albumin 3.9 g/dL, AST 30 U/L, ALT 24 U/L, BUN 12 mg/dL, creatinine 0.7 mg/dL, Na 142 mEq/L, K 3.2 mEq/L, Cl 98 mEq/L

Ultrasound findings: Bilateral ovarian enlargement is observed, with multiple cysts consistent with ovarian hyperstimulation syndrome (OHSS). There is also free fluid in the abdomen, indicating ascites.

What is the first treatment to be administered?

a. Intravenous fluids
b. Plasma exchange
c. Administration of antibiotics
d. Bilateral adnexectomy
e. Administration of albumin products

The correct answer is a. Intravenous fluids.

The patient suffers from polycystic ovary syndrome (PCOS) and has undergone IVF with ovulation induction, which can lead to ovarian hyperstimulation syndrome (OHSS).
OHSS can cause hypotension, hypovolemia, and an increased risk of thromboembolic events. The patient presents with symptoms such as abdominal pain, abdominal distention, and shortness of breath. The diagnosis is confirmed by ultrasound findings showing enlarged ovaries with multiple cysts.
Intravenous fluid therapy is the first-line treatment to restore intravascular volume, correct hemoconcentration, and ensure hemodynamic stability.

118D51

A 26-year-old woman (G0P0) visited the clinic after abnormalities were noted during a cervical cancer screening. Her cervical cancer screening 4 years ago was normal. She has no significant medical or family history. She has a history of smoking 20 cigarettes/day for 5 years starting at age 20. She drinks alcohol occasionally. Pelvic examination and transvaginal ultrasound showed no abnormalities in the uterus or ovaries. Vaginal speculum examination revealed no gross abnormalities of the cervix. The colposcopy image after acetic acid application is shown.

What is the diagnosis?

a. Behçet's disease
b. Bowen's disease
c. Chronic cervicitis
d. Cervical adenocarcinoma
e. Cervical intraepithelial neoplasia (CIN)

The correct answer is e. Cervical intraepithelial neoplasia (CIN).

The colposcopy image after the application of acetic acid shows an acetowhite epithelium with irregular borders and possible vascular changes. These characteristics are typical of CIN.
The patient’s smoking history (20 cigarettes/day for 5 years) is a risk factor for cervical dysplasia, as smoking reduces the immune defenses against human papillomavirus (HPV), the primary risk factor for cervical cancer.
Behçet’s disease is an autoimmune condition that causes ulcers and systemic inflammation.
Bowen’s disease is an in situ squamous cell carcinoma of the skin.
Chronic cervicitis is generally associated with redness and vaginal discharge.
Cervical adenocarcinoma originates from the glandular epithelium and typically does not produce acetowhite changes.

118D52

A 19-year-old male visited the clinic for evaluation of leukocytosis. One week ago, he developed fever and sore throat and visited a local clinic, where leukocytosis was noted. He was referred for further evaluation. His body temperature is 37.8°C, pulse 92/min (regular), and blood pressure 118/76 mmHg. No abnormalities are noted in the palpebral or bulbar conjunctiva. There is redness and swelling of both tonsils with a white coating on their surface. Multiple lymph nodes, 2 cm in diameter, are palpable in both sides of the neck and are tender. Heart and lung sounds are normal. The abdomen is flat and soft, with the liver palpable 2 cm below the costal margin. The spleen is not palpable.

Blood test results: Hematology: RBC 4.93 million/μL, Hb 14.3 g/dL, Ht 44%, WBC 26,000/μL (bands 1%, segmented neutrophils 7%, eosinophils 0%, basophils 0%, monocytes 2%, lymphocytes 75%, atypical lymphocytes 15%), platelets 180,000/μL. Biochemistry: Total bilirubin 1.3 mg/dL, direct bilirubin 0.7 mg/dL, AST 202 U/L, ALT 268 U/L, LD 637 U/L (normal range: 124–222), ALP 306 U/L (normal range: 38–113), creatinine 0.9 mg/dL, uric acid 7.1 mg/dL, CRP 0.9 mg/dL.

What is the appropriate management for this patient?

a. Observation
b. Plasma exchange
c. Administration of acyclovir
d. Administration of ampicillin
e. Administration of cytotoxic anticancer drugs

The correct answer is a. Observation.

Infectious mononucleosis caused by the Epstein-Barr virus (EBV) typically presents with fever, tonsillar redness and swelling, lymphadenopathy, and hepatomegaly.
Moreover, its laboratory findings include leukocytosis with a predominance of lymphocytes and atypical lymphocytes, as well as elevated liver enzymes.
A normal platelet count and CRP support the absence of a severe bacterial infection or a systemic inflammatory response.
Observation and supportive care are the standard approaches for managing infectious mononucleosis.

118D53

A 55-year-old man presented with exertional dyspnea. Six months ago, he reported blurred vision and was diagnosed with uveitis, for which he received treatment. Over the past month, he experienced shortness of breath while climbing stairs, prompting his visit.

He is alert and conscious. His vital signs include a body temperature of 36.5°C, pulse rate of 40/min (regular), blood pressure of 112/74 mmHg, respiratory rate of 16/min, and SpO₂ of 97% on room air. On auscultation, a third heart sound (S3) is heard. No abnormalities are noted in breath sounds or the neurological examination.

Laboratory findings: Hematology: RBC 4.23 million/μL, Hb 13.1 g/dL, Hct 42%, WBC 5,800/μL, platelets 180,000/μL. Biochemistry: Total protein 6.7 g/dL, AST 25 U/L, ALT 20 U/L, blood urea nitrogen 24 mg/dL, creatinine 1.2 mg/dL, blood glucose 92 mg/dL, BNP 470 pg/mL (normal: ≤18.4 pg/mL), CRP 0.1 mg/dL.

A 12-lead ECG shows a complete atrioventricular (AV) block with a heart rate of 42/min. Echocardiography reveals a left ventricular end-diastolic diameter (LVEDD) of 60 mm, a left ventricular ejection fraction (LVEF) of 38%, and thinning of the basal interventricular septum (8 mm).

Histopathological examination of myocardial biopsy with H&E staining is shown.

What is the diagnosis?

a. Dilated cardiomyopathy
b. Restrictive cardiomyopathy
c. Hypertrophic cardiomyopathy
d. Cardiac amyloidosis
e. Cardiac sarcoidosis

The correct answer is e. Cardiac sarcoidosis.

The combination of uveitis, AV block, ventricular dysfunction, and non-caseating granulomas on biopsy is diagnostic of cardiac sarcoidosis.
Dilated cardiomyopathy would present with similar left ventricular dilation and systolic dysfunction but would not explain the complete AV block, uveitis, or granulomas on biopsy.
Restrictive cardiomyopathy typically involves diastolic dysfunction without significant left ventricular dilation.
Hypertrophic cardiomyopathy would show asymmetric septal hypertrophy, not thinning, and is unrelated to granulomatous inflammation or AV block.
Amyloidosis would present with increased ventricular wall thickness and diastolic dysfunction due to amyloid deposition.

118D54

A 56-year-old man presented with pain in his right eye. One month ago, he underwent resection of a right vestibular schwannoma (acoustic neuroma). Shortly after the surgery, he noticed redness and pain in his right eye. The pain in his right eye has persisted. Photographs taken during eye opening and closing are shown.

What is the diagnosis?

a. Exotropia
b. Ptosis
c. Entropion
d. Facial nerve palsy
e. Oculomotor nerve palsy

The correct answer is d. Facial nerve palsy.

The persistent eye pain and redness, combined with incomplete eyelid closure after vestibular schwannoma surgery, strongly suggest facial nerve palsy.
Exotropia is a misalignment of the eyes where one eye deviates outward.
Ptosis refers to drooping of the upper eyelid due to dysfunction of the oculomotor nerve (cranial nerve III) or the levator palpebrae superioris muscle.
Entropion is inward turning of the eyelid, leading to eyelashes rubbing against the cornea.
While oculomotor nerve palsy can cause ptosis and other ocular movement issues, it would not explain the inability to close the eyelid or the facial asymmetry typically seen in facial nerve palsy.

118D55

A 78-year-old man developed pneumonia during hospitalization, and a sputum test revealed multidrug-resistant Pseudomonas aeruginosa.

What is the appropriate infection prevention measure?

a. Isolation in a private room is not necessary.
b. Wear an N95 mask during examination.
c. Ensure that everyone entering the room understands the same prevention measures.
d. If gloves are used during contact with the patient, handwashing is not required after removing the gloves.
e. If sputum suctioning is not performed, Personal Protective Equipment (PPE) is not required.

The correct answer is c. Ensure that everyone entering the room understands the same prevention measures.

To effectively control the spread of multidrug-resistant Pseudomonas aeruginosa (MDR-PA), it is crucial that all individuals entering the room understand and adhere to the same infection prevention measures.
Patients with MDR-PA are typically isolated in a private room or cohorted with other patients infected by the same pathogen to reduce the risk of cross-contamination.
This pathogen is primarily spread through contact, not airborne transmission, so N95 masks are unnecessary unless there is concern about aerosol-generating procedures.
Even after glove removal, hand hygiene is essential because pathogens can contaminate hands during glove removal or through microscopic glove breaches.
Personal protective equipment (PPE), including gloves and gowns, is required during patient care to prevent contact transmission, regardless of whether suctioning is performed.

118D56

A 55-year-old man presented with dysphagia. Around the age of 35, he developed coarse action tremors in both hands and muscle weakness in the lower limbs, which gradually progressed. By the age of 40, muscle weakness had also appeared in the upper limbs. By the age of 50, he began to experience slurred speech, and six months ago, dysphagia developed along with a nasal voice. He is barely able to walk on level ground. Fasciculations of the facial muscles are observed during speech. He is the youngest of three siblings, and his older brother reportedly has the same symptoms. A photograph taken during tongue protrusion is shown.

What is the most likely diagnosis?

a. Huntington's disease
b. Spinal and bulbar muscular atrophy (SBMA)
c. Adrenoleukodystrophy
d. Charcot-Marie-Tooth disease
e. Becker muscular dystrophy

The correct answer is b. Spinal and bulbar muscular atrophy (SBMA), also known as Kennedy's disease.

The combination of progressive limb weakness, bulbar involvement, fasciculations, and a family history strongly supports the diagnosis of spinal and bulbar muscular atrophy (SBMA).
Although Huntington's disease is hereditary, it primarily causes chorea, cognitive decline, and psychiatric symptoms.
Adrenoleukodystrophy is associated with adrenal dysfunction and neurological symptoms related to white matter damage.
Charcot-Marie-Tooth (CMT) disease typically causes distal muscle weakness and sensory loss.
Becker muscular dystrophy causes proximal muscle weakness and calf hypertrophy.

118D57

A 67-year-old man was brought to the emergency department by ambulance due to altered consciousness and had been experiencing headache and nausea for a week while last night he developed weakness in both lower limbs and was unable to move which progressed to worsening consciousness this morning prompting his family to call an ambulance approximately 1.5 months after he fell and hit his head his level of consciousness on arrival was JCS II-20 with vital signs showing a body temperature of 36.3°C heart rate of 64 bpm regular blood pressure of 134/88 mmHg respiratory rate of 16/min and SpO₂ of 98% on room air both pupils were 2.5 mm in size with no asymmetry and there were no lateral differences in limb movement though the patient could not stand his blood glucose level was 116 mg/dL and horizontal head CT scans from 1.5 months ago and upon arrival were reviewed.

What is the appropriate management for this patient?

a. Observation
b. Decompressive craniectomy
c. Stent placement
d. Ventricular drainage
e. Burr hole drainage of hematoma

The correct answer is e. Burr hole drainage of hematoma.

The patient has a history of head trauma 1.5 months ago. Symptoms such as headache, nausea, bilateral lower limb weakness, and worsening consciousness suggest increasing intracranial pressure and mass effect caused by the hematoma.
The CT scans show findings typical of a chronic subdural hematoma (SDH), including a hypodense or mixed-density crescent-shaped lesion on the brain's surface, consistent with old blood that has liquefied over time.
Chronic SDH is treated effectively by burr hole drainage, a minimally invasive procedure that allows the evacuation of the hematoma and relieves pressure on the brain.
Decompressive craniectomy is typically used for severe traumatic brain injury or acute swelling.
Stents are used in conditions such as cerebral aneurysms or vascular stenosis.
Ventricular drainage is used for conditions like hydrocephalus or intraventricular hemorrhage.

118D58

A 63-year-old man presented with diarrhea and had been experiencing upper abdominal pain and back pain after drinking alcohol since the age of 50 for which he sought treatment at a nearby clinic where he was advised to stop drinking but he discontinued his visits at the age of 55 and has not sought medical attention for 8 years now returning due to persistent diarrhea occurring 8 times a day for the past 6 months he has a history of heavy alcohol consumption equivalent to 5 servings of sake daily for 43 years his height is 168 cm and weight is 45 kg and physical examination reveals no abnormalities in the chest or abdomen his blood tests show red blood cell count of 4.02 million per μL hemoglobin 12.1 g/dL hematocrit 40% white blood cell count 4,200 per μL and platelets 180,000 per μL his biochemistry results reveal total protein 6.8 g/dL albumin 3.5 g/dL total bilirubin 0.8 mg/dL AST 17 U/L ALT 28 U/L LD 199 U/L (normal range 124–222) ALP 43 U/L (normal range 38–113) amylase 40 U/L (normal range 44–132) blood glucose 96 mg/dL HbA1c 6.2% (normal range 4.9–6.0%) and CA19-9 36 U/mL (normal ≤37) abdominal ultrasound reveals diffuse calcification of the pancreas but no masses.

What is the likely finding in this patient?

a. Melena (black stools)
b. Steatorrhea (fatty stools)
c. Mucus and bloody stools
d. Pale-colored stools
e. Pellet-like stools (rabbit droppings)

The correct answer is b. Steatorrhea (fatty stools).

The patient’s long history of alcohol use, symptoms of chronic diarrhea, and findings of pancreatic calcification point to chronic pancreatitis with exocrine pancreatic insufficiency, leading to steatorrhea.
Melena (black stools) indicates upper gastrointestinal bleeding.
Mucus and bloody stools suggest inflammatory or infectious colitis.
Pale-colored stools are typically seen in biliary obstruction (e.g., bile duct stones or tumors).
Pellet-like stools (rabbit droppings) suggest constipation.

118D59

A 24-year-old woman visited a psychiatrist due to repeated episodes of overdosing on medication at her workplace. Until elementary school, she had no issues with her academic performance or daily life and was highly praised by her teachers. However, starting in middle school, she began to have sudden outbursts of anger at school, and during high school, she repeatedly entered and ended relationships with men. From around the age of 20, whenever a breakup with a partner was discussed, she engaged in self-harming behaviors. After graduating from university at the age of 22, she began working in an office job. She started visiting a psychiatrist and was prescribed antidepressants and sleeping pills. At her workplace, whenever she was criticized for mistakes, she would repeatedly take approximately 10 sleeping pills at once.

What is the diagnosis?

a. Bipolar disorder
b. Schizophrenia
c. Autism spectrum disorder
d. Attention-deficit hyperactivity disorder (ADHD)
e. Personality disorder

The correct answer is e. Personality disorder.

The combination of emotional instability, self-harming behavior, impulsivity, and relationship difficulties strongly suggests borderline personality disorder.
Bipolar disorder presents with distinct phases of mania and depression.
Schizophrenia is characterized by psychotic symptoms such as delusions, hallucinations, or disorganized thinking.
Self-harming behavior or impulsive actions are not typically observed in autism spectrum disorder or attention-deficit/hyperactivity disorder (ADHD).

118D60

A 56-year-old woman presented with headaches and had been taking calcium channel blockers for hypertension diagnosed 10 years ago she noticed her fingers turning pale during the winter starting two years ago and developed swelling in her fingers six months ago she began experiencing persistent headaches two weeks ago prompting her to seek medical attention her consciousness is clear she is 165 cm tall and weighs 52 kg her temperature is 36.5°C her pulse rate is 100 bpm regular her blood pressure is 176/102 mmHg (previously 120/80 mmHg one month ago) her respiratory rate is 16/min and her SpO₂ is 96% on room air she has skin hardening from the fingers to the forearms her heart and lung sounds are normal her abdomen is flat and soft with no palpable liver or spleen pitting edema is observed in both lower legs and neurological examination shows no abnormalities her urine test reveals proteinuria 1+ and occult blood 1+ her blood test shows red blood cells 4.06 million/μL hemoglobin 10.9 g/dL hematocrit 40% reticulocytes 1.2% white blood cells 4,300/μL (neutrophils 69% eosinophils 1% basophils 1% monocytes 8% lymphocytes 21%) platelets 150,000/μL her biochemical findings reveal total protein 7.5 g/dL albumin 3.6 g/dL total bilirubin 1.1 mg/dL AST 28 U/L ALT 16 U/L LD 197 U/L (normal range 124–222) γ-GT 32 U/L (normal range 9–32) CK 122 U/L (normal range 41–153) blood urea nitrogen 40 mg/dL creatinine 1.8 mg/dL (previously 0.7 mg/dL one month ago) Na 139 mEq/L K 4.8 mEq/L Cl 97 mEq/L plasma renin activity 8.6 ng/mL/hour (normal range 1.2–2.5) her immunoserological findings show CRP 0.5 mg/dL ANA titer 1:160 (normal ≤20) and positive anti-RNA polymerase III antibodies abdominal ultrasound shows no abnormalities in the renal or urinary systems.

What is the appropriate treatment for this patient?

a. Beta-blockers
b. Loop diuretics
c. Glucocorticoids
d. Anticholinesterase drugs
e. Angiotensin-converting enzyme (ACE) inhibitors

The correct answer is e. Angiotensin-converting enzyme inhibitors (ACE inhibitors).

The combination of features associated with systemic sclerosis, including Raynaud's phenomenon (pale fingers in winter), acute kidney injury, and accelerated hypertension, strongly suggests scleroderma renal crisis (SRC).
ACE inhibitors reduce the activity of the renin-angiotensin-aldosterone system (RAAS) and are the first-line treatment because they control hypertension and protect renal function.

118D61

A 35-year-old man presented with throat pain and fever. He had experienced throat pain and a fever of 38°C for the past three days. The pain gradually worsened, and this morning, he had difficulty opening his mouth and swallowing, prompting him to visit the emergency department. His consciousness was clear. His temperature was 38.5°C, pulse rate 92/min (regular), blood pressure 124/80 mmHg, and SpO₂ 98% on room air. No stridor was heard in the neck. The pharyngeal image is shown.

What is the diagnosis?

a. Oropharyngeal cancer
b. Tonsillar hypertrophy
c. Acute epiglottitis
d. Peritonsillar abscess
e. Infectious mononucleosis

The correct answer is d. Peritonsillar abscess.

The combination of trismus (inability to open the mouth), dysphagia (difficulty swallowing), fever, worsening throat pain, and the characteristic findings on examination (asymmetry of the tonsillar area) strongly indicates a peritonsillar abscess.
Oropharyngeal cancer typically presents with chronic symptoms, such as a non-healing sore or progressive difficulty swallowing, rather than acute fever and trismus.
Tonsillar hypertrophy involves enlarged tonsils but does not cause acute fever, trismus, or severe pain.
Acute epiglottitis is typically associated with stridor, drooling, and difficulty breathing.
While infectious mononucleosis can cause fever, throat pain, and tonsillar swelling, it does not typically cause trismus or uvular displacement.

118D62

A 67-year-old woman was transferred due to fever and abdominal pain. She had been hospitalized in a nearby hospital for severe acute pancreatitis for four weeks. Her condition had improved with fasting, large-volume intravenous fluids, and protease inhibitors, but fever and abdominal pain appeared five days ago and did not improve with antibiotic treatment, prompting her transfer. Her consciousness was clear, body temperature was 37.6°C, heart rate was 84/min and regular, blood pressure was 128/80 mmHg, respiratory rate was 18/min, and oxygen saturation was 98% on room air. There was tenderness in the epigastrium but no rebound tenderness or guarding. Blood test results showed red blood cells at 4.3 million/μL, hemoglobin at 11.9 g/dL, hematocrit at 35%, white blood cells at 11,100/μL, and platelets at 250,000/μL. Biochemical findings included albumin at 2.9 g/dL, AST at 27 U/L, ALT at 17 U/L, LD at 220 U/L (normal range 124–222), amylase at 58 U/L (normal range 44–132), BUN at 10 mg/dL, and creatinine at 0.5 mg/dL. C-reactive protein was elevated at 17 mg/dL. Abdominal contrast-enhanced CT is shown.

What is the diagnosis?

a. Chronic pancreatitis
b. Pancreatic pseudocyst
c. Anomalous pancreaticobiliary junction
d. Walled-off necrosis (WON)
e. Intraductal papillary mucinous neoplasm (IPMN)

The correct answer is d. Walled-off necrosis (WON).

The patient had a history of severe acute pancreatitis treated with fasting, large-volume intravenous fluids, and protease inhibitors, which initially improved her condition.
Five days ago, she developed fever and abdominal pain that did not respond to antibiotics, indicating a complication of pancreatitis.
The abdominal contrast-enhanced CT likely shows a well-defined collection surrounded by a thick capsule, which is characteristic of walled-off necrosis (WON).
WON is a late complication of acute pancreatitis, typically occurring 4 weeks or more after the initial episode. It involves necrotic pancreatic tissue that has become encapsulated.
Chronic pancreatitis develops over time with recurrent inflammation and does not present with acute symptoms like fever or abdominal pain in the short term.
While pancreatic pseudocysts also occur as a complication of pancreatitis, they consist of fluid without necrotic tissue.
Anomalous pancreaticobiliary junction is a congenital anomaly.
Intraductal papillary mucinous neoplasm (IPMN) is a premalignant cystic lesion of the pancreas.

118D63

A 7-year-old boy presented with frequent vomiting and generalized fatigue, brought in by his mother. At the start of the new school term, he experienced easy fatigability and reduced appetite. Last night, he vomited and was unable to eat. Since this morning, he has been vomiting repeatedly and appeared lethargic, prompting his visit to the clinic. He has had similar episodes since the age of 6, with multiple recurrences, and was hospitalized one month ago for further investigation without any structural abnormalities identified. His consciousness is clear, and his face is pale. He is 121 cm tall, weighs 21 kg, and has a temperature of 36.3°C. His pulse is 124 beats per minute and regular, with a blood pressure of 100/68 mmHg, a respiratory rate of 30 breaths per minute, and an SpO2 of 98% on room air. Cardiac and respiratory sounds are normal. His abdomen is flat and soft, with reduced bowel sounds, and his skin turgor is decreased. Urinalysis shows ketone bodies 3+.

Which of the following is the venous blood gas analysis (on room air) result for this patient?

a. a
b. b
c. c
d. d
e. e

The correct answer is a.

The patient has repeated vomiting, resulting in metabolic acidosis due to the loss of bicarbonate in gastric contents and the presence of ketone bodies in the urine, indicating ketosis, likely caused by prolonged fasting or insufficient caloric intake. The blood gas analysis should show a low pH, normal or slightly low PCO₂, and reduced HCO₃⁻, which matches option a.

118D64

A 52-year-old man presented with a 2-week history of fever around 38°C and cough and was admitted to the hospital following a bronchoscopy. He reported coughing at work but not at home. His past medical history is unremarkable. He has a smoking history of 40 cigarettes per day from age 20 to 48. He lives in a 30-year-old detached house. His occupational history includes working as an office worker until 5 years ago and since then, engaging in indoor mushroom cultivation. He is alert and oriented. His height is 163 cm, weight 61 kg, body temperature 37.3°C, pulse 84/min regular, blood pressure 132/80 mmHg, respiratory rate 20/min, and SpO₂ 94% on room air. Heart and lung sounds are normal. Blood tests show RBC 4.4 million/μL, Hb 13.6 g/dL, WBC 4,200/μL, platelets 210,000/μL, KL-6 1,300 U/mL (normal <500), CRP 3.1 mg/dL, and negative antinuclear antibody. Chest X-ray reveals bilateral granular and faint infiltrative shadows in the lung fields. Chest CT shows granular shadows and ground-glass opacities. After admission, the fever and cough resolved spontaneously. On the 7th day of hospitalization, SpO₂ was 98% on room air. A trial of discharge to home revealed no recurrence of symptoms, and the patient was discharged on the 10th day.

Which of the following is a characteristic finding of this disease?

a. Sputum: Positive for acid-fast bacilli
b. Biochemical test: Elevated serum IgA levels
c. Pulmonary function test FEV1%: 60% or lower
d. Bronchoalveolar lavage (BAL): Increased lymphocyte fraction
e. Transbronchial lung biopsy histology: Diffuse alveolar damage (DAD)

The correct answer is d. Increased lymphocyte fraction in bronchoalveolar lavage (BAL).

The patient has a cough but does not experience it at home. His symptoms of fever and cough improved after hospitalization, which suggests an allergic reaction.
He works in indoor mushroom cultivation, a known occupational risk for hypersensitivity pneumonitis (HP).
This condition is associated with lymphocytic alveolitis, confirmed by an increased lymphocyte fraction in BAL, which is a hallmark feature of HP.
A positive sputum test for acid-fast bacilli would suggest tuberculosis.
Elevated serum IgA is not a typical finding.
FEV1% ≤ 60% is characteristic of obstructive lung diseases such as COPD or asthma.
Diffuse alveolar damage (DAD) occurs in acute respiratory distress syndrome (ARDS) or severe lung injuries.

118D65
An 8-year-old girl was brought by her father due to a rash on her face and trunk She had a low-grade fever yesterday and today the rash appeared on her face and trunk leading to this consultation Her body temperature is 37.7°C The skin findings on her face are shown in the image Her general condition is good and pharyngeal redness is noted A rapid test for group A streptococcus was positive

Which complication should be monitored in this patient?

a. Coronary aneurysm
b. Interstitial pneumonia
c. Thrombocytopenia
d. Acute glomerulonephritis
e. Subacute sclerosing panencephalitis

The correct answer is d. Acute glomerulonephritis.

This 8-year-old girl presents with a rash, pharyngeal redness, and a positive rapid test for group A streptococcus (GAS), suggesting scarlet fever caused by streptococcal infection.
A potential complication of GAS infection is acute post-streptococcal glomerulonephritis (APSGN).
APSGN typically develops 1–2 weeks after a streptococcal throat infection or scarlet fever and is caused by immune complex deposition in the glomeruli.
Symptoms include hematuria (cola-colored urine), proteinuria, edema, and hypertension.

118D66
A 9-year-old boy presented by ambulance due to abdominal pain. Vomiting began two days ago and gradually increased in frequency, accompanied by intermittent abdominal pain. His vital signs showed a body temperature of 36.8°C, a heart rate of 120 beats per minute (regular), a blood pressure of 116/66 mmHg, and a respiratory rate of 24 breaths per minute. His SpO₂ was 98% on room air. On examination, the abdomen was mildly distended, soft, with diminished bowel sounds. A mass was palpable in the right flank, and tenderness was noted in the right upper abdomen. Abdominal ultrasound revealed a target sign in the midline abdomen. Noninvasive air reduction was successfully performed. A subsequent 99mTcO₄⁻ scintigraphy scan is shown.
What is the diagnosis?
a. Crohn's disease
b. Meckel's diverticulum
c. Malignant lymphoma
d. Intestinal malrotation
e. Colonic polyposis

The answer is b. Diverticulum of Meckel.

Intermittent abdominal pain and vomiting are common in complications of a Meckel’s diverticulum, such as intussusception, which was likely indicated by the "target sign" seen on the ultrasound.
The reduction of the intussusception with air enema supports the presence of a leading point for the intussusception, which in this case, is likely the Meckel’s diverticulum.
Technetium-99m pertechnetate scan detects ectopic gastric mucosa, which is often present in a Meckel’s diverticulum. The scan shows abnormal uptake, confirming the presence of ectopic gastric mucosa.
Crohn’s disease typically presents with chronic symptoms such as diarrhea, weight loss, and abdominal pain, not acute intussusception or a positive technetium scan.
Malignant lymphoma is rare in children and would present with systemic symptoms like fever, weight loss, or lymphadenopathy, and not a target sign or positive technetium scan.
Malrotation would typically cause volvulus or bilious vomiting but is unrelated to a technetium scan.
Colonic polyposis presents with rectal bleeding or multiple polyps seen on colonoscopy, not intussusception or findings on a technetium scan.

118D67
A 47-year-old man was referred to the clinic after an enlarged optic disc cupping was noted in both eyes during a health checkup. He has no subjective symptoms. His corrected visual acuity is 1.0 in both eyes, and his intraocular pressure is 20 mmHg in the right eye and 18 mmHg in the left eye.

Which tests should be performed first? Select two.
a. Gonioscopy
b. Color vision test
c. Visual field test
d. Hess red-green test
e. Electroretinography (ERG)

The correct answers are a. Gonioscopy and c. Visual field examination.

This patient was found to have bilateral optic disc cupping during a screening, which raises the suspicion of glaucoma, even though he has no subjective symptoms and normal corrected visual acuity. The slightly elevated intraocular pressure in the right eye (20 mmHg) also supports this concern.
Gonioscopy is essential to determine whether the patient has open-angle glaucoma or angle-closure glaucoma.
A visual field test can detect functional deficits in vision, even if the patient does not report symptoms, and is essential for evaluating the extent of damage caused by glaucoma.
Color vision test is useful for certain retinal or optic nerve diseases.
Hess test assesses ocular motility and alignment.
Electroretinogram evaluates retinal function.

118D68
A 60-year-old woman visited the clinic after a right adrenal tumor was pointed out during an abdominal ultrasound examination conducted during a health check-up. She has been attending a local clinic near her home for hypertension and diabetes for the past three years, with a gradual increase in her medication. Her height is 163 cm and weight is 64 kg. Her body temperature is 36.2°C, pulse rate is 60/min (regular), and blood pressure is 156/90 mmHg. Her respiratory rate is 14/min and SpO₂ is 98% (room air). She does not show moon face, central obesity, or abdominal and thigh striae. Pitting edema is observed in both lower extremities. Biochemical blood findings reveal fasting blood glucose at 148 mg/dL, HbA1c at 7.4% (reference: 4.9–6.0), sodium at 138 mEq/L, potassium at 3.7 mEq/L, chloride at 102 mEq/L, adrenocorticotropic hormone (ACTH) at 6.2 pg/mL (reference: ≤60), and cortisol at 14.0 μg/dL (reference: 5.2–12.6). A coronal abdominal CT image is shown.

Which tests are useful for evaluating the adrenal tumor in this patient? Choose two.
a. CRH stimulation test
b. Insulin tolerance test
c. Dexamethasone suppression test
d. Adrenal cortex scintigraphy
e. 75 g oral glucose tolerance test

The correct answers are c. Dexamethasone suppression test and d. Adrenal cortex scintigraphy.

The low-dose dexamethasone suppression test assesses if cortisol secretion is appropriately suppressed when exogenous steroids are administered. This patient shows signs of hypercortisolism, including elevated fasting glucose, hypertension, and unsuppressed cortisol levels despite low ACTH levels. These findings raise suspicion of an adrenal tumor producing cortisol autonomously (Cushing's syndrome).
Adrenal cortex scintigraphy helps determine whether the tumor is functioning (hormone-secreting) or non-functioning. This imaging study can evaluate the functional activity of the adrenal lesion and differentiate between benign and malignant etiologies or bilateral versus unilateral hormone secretion, guiding management.
CRH stimulation test is used to differentiate between pituitary-dependent Cushing's disease and ectopic ACTH production, not adrenal tumors.
Insulin tolerance test is used to assess pituitary or hypothalamic function in conditions like hypopituitarism.
Oral glucose tolerance test evaluates glucose metabolism and insulin resistance, primarily for diagnosing diabetes or prediabetes.

118D69
A 62-year-old male presents with palpitations and dyspnea. He had been previously noted to have a heart murmur during a health checkup but left it unaddressed due to the absence of symptoms. Palpitations started three months ago, with episodes becoming progressively longer. He noticed irregular rhythm upon self-checking his pulse. Over the past week, he experienced nocturnal dyspnea causing insomnia, and since three days ago, he developed exertional dyspnea. Two days ago, his palpitations lasted approximately an hour. Physical findings include a height of 168 cm, weight 67 kg, body temperature 36.0°C, pulse rate 68 bpm (regular), blood pressure 120/68 mmHg, respiratory rate 14/min, and SpO₂ 97% (room air). No abnormalities were observed in the palpebral or bulbar conjunctiva. Cardiac examination revealed a pansystolic murmur, grade 3/6, with its maximum intensity at the apex. Breath sounds were unremarkable, and there was no lower limb edema.
Laboratory findings showed red blood cell count 4.11 million, hemoglobin 13.7 g/dL, hematocrit 42%, white blood cell count 7,600, platelet count 240,000. Biochemical findings included total protein 6.9 g/dL, AST 30 U/L, ALT 22 U/L, LD 201 U/L (reference 124–222), blood urea nitrogen 18 mg/dL, creatinine 0.9 mg/dL, Na 136 mEq/L, K 3.7 mEq/L, Cl 110 mEq/L, TSH 0.2 μU/mL (reference 0.2–4.0), FT4 1.0 ng/dL (reference 0.8–2.2), brain natriuretic peptide (BNP) 408 pg/mL (reference ≤18.4), and CRP 0.1 mg/dL.
Non-episode ECG, chest X-ray, parasternal long-axis echocardiographic view, and apical four-chamber echocardiographic view are provided.

Which conditions are likely in this patient? Select two.

a. Pneumonia
b. Anemia
c. Heart failure
d. Atrial fibrillation
e. Hyperthyroidism

The correct answers are c. Heart failure and d. Atrial fibrillation.

The patient presents with symptoms of dyspnea on exertion and orthopnea (difficulty breathing while lying down). The BNP level (408 pg/mL) is significantly elevated, indicating myocardial stress and volume overload, which are consistent with heart failure.
The patient describes noticing an irregular pulse during episodes of palpitations. This is characteristic of atrial fibrillation.
There is no fever, productive cough, or signs of infection on the chest X-ray, making pneumonia unlikely.
The hemoglobin level is normal (13.7 g/dL), ruling out anemia.
While the TSH level is at the lower end of normal (0.2 μU/mL), the FT4 level is normal, which does not support hyperthyroidism as a cause of symptoms.

118D70

A 35-year-old male presents with weight loss as the chief complaint. No abnormalities were noted in last year’s health checkup. Ten days ago, he experienced fever and sore throat, followed by thirst and increased urination. He has nausea and decreased food intake. He has lost 5 kg of weight in the past week. He is alert and oriented. His height is 173 cm, weight is 61 kg, body temperature is 36.8°C, pulse rate is 96 bpm and regular, blood pressure is 108/80 mmHg, respiratory rate is 20 breaths per minute, and oxygen saturation is 98% on room air. No abnormalities are observed in the palpebral or bulbar conjunctiva.

Which two urine test items should be checked first?
a. Glucose
b. Occult blood
c. Protein
d. Ketone bodies
e. Urobilinogen

The correct answers are a. Glucose and d. Ketone bodies.

The patient presents with symptoms of increased thirst, frequent urination, and unintentional weight loss, which are classic signs of diabetes mellitus.
Checking for glucose in the urine can quickly indicate whether there is hyperglycemia causing glucosuria, a hallmark of diabetes.
The presence of ketones in the urine would support a diagnosis of ketosis or diabetic ketoacidosis (DKA), both of which require urgent evaluation and management.
Occult blood is useful for diagnosing conditions like urinary tract infections or glomerulonephritis.
Proteinuria is associated with kidney damage or conditions like nephrotic syndrome.
Elevated urobilinogen is related to liver dysfunction or hemolysis.

118D71

A 72-year-old male visited the hospital with complaints of coughing and loss of appetite. About a month ago, he started experiencing a persistent cough and loss of appetite, which have not improved, prompting the visit. Over the past month, his weight has decreased by 3 kilograms. He is alert and conscious. His height is 168 cm, and his weight is 62 kg. His temperature is 37.2°C. Pulse rate is 92 beats per minute and regular. Blood pressure is 126/82 mmHg. Respiratory rate is 16 breaths per minute. SpO₂ is 94% on room air. There are no abnormalities in the skin. Heart sounds are normal. On lung auscultation, fine crackles are heard at the end of inspiration at the bases of both lungs. The abdomen is flat and soft, with no tenderness, and the liver and spleen are not palpable. There is no edema in the lower extremities. Urinalysis shows protein 2+, glucose 1+, ketone body negative, and occult blood 3+. Blood test results are red blood cells 4.33 million, hemoglobin 12.9 g/dL, hematocrit 41%, reticulocyte count 1.2%, white blood cells 14,400 (neutrophils 78%, eosinophils 1%, monocytes 8%, lymphocytes 13%), platelets 330,000. Blood biochemistry results are total protein 6.8 g/dL, albumin 2.8 g/dL, total bilirubin 0.6 mg/dL, direct bilirubin 0.2 mg/dL, AST 28 U/L, ALT 16 U/L, LD 247 U/L (normal range 124–222), ALP 111 U/L (normal range 38–113), CK 32 U/L (normal range 59–248), BUN 36 mg/dL, creatinine 1.3 mg/dL, blood glucose 138 mg/dL, HbA1c 6.3% (normal range 4.9–6.0). Immunoserology results are CRP 11 mg/dL, β-D-glucan 2.2 pg/mL (normal range ≤10), rheumatoid factor 46 IU/mL (normal range ≤15), ANA negative, MPO-ANCA 122 U/mL (normal range <3.5), PR3-ANCA negative. Abdominal ultrasound reveals no abnormalities in the kidneys or urinary system. Plain chest CT images are shown below.

Which conditions are likely to develop in this patient? Select two options.

a. Myocarditis
b. Alveolar hemorrhage
c. Retroperitoneal fibrosis
d. Autoimmune hepatitis
e. Rapidly progressive glomerulonephritis

The correct answers are b. Alveolar hemorrhage and e. Rapidly progressive glomerulonephritis.

The elevated MPO-ANCA (myeloperoxidase-antineutrophil cytoplasmic antibody) supports the diagnosis of ANCA-associated vasculitis, which can cause pulmonary and renal manifestations.

118D72

A 75-year-old woman (4 pregnancies, 3 births) visited the hospital for the results of her routine postoperative examination. She was diagnosed with stage IB cervical cancer three years ago and underwent a radical hysterectomy and bilateral salpingo-oophorectomy. She has no symptoms. She is being treated for hypertension and dyslipidemia. Her cognitive function is normal, and she is independent in her daily life. Apart from an abdominal surgical scar, no abnormalities were found in her physical examination, urine tests, blood tests, or biochemical tests. Contrast-enhanced CT of the abdomen and pelvis revealed multiple lymph node metastases in the pelvic region. Based on her and her family’s wishes, external pelvic radiation therapy was initiated on an outpatient basis.

What could potentially appear early after starting radiation therapy? Select two.

a. Nausea
b. Hematuria
c. Diarrhea
d. Bowel obstruction
e. Sacroiliitis

The correct answers are a. Nausea and c. Diarrhea.

Radiation therapy, especially when targeting the pelvic region, can cause irritation to the gastrointestinal tract, leading to nausea.
Diarrhea is another common early side effect of pelvic radiation therapy. Radiation can damage the lining of the intestines, particularly the colon, leading to increased stool frequency and watery stools.

118D73

A 52-year-old male visited the clinic with complaints of pain in both soles. He was diagnosed with type 2 diabetes five years ago but left it untreated. For the past three months, he has been taking a sulfonylurea drug prescribed by a local clinic. One month ago, he began experiencing sharp, needle-like pain in the soles of his feet at bedtime, which has affected his ability to sleep. He is employed as an office worker. He has no smoking history and drinks alcohol occasionally. There is no history of chemical exposure. He is alert and oriented. His height is 176 cm, weight 56 kg, body temperature 36.3°C, pulse 82 beats per minute and regular, blood pressure 128/78 mmHg, respiratory rate 18 breaths per minute, and SpO₂ 96% on room air. Heart and breath sounds are normal. His abdomen is flat and soft, with no palpable liver or spleen. Urine findings: protein (-), glucose 1+, ketone bodies (-). Blood biochemistry: total protein 7.5 g/dL, albumin 3.9 g/dL, blood urea nitrogen 12 mg/dL, creatinine 0.6 mg/dL, fasting blood glucose 162 mg/dL, HbA1c 7.8% (normal range 4.9–6.0).

Which findings are most likely in this patient? Select two.

a. Bilateral grip strength weakness
b. Bilateral gastrocnemius muscle atrophy
c. Bilateral reduced vibration sense in lower limbs
d. Bilateral absence of Achilles tendon reflex
e. Bilateral absence of biceps tendon reflex

The correct answers are c. Bilateral reduced vibration sense in lower limbs and d. Bilateral absence of Achilles tendon reflex.

Peripheral neuropathy, particularly in the lower limbs, is a common complication of long-standing diabetes that often causes reduced vibration sensation and loss of deep tendon reflexes. The Achilles reflex is typically the first to be lost in diabetic neuropathy.

118D74

A 72-year-old woman presented with right knee pain for 3 months. She experiences no pain at rest but feels significant pain when starting to walk or going up and down stairs. The physical examination shows mild swelling in the right knee joint without warmth or redness. Tenderness is noted on the medial side of the right knee. A knee X-ray is shown.

Which of the following is appropriate for conservative treatment? Select three.

a. Exercise therapy
b. Weight loss counseling
c. Cast immobilization
d. Creation of orthotic devices
e. Glucocorticoid oral therapy

The correct answers are a. Exercise therapy, b. Weight loss counseling, and d. Creation of orthotic device.

This patient likely has knee osteoarthritis, as suggested by the X-ray findings, chronic knee pain, and symptoms aggravated by movement such as walking or climbing stairs.
Regular physical activity can improve joint mobility, strengthen the muscles around the knee, and reduce pain. Low-impact exercises, such as swimming or cycling, are particularly beneficial.
Since the patient is overweight (BMI > 29), reducing body weight can alleviate excess stress on the knee joint, significantly improving symptoms and slowing disease progression.
Using braces, orthotics, or a walking aid can help redistribute weight and reduce pressure on the medial side of the knee, where pain and tenderness are observed.
Cast immobilization is not appropriate for managing osteoarthritis because it restricts joint movement, potentially leading to stiffness and muscle atrophy.
Glucocorticoid oral therapy is not suitable as a long-term therapy due to its systemic side effects and is generally not used for chronic osteoarthritis management unless inflammation is severe.

118D75

A male infant, 1 hour after birth, born at 37 weeks gestation, weighing 4,000 g, was found to have a blood glucose level of 25 mg/dL after being tested due to macrosomia. Intravenous administration of 10% glucose solution via a peripheral vein was decided. The glucose infusion rate is set at 4 mg/kg/min.

Calculate the hourly infusion rate of the 10% glucose solution. If a decimal value is obtained, round it to the nearest second decimal place.

The correct answer is 9.6 mL/hour.

Step 1: Calculate the required glucose dose per minute
Step 2: Convert this to the volume of 10% glucose solution per minute

The concentration of the 10% glucose solution is 100 mg/mL. Therefore:
Step 3: Convert to the hourly infusion rate

Since there are 60 minutes in an hour: