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001A 49-year-old man has a large right MCA infarct with NIHSS 20. Over 36 hours he develops declining consciousness. CT shows extensive hemispheric edema, 9-mm midline shift and early uncal compression. He has no major comorbidity limiting survival. Which intervention offers the best chance of survival with acceptable outcome? Neurology
A. Early decompressive hemicraniectomy in an appropriately selected patient
B. Delay surgery until fixed pupils develop
C. Routine prophylactic hyperventilation for several days
D. Prolonged high-dose corticosteroid therapy
Correct answer: A. Early decompressive hemicraniectomy in an appropriately selected patient
Explanation: Decompressive hemicraniectomy reduces mortality in selected patients with malignant hemispheric infarction when performed before irreversible herniation. Concept: Malignant middle-cerebral-artery infarction.
Explanation: Decompressive hemicraniectomy reduces mortality in selected patients with malignant hemispheric infarction when performed before irreversible herniation. Concept: Malignant middle-cerebral-artery infarction.
002A 36-year-old ventilated patient with severe brain injury receives high-dose propofol for several days and develops unexplained lactic acidosis, bradyarrhythmia, rhabdomyolysis, hyperkalemia and rapidly worsening cardiovascular collapse. CK is markedly elevated and triglycerides are high. What is the most important immediate action? Critical Care
A. Treat only the hyperkalemia while leaving the infusion unchanged
B. Stop propofol and change the sedation strategy while aggressively supporting cardiovascular, metabolic and renal complications
C. Continue propofol because abrupt withdrawal worsens acidosis
D. Exclude the syndrome because triglycerides are not diagnostic
Correct answer: B. Stop propofol and change the sedation strategy while aggressively supporting cardiovascular, metabolic and renal complications
Explanation: Propofol infusion syndrome is a rare but catastrophic mitochondrial/metabolic toxicity. The infusion should be stopped immediately and organ support escalated. Concept: Propofol infusion syndrome.
Explanation: Propofol infusion syndrome is a rare but catastrophic mitochondrial/metabolic toxicity. The infusion should be stopped immediately and organ support escalated. Concept: Propofol infusion syndrome.
003A 24-year-old woman on day 5 of dengue becomes restless with narrow pulse pressure, cool extremities and delayed capillary refill. Hematocrit has risen from 37% to 48% while platelets fall to 28,000/ĀµL. There is no major external bleeding. Which immediate fluid strategy is most appropriate? Infectious Diseases
A. Prophylactic platelet transfusion as the primary shock treatment
B. Large unmonitored fluid boluses until hematocrit normalizes
C. Carefully titrated isotonic crystalloid with frequent reassessment of perfusion and hematocrit
D. Diuretic therapy because the hematocrit is elevated
Correct answer: C. Carefully titrated isotonic crystalloid with frequent reassessment of perfusion and hematocrit
Explanation: Dengue shock is driven by plasma leakage. Fluid resuscitation should be carefully titrated to perfusion because both under-resuscitation and fluid overload are dangerous. Concept: Dengue shock syndrome during critical phase.
Explanation: Dengue shock is driven by plasma leakage. Fluid resuscitation should be carefully titrated to perfusion because both under-resuscitation and fluid overload are dangerous. Concept: Dengue shock syndrome during critical phase.
004A 23-year-old woman has fatigue and salt craving with BP 96/60 mmHg. Potassium is 2.8 mmol/L, magnesium 1.2 mg/dL and bicarbonate 32 mmol/L. Renin and aldosterone are elevated, urine chloride is high and urinary calcium is low. Which diagnosis is most likely? Nephrology
A. Liddle syndrome
B. Apparent mineralocorticoid excess
C. Bartter syndrome
D. Gitelman syndrome
Correct answer: D. Gitelman syndrome
Explanation: Gitelman syndrome mimics thiazide effect and classically produces hypokalemic metabolic alkalosis, hypomagnesemia and hypocalciuria. Concept: Gitelman syndrome phenotype.
Explanation: Gitelman syndrome mimics thiazide effect and classically produces hypokalemic metabolic alkalosis, hypomagnesemia and hypocalciuria. Concept: Gitelman syndrome phenotype.
005A 66-year-old man has back pain, anemia, creatinine 5.1 mg/dL and calcium 12.4 mg/dL. Serum free lambda light chain is extremely high and urine protein is predominantly light chain rather than albumin. Kidney biopsy shows fractured eosinophilic casts with giant-cell reaction. What is the most important disease-directed intervention? Hematology-Oncology
A. Rapid initiation of effective anti-myeloma therapy to reduce free-light-chain production
B. Routine plasma exchange as mandatory definitive therapy for every case
C. Delay anti-myeloma therapy until dialysis is required
D. NSAID therapy for bone pain despite AKI
Correct answer: A. Rapid initiation of effective anti-myeloma therapy to reduce free-light-chain production
Explanation: Cast nephropathy depends on ongoing monoclonal light-chain production; rapid clone-directed therapy is central to kidney recovery. Concept: Myeloma cast nephropathy.
Explanation: Cast nephropathy depends on ongoing monoclonal light-chain production; rapid clone-directed therapy is central to kidney recovery. Concept: Myeloma cast nephropathy.
006A 77-year-old woman develops acute severe neck pain, fever and stiffness. CRP is high, but blood cultures are negative. CT of the cervical spine shows crown-like calcification surrounding the odontoid process. There is no epidural abscess. Which diagnosis is most likely? Rheumatology
A. Meningococcal meningitis
B. Crowned dens syndrome due to CPPD
C. Giant-cell arteritis
D. Atlantoaxial rheumatoid pannus
Correct answer: B. Crowned dens syndrome due to CPPD
Explanation: CPPD deposition around the odontoid can cause acute inflammatory neck pain and fever known as crowned dens syndrome. Concept: Calcium pyrophosphate deposition with crowned dens syndrome.
Explanation: CPPD deposition around the odontoid can cause acute inflammatory neck pain and fever known as crowned dens syndrome. Concept: Calcium pyrophosphate deposition with crowned dens syndrome.
007A 48-year-old man with BMI 46 kg/mĀ² has daytime somnolence and morning headache. Awake ABG shows PaCO2 54 mmHg and bicarbonate 31 mmol/L. Polysomnography demonstrates severe obstructive sleep apnea, and there is no significant COPD, neuromuscular weakness or hypothyroidism. Which diagnosis best fits? Pulmonology
A. Isolated obstructive sleep apnea without daytime hypoventilation
B. Central sleep apnea due to heart failure
C. Obesity hypoventilation syndrome with coexisting obstructive sleep apnea
D. Chronic hyperventilation syndrome
Correct answer: C. Obesity hypoventilation syndrome with coexisting obstructive sleep apnea
Explanation: OHS requires obesity plus awake daytime hypercapnia after excluding alternative causes; most patients also have obstructive sleep apnea. Concept: Obesity hypoventilation syndrome.
Explanation: OHS requires obesity plus awake daytime hypercapnia after excluding alternative causes; most patients also have obstructive sleep apnea. Concept: Obesity hypoventilation syndrome.
008A 47-year-old man has chest pain, ST depression and a troponin rise. Angiography shows no stenosis above 30%. LV angiography is nondiagnostic. He had a recent viral syndrome and has no clear coronary embolic source. The team needs to distinguish true infarction from myocarditis or takotsubo before committing to long-term secondary prevention. Which test has the highest diagnostic yield now? Cardiology
A. Repeat exercise ECG within 24 hours
B. Routine right-heart catheterization
C. Coronary calcium score alone
D. Cardiac MRI with tissue characterization
Correct answer: D. Cardiac MRI with tissue characterization
Explanation: Cardiac MRI is central in MINOCA evaluation because it can identify infarction patterns, myocarditis and takotsubo through tissue characterization. Concept: MINOCA due to myocarditis versus infarction.
Explanation: Cardiac MRI is central in MINOCA evaluation because it can identify infarction patterns, myocarditis and takotsubo through tissue characterization. Concept: MINOCA due to myocarditis versus infarction.
009A 56-year-old man with alcohol-related cirrhosis presents with massive hematemesis, BP 86/52 mmHg and Hb 6.7 g/dL. He has ascites and no focal abdominal tenderness. Two large-bore IV lines are in place and cross-matched blood is available. There is no known severe cardiopulmonary disease. Which early management bundle is most appropriate? Gastro-Hepatology
A. Restrictive transfusion strategy, vasoactive therapy, antibiotic prophylaxis and urgent endoscopic variceal ligation
B. Transfuse immediately to hemoglobin above 12 g/dL and delay endoscopy
C. Administer fibrinolysis because portal-vein thrombosis may be present
D. Give proton-pump inhibitor alone and await spontaneous hemostasis
Correct answer: A. Restrictive transfusion strategy, vasoactive therapy, antibiotic prophylaxis and urgent endoscopic variceal ligation
Explanation: Acute variceal bleeding requires resuscitation, early vasoactive therapy, antibiotics and urgent endoscopic therapy; overtransfusion can increase portal pressure. Concept: Acute esophageal variceal hemorrhage.
Explanation: Acute variceal bleeding requires resuscitation, early vasoactive therapy, antibiotics and urgent endoscopic therapy; overtransfusion can increase portal pressure. Concept: Acute esophageal variceal hemorrhage.
010A 36-year-old man has a 4.5-cm pituitary macroadenoma with visual-field loss and hypogonadism. Serum prolactin returns only 85 ng/mL, unexpectedly low for the tumor size. He is taking no dopamine antagonist and kidney function is normal. What should be done next? Endocrinology
A. Start testosterone before clarifying tumor type
B. Repeat prolactin measurement on serially diluted serum to exclude the high-dose hook effect
C. Perform water-deprivation testing
D. Conclude the tumor is nonfunctioning because prolactin is below 100 ng/mL
Correct answer: B. Repeat prolactin measurement on serially diluted serum to exclude the high-dose hook effect
Explanation: Extremely high prolactin concentrations can saturate some immunoassays and produce falsely modest values. Dilution testing is essential when tumor size and prolactin are discordant. Concept: Prolactinoma with hook effect.
Explanation: Extremely high prolactin concentrations can saturate some immunoassays and produce falsely modest values. Dilution testing is essential when tumor size and prolactin are discordant. Concept: Prolactinoma with hook effect.
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