Foundations
A 20-year-old woman presents with heavy menstrual bleeding and easy bruising. Coagulation panel (PT, aPTT, INR) is normal, but platelets are low. Which diagnosis should you consider first?
TTP (Thrombotic Thrombocytopenic Purpura)
A 4-year-old previously healthy child is brought to the emergency department with sudden onset of high fever, sore throat, difficulty swallowing, and drooling. The child appears anxious, is leaning forward with their neck extended, and refuses to lie down. Their voice is muffled and they are breathing rapidly. No cough is reported. On physical exam, they are febrile, tachypneic, and have inspiratory stridor. Oxygen saturation is borderline.
What is the most likely diagnosis?
Epiglottitis
A patient presents with hypotension, distended neck veins, and muffled heart sounds. What life-threatening condition is this?
Cardiac tamponade
A 63-year-old man is brought in by his family due to progressive personality changes over several weeks. He has become increasingly irritable, forgetful, and now exhibits left-sided weakness. What should be at the top of your differential?
Glioblastoma multiforme
Explanation: Rapidly progressive neurologic deficits, behavioral changes, and mass effect in an older adult are classic for glioblastoma, the most aggressive primary brain tumor. It often crosses the corpus callosum (“butterfly glioma”).
A 3-year-old child presents with mild hearing loss noted during a routine checkup. Otoscopy reveals a retracted and dull tympanic membrane with no erythema or bulging. The child has had multiple colds recently but no fever.
Otitis media with effusion
A 35-year-old patient presents with frequent spontaneous gum bleeding, easy bruising on the arms and legs, and prolonged bleeding after minor cuts. They deny any anticoagulant use. Physical exam shows petechiae on the lower limbs. Laboratory tests reveal a normal PT, aPTT, and INR, but platelet count is borderline low.
What is the most likely cause of these symptoms?
A. Hemophilia A
B. von Willebrand Disease
C. Primary platelet dysfunction
D. Vitamin K deficiency
Primary platelet dysfunction
On exam, a patient has decreased breath sounds, reduced tactile fremitus, and dullness to percussion over the left lower lobe. What is the most likely cause?
Pleural effusion
Which of the following findings is most specific to constrictive pericarditis?
A. Pulsus paradoxus
B. Kussmaul’s sign
C. S3 gallop
D. Friction rub
B: Kussmauls sign
A 12-month-old child presents with delayed gross motor milestones. The parents note that she prefers to use her right hand for most tasks and avoids using her left. On exam, there is increased tone in the left upper and lower limbs. Whats at the top at the DDx?
Cerebral palsy
A 35-year-old man falls on an outstretched hand and sustains a mid-shaft fracture of the humerus. He is unable to extend his wrist and fingers.
Which nerve is likely injured?
Radial Nerve
A 55-year-old man presents to the emergency department with black, tarry stools and lightheadedness. He reports a history of gastric ulcers and admits to using NSAIDs regularly for chronic knee pain. On examination, he is pale and tachycardic. Rectal exam confirms melena. Labs show hemoglobin of 85 g/L. He is hemodynamically stable after IV fluids and has been typed and crossmatched for blood. Upper GI bleed is suspected.
Which medications should be started immediately to reduce the risk of further gastrointestinal bleeding?
Proton pump inhibitor
Spirometry shows a low FEV1/FVC ratio that improves significantly after bronchodilator administration. What condition does this support?
Asthma
A crescendo-decrescendo systolic murmur is heard loudest at the right upper sternal border and radiates to the neck. What is the likely diagnosis?
Aortic stenosis
A 28-year-old vegan reports tingling in their hands and feet, difficulty walking, and feeling increasingly tired. Exam reveals decreased proprioception and a positive Romberg sign. What lab test should be ordered first?
Vitamin B12 levels
Explanation: B12 deficiency causes subacute combined degeneration of the spinal cord, affecting dorsal columns and corticospinal tracts. Vegans are at high risk due to dietary deficiency. Early diagnosis is essential to prevent irreversible neurologic damage.
A 7-year-old girl presents with increasing difficulty climbing stairs and getting up from the floor. She also has a red-purple rash on her eyelids (heliotrope rash) and scaling on her knuckles (Gottron’s papules). What condition should be considered?
Juvenile dermatomyositis
A 32-year-old woman presents for evaluation of a bleeding tendency. She reports significant postpartum hemorrhage requiring transfusion after both of her previous deliveries. She also notes prolonged bleeding after dental extractions and easy bruising. Her menstrual cycles are heavy and prolonged. There is no family history of bleeding disorders. Her CBC is normal, and coagulation studies reveal a slightly prolonged aPTT, normal PT/INR, and normal platelet count. What is your next step?
Investigate for an inherited clotting disorder (e.g., von Willebrand disease)
The diaphragm is pierced by the aorta at which vertebral level?
A. T8
B. T10
C. T12
D. L1
C. T12
A 42-year-old woman presents to the emergency department with progressive shortness of breath over the past week. She underwent a bariatric surgery (Roux-en-Y gastric bypass) three weeks ago without immediate complications. On examination, she is tachycardic with elevated jugular venous pressure (JVP), but her lungs are clear to auscultation. There is no lower extremity edema, and oxygen saturation is borderline low. Chest X-ray shows a normal cardiac silhouette and no pulmonary edema.
Cardiac tamponade or pericardial constriction
Which of the following is not part of the stages of change model used in behavioral interventions (e.g. smoking cessation)?
A. Pre-contemplation
B. Contemplation
C. Denial
D. Action
Denial
A 26-year-old man with a painless, enlarging testicular mass is diagnosed with a non-seminomatous germ cell tumor. What is the most common first site of metastasis?
Retroperitoneal lymph nodes
A 68-year-old man with multiple myeloma presents with unilateral leg swelling and pain. Doppler confirms a DVT. What is the most likely underlying cause?
Paraneoplastic hypercoagulability
A 28-year-old refugee presents with low-grade fever, dry cough, and fatigue. Chest X-ray shows patchy infiltrates. Sputum Gram stain is negative. Which of the following is the most likely cause?
A. Strep pneumoniae
B. Klebsiella pneumoniae
C. Mycoplasma pneumoniae
D. Histoplasmosis
C. Mycoplasma pneumoniae
A 68-year-old man with a history of hypertension and hyperlipidemia presents to the emergency department with acute-onset chest pressure that radiates to his left arm. He is diaphoretic and short of breath. Vital signs show BP 105/65, HR 98, RR 20, SpO₂ 95% on room air. ECG reveals a new left bundle branch block (LBBB). (wide QRS complexes (>120 ms), absent Q waves in leads I, V5, and V6, and ST-segment elevations and discordant T waves).
What is the next best step in management?
A. Repeat the ECG in 15 minutes to confirm LBBB
B. Obtain troponins and wait for results before acting
C. Treat as a STEMI equivalent and initiate emergent reperfusion protocol
D. Order an echocardiogram before initiating treatment
Correct Answer:
C. Treat as a STEMI equivalent and initiate emergent reperfusion protocol
60-year-old man with longstanding rheumatoid arthritis was on daily prednisone for 6 months. He stopped his medication abruptly and now presents with fatigue, hypotension, nausea, and abdominal discomfort.
What endocrine emergency is he experiencing?
Adrenal crisis
A 45-year-old man presents with gradual loss of peripheral vision. He reports bumping into things while walking. MRI shows a large pituitary macroadenoma compressing the optic chiasm. What visual field defect is expected?
Bitemporal hemianopsia