118E (2024)

118E1
Which areas of the body are most prone to developing pressure ulcers?
a. Auricle (ear)
b. Palms
c. Navel (umbilicus)
d. External genitalia
e. Heels

The correct answer is e. Heels.

• Pressure ulcers (also known as bedsores or decubitus ulcers) tend to develop on areas of the body where there is prolonged pressure over bony prominences.

118E2
Which of the following is correct regarding meta-analysis?
a. The evidence level is low.
b. Multiple studies can be integrated.
c. Publication bias does not need to be considered.
d. It is synonymous with randomized controlled trials (RCTs).
e. Researchers directly intervene with the target population to collect data.

The correct answer is b. Multiple studies can be integrated.

• Meta-analysis is a statistical technique used to combine and synthesize results from multiple independent studies on the same topic. By aggregating data, meta-analysis can increase the overall statistical power, identify patterns, and provide more robust conclusions than individual studies.
• Meta-analyses are considered one of the highest levels of evidence in the hierarchy of evidence-based medicine, especially when conducted on high-quality randomized controlled trials (RCTs).
• Publication bias, which occurs when studies with positive results are more likely to be published than those with negative or null results, is a significant concern in meta-analysis. It must be assessed and addressed using tools such as funnel plots or statistical tests.
• A meta-analysis is a method of analyzing and combining data from multiple studies, including RCTs. While RCTs may be included in a meta-analysis, the two terms are not synonymous.
• Meta-analysis involves analyzing existing data from previous studies rather than directly interacting with study participants or collecting new data.

118E3
When only one of two sets of blood cultures is positive, which of the following organisms is sometimes considered a contaminant (commensal flora) rather than a causative pathogen, and may not warrant treatment?
a. Candida albicans
b. Escherichia coli
c. Pseudomonas aeruginosa
d. Staphylococcus aureus
e. Staphylococcus epidermidis

The correct answer is e. Staphylococcus epidermidis.

• Staphylococcus epidermidis is a frequent contaminant due to its presence on the skin and medical equipment. However, in certain situations (e.g., in immunocompromised patients or those with indwelling devices), S. epidermidis can also be a true pathogen, requiring clinical correlation to determine its significance.

118E4
Which of the following is NOT the correct combination of a risk factor and its associated disease?
a. Smoking – Bladder cancer
b. Lack of physical activity – Colon cancer
c. Obesity after menopause – Breast cancer
d. Excessive alcohol consumption – Esophageal cancer
e. Excessive dietary sodium intake – Lung cancer

The answer is e. Excessive dietary sodium intake – Lung cancer.

• While excessive sodium consumption is associated with conditions such as hypertension, cardiovascular diseases, and stomach cancer, there is no significant evidence linking it to lung cancer.
• Carcinogens in tobacco smoke are excreted through urine, where they come into prolonged contact with the bladder lining, increasing cancer risk.
• Physical inactivity can contribute to obesity, insulin resistance, and chronic inflammation, all of which increase the risk of colorectal cancer.
• Increased body fat leads to higher levels of estrogen production, which can fuel the growth of hormone-sensitive breast cancers.
• Alcohol can irritate and damage the esophageal lining, increasing cancer susceptibility.

118E5
Which of the following is an appropriate physical change observed within the last three days before death in terminal cancer patients?
a. Warm sensation in the hands and feet
b. Increased urine output
c. Increased oxygen saturation
d. Inability to palpate the radial artery
e. Shortening of capillary refill time

The correct answer is d. Inability to palpate the radial artery.

• The inability to palpate the radial artery reflects the physiological changes associated with circulatory decline and impending death.
• In the final stages of life, reduced circulation typically causes the hands and feet to become cold and clammy, not warm.
• Kidney function often declines significantly as the body shuts down, leading to reduced or absent urine output in the final days.
• Oxygen saturation typically declines as respiratory function deteriorates in the dying process.
• Capillary refill time usually becomes prolonged due to decreased perfusion and circulatory failure.

118E7
Which of the following is incorrect regarding the procedure for collecting a nasopharyngeal swab sample from a seated patient?

a. Wear personal protective equipment.
b. Stand to the side of the patient.
c. Support the patient's head to prevent movement.
d. Insert the swab upward from the patient's nostril.
e. Collect the sample from the posterior pharyngeal wall.

The answer is d. Insert the swab upward from the patient's nostril.

• The correct method involves inserting the swab horizontally and gently advancing it along the nasal floor toward the nasopharynx, not upward. The nasal anatomy requires this approach to avoid discomfort and ensure an accurate sample is collected from the nasopharyngeal area.
• Personal protective equipment (PPE) is essential to protect the healthcare provider from potential exposure to infectious agents during the procedure.
• Standing to the side minimizes the risk of direct exposure to respiratory droplets if the patient coughs or sneezes during the procedure.
• Stabilizing the patient’s head is crucial to ensure accurate swab placement and to prevent injury caused by sudden movements.
• The goal of the procedure is to collect a sample from the posterior nasopharynx, where the highest concentration of respiratory pathogens is typically found.

118E8
For a patient under standard precautions, which of the following can healthcare workers handle without wearing disposable gloves?

a. The patient's eyeglasses
b. Gauze applied to a wound
c. A diaper soiled with feces
d. A toothbrush used for oral care
e. Tissue paper with sputum on it

The correct answer is a. The patient's eyeglasses.

• Only items that are free of contamination by infectious materials, like eyeglasses, can be handled without gloves under standard precautions. For all other items that may come into contact with bodily fluids or secretions, gloves are necessary to ensure safety.

118E9
Which symptom is commonly associated with obstructive jaundice?

a. Purpura
b. Itching (pruritus)
c. Black stools
d. Dizziness upon standing (orthostatic dizziness)
e. Macroscopic hematuria (visible blood in urine)

The correct answer is b. Itching (pruritus).

• Pruritus is a hallmark symptom of obstructive jaundice, caused by the accumulation of bile salts in the blood.
• Purpura (bruising) is more commonly linked to conditions that affect platelet function or blood clotting, such as coagulopathies or thrombocytopenia.
• Black stools (melena) indicate gastrointestinal bleeding, usually in the upper digestive tract. Obstructive jaundice often leads to pale (clay-colored) stools due to reduced bile excretion into the intestines.
• Orthostatic dizziness is usually related to dehydration, anemia, or autonomic dysfunction.
• Hematuria is related to conditions affecting the urinary tract, such as infections, stones, or cancers.

118E12
Which of the following is correct regarding cerebrospinal fluid (CSF) examination through lumbar puncture?

a. Position the patient in the prone position.
b. Perform the puncture while wearing sterile gloves.
c. Use the thickest needle possible.
d. Puncture between the L1 and L2 vertebrae.
e. Have the patient remain seated for a set period after CSF collection.

The correct answer is b. Perform the puncture while wearing sterile gloves.

• Maintaining sterility is a critical aspect of performing a lumbar puncture to minimize the risk of introducing infection into the cerebrospinal fluid (CSF).
• The patient is typically positioned either in the lateral decubitus position (lying on their side with knees drawn to the chest) or in a seated position leaning forward.
• The thinnest needle appropriate for the procedure should be used to minimize trauma and reduce the risk of post-lumbar puncture complications, such as headaches.
• The puncture is typically performed between the L3-L4 or L4-L5 intervertebral spaces to avoid damaging the spinal cord, which ends at the L1-L2 level in most adults.
• After the procedure, the patient is usually advised to lie flat to reduce the risk of post-lumbar puncture headache.

118E13
Which of the following is correct regarding the explanation of shared decision-making (SDM)?

a. The healthcare provider explains the plan they consider best and obtains consent.
b. The patient selects from the options provided by the healthcare provider.
c. The healthcare provider and the patient work together to find the best approach.
d. It is synonymous with informed consent.
e. It is suitable when the patient’s course can be reliably predicted.

The correct answer is c. The healthcare provider and the patient work together to find the best approach.

• Shared decision-making (SDM) is a collaborative process where both the healthcare provider and the patient actively participate in making decisions about the patient’s care.
• Informed consent is the process of ensuring that a patient understands and agrees to a proposed treatment, while SDM emphasizes a partnership in the decision-making process.
• SDM is particularly valuable in situations where there are multiple treatment options with different risks and benefits, or when the outcome is uncertain.

118E14
Which of the following diseases primarily causes a productive (wet) cough?

a. Cough variant asthma
b. Interstitial pneumonia
c. Post-infectious cough
d. Gastroesophageal reflux disease (GERD)
e. Sinobronchial syndrome

The correct answer is e. Sinobronchial syndrome.

• Sinobronchial syndrome involves mucus production in both the sinuses and bronchi, leading to a productive cough.
• Other conditions listed primarily cause dry coughs or are not associated with mucus production.

118E15
Which of the following is against the professional ethics of a physician?

a. Responding to a patient's request for a second opinion.
b. Advising another physician about inappropriate medical practices.
c. Accessing the electronic medical records of a patient unrelated to their duties.
d. Providing information about clinical trials to a patient eligible for the trial.
e. Explaining the condition and treatment plan to the advocate of an incapacitated patient.

The correct answer is c. Accessing the electronic medical records of a patient unrelated to their duties.

• Accessing a patient's medical records without a legitimate professional reason violates both patient confidentiality and the ethical principles of medical practice.
• Supporting a patient's request for a second opinion is ethical and encouraged. It respects the patient's autonomy and right to make informed decisions about their care.
• It is an ethical responsibility for physicians to address and correct inappropriate or harmful medical practices to ensure patient safety and uphold professional standards.
• Sharing information about clinical trials with eligible patients is ethical, as long as it is done transparently, with informed consent, and without coercion. This allows patients to consider all available treatment options.
• It is ethical and necessary to communicate with a surrogate or advocate when a patient lacks decision-making capacity, ensuring that care aligns with the patient’s best interests or previously expressed wishes.

118E16
Which of the following findings is NOT indicative of suspected breast cancer?

a. Nipple discharge
b. Nipple inversion
c. Dimpling (dimple sign)
d. Peau d’orange (orange peel appearance)
e. A mass adhered to the pectoralis major muscle

The correct answer is a. Nipple discharge.

• While nipple discharge can occur in breast cancer, it is not a definitive or specific sign and is more commonly associated with benign conditions.
• The other findings—such as nipple inversion, dimpling, peau d’orange, and a fixed mass—are classic and more specific indicators of breast cancer.

118E17
Which of the following statements about kidney function is correct?

a. Renal blood flow increases with age.
b. Urine concentrating ability increases with age.
c. Glomerular filtration rate (GFR) decreases during the second trimester of pregnancy.
d. Serum cystatin C decreases when GFR declines.
e. Estimated GFR using serum creatinine is influenced by muscle mass.

The correct answer is e. Estimated GFR using serum creatinine is influenced by muscle mass.

• Serum creatinine levels are a byproduct of muscle metabolism. As a result, individuals with greater muscle mass tend to have higher baseline serum creatinine levels, while those with lower muscle mass (e.g., elderly or malnourished individuals) may have lower levels, even if their kidney function is impaired.
• Renal blood flow typically decreases with age due to changes in vascular structure and function, leading to a decline in kidney perfusion.
• The ability of the kidneys to concentrate urine diminishes with age due to a reduction in the responsiveness of the renal tubules to antidiuretic hormone (ADH).
• GFR actually increases during pregnancy, particularly in the second trimester, due to increased cardiac output and renal blood flow.
• Serum cystatin C levels increase when GFR declines, making it a useful marker for assessing kidney function independently of muscle mass.

118E18
Which of the following is appropriate when informing a patient about advanced cancer?

a. Do not allow family members to be present.
b. Explain the situation only once.
c. Do not inquire about the patient’s interpretative model.
d. Provide a brief explanation regardless of the patient’s level of understanding.
e. Confirm with the patient whether they are willing to hear bad news.

The correct answer is e. Confirm with the patient whether they are willing to hear bad news.

• Asking the patient if they are willing to hear bad news demonstrates respect for their emotional state and ensures they are mentally prepared to receive potentially distressing information.
• The other choices do not align with the interests of the patient.

118E19
Which of the following is a symptom of panic disorder?

a. Amnesia
b. Apathy
c. Flight of ideas
d. Anticipatory anxiety
e. Flashbacks

The correct answer is d. Anticipatory anxiety.

• Anticipatory anxiety refers to the intense fear or worry about the possibility of experiencing another panic attack. This anxiety often leads individuals to avoid situations or places where they fear an attack might occur, which can significantly impact their daily life and functioning.
• Amnesia (loss of memory) is more commonly associated with dissociative disorders or neurological conditions.
• Apathy (lack of interest or motivation) is more commonly associated with depression or certain neurological disorders, such as Parkinson's disease.
• Flight of ideas (rapidly shifting thoughts) is typically seen in manic episodes of bipolar disorder.
• Flashbacks are vivid re-experiences of traumatic events and are a key symptom of post-traumatic stress disorder (PTSD).

118E20
Which of the following is correct regarding physical examination?

a. Measure respiratory rate over 5 seconds.
b. Measure blood pressure while the patient is talking.
c. Measure proximal upper limb muscle strength using a handgrip dynamometer.
d. Estimate central venous pressure (CVP) via the internal jugular vein while the patient is lying down.
e. Observe inability to maintain a fixed posture (asterixis) by asking the patient to hold their arms horizontally forward.

The correct answer is e. Observe inability to maintain a fixed posture (asterixis) by asking the patient to hold their arms horizontally forward.

• Asterixis is observed in conditions such as hepatic encephalopathy or uremia and is a result of impaired motor control. The patient is asked to extend their arms forward with wrists dorsiflexed (hands pointing upward), and the examiner observes for sudden, involuntary downward "flapping" movements.
• Respiratory rate should be measured over a full minute or at least 30 seconds (then multiplied by 2) to obtain an accurate assessment.
• Talking can artificially elevate blood pressure and produce inaccurate readings. The patient should remain silent and relaxed during the measurement.
• A handgrip dynamometer measures grip strength, which reflects distal muscle strength.
• Central venous pressure (CVP) is typically assessed with the patient in a semi-reclined position (30–45 degrees).

118E21
The photos (A–E) are shown.
Which instrument is used for the examination of the anus and rectum?

a. A
b. B
c. C
d. D
e. E

The correct answer is a. A.

• The instrument shown in Photo A is called an anal speculum (anoscope). An anal speculum is specifically designed for observing the anal canal and lower rectum. It consists of a tubular body and a lighting device, and it is inserted into the anus to examine the rectal mucosa, perform biopsies, or carry out other diagnostic and therapeutic procedures.
• The instrument in Photo B is an otoscope, which is used to examine the external auditory canal and tympanic membrane (eardrum).
• The instrument in Photo C is a pair of scissors, commonly used to cut sutures or bandages.
• The instrument in Photo D is a nasal speculum, which is used to inspect the nasal cavity.
• The instrument in Photo E is a forceps (tweezers), typically used to grasp tissues or remove foreign objects.

118E23
What is the first action that should be taken for a person who lost consciousness and collapsed after choking?

a. Chest compressions
b. Back blows
c. Abdominal thrusts
d. Mouth-to-mouth artificial respiration
e. Removal of foreign objects from the mouth

The correct answer is a. Chest compressions.

• When a person becomes unconscious after choking, the priority is to assess and ensure adequate circulation.
• Chest compressions can help to dislodge the obstruction by creating internal pressure and maintain blood flow to vital organs if the heart has stopped.

118E25
Which combination of shock type and symptom is incorrect?

a. Hemorrhagic shock – Tachycardia
b. Cardiogenic shock – Oliguria
c. Neurogenic shock – Bradycardia
d. Septic shock – Urticaria
e. Anaphylactic shock – Laryngeal edema

The answer is d. Septic shock – Urticaria.

• Septic shock is caused by a severe infection leading to systemic inflammation, which results in hypotension, fever, warm extremities (in early stages), and organ dysfunction.
• Urticaria, however, is typically associated with allergic reactions or anaphylactic shock, not septic shock.
• In hemorrhagic shock, the body compensates for blood loss by increasing heart rate (tachycardia) to maintain cardiac output and perfusion.
• Cardiogenic shock leads to reduced cardiac output, resulting in poor renal perfusion and a decrease in urine output (oliguria).
• Neurogenic shock is caused by a loss of sympathetic tone, leading to vasodilation and bradycardia (unlike other forms of shock, which usually cause tachycardia).
• Anaphylactic shock often causes laryngeal edema due to severe allergic reactions, leading to airway obstruction and breathing difficulties.

118E26
A 36-year-old man visited the clinic after being diagnosed with hypertension during a routine health checkup. He has no history of smoking. He drinks alcohol occasionally. His father is being treated for hypertension.

His height is 168 cm. His weight is 60 kg. His waist circumference is 77 cm. His pulse is 76 bpm and regular. His blood pressure is 144/78 mmHg.

Urine findings: His urine protein is negative. His urine glucose is negative.

Blood biochemistry: His fasting blood glucose is 99 mg/dL. His uric acid level is 6.8 mg/dL. His total cholesterol is 170 mg/dL. His triglyceride level is 70 mg/dL. His HDL cholesterol is 58 mg/dL.

No abnormalities were detected on the ECG. Based on the dietitian's interview, his daily estimated energy intake is 1,900 kcal, and his salt intake is estimated at 15 g/day.

What is the appropriate recommendation?
a. Salt reduction
b. Avoid alcohol
c. Weight reduction
d. Restrict fat intake
e. Restrict purine intake

The correct answer is a. Salt reduction.

• The World Health Organization (WHO) and most guidelines for hypertension recommend reducing salt intake to less than 5–6 g/day to help lower blood pressure and reduce cardiovascular risk.
• Moderate or occasional alcohol consumption is generally not a significant contributor to hypertension unless it becomes excessive.
• The patient’s body mass index (BMI) is 21.3 (calculated as weight in kg divided by height in meters squared), which falls within the normal range.
• The patient’s cholesterol and triglyceride levels are within normal ranges.
• While the patient’s uric acid level (6.8 mg/dL) is slightly elevated, it is not at a level requiring immediate dietary restrictions.

118E27
An 11-year-old boy was brought to the clinic by his school teacher with complaints of lower abdominal pain. The pain started suddenly in the afternoon and gradually intensified to the point where it became unbearable, prompting the visit.

His body temperature is 36.8°C. His pulse is 108 bpm and regular. His blood pressure is 118/62 mmHg. His respiratory rate is 18 breaths per minute. His SpO2 is 99% (room air).

His heart sounds and breath sounds are normal. His abdomen is flat with mild tenderness in the lower abdomen, but no muscle guarding or rebound tenderness is noted. The liver and spleen are not palpable. No abnormalities are noted in bowel sounds. No masses are palpated in the inguinal region.

The left scrotum is swollen compared to the right, with no transillumination, mild redness, and marked tenderness. A color Doppler scrotal ultrasound shows reduced blood flow signals within the left testicular parenchyma.

What is the diagnosis?
a. Testicular tumor
b. Hydrocele
c. Varicocele
d. Testicular torsion
e. Inguinal hernia

The correct answer is d. Testicular torsion.

• The combination of sudden onset pain, scrotal swelling, tenderness, and reduced blood flow on Doppler ultrasound is diagnostic of testicular torsion.
• Testicular torsion occurs when the spermatic cord twists, cutting off blood flow to the testicle. Prompt surgical intervention is crucial to save the testicle.
• Tumors typically present as painless, firm masses in the scrotum.
• A hydrocele presents as a painless, fluid-filled swelling that transilluminates.
• A varicocele involves painless, dilated veins in the scrotum with a "bag of worms" texture.
• Inguinal hernias may cause a painless mass in the inguinal or scrotal region.

118E28
An ambulance brought a 28-year-old man to the emergency room. He was found on the street unconscious.

In his wallet, he had a memo stating, "I have thrombocytopenia from aplastic anemia. If I pass out, please obtain a CT scan to rule out intracranial hemorrhage immediately. Thank you in advance."

Which test should you order next?
a. Head CT
b. Brain MRI
c. Serum alcohol level
d. Serum ammonia level
e. Electroencephalogram

The correct answer is a. Head CT.

• The patient’s memo explicitly indicates a high risk of intracranial hemorrhage (ICH) due to thrombocytopenia from aplastic anemia.
• Thrombocytopenia significantly increases the risk of spontaneous bleeding, including into the brain, and an intracranial hemorrhage could explain the patient’s unconscious state.
• A CT scan of the head is the most appropriate and rapid imaging modality to detect or rule out ICH.

118E29
A 5-year-old boy was brought to the clinic by his parents with fever and ear pain as the main complaints. He had nasal discharge starting two days ago. Yesterday, he developed right ear pain and fever, prompting the visit. His temperature is 37.5°C. The findings of the right tympanic membrane are shown in the image.

What is the appropriate treatment?
a. Ear irrigation
b. Eustachian tube inflation
c. Administration of antibiotics
d. Tympanoplasty
e. Tympanostomy tube insertion

The correct answer is c. Administration of antibiotics.

• The clinical features include fever, ear pain, nasal discharge, and an inflamed, bulging tympanic membrane (as seen in the image). The child presents with symptoms and findings consistent with acute otitis media (AOM), which is a bacterial or viral infection of the middle ear. 
• Amoxicillin is the first-line antibiotic in most cases unless there is a penicillin allergy.

118E31
A 38-year-old woman (G3P0) was brought in by ambulance due to severe abdominal pain. Her menstrual cycle is regular at 28 days. Her last menstrual period was 7 weeks ago. She developed sudden, severe lower abdominal pain today and called for an ambulance. There is no genital bleeding.

Her consciousness is clear. Her temperature is 37.1°C. Her heart rate is 116 bpm, regular. Her blood pressure is 78/52 mmHg. Her respiratory rate is 20 breaths per minute. SpO2 is 98% (room air).

Her abdomen is mildly distended with tenderness and rebound tenderness in the right lower quadrant. A pregnancy test is positive.

Abdominal ultrasound shows low-echo fluid accumulation in Morrison's pouch and the pouch of Douglas. Transvaginal ultrasound reveals a thickened, echogenic endometrium and an irregular, low-echo structure in the right adnexal region.

What is the appropriate management for this patient?
a. Emergency surgery
b. Hysteroscopy
c. Uterine artery embolization
d. One-week observation
e. Administration of a folate metabolism antagonist

The correct answer is a. Emergency surgery.

• The patient’s positive pregnancy test, severe lower abdominal pain, signs of hemodynamic instability, and ultrasound findings of intraperitoneal hemorrhage confirm a diagnosis of ruptured ectopic pregnancy. Immediate emergency surgery is required to control the bleeding and save the patient’s life.
• Hysteroscopy examines the inside of the uterus.
• Uterine artery embolization is used for conditions like postpartum hemorrhage or uterine fibroids.
• Methotrexate, a folate antagonist, is used for medically managing early, unruptured ectopic pregnancies.

118E32
A 34-year-old woman presented with fever and rash. She had a sore throat yesterday but was able to carry on with her daily activities. Today, she developed shaking chills, a fever of 39.6°C, headache, nausea, and joint pain. She has been healthy previously.

Her consciousness is clear. Her height is 165 cm, and her weight is 60 kg. Her temperature is 39.8°C, pulse 120 bpm and regular, blood pressure 90/58 mmHg, respiratory rate 28 breaths per minute, and SpO2 96% (room air).

Pupils are equal, and light reflexes are normal. There are petechiae and jaundice in the bulbar conjunctivae. The oral cavity is slightly dry, but there is no pharyngeal redness. There is no jugular vein distention. Nuchal rigidity is present. Heart and lung sounds are normal. The abdomen is flat and soft, with normal bowel sounds. The liver and spleen are not palpable. Diffuse purpuric lesions are noted on the palms of both hands and the soles of both feet.

Blood cultures obtained at admission revealed gram-negative diplococci.

Which is the most likely causative microorganism?
a. Escherichia coli
b. Group A Streptococcus
c. Moraxella catarrhalis
d. Neisseria gonorrhoeae
e. Neisseria meningitidis

The correct answer is e. Neisseria meningitidis.

• The patient’s symptoms (fever, rash, nuchal rigidity, and sepsis) and findings (petechiae, purpura, and gram-negative diplococci) are classic for Neisseria meningitidis. Immediate antibiotic therapy and supportive care are critical for survival.
• Escherichia coli typically causes infections such as urinary tract infections or neonatal meningitis.
• Group A Streptococcus causes conditions like pharyngitis, cellulitis, and streptococcal toxic shock syndrome.
• Moraxella catarrhalis is primarily associated with respiratory infections like otitis media or sinusitis.
• Neisseria gonorrhoeae typically causes sexually transmitted infections.

118E33
A 78-year-old man presented with lower abdominal pain and an inability to urinate as his main complaints. He has experienced frequent urination for the past three months. Since dinner the day before yesterday, he has had cold-like symptoms and has been taking over-the-counter cold medicine. From yesterday afternoon, he was unable to urinate, and lower abdominal pain developed, prompting his visit.

His height is 165 cm, and his weight is 60 kg. His temperature is 36.6°C, pulse 84 bpm and regular, and blood pressure 154/88 mmHg. A soft, elastic mass is palpable in the lower abdomen, with tenderness in the same region. On rectal examination, a 5 cm, elastic, firm prostate is palpated, without tenderness.

What is the most appropriate imaging test to perform first?
a. Pelvic MRI
b. Contrast-enhanced abdominal CT
c. Abdominal ultrasound
d. Abdominal X-ray
e. Lower gastrointestinal endoscopy

The correct answer is c. Abdominal ultrasound.

• The patient presents with classic signs of acute urinary retention, most likely due to benign prostatic hyperplasia (BPH) exacerbated by the anticholinergic effects of over-the-counter cold medicine.
• Abdominal ultrasound is the most appropriate initial imaging modality to confirm bladder distension, assess post-void residual urine, and evaluate the prostate.
• MRI provides detailed imaging but is not necessary as an initial test for urinary retention.
• CT scans are more appropriate for evaluating complicated or uncertain cases (e.g., masses or trauma).
• X-rays are not useful for visualizing the bladder or prostate.
• Endoscopy evaluates the gastrointestinal tract.

118E34
A 28-year-old primigravida (G1P0) was referred to the clinic at 18 weeks of gestation after being diagnosed with hyperglycemia. At 16 weeks of gestation, glucosuria was noted, and a random blood glucose level two weeks later was elevated at 162 mg/dL, prompting the referral.

Her medical history is unremarkable. Her height is 158 cm, and her weight is 57 kg (pre-pregnancy weight: 54 kg). Her blood pressure is 124/62 mmHg. No edema is observed in the lower legs.

At 19 weeks of gestation, a 75 g oral glucose tolerance test (OGTT) was performed, yielding the following results: fasting blood glucose 112 mg/dL, 1-hour blood glucose 218 mg/dL, and 2-hour blood glucose 202 mg/dL.

Ultrasound findings showed a cervical length of 4.2 cm, an estimated fetal weight of 190 g (0.0 SD), and a normal amniotic fluid volume.

What is the appropriate management?
a. Advise against exercise therapy.
b. Start oral hypoglycemic agents.
c. Implement a 1,200 kcal/day diet plan.
d. Aim for a postprandial 2-hour blood glucose level of less than 150 mg/dL.
e. Repeat the 75 g oral glucose tolerance test 6 weeks postpartum.

The correct answer is e. Repeat the 75 g oral glucose tolerance test 6 weeks postpartum.

• This patient has gestational diabetes mellitus (GDM), which resolves in most cases after delivery. However, women with GDM have an increased risk of developing type 2 diabetes mellitus (T2DM) later in life, and follow-up testing is crucial for identifying persistent or developing glucose intolerance.
• Physical activity is beneficial during pregnancy for managing blood glucose levels and improving insulin sensitivity.
• Oral hypoglycemic medications, such as metformin and sulfonylureas, are generally avoided during pregnancy due to potential risks to the fetus.
• The patient is not overweight (pre-pregnancy BMI ≈ 21.6), and during the mid-pregnancy period (18 weeks), an additional 200–250 kcal/day is required to meet both maternal and fetal nutritional needs.
• For GDM management, the goal is stricter: postprandial 2-hour blood glucose levels should remain below 120 mg/dL to minimize risks to the fetus, such as macrosomia.

118E35
An 88-year-old woman was brought to the hospital by ambulance with complaints of back pain. This morning, she fell at home and became unable to walk due to back pain, prompting the ambulance call. She is undergoing treatment for hypertension and dementia. Her score on the revised Hasegawa Dementia Scale is 7/30. She has a nursing care level of 1 (requires minimal care).

Lumbar X-rays revealed a compression fracture at the third lumbar vertebra. She was admitted for pain management and rehabilitation. After one month of hospitalization, her condition stabilized, and a discussion about her discharge plan was held with her husband.

What is the appropriate explanation for her husband?
a. "We will not document the content of the discussion in writing."
b. "A spouse cannot act as a surrogate decision-maker."
c. "Since the patient has dementia, her participation is unnecessary."
d. "Decisions made during the discussion can be revised later."
e. "There is no need to inform the care manager about the discussion."

The correct answer is d. ("Decisions made during the discussion can be revised later.").

• When discussing discharge planning and care options with the patient's husband, it is important to emphasize that the decisions made are not necessarily permanent. This flexibility is crucial because the patient's needs or circumstances may change over time, requiring adjustments to the care plan.
• Documentation is a critical part of medical and care planning. It ensures transparency, accountability, and continuity of care among healthcare providers and caregivers.
• In most cases, a spouse is considered an appropriate surrogate decision-maker, especially when the patient has cognitive impairments such as dementia and is unable to make decisions independently.
• Even patients with dementia should be involved in discussions about their care to the extent that they are able to understand and express their preferences. Excluding the patient entirely is not consistent with ethical or patient-centered care.
• It is important to involve the care manager (or case manager) in discussions, as they play a key role in coordinating care, especially for patients with chronic conditions and post-discharge needs.

118E37
An 80-year-old woman was diagnosed with lung cancer and multiple bone metastases at a hospital near her home one month ago. At her strong request, she declined aggressive treatments, including drug-based anticancer therapy, and receives home-based care through visiting medical services. She can go to the bathroom but spends most of the day in bed. She has lived alone since losing her husband at the age of 65. Her son lives far away and rarely visits. Her facial expression appears tense, and she seldom engages in conversation with the visiting staff.

One day, during a visit from her doctor, she said, "I just want to end it all."

What is the most appropriate initial response from the doctor to her statement?
a. "Let's consider admitting you to a palliative care unit."
b. "I will prepare medication to help you pass away peacefully right away."
c. "Please tell me the most distressing physical symptom you are experiencing right now."
d. "I'm sorry to hear that. Could you share more about how you're feeling?"
e. "Don't say that. Let's try to keep going a little longer."

The correct answer is d. ("I'm sorry to hear that. Could you share more about how you're feeling?").

• The patient’s statement, "I just want to end it all," requires an empathetic and exploratory response to understand their underlying distress and provide appropriate support. By saying, "I'm sorry to hear that. Could you share more about how you're feeling?" the doctor acknowledges the patient’s pain and opens the door for meaningful communication.

118E39
A 72-year-old woman presented with difficulty walking. She has had constipation for 10 years and noticed a decline in her sense of smell 5 years ago. Two years ago, she began having difficulty stirring food with her right hand while cooking. Her symptoms have gradually progressed, and for the past three months, her walking has become unsteady, prompting her visit to the clinic.

Her eye movements are normal. She exhibits a masked facial expression and dysarthria characterized by a soft and rapid speech pattern. In her limbs, she has moderate rigidity and resting tremor, particularly in the right upper limb, but no muscle weakness. The Romberg test is negative, and there are no sensory disturbances. There is no spasticity, and tendon reflexes are normal. She can stand up independently but shows impaired postural reflexes. Brain MRI shows no abnormalities, but dopamine transporter SPECT reveals reduced uptake in the left striatum.

What type of gait disturbance does this patient exhibit?
a. Steppage gait
b. Shuffling gait
c. Waddling gait
d. Scissor gait
e. Magnetic gait

The correct answer is b. Shuffling gait, which is characteristic of Parkinson’s disease or parkinsonian syndromes.

• The patient’s symptoms, including rigidity, resting tremor, bradykinesia, postural instability, and findings on dopamine transporter SPECT, are diagnostic of Parkinson’s disease. The shuffling gait (small, short steps) is a hallmark of this condition.
• Steppage gait occurs in conditions like peripheral neuropathy or foot drop, where patients lift their knees higher than normal to compensate for weakness in dorsiflexion.
• Waddling gait is seen in conditions like muscular dystrophies or hip girdle weakness.
• Scissor gait is commonly associated with spasticity in conditions like cerebral palsy. This gait involves crossing of the legs during walking due to increased muscle tone.
• Magnetic gait is seen in normal pressure hydrocephalus (NPH). This gait is characterized by difficulty lifting the feet off the ground, as if the feet are "magnetically" stuck to the floor.

118E41-42

A 48-year-old woman was brought to the hospital by ambulance due to a sudden headache.

History of Present Illness:
At 8 PM tonight, during dinner, she suddenly developed a severe headache and vomiting. Her husband, who lives with her, noticed the abnormality and called an ambulance.

Past Medical History:
She was diagnosed with hypertension during a health checkup but left it untreated.

Lifestyle History:
She lives with her husband. She has been smoking 10 cigarettes per day since the age of 20. She drinks alcohol occasionally.

Family History:
Nothing notable.

Current Condition:
The patient appears lethargic. She does not open her eyes spontaneously but opens them when called. She groans in response to painful stimuli but does not speak. In response to painful stimuli, both her upper and lower limbs attempt to push away the source of pain.
Her height is 150 cm, weight 70 kg, temperature 36.4°C, heart rate 120 bpm (regular), blood pressure 200/106 mmHg, respiratory rate 18/min, and SpO2 is 100% under 10 L/min oxygen via a reservoir mask.

Her pupils are 5.0 mm in both eyes, with sluggish light reflexes bilaterally. No jugular vein distension is noted. Thyroid and cervical lymph nodes are not palpable. No abnormalities are heard in heart or lung sounds. The abdomen is flat and soft, with no palpable liver or spleen. There is no edema in the lower legs.

Laboratory Findings:
Blood glucose measured with a portable device was 128 mg/dL.

What is the patient's Glasgow Coma Scale (GCS)?
a. E4 V5 M5
b. E4 V4 M5
c. E3 V4 M4
d. E3 V2 M5
e. E3 V2 M4

What is the first test to perform?
a. Electroencephalogram (EEG)
b. Non-contrast head CT
c. Cerebrospinal fluid examination
d. Non-contrast head MRI
e. Brain single-photon emission CT (SPECT)

The correct answer is d. E3 V2 M5.

• The GCS score evaluates three components: eye response (E), verbal response (V), and motor response (M).
• E3 (The patient does not open her eyes spontaneously but does so when called).
• V2 (The patient groans in response to painful stimuli but does not speak).
• M5 (The patient localizes pain by moving her limbs to push away the source of the pain).

The correct answer is b. Non-contrast head CT.

• The patient presents with the sudden onset of a severe headache ("thunderclap headache"), vomiting, and significantly elevated blood pressure. These symptoms strongly suggest the possibility of an acute intracranial event, such as a subarachnoid hemorrhage (SAH) or intracranial bleeding.

• A non-contrast CT scan is the gold standard for detecting acute hemorrhage in the brain. It can identify bleeding in the subarachnoid space, ventricles, or parenchyma with high sensitivity.

• EEG is used to assess seizures or encephalopathy but is not appropriate as the first test for acute headache with neurological signs.

• Cerebrospinal fluid examination (CSF) can confirm SAH by detecting blood in the CSF, but it is performed only if the CT scan is inconclusive.

• MRI without contrast is useful for identifying ischemia or structural abnormalities; however, it is less sensitive and slower than CT for detecting acute hemorrhage.

• Brain SPECT is primarily used to assess perfusion or functional abnormalities and is not appropriate in an acute emergency.

118E43-44

118E45-46

A 68-year-old man presented with difficulty walking.

History of Present Illness:
For the past two years, the patient’s family has noticed that his walking style resembles that of someone intoxicated. Around the same time, he began to feel unsteady while walking, which led him to adopt a wide-based gait. His unsteadiness is the same in both dark and well-lit conditions. He can rise from a chair but experienced near falls due to unsteadiness upon standing six months ago. He can climb stairs but uses a handrail to descend. Writing has become difficult, and he cannot draw straight lines. He can grip chopsticks and hold a bowl but struggles to move the chopsticks accurately to his mouth. His speech has gradually become slurred, resembling that of someone intoxicated. Walking difficulties have progressed, and two months ago, he fell while changing direction He has no numbness or sensory deficits in his limbs. He sought medical attention due to the gradual worsening of his symptoms.

Past Medical History:
No notable findings.

Lifestyle History:
No history of smoking or alcohol consumption.

Family History:
No notable findings.

Current Symptoms:
The patient is conscious and alert. He is 168 cm tall and weighs 60 kg. His temperature is 36.1°C, pulse 64 bpm (regular), and blood pressure 128/68 mmHg. Heart and lung sounds are normal. The abdomen is flat and soft, with no palpable liver or spleen.

Laboratory Findings:
Urinalysis shows no protein or glucose abnormalities. Hematology results include RBC 5.10 million, Hb 14.2 g/dL, WBC 8,300, and platelets 200,000. Blood chemistry results include total protein 7.8 g/dL, total bilirubin 0.8 mg/dL, AST 26 U/L, ALT 20 U/L, LDH 180 U/L (normal range 124–222), γ-GT 45 U/L (normal range 13–64), CK 70 U/L (normal range 59–248), BUN 19 mg/dL, creatinine 0.8 mg/dL, glucose 92 mg/dL, HbA1c 5.0% (normal range 4.9–6.0), total cholesterol 152 mg/dL, triglycerides 50 mg/dL, sodium 140 mEq/L, and potassium 4.0 mEq/L. ECG findings are normal. X-rays of the chest, abdomen, and cervical spine show no abnormalities.

What condition is observed in this patient?
a. Spasticity
b. Apraxia
c. Ataxia
d. Paralysis
e. Involuntary movements

What finding would be observed on neurological examination?
a. Positive Gowers’ sign
b. Positive Romberg’s sign
c. Positive Chaddock reflex
d. Poor performance on finger-to-nose test
e. Difficulty maintaining a fixed posture (asterixis)

The correct answer is c. Ataxia.

• The patient exhibits a wide-based gait, unsteadiness while walking, slurred speech, and difficulty with fine motor tasks such as writing and using chopsticks, which are hallmark features of ataxia.
• These symptoms indicate dysfunction in the cerebellum or its connections, leading to impaired coordination of voluntary movements.
• Spasticity involves increased muscle tone and resistance to passive movement, typically seen in conditions like upper motor neuron lesions.
• Apraxia is the inability to perform learned purposeful movements despite normal strength and coordination, often due to cortical lesions.
• Paralysis is a complete or partial loss of muscle strength.
• Involuntary movements, such as tremors or chorea, are not described in the patient’s presentation. Their movements are uncoordinated, not involuntary.

The correct answer is d. Poor performance on finger-to-nose test.

• The finger-to-nose test evaluates coordination and is a sensitive test for cerebellar dysfunction. Poor performance, such as missing the target or tremor-like movements during the test, indicates ataxia and cerebellar involvement. This aligns with the patient’s symptoms of uncoordinated limb movements.
• Gowers’ sign is associated with proximal muscle weakness, as seen in muscular dystrophies.
• Romberg’s sign evaluates sensory ataxia, which is caused by impaired proprioception.
• The Chaddock reflex is a pathological reflex indicating upper motor neuron lesions.
• Asterixis, often called a "flapping tremor," is associated with metabolic encephalopathies such as liver failure.

118E47-48

118E49-50

A 42-year-old man presented with pain in his right ankle joint.

History of Present Illness:
Since last evening, he has felt discomfort in his right ankle. Late at night, pain and swelling developed in the same area. This morning, the symptoms worsened rapidly, making it difficult for him to walk, prompting him to visit the emergency department. For the past two years, he has experienced recurrent episodes of swelling and pain at the base of his right big toe, which resolve within a few days.

Past Medical History:
He has been receiving treatment for hypertension and diabetes at a local clinic for the past three years.

Lifestyle History:
He smoked 20 cigarettes per day from the age of 20 to 30. He drinks 500 mL of beer daily.

Family History:
His sister has rheumatoid arthritis.

Current Symptoms:
The patient is 160 cm tall and weighs 76 kg. His temperature is 37.2°C, pulse 92 bpm (regular), blood pressure 160/88 mmHg, and respiratory rate 16/min. No abnormalities are observed in the head and neck. Heart and lung sounds are normal. The abdomen is flat and soft with no palpable liver or spleen. No rash is noted. The right ankle is visibly swollen, with significant tenderness and warmth. He is unable to move the joint due to pain.

Laboratory Findings:
Urine: Protein (-), Glucose (+++), Ketones (+), Occult blood (-)
Blood: RBC 4.72 million, Hb 14.0 g/dL, Ht 43%, WBC 12,300, Platelets 210,000
Biochemistry: Total protein 7.5 g/dL, Albumin 3.9 g/dL, AST 48 U/L, ALT 62 U/L, LDH 246 U/L (reference 124–222), γ-GT 120 U/L (reference 13–64), BUN 12 mg/dL, Creatinine 0.6 mg/dL, Uric acid 7.9 mg/dL, Glucose 328 mg/dL, HbA1c 9.2% (reference 4.9–6.0)
CRP: 10 mg/dL
Joint aspiration: The joint fluid appears yellow and cloudy. Gram staining reveals no bacteria, but needle-shaped crystals phagocytosed by white blood cells are observed.

What is the diagnosis?
a. Gout
b. Pseudogout
c. Spondyloarthritis
d. Rheumatoid arthritis
e. Osteoarthritis

What should be administered first?
a. NSAIDs
b. Narcotic analgesics
c. Uric acid synthesis inhibitors
d. Glucocorticoids
e. Disease-modifying antirheumatic drugs (DMARDs)

The correct answer is a. Gout.

• The diagnosis is gout due to recurrent joint symptoms, elevated uric acid levels, and the presence of urate crystals in the joint fluid.
• Pseudogout typically involves calcium pyrophosphate dihydrate (CPPD) crystals and affects larger joints like the knee, not the ankle or toe.
• Spondyloarthritis is associated with chronic back pain, sacroiliitis, and enthesitis.
• Rheumatoid arthritis is a symmetric, polyarticular arthritis that often involves the smaller joints of the hands and wrists.
• Osteoarthritis is a degenerative joint disease with chronic symptoms and typically affects weight-bearing joints, such as the knees and hips.

The correct answer is a. NSAIDs.

• NSAIDs (e.g., indomethacin or naproxen) are the first-line treatment for acute gout flares. They rapidly reduce inflammation and relieve pain. The patient’s symptoms—severe joint pain, redness, and swelling—indicate an acute inflammatory response.
• Uric acid synthesis inhibitors are used for long-term management to lower uric acid levels but are not recommended during acute attacks, as they can worsen or prolong the flare.