CAM III FINALLLLLLLL #kms

CAM III — Clinical Assessment & Management

Cumulative Final Exam  ·  75 Questions

PAS 5462  ·  South College Atlanta ATL-2026  ·  Orthopaedics · Psychiatry · Rheumatology · Hematology/Oncology  ·  PANCE-Style Clinical Vignettes

PART I — QUESTIONS  (Q1–75)

Q1  |  ORTHO — Hip & Pelvis

A 45-year-old male with a history of chronic alcohol use and long-term corticosteroid therapy presents with progressive right groin pain worsening with weight-bearing over 3 months. He has limited internal rotation of the hip. X-ray shows mild flattening of the femoral head. MRI confirms segmental collapse. What is the diagnosis, and which vessels are responsible for the compromised blood supply?

A. Greater trochanteric bursitis; lateral circumflex femoral artery

B. Avascular necrosis (osteonecrosis) of the femoral head; medial and lateral circumflex femoral arteries — most commonly medial circumflex

C. Septic arthritis of the hip; capsular branches of the obturator artery

D. Hip osteoarthritis; no vascular involvement

Q2  |  ORTHO — Hip & Pelvis

A PA performs a Trendelenburg test on a 52-year-old woman with a limp. When she stands on her right leg, her left pelvis drops. What does this indicate?

A. Weakness of the right hip adductors (adductor longus/brevis)

B. Weakness of the RIGHT hip ABductors (gluteus medius/minimus) on the STANCE side — pelvis drops on the opposite (swing) side

C. Weakness of the left hip abductors; the pelvis drops on the same side as weakness

D. Normal finding in women over 50

Q3  |  ORTHO — Hip & Pelvis

A 34-year-old woman presents with lateral hip pain that worsens with lying on the affected side, climbing stairs, and running. She is tender to palpation over the greater trochanter. FABER test is negative. X-ray is normal. What is the diagnosis and first-line treatment?

A. Labral tear; MRI arthrogram, surgical repair

B. Iliopsoas bursitis; ultrasound-guided injection

C. Greater trochanteric bursitis (trochanteric pain syndrome); NSAIDs, physical therapy, activity modification, and corticosteroid injection if refractory

D. IT band syndrome; Ober test positive; stretching program

Q4  |  ORTHO — Hip & Pelvis

A 70-year-old woman falls and complains of right hip pain. She cannot bear weight. Her right leg appears shortened and externally rotated. X-ray confirms a femoral neck fracture. Which complication is she MOST at risk for and why?

A. Deep vein thrombosis; prolonged immobilization impairs venous return

B. Avascular necrosis of the femoral head; disruption of the medial circumflex femoral artery during fracture displaces the blood supply to the femoral head

C. Compartment syndrome; fascial compartments of the thigh become tense

D. Malunion only; femoral neck fractures always heal with conservative management

Q5  |  ORTHO — Hip & Pelvis

A 16-year-old obese male presents with left hip pain and a limp. He reports medial knee pain. On exam, his left hip has limited internal rotation and is held in external rotation. X-ray shows posterior and inferior displacement of the femoral epiphysis on the frog-leg lateral view (Klein line does not intersect the epiphysis). What is the diagnosis and immediate management?

A. Legg-Calvé-Perthes disease; activity restriction and bracing

B. Slipped capital femoral epiphysis (SCFE); IMMEDIATE non-weight-bearing and surgical pinning in situ — do not attempt closed reduction

C. Transient synovitis; NSAIDs and activity restriction; labs typically normal

D. Hip labral tear; MRI arthrogram for confirmation

Q6  |  ORTHO — Hip & Pelvis

A 6-year-old male presents with a 3-week history of painless right hip limp. He is afebrile, WBC is normal, ESR is mildly elevated. X-ray shows increased joint space and flattening of the femoral head with subchondral sclerosis. What is the diagnosis and distinguishing feature from septic arthritis?

A. Developmental dysplasia of the hip; Barlow/Ortolani tests positive in infancy

B. Legg-Calvé-Perthes disease (LCP); avascular necrosis of the femoral head in children ages 4–10; labs minimally elevated or normal — distinguishes from septic arthritis (septic = WBC, ESR, CRP ALL markedly elevated, toxic appearance, fever)

C. Transient synovitis; resolves completely within 2 weeks with NSAIDs

D. SCFE; Klein line abnormality on X-ray; obese adolescent

Q7  |  ORTHO — Shoulder & Elbow

A 28-year-old male football player sustains a direct blow to the lateral shoulder. He has focal tenderness over the AC joint, pain with cross-body adduction, and visible step-off deformity. X-ray shows 3cm coracoclavicular distance. He can raise his arm above his head with difficulty. What is the Rockwood classification and management?

A. Type I — sprain of AC ligament only; sling and NSAIDs

B. Type II — AC ligament torn, AC instability; conservative management with sling

C. Type V — severe shoulder droop, CC distance >3× normal, both AC and CC ligaments torn; surgical repair

D. Type III — AC and CC ligaments torn; management is controversial (conservative vs surgical)

Q8  |  ORTHO — Shoulder & Elbow

A 55-year-old right-hand dominant female presents with 4 months of right shoulder pain and significant stiffness. She cannot reach behind her back or raise her arm above shoulder height. She had a prior minor injury that she ignored. On exam, passive AND active ROM are both severely restricted in all planes. X-ray is normal. What is the diagnosis and pathophysiology?

A. Rotator cuff tear; active ROM worse than passive ROM; MRI confirms

B. Adhesive capsulitis (frozen shoulder); inflammation and fibrosis of the glenohumeral joint capsule causing progressive restriction of both active AND passive ROM in all planes; X-ray normal

C. Shoulder impingement; Neer and Hawkins tests positive; painful arc 60–120°

D. Labral tear; positive O'Brien test; pain with overhead activity

Q9  |  ORTHO — Shoulder & Elbow

A 48-year-old male construction worker has 6 months of right shoulder pain with overhead activities. Neer test (pain with passive forward flexion with arm internally rotated) and Hawkins test (pain with passive internal rotation at 90° forward flexion) are both positive. Painful arc is noted between 60–120° of abduction. MRI shows rotator cuff tendinosis without full-thickness tear. What is the initial management?

A. Immediate surgical rotator cuff repair

B. Shoulder impingement syndrome; conservative management first: NSAIDs, PT (rotator cuff strengthening, scapular stabilization), activity modification, corticosteroid injection if refractory; surgery if >3–6 months conservative therapy fails

C. AC joint injection; AC joint pathology is primary concern

D. Cervical MRI; radiculopathy must be ruled out before any shoulder treatment

Q10  |  ORTHO — Shoulder & Elbow

A 62-year-old male has acute-onset inability to lift his right arm after reaching overhead for a box. He has weakness with shoulder abduction initiation and a visible drop arm sign. He had chronic shoulder pain for years. MRI shows a full-thickness supraspinatus tear. What is the drop arm sign and what does it indicate?

A. Positive drop arm sign: patient cannot maintain 90° abduction against gravity — indicates full-thickness rotator cuff tear (most commonly supraspinatus); surgical repair indicated in active patients

B. Drop arm sign: elbow falls with supination against resistance — indicates biceps tendon rupture

C. Drop arm sign: wrist drops with elbow extension — indicates radial nerve palsy

D. Drop arm sign is a normal finding in patients over 60

Q11  |  ORTHO — Shoulder & Elbow

A 19-year-old male baseball pitcher complains of medial elbow pain, ulnar nerve tingling in the ring and small fingers, and weakness with grip. He reports the elbow feels unstable during the late cocking phase of pitching. Tinel sign is positive at the cubital tunnel. What is the diagnosis?

A. Lateral epicondylitis (tennis elbow); pain with wrist extension against resistance; common extensor origin

B. Medial epicondylitis (golfer's elbow) alone; pain with resisted wrist flexion; common flexor origin

C. Cubital tunnel syndrome; ulnar nerve compression at the elbow; medial elbow pain + ulnar nerve distribution (ring and small fingers) + positive Tinel at cubital tunnel; may coexist with UCL injury in throwers

D. Radial tunnel syndrome; posterior interosseous nerve compression; lateral forearm pain

Q12  |  ORTHO — Shoulder & Elbow

A 3-year-old girl is brought in after her father pulled her up by her arm to prevent her from falling. She now holds her arm pronated at her side and cries when the elbow is moved. X-ray is normal. What is the diagnosis and treatment?

A. Supracondylar fracture; emergent orthopedic referral

B. Nursemaid's elbow (radial head subluxation); annular ligament slips over the radial head; treatment = hyperpronation or supination-flexion maneuver — no imaging needed if classic history

C. Lateral condyle fracture; X-ray shows lucency at lateral condyle

D. Elbow dislocation; posterior dislocation most common; closed reduction required

Q13  |  ORTHO — Shoulder & Elbow

A 42-year-old tennis player has lateral elbow pain for 3 months that worsens with wrist extension against resistance and gripping. Tenderness is localized to the lateral epicondyle. Which test confirms the diagnosis and what structure is involved?

A. Tinel test at cubital tunnel; ulnar nerve

B. Cozen's test (resisted wrist extension with elbow extended reproduces lateral epicondyle pain); lateral epicondylitis (tennis elbow); common extensor tendon origin (ECRB most commonly involved)

C. Phalen's test; median nerve at carpal tunnel

D. Speed's test; long head of biceps tendon

Q14  |  ORTHO — Wrist & Hand

A 22-year-old male fell on an outstretched hand (FOOSH) while playing basketball. He has anatomical snuffbox tenderness and radial-sided wrist pain. Initial X-ray is negative. What is the next step and why?

A. Reassure and discharge — negative X-ray rules out fracture

B. Scaphoid fracture until proven otherwise; treat empirically with thumb spica cast and repeat X-ray or MRI/CT in 10–14 days — scaphoid fractures frequently occult on initial X-ray; risk of AVN if untreated

C. Boxer's fracture; splint the 4th-5th metacarpal neck

D. Colles fracture; dinner fork deformity on X-ray

Q15  |  ORTHO — Wrist & Hand

A 35-year-old female secretary has 4 months of bilateral hand numbness and tingling, worse at night and with prolonged typing, in the thumb, index, middle, and radial half of the ring finger. She occasionally drops objects. Thenar atrophy is present. Phalen and Tinel tests are positive. What is the diagnosis and gold-standard confirmatory test?

A. Cubital tunnel syndrome; ulnar nerve distribution (ring and small fingers); EMG/NCS confirms

B. Carpal tunnel syndrome (CTS); median nerve compression; gold standard = EMG/nerve conduction study (NCS) showing delayed conduction across the carpal tunnel

C. De Quervain's tenosynovitis; positive Finkelstein test; radial wrist pain

D. Thoracic outlet syndrome; entire hand involved; Adson test

Q16  |  ORTHO — Wrist & Hand

A 28-year-old female has radial wrist pain and swelling over the first dorsal compartment for 6 weeks after caring for a newborn. Pain worsens with thumb movement and gripping. Finkelstein test is markedly positive. What is the diagnosis, structures involved, and first-line treatment?

A. Trigger finger; flexor tendon catching in A1 pulley; corticosteroid injection

B. De Quervain's tenosynovitis; stenosing tenosynovitis of the APL (abductor pollicis longus) and EPB (extensor pollicis brevis) tendons in the first dorsal compartment; Finkelstein test positive; treatment = thumb spica splint, NSAIDs, corticosteroid injection

C. Carpal tunnel syndrome; median nerve compression; night splinting

D. Scaphoid fracture; anatomical snuffbox tenderness; thumb spica cast

Q17  |  ORTHO — Wrist & Hand

A 45-year-old male mechanic presents with a 5th metacarpal neck fracture after punching a wall. The fracture has 30° of dorsal angulation. His ring and small fingers are unaffected neurovascularly. What is the diagnosis, acceptable angulation threshold, and initial management?

A. Bennett fracture; intra-articular thumb metacarpal base; requires surgical fixation

B. Boxer's fracture (5th metacarpal neck); acceptable angulation up to 30–40° for ring finger, up to 40–70° for small finger — within acceptable range here; ulnar gutter splint in intrinsic plus position; orthopedic referral if exceeds threshold

C. Rolando fracture; comminuted intra-articular thumb metacarpal; surgical fixation

D. Nightstick fracture; isolated ulnar shaft; long arm cast

Q18  |  ORTHO — Wrist & Hand

A 30-year-old female has a painless, smooth, compressible mass on the dorsal wrist that has been present for 6 months. It transilluminates. It occasionally aches with repetitive wrist use. What is this and how is it managed?

A. Lipoma; excision required

B. Ganglion cyst; fluid-filled cyst arising from joint capsule or tendon sheath (most common dorsal wrist); transillumination positive; management = reassurance and observation (many spontaneously resolve), aspiration, or surgical excision if symptomatic and refractory

C. Felon; tense painful abscess of the fingertip pulp; incision and drainage

D. Flexor tenosynovitis; Kanavel signs; IV antibiotics and surgical irrigation

Q19  |  ORTHO — Wrist & Hand

A 25-year-old male presents with a swollen, fusiformly enlarged index finger held in slight flexion. He has severe pain with passive extension, exquisite tenderness along the flexor tendon sheath, and significant pain with any attempt to extend the finger. He cut his finger on a fish hook 2 days ago. What is the diagnosis and management?

A. Trigger finger; corticosteroid injection into A1 pulley

B. Flexor tenosynovitis (infectious); Kanavel's 4 cardinal signs = fusiform swelling + semiflexed resting posture + tenderness along flexor sheath + pain with passive extension; SURGICAL EMERGENCY — IV antibiotics + urgent surgical irrigation and debridement

C. Paronychia; warm soaks and I&D of nail fold abscess

D. Felon; I&D of the distal pulp space

Q20  |  ORTHO — Lower Extremity (Knee)

A 22-year-old female soccer player has an acute non-contact knee injury after pivoting. She heard a "pop" and has immediate knee swelling (hemarthrosis) within 2 hours. Anterior drawer and Lachman tests are positive. McMurray test is negative. What is the diagnosis, most sensitive test, and management?

A. Meniscus tear; McMurray test positive; MRI; conservative management or arthroscopic meniscectomy

B. ACL tear; Lachman test (most sensitive for ACL) — anterior tibial translation with knee at 20–30° flexion; MRI confirms; conservative (physical therapy) or surgical reconstruction (especially for athletes)

C. PCL tear; posterior drawer test positive; knee in posterior sag

D. MCL tear; valgus stress test positive; medial knee pain and instability

Q21  |  ORTHO — Lower Extremity (Knee)

A 55-year-old male landscaper has progressive bilateral knee pain worsening over 3 years. He reports morning stiffness lasting <30 minutes, bony crepitus, and pain with activity that improves with rest. X-ray shows joint space narrowing, subchondral sclerosis, osteophytes, and subchondral cysts. What is the diagnosis and first-line management?

A. Rheumatoid arthritis; symmetrical joint involvement; morning stiffness >1 hour; RF and anti-CCP positive; DMARDs

B. Knee osteoarthritis (OA); X-ray findings = LOSS of joint space, subchondral sclerosis, osteophytes (bone spurs), subchondral cysts; morning stiffness <30 minutes; first-line = exercise, weight loss, PT, acetaminophen or topical NSAIDs, oral NSAIDs

C. Septic arthritis; acute onset, fever, WBC markedly elevated; joint aspiration required

D. Pseudogout; calcium pyrophosphate crystals; chondrocalcinosis on X-ray

Q22  |  ORTHO — Lower Extremity (Knee)

A 17-year-old male wrestler presents with pre-patellar swelling, redness, and warmth. He fell on his knee during practice. The swelling is anterior to the patella and does not affect the knee joint space. He is afebrile. Which diagnoses must be distinguished and what test determines if this is infectious vs. aseptic?

A. Pes anserine bursitis vs. knee OA; aspiration not needed

B. Prepatellar bursitis (aseptic vs. septic); aspiration of the bursa for cell count, crystal analysis, gram stain, and culture — WBC >20,000 cells/μL, positive gram stain, or positive culture = septic (treat with antibiotics ± I&D); lower WBC = aseptic (NSAIDs, ice, compression)

C. Patellar fracture vs. quadriceps tendon rupture; X-ray differentiates

D. ACL tear vs. meniscus tear; Lachman and McMurray tests differentiate

Q23  |  ORTHO — Lower Extremity (Knee)

A 28-year-old male cyclist presents with lateral knee pain that begins after a fixed distance of cycling and improves with rest. There is point tenderness 2–3 cm above the lateral joint line at the area where the IT band crosses the lateral femoral epicondyle. McMurray is negative. What is the diagnosis and initial treatment?

A. LCL tear; varus stress test positive; bracing

B. IT band syndrome (iliotibial band friction syndrome); repetitive friction of the IT band over the lateral femoral epicondyle; common in runners and cyclists; Ober test assesses IT band tightness; treatment = activity modification, stretching, foam rolling, PT, NSAIDs

C. Lateral meniscus tear; McMurray positive; MRI confirmation

D. Popliteal cyst (Baker's cyst); posterior knee swelling; ultrasound confirmation

Q24  |  ORTHO — Lower Extremity (Knee)

A 25-year-old male has severe left leg pain after a motor vehicle accident where his left lower leg was crushed. On exam the compartment is tense and wooden. He has extreme pain with passive stretch of the toes. Distal pulses are present. What is the diagnosis and management?

A. Deep vein thrombosis; anticoagulation and elevation

B. Acute compartment syndrome; PAIN WITH PASSIVE STRETCH is the earliest and most sensitive sign; fasciotomy is the EMERGENCY treatment — do NOT wait for loss of pulses (late finding); elevation and compression are CONTRAINDICATED

C. Popliteal artery injury; doppler ultrasound and vascular surgery referral

D. Tibial shaft fracture; long leg splint and orthopedic referral

Q25  |  ORTHO — Lower Extremity (Foot & Ankle)

A 32-year-old male runner rolled his right ankle laterally while trail running. He has lateral ankle pain and swelling. He can bear weight with difficulty. The ATFL area is tender. Ottawa Ankle Rules are applied. He has NO tenderness over the posterior 6 cm of either fibula or tibia, and NO tenderness over the navicular or base of the 5th metatarsal. X-ray is ordered. Should it have been ordered?

A. Yes — all ankle injuries require X-ray

B. Ottawa Ankle Rules indicate X-ray is NOT required — no bony tenderness at the posterior fibula, posterior tibia, navicular, or base of 5th metatarsal, and he can bear weight; high-grade lateral ankle sprain; ATFL most commonly injured; treatment = RICE, NSAIDs, functional rehabilitation

C. MRI is required for all ankle sprains to rule out ligament tears

D. CT scan is required for any ankle injury with swelling

Q26  |  ORTHO — Lower Extremity (Foot & Ankle)

A 24-year-old basketball player has left foot pain after landing awkwardly. Tenderness is at the base of the 5th metatarsal, approximately 1.5 cm from the tip. X-ray shows a transverse fracture at the metaphyseal-diaphyseal junction. What fracture is this and why does it carry a higher risk of nonunion?

A. Avulsion fracture of the 5th metatarsal base; peroneus brevis avulsion; boot cast; excellent prognosis

B. Jones fracture; transverse fracture at the metaphyseal-diaphyseal junction (zone 2) of the 5th metatarsal; watershed area with poor blood supply → HIGH RISK of nonunion and refracture; treatment = non-weight-bearing cast 6–8 weeks or surgical fixation for athletes/active patients

C. Dancer's fracture; spiral fracture of the 5th metatarsal shaft; walking boot

D. Lisfranc fracture; tarsometatarsal joint disruption; surgical fixation

Q27  |  ORTHO — Lower Extremity (Foot & Ankle)

A 48-year-old female has plantar heel pain worse with the first steps in the morning and after prolonged sitting, improving after a few minutes of walking. She is obese and works as a teacher standing all day. Point tenderness is at the medial calcaneal tubercle. X-ray shows a heel spur. What is the diagnosis and first-line management?

A. Tarsal tunnel syndrome; tibial nerve compression; positive Tinel posterior to medial malleolus; splinting and steroid injection

B. Plantar fasciitis; inflammation at the plantar fascia insertion on the medial calcaneal tubercle; heel spur may be present but is NOT the cause; first-line = stretching (plantar fascia and Achilles), supportive footwear/orthotics, NSAIDs, ice; steroid injection if refractory

C. Achilles tendinopathy; posterior heel pain; eccentric strengthening exercises

D. Morton's neuroma; interdigital pain; Mulder's click; metatarsal pad

Q28  |  ORTHO — Neoplasms

A 15-year-old male presents with months of dull aching nocturnal pain in the right proximal femur that is COMPLETELY relieved by aspirin/NSAIDs. X-ray shows a small central lytic lesion <1 cm surrounded by dense sclerosis. CT is most useful for diagnosis. What is this and what is the gold standard treatment?

A. Osteosarcoma; aggressive sunburst periosteal reaction; chemotherapy and surgical resection

B. Osteoid osteoma; most common benign osteoid tumor; classic = nocturnal pain completely relieved by ASA/NSAIDs; central lytic nidus <1cm with surrounding sclerosis; CT imaging of choice; gold standard treatment = radiofrequency ablation (RFA) — less invasive, same success as surgical excision

C. Ewing sarcoma; onion-skin periosteal reaction; chemotherapy and radiation

D. Enchondroma; medullary cartilage tumor; hand bones most common; usually asymptomatic

Q29  |  ORTHO — Neoplasms

A 16-year-old male presents with progressive right thigh pain, swelling, and a palpable mass for 3 months. He has constitutional symptoms including fever, weight loss, and fatigue. X-ray shows a destructive diaphyseal lesion of the femur with "onion-skin" periosteal reaction. LDH is elevated. What is the diagnosis and management?

A. Osteosarcoma; metaphyseal location; sunburst periosteal reaction; chemotherapy + surgical resection

B. Ewing sarcoma; diaphyseal location in long bones; "onion-skin" periosteal reaction; elevated LDH; small round blue cells on histology; treatment = chemotherapy + radiation ± surgical resection

C. Osteoid osteoma; nocturnal pain relieved by NSAIDs; radiofrequency ablation

D. Chondrosarcoma; cartilaginous matrix; adults >40; surgical resection

Q30  |  ORTHO — Neoplasms

A 19-year-old male presents with a painless hard mass arising from the distal femur. X-ray shows an osseous protrusion with a cartilaginous cap projecting away from the joint. It has been present since childhood and has stopped growing. His father had a similar lesion removed. What is the diagnosis and key concern?

A. Osteosarcoma; sunburst periosteal reaction; aggressive; chemotherapy and resection

B. Osteochondroma (exostosis); most common benign bone tumor overall; cortex and medullary cavity continuous with host bone; grows away from joint; hereditary multiple exostoses (autosomal dominant) if multiple; KEY CONCERN = malignant transformation to chondrosarcoma (<1% solitary, higher in hereditary multiple exostoses); resect if symptomatic or cartilage cap >2cm

C. Enchondroma; medullary cartilage; Ollier disease if multiple

D. Giant cell tumor; epiphyseal location; soap bubble appearance; adults 20–40

Q31  |  PSYCH — Somatic Symptom & Related Disorders

A 38-year-old woman presents to her PCP for the 12th visit this year with multiple physical complaints including pain, fatigue, and GI symptoms. Extensive workup has been consistently negative. She spends hours researching her symptoms online and is convinced something serious is being missed. She experiences high anxiety about her symptoms daily. All other medical causes have been excluded. What is the diagnosis and key diagnostic requirement?

A. Illness anxiety disorder (hypochondriasis); the PRIMARY feature is fear of having a serious illness with minimal or no somatic symptoms

B. Somatic symptom disorder; one or more somatic symptoms causing distress + excessive thoughts/feelings/behaviors (disproportionate thoughts about seriousness, high anxiety, excessive time devoted) present for >6 months; DIAGNOSIS OF EXCLUSION; patient's suffering is authentic

C. Factitious disorder; patient is intentionally producing symptoms for the sick role

D. Malingering; patient is producing symptoms for external gain (disability, avoiding legal trouble)

Q32  |  PSYCH — Somatic Symptom & Related Disorders

A 24-year-old female college student presents with sudden-onset inability to move her right arm following a highly stressful academic exam. Neurological examination reveals no objective weakness, normal reflexes, and normal sensation. MRI of the brain and cervical spine are normal. Symptoms are not feigned. There is no external motivation. What is the diagnosis (DSM-5 term) and key distinguishing features from malingering?

A. Somatic symptom disorder; multiple somatic complaints with excessive health anxiety

B. Functional neurological symptom disorder (formerly conversion disorder); neurological symptoms inconsistent with known neurological pathology; typically preceded by psychological stressor; symptoms NOT intentionally produced (distinguishes from malingering and factitious disorder); positive clinical signs such as Hoover sign (hip extension weakness resolves with contralateral hip flexion)

C. Malingering; symptoms produced for external gain

D. Factitious disorder; symptoms intentionally produced to assume sick role

Q33  |  PSYCH — Eating Disorders

A 17-year-old female competitive gymnast is brought in by her parents. She weighs 82 lbs at 5'4" (BMI 14.1). She refuses to eat, has an intense fear of gaining weight, and states she still "feels fat." She has not had a period in 8 months. EKG shows a prolonged QTc. What is the most life-threatening complication and what syndrome must be prevented during treatment?

A. Osteoporosis is the leading cause of death; calcium supplementation is the priority

B. Anorexia nervosa; LEADING CAUSE OF DEATH = cardiac arrhythmia (prolonged QT + electrolyte imbalances); highest mortality of any psychiatric disorder; REFEEDING SYNDROME must be prevented — rapid refeeding causes hypophosphatemia → cardiac failure, respiratory failure, seizures — feed SLOWLY and monitor electrolytes closely

C. Aspiration pneumonia from forced nasogastric feeding is the primary concern

D. Hepatic failure from malnutrition; LFTs should be the primary monitoring parameter

Q34  |  PSYCH — Eating Disorders

A 20-year-old female college student presents privately. She reports binge eating large amounts of food followed by self-induced vomiting 4–5 times per week for 8 months. Her BMI is 22. She has dental erosions on the lingual surfaces. Labs show potassium of 2.9 mEq/L and CO₂ of 32 mEq/L. What is the diagnosis, electrolyte pattern, and first-line pharmacotherapy?

A. Anorexia nervosa, binge-purge subtype; severely low BMI; olanzapine

B. Bulimia nervosa; purging → loss of gastric HCl → HYPOKALEMIA + METABOLIC ALKALOSIS (elevated CO₂/bicarb); dental erosions on lingual surfaces (acid from vomiting); first-line pharmacotherapy = FLUOXETINE (only FDA-approved medication for bulimia nervosa, at higher dose 60mg); first-line therapy = CBT

C. Binge eating disorder; no compensatory behaviors; SSRIs and CBT

D. Somatic symptom disorder; physical symptoms predominate

Q35  |  PSYCH — Somatic & Eating

A parent brings their 8-year-old son in for a pediatric well visit. Over the past 4 months the child has had multiple hospitalizations with varied symptoms: high fever, vomiting, and altered consciousness — all of which resolved completely when separated from the mother. Staff have observed the mother adding substances to the IV bag. What is this diagnosis and the appropriate action?

A. Factitious disorder in the child; child is producing his own symptoms

B. Factitious disorder imposed on another (formerly Munchausen syndrome by proxy); a caregiver (mother) INTENTIONALLY induces or fabricates illness in another person (child) to assume caregiver/patient role; MANDATORY REPORT TO CPS; separate the child from the caregiver; multidisciplinary team required

C. Somatic symptom disorder by proxy; the mother is anxious about the child's health

D. Malingering by proxy; the mother seeks external gain (insurance payments)

Q36  |  PSYCH — Somatic & Eating

A 45-year-old male presents to a PA requesting opioid pain medication, claiming severe back pain. He has no imaging findings of pathology on MRI. He recently lost a lawsuit and is appealing. He acknowledges he is not in significant pain but states he needs the medication to "get through the legal process." What distinguishes malingering from factitious disorder?

A. Malingering produces symptoms unconsciously; factitious disorder is deliberate

B. MALINGERING = INTENTIONAL production/feigning of symptoms for EXTERNAL INCENTIVES (financial gain, avoiding legal consequences, obtaining drugs, avoiding military service) — NOT a mental disorder; FACTITIOUS DISORDER = intentional production/feigning symptoms to assume the SICK ROLE with NO external gain; this patient = malingering

C. Factitious disorder occurs only in children; malingering only in adults

D. Both are identical diagnoses managed with the same treatment

Q37  |  PSYCH — Substance Use Disorders

A 45-year-old male with a 20-year history of heavy daily alcohol use presents to the ED 36 hours after his last drink. He is tremulous, diaphoretic, agitated, and has BP of 164/102 and HR of 118. He has had two seizures during prior withdrawals. What is the first-line pharmacologic treatment and what is the life-threatening complication if untreated?

A. Haloperidol; antipsychotics treat the agitation and prevent seizures in alcohol withdrawal

B. Benzodiazepines (diazepam or lorazepam, CIWA-guided); GABA-A agonists cross-tolerant with alcohol; treat and PREVENT seizures and DELIRIUM TREMENS (DTs) — life-threatening complication: DTs = tremor + autonomic instability + confusion + hallucinations; mortality up to 5–15% untreated

C. Naltrexone; opioid antagonist; first-line for acute alcohol withdrawal

D. Methadone; used for opioid withdrawal, not alcohol withdrawal

Q38  |  PSYCH — Substance Use Disorders

A 28-year-old male is brought in unresponsive with pinpoint pupils and respiratory rate of 5. He is found with a syringe. Naloxone reverses his respiratory depression, but he becomes alert and agitated within minutes. He refuses to stay. An hour later he is found unresponsive again. What explains this recurrence and how should his long-term opioid use disorder be managed?

A. He developed naloxone resistance; higher dose naloxone is needed

B. NALOXONE HAS A SHORTER HALF-LIFE THAN MOST OPIOIDS (30–90 minutes); opioid re-narcotization occurs as naloxone wears off — requires repeat dosing or infusion; long-term management = MEDICATION-ASSISTED TREATMENT (MAT): BUPRENORPHINE/NALOXONE (Suboxone) or METHADONE (in licensed OTP); naltrexone for motivated patients with detox completed

C. The patient has benzodiazepine intoxication; flumazenil is the next step

D. Observation only; naloxone cures opioid overdose permanently

Q39  |  PSYCH — Substance Use Disorders

A 35-year-old female in recovery from opioid use disorder is prescribed buprenorphine/naloxone. She asks why naloxone is added to the buprenorphine. What is the purpose of combining these two drugs?

A. Naloxone treats pain while buprenorphine prevents withdrawal

B. ABUSE-DETERRENT FORMULATION: if swallowed/dissolved under the tongue as prescribed, buprenorphine is absorbed sublingually and naloxone has poor bioavailability — therapeutic effect. If injected IV (attempted misuse), naloxone IS absorbed systemically → PRECIPITATES WITHDRAWAL in opioid-dependent individuals → deters IV abuse

C. Naloxone enhances the analgesic effect of buprenorphine

D. Naloxone prevents respiratory depression at all doses of buprenorphine

Q40  |  PSYCH — Substance Use Disorders

A 30-year-old male with benzodiazepine use disorder requests detox. He has been taking alprazolam 6mg daily for 3 years. Why is abrupt discontinuation dangerous and what is the safest management?

A. Abrupt discontinuation causes only mild discomfort; taper is not medically necessary

B. BENZODIAZEPINE WITHDRAWAL CAN BE LIFE-THREATENING — risk of SEIZURES and DELIRIUM; mechanism = GABA-A receptor downregulation from chronic use; safe management = GRADUAL TAPER (10% dose reduction per week or equivalent long-acting benzodiazepine like diazepam); NEVER abruptly discontinue in physically dependent patients

C. Switch immediately to naltrexone; opioid antagonist treats benzodiazepine dependence

D. Methadone is the standard of care for benzodiazepine withdrawal

Q41  |  PSYCH — Substance Use Disorders

A 52-year-old male with a 15-year history of heavy alcohol use presents for relapse prevention after completing detox. He is motivated to maintain sobriety but has relapsed twice. He has no liver disease. Which medication is FDA-approved for alcohol use disorder maintenance and works by blocking opioid receptors to reduce the rewarding effects of alcohol?

A. Disulfiram (Antabuse); blocks aldehyde dehydrogenase; causes flushing, nausea, vomiting with alcohol ingestion — aversion therapy

B. NALTREXONE (oral or monthly injection Vivitrol); opioid antagonist — blocks mu-opioid receptors that mediate alcohol's rewarding effects; reduces craving and relapse; preferred in motivated patients without liver failure; monthly injection improves adherence

C. Methadone; full opioid agonist; only for opioid use disorder

D. Bupropion; reduces alcohol cravings through dopamine and norepinephrine reuptake inhibition

Q42  |  PSYCH — Trauma & Stressor-Related Disorders

A 34-year-old combat veteran presents 8 months after returning from deployment. He has intrusive flashbacks, nightmares, emotional numbing, hypervigilance, avoidance of driving (he was in an IED blast), negative alterations in cognition/mood, and sleep disturbance. Symptoms have been present for 7 months. What is the diagnosis and first-line treatment?

A. Acute stress disorder; symptoms present within 1 month and lasting 3 days to 1 month

B. PTSD; symptoms >1 month after traumatic event; 4 core symptom clusters: intrusion (flashbacks/nightmares), avoidance, negative alterations in cognition/mood, hyperarousal; FIRST-LINE: trauma-focused CBT (Prolonged Exposure or CPT) + SSRI (sertraline or paroxetine — both FDA-approved)

C. Adjustment disorder; stressor-related; symptoms resolve within 6 months after stressor ends

D. Major depressive disorder; depressive episode precipitated by trauma; antidepressants only

Q43  |  PSYCH — Trauma & Stressor-Related Disorders

A 28-year-old female nurse witnessed a traumatic death at work 2 weeks ago. She has intrusive memories, emotional numbing, dissociative amnesia about parts of the event, and marked hypervigilance for the past 10 days. She meets full PTSD symptom criteria. What is the correct diagnosis at this time point?

A. PTSD; symptoms meet full criteria; start sertraline immediately

B. Acute stress disorder (ASD); same symptom clusters as PTSD but duration is 3 DAYS to 1 MONTH; occurs within 1 month of trauma; may or may not progress to PTSD; treatment = trauma-focused CBT; SSRIs not first-line for ASD

C. Adjustment disorder; symptoms are a disproportionate response to the stressor

D. Normal grief reaction; no treatment needed at 2 weeks

Q44  |  PSYCH — Sleep Disorders

A 48-year-old male presents with excessive daytime sleepiness, loud snoring reported by his wife, observed apneas during sleep, and morning headaches. BMI is 34. He wakes frequently to urinate. Epworth Sleepiness Scale score is 16/24. What is the diagnosis, gold-standard diagnostic test, and first-line treatment?

A. Narcolepsy; sleep paralysis and cataplexy; multiple sleep latency test (MSLT); sodium oxybate

B. Obstructive sleep apnea (OSA); GOLD STANDARD DIAGNOSIS = overnight polysomnography (PSG) (in-lab sleep study); AHI ≥5 with symptoms or ≥15 regardless of symptoms = OSA; first-line treatment = CPAP (continuous positive airway pressure)

C. Insomnia disorder; difficulty initiating or maintaining sleep; CBT-I is first-line

D. Restless legs syndrome; uncomfortable leg sensations worse at rest/evening; dopamine agonists

Q45  |  PSYCH — Sleep Disorders

A 35-year-old female has persistent difficulty falling asleep (takes >60 minutes) and frequent nighttime awakenings at least 3 nights/week for 5 months, causing daytime fatigue and occupational impairment. She spends 10 hours in bed trying to sleep. Medical and psychiatric causes are excluded. What is the diagnosis and gold-standard treatment?

A. Obstructive sleep apnea; polysomnography and CPAP

B. Insomnia disorder; difficulty initiating or maintaining sleep ≥3 nights/week for ≥3 months causing daytime impairment; GOLD STANDARD TREATMENT = CBT-I (cognitive behavioral therapy for insomnia) — stimulus control, sleep restriction, relaxation techniques, sleep hygiene; superior to medications long-term

C. Delayed sleep phase syndrome; melatonin and light therapy

D. Hypersomnia; excessive daytime sleepiness despite adequate nighttime sleep

Q46  |  PSYCH — Sleep Disorders

A 16-year-old male is brought in by his parents because he cannot fall asleep until 2–3 AM and naturally wakes at 11 AM–noon. When allowed to sleep on his own schedule he feels well and functions normally. He is failing classes because school starts at 7:30 AM. What is the diagnosis and treatment?

A. Insomnia disorder; CBT-I and sleep restriction therapy

B. Delayed sleep phase syndrome (DSPS); circadian rhythm sleep-wake disorder; natural sleep phase shifted later; treatment = CHRONOTHERAPY (gradual phase advancement), morning BRIGHT LIGHT THERAPY upon waking, low-dose MELATONIN in the evening (3–6 hours before target sleep time)

C. Narcolepsy; excessive daytime sleepiness; polysomnography and MSLT

D. Obstructive sleep apnea; obesity-related; polysomnography and CPAP

Q47  |  PSYCH — Personality Disorders

A 26-year-old female has a 7-year history of unstable intense relationships, impulsivity (spending sprees, risky sex, substance use), recurrent suicidal gestures and self-cutting when feeling abandoned, intense emotional swings, chronic feelings of emptiness, and identity disturbance. She describes her therapist as "the only person who truly understands me" one week and "completely useless" the next. What is the diagnosis and the defense mechanism characterizing it?

A. Narcissistic personality disorder; grandiosity and lack of empathy; feels special/unique

B. Borderline personality disorder (BPD); SPLITTING = defense mechanism (seeing people as all good or all bad, alternating); pervasive pattern of unstable relationships, self-image, affect, and marked impulsivity; suicidal gestures; chronic emptiness; identity disturbance; GOLD STANDARD TREATMENT = Dialectical Behavior Therapy (DBT)

C. Histrionic personality disorder; excessive emotionality and attention-seeking; theatrical

D. Antisocial personality disorder; disregard for rights of others; must be ≥18 with conduct disorder before age 15

Q48  |  PSYCH — Personality Disorders

A 38-year-old male executive is referred by his HR department after multiple complaints from subordinates. He believes he deserves special treatment, exaggerates his accomplishments, lacks empathy for colleagues, frequently interrupts meetings to discuss his own achievements, expects admiration, and becomes rageful when he perceives criticism. He is surprised that anyone has complaints. What is the diagnosis and the key distinction from BPD?

A. Borderline personality disorder; unstable self-image and splitting

B. Narcissistic personality disorder (NPD); GRANDIOSITY (not present in BPD) + pervasive pattern of: grandiose self-importance, fantasies of unlimited success/power, believes he is special and unique, requires excessive admiration, lacks empathy, exploits relationships, envious; ego-SYNTONIC (consistent with self); key distinction from BPD = stable (not fragile) self-image and GRANDIOSITY rather than identity disturbance

C. Antisocial personality disorder; disregard for and violation of rights of others; criminal behavior

D. Histrionic personality disorder; excessive emotionality; attention-seeking; sexually provocative

Q49  |  PSYCH — Personality Disorders

A 42-year-old female has a pervasive pattern of excessive emotionality and attention-seeking. She is uncomfortable when not the center of attention, dresses provocatively, speaks dramatically with little substance, is easily influenced by others, and considers all relationships more intimate than they actually are. What is this personality disorder and its cluster?

A. Cluster A (odd/eccentric) — Schizoid personality disorder; social detachment, emotional coldness

B. Cluster B (dramatic/impulsive/erratic) — HISTRIONIC personality disorder; key features = excessive emotionality, attention-seeking, inappropriate sexual/provocative behavior, theatrical speech, suggestibility, considers relationships more intimate than they are; ego-syntonic

C. Cluster C (anxious/fearful) — Dependent personality disorder; excessive need to be cared for

D. Cluster A — Paranoid personality disorder; pervasive distrust and suspiciousness of others

Q50  |  PSYCH — Personality Disorders

A 32-year-old male is pervasively suspicious of others, believes his coworkers are conspiring against him despite no evidence, reads hidden demeaning meanings into benign remarks, is reluctant to confide in anyone, persistently bears grudges, and perceives attacks on his character that others don't notice. He has no psychosis and his beliefs are not delusional in intensity. What is the diagnosis and cluster?

A. Cluster B — Antisocial personality disorder; violation of rights of others

B. Cluster A (Odd/Eccentric) — PARANOID personality disorder; pervasive distrust and suspiciousness of others; suspects exploitation/harm without sufficient basis; reads hidden threatening meanings into remarks; reluctant to confide; bears grudges; perceives counterattacks; NOT psychotic (beliefs do not reach delusional intensity — distinguishes from delusional disorder/schizophrenia)

C. Cluster C — Avoidant personality disorder; social inhibition due to fear of rejection

D. Schizoid personality disorder; detachment from social relationships; restricted emotional expression

Q51  |  PSYCH — Personality Disorders

A 29-year-old male has held 12 jobs in 5 years, has been arrested multiple times for assault and fraud, shows no remorse for hurting others, is manipulative, lies chronically, and was expelled from school at age 12 for aggressive behavior and stealing. He is charming and intelligent in conversation. He meets criteria that were apparent before age 15. What is the diagnosis and required age specification?

A. Narcissistic personality disorder; grandiosity and entitlement; no prior conduct disorder required

B. ANTISOCIAL personality disorder (ASPD); pervasive disregard for and violation of rights of others SINCE AGE 15; must have had CONDUCT DISORDER before age 15; diagnosis requires age ≥18; callousness, deceitfulness, impulsivity, aggressiveness, irresponsibility, lack of remorse; ego-syntonic

C. Borderline personality disorder; impulsivity and unstable relationships; self-harm

D. Intermittent explosive disorder; recurrent impulsive aggressive episodes; no persistent pattern of rights violations

Q52  |  Rheumatology — Inflammatory Arthritis

A 52-year-old female has bilateral symmetric swelling of the MCPs and PIPs, morning stiffness lasting 3 hours, and fatigue for 4 months. X-ray shows periarticular osteopenia and marginal erosions. RF is positive. Anti-CCP antibody is markedly elevated. What is the diagnosis, the most specific antibody, and the preferred DMARD?

A. Osteoarthritis; DIP and PIP involvement; Heberden and Bouchard nodes; Tx = NSAIDs

B. Rheumatoid arthritis; ANTI-CCP is the most SPECIFIC antibody (RF is sensitive but not specific); MCP and PIP involvement (spares DIP); morning stiffness >1 hour; erosive, symmetric; preferred DMARD = METHOTREXATE (anchor DMARD); biologic if inadequate response (TNF inhibitors, etc.)

C. Psoriatic arthritis; DIP involvement; nail pitting; X-ray = pencil-in-cup deformity

D. Reactive arthritis; Reiter triad = urethritis + conjunctivitis + arthritis; asymmetric lower extremity

Q53  |  Rheumatology — Crystal Arthropathy

A 55-year-old male with HTN on hydrochlorothiazide presents with sudden severe pain, redness, and swelling of his right first MTP joint that woke him from sleep. Joint aspiration shows negatively birefringent needle-shaped crystals. Serum uric acid is 9.8 mg/dL. What is the diagnosis, crystal type, and first-line acute treatment?

A. Pseudogout; calcium pyrophosphate crystals; positively birefringent rhomboid-shaped; NSAIDS

B. GOUT; MONOSODIUM URATE (MSU) crystals; NEGATIVELY birefringent, needle-shaped; classic podagra (1st MTP); ACUTE treatment = NSAIDs (first-line) OR colchicine (if NSAIDs contraindicated) OR corticosteroids; URATE-LOWERING THERAPY (allopurinol or febuxostat) for prevention after acute attack resolves

C. Septic arthritis; gram-positive cocci on gram stain; IV antibiotics required

D. Reactive arthritis; asymmetric lower extremity; preceding infection

Q54  |  Rheumatology — Spondyloarthropathy

A 26-year-old male has 3 years of inflammatory low back pain: insidious onset, age <40, morning stiffness >1 hour that IMPROVES with exercise and WORSENS with rest, and buttock pain alternating sides. Sacroiliac joint tenderness is present. HLA-B27 is positive. MRI shows sacroiliitis bilaterally. X-ray shows bamboo spine. What is the diagnosis and extra-articular manifestations?

A. Rheumatoid arthritis; symmetric peripheral joint involvement; RF and anti-CCP positive

B. Ankylosing spondylitis (AS); HLA-B27 strongly associated (90%); INFLAMMATORY back pain = improves with exercise/worsens with rest; sacroiliitis; bamboo spine (syndesmophytes bridging vertebrae); extra-articular = uveitis (most common), aortic regurgitation, IBD, psoriasis, apical pulmonary fibrosis; Tx = NSAIDs first-line; TNF inhibitors if refractory

C. Lumbar degenerative disc disease; mechanical pain worsens with activity; X-ray disc space narrowing

D. Reactive arthritis; asymmetric lower extremity + preceding GI or GU infection

Q55  |  Rheumatology — Connective Tissue Disease

A 32-year-old female presents with a malar (butterfly) rash across both cheeks sparing the nasolabial folds, oral ulcers, alopecia, photosensitivity, serositis (pleuritis), and thrombocytopenia. ANA is positive at 1:640. Anti-dsDNA and anti-Smith antibodies are positive. What is the diagnosis and the most SPECIFIC antibody?

A. Systemic sclerosis; skin thickening, Raynaud phenomenon, anti-Scl-70 (diffuse) or anti-centromere (limited)

B. Systemic lupus erythematosus (SLE); anti-SMITH (anti-Sm) is most SPECIFIC for SLE; anti-dsDNA is also specific and correlates with disease activity/nephritis; ANA is sensitive (not specific); hydroxychloroquine is used in all SLE patients

C. Dermatomyositis; heliotrope rash, Gottron's papules, proximal muscle weakness; anti-Jo-1

D. Sjögren syndrome; sicca symptoms (dry eyes/mouth); anti-SSA (Ro) and anti-SSB (La)

Q56  |  Rheumatology — Vasculitis

A 68-year-old female presents with new temporal headache, scalp tenderness, jaw claudication, and sudden transient vision loss in her right eye. ESR is 105 mm/hr, CRP is markedly elevated. What is the diagnosis, most feared complication if untreated, and treatment?

A. Migraine with aura; triptans; not a vasculitis

B. Giant cell arteritis (temporal arteritis); most feared complication = PERMANENT BLINDNESS (anterior ischemic optic neuropathy); START HIGH-DOSE PREDNISONE IMMEDIATELY — do NOT wait for biopsy; temporal artery biopsy confirms (skip lesions — biopsy segment ≥2cm); ESR/CRP markedly elevated; associated with PMR

C. Takayasu arteritis; large vessel vasculitis; young women; subclavian artery involvement

D. Wegener's granulomatosis (GPA); upper and lower respiratory tract + renal; c-ANCA/PR3

Q57  |  Rheumatology — Fibromyalgia & Osteoporosis

A 44-year-old female has 8 months of widespread musculoskeletal pain, fatigue, non-restorative sleep, cognitive difficulties ("fibro fog"), headaches, and IBS. Physical exam shows diffuse tender points but no joint swelling, normal inflammatory markers, and a negative ANA. What is the diagnosis and first-line management?

A. Rheumatoid arthritis; morning stiffness; elevated RF and anti-CCP; methotrexate

B. Fibromyalgia; widespread pain ≥3 months + multiple somatic symptoms; NORMAL inflammatory markers and labs; no structural pathology; FIRST-LINE = aerobic exercise (most evidence) + CBT; pharmacotherapy = duloxetine (SNRI), milnacipran (SNRI), or pregabalin (FDA-approved); AVOID opioids

C. SLE; malar rash; positive ANA; hydroxychloroquine

D. Polymyalgia rheumatica; proximal muscle pain; age >50; elevated ESR; prednisone

Q58  |  Rheumatology — Osteoporosis

A 68-year-old postmenopausal female has a T-score of -2.7 at the hip on DEXA scan. She has no prior fractures. FRAX 10-year probability is 18% for major osteoporotic fracture. She has no secondary causes. What is the diagnosis and first-line pharmacotherapy?

A. Osteopenia (T-score -1.0 to -2.5); lifestyle modifications only; no pharmacotherapy

B. OSTEOPOROSIS (T-score ≤-2.5); first-line pharmacotherapy = BISPHOSPHONATES (alendronate, risedronate — oral; zoledronate — IV annual); calcium (1200mg/day) + vitamin D (800–1000 IU/day) for all patients; DEXA monitoring every 1–2 years; FRAX ≥20% for major fracture = treat

C. Severe osteoporosis with fracture; teriparatide (PTH analog) is first-line

D. Paget disease of bone; elevated alkaline phosphatase; bisphosphonates

Q59  |  Hematology — Anemia

A 72-year-old male has fatigue, pallor, and macrocytic anemia (MCV 108 fL). His peripheral smear shows hypersegmented neutrophils (≥5 lobes). He is a strict vegan and has been on metformin for 10 years. Serum B12 is very low. Folate is normal. Methylmalonic acid (MMA) and homocysteine are both elevated. What is the diagnosis and treatment?

A. Folate deficiency; low folate level; folic acid supplementation

B. Vitamin B12 deficiency (cobalamin deficiency); macrocytic/megaloblastic anemia + hypersegmented neutrophils; BOTH MMA AND homocysteine elevated (folate deficiency elevates homocysteine ONLY, not MMA — key distinguishing test); causes: strict veganism, metformin (reduces absorption), pernicious anemia (anti-IF Ab), GI surgery; Tx = IM cyanocobalamin or high-dose oral B12

C. Iron deficiency anemia; microcytic, hypochromic; low ferritin; oral iron supplementation

D. Anemia of chronic disease; normocytic; elevated ferritin; treat underlying disease

Q60  |  Hematology — Anemia

A 28-year-old female marathon runner has fatigue and exertional dyspnea. CBC: Hgb 9.8, MCV 72 fL, RDW elevated. Iron studies: serum iron low, TIBC elevated, ferritin 6 ng/mL. Peripheral smear shows hypochromic microcytic cells with pencil cells. What is the diagnosis and treatment?

A. Thalassemia trait; microcytic anemia with NORMAL or LOW ferritin and elevated RBC count; hemoglobin electrophoresis

B. Iron deficiency anemia; low ferritin (most sensitive/specific marker of iron stores), low serum iron, HIGH TIBC (increased transferrin production to scavenge iron); treat = oral ferrous sulfate (take on empty stomach with vitamin C; avoid antacids/calcium within 2 hours; expect reticulocytosis in 7–10 days, Hgb rise in 4–8 weeks)

C. Anemia of chronic disease; low serum iron, LOW TIBC (stored in macrophages), NORMAL or HIGH ferritin

D. Lead poisoning; basophilic stippling on smear; chelation therapy

Q61  |  Hematology — Hemoglobinopathies

A 24-year-old African American female with known sickle cell disease (HbSS) presents with severe bilateral hip pain, fever of 38.2°C, and new respiratory distress. Her oxygen saturation is 89%. CXR shows a new bilateral lower lobe infiltrate. WBC is 18,000. What is this complication, what finding is REQUIRED for diagnosis, and what is the treatment?

A. Vaso-occlusive pain crisis; treat with IV fluids and opioids only

B. ACUTE CHEST SYNDROME (ACS); NEW PULMONARY INFILTRATE ON CXR IS REQUIRED for diagnosis (distinguishes from pain crisis); O₂ + IV fluids + analgesia + broad-spectrum antibiotics (covers S. pneumoniae, Mycoplasma, Chlamydia) + EXCHANGE TRANSFUSION for severe ACS; leading cause of death in SCD

C. Community-acquired pneumonia; azithromycin outpatient treatment

D. Pulmonary embolism; CT pulmonary angiography; anticoagulation

Q62  |  Hematology — Malignant

A 6-year-old male has 3 weeks of fatigue, pallor, easy bruising, bone pain, and lymphadenopathy. CBC: WBC 45,000 (lymphoblasts on smear), Hgb 6.8, platelets 28,000. Peripheral smear shows lymphoblasts. Bone marrow biopsy shows >20% blasts. TdT positive, CALLA (CD10) positive. What is the most likely diagnosis and overall prognosis in children?

A. AML; myeloblasts with Auer rods; cytogenetics guide treatment

B. ALL (Acute Lymphoblastic Leukemia); most common childhood cancer; lymphoblasts (TdT+, CALLA/CD10+, PAS+); pancytopenia + lymphadenopathy + bone pain; EXCELLENT prognosis in children (>90% cure rate with modern chemotherapy including induction, consolidation, maintenance, CNS prophylaxis)

C. CLL; chronic course; smudge cells; adults >50; watch and wait

D. Hodgkin lymphoma; Reed-Sternberg cells; bimodal distribution; excellent prognosis

Q63  |  Hematology — Malignant

A 62-year-old male presents with fatigue, bone pain, hypercalcemia, renal insufficiency, and anemia. Serum protein electrophoresis shows an M-spike. Urine shows Bence Jones proteins. Bone marrow biopsy has 25% plasma cells. X-ray shows "punched-out" lytic lesions in the skull. What is the diagnosis and the classic mnemonic for its complications?

A. Waldenstrom macroglobulinemia; IgM paraprotein; hyperviscosity syndrome; plasmapheresis

B. MULTIPLE MYELOMA; clonal plasma cell neoplasm; CRAB = Hypercalcemia, Renal failure, Anemia, Bone lesions (punched-out lytic); M-spike on SPEP; Bence Jones proteins (free light chains in urine); treatment = bortezomib + lenalidomide + dexamethasone followed by autologous stem cell transplant for eligible patients

C. CML; bcr-abl translocation t(9;22); imatinib (tyrosine kinase inhibitor)

D. Hodgkin lymphoma; Reed-Sternberg cells; bimodal distribution; curative with chemo/radiation

Q64  |  Hematology — Platelet & Coagulation

A 5-year-old girl has acute onset of petechiae and purpura 2 weeks after a viral URI. She is otherwise healthy. CBC: platelets 8,000; WBC and Hgb normal. Peripheral smear shows isolated thrombocytopenia with large platelets. Bone marrow shows normal to increased megakaryocytes. What is the diagnosis and management for a child with platelet count >20,000 and no active bleeding?

A. TTP; microangiopathic hemolytic anemia + thrombocytopenia + neurological symptoms; ADAMTS13 activity; plasma exchange

B. Immune thrombocytopenic purpura (ITP); post-viral IgG autoantibodies coat platelets → splenic destruction; isolated thrombocytopenia + normal WBC/Hgb; MANAGEMENT in children with platelet count >20,000 and no significant bleeding = OBSERVATION (majority self-resolve within 6 months); IVIG or corticosteroids if <20,000 or significant bleeding

C. Aplastic anemia; pancytopenia; hypocellular bone marrow; antithymocyte globulin

D. Leukemia; blasts on peripheral smear; bone marrow replacement

Q65  |  Hematology — Neutropenia & Transfusions

A 58-year-old female with AML is receiving induction chemotherapy. She develops a fever of 38.8°C. Her ANC (absolute neutrophil count) is 320 cells/μL. Blood cultures are drawn. What is the diagnosis, how is ANC calculated, and what is the empiric treatment?

A. Simple viral URI; supportive care; repeat CBC in 1 week

B. FEBRILE NEUTROPENIA; ANC = WBC × (% neutrophils + % bands) / 100; ANC <500 with fever ≥38.3°C OR ANC <1000 expected to decline to <500; MEDICAL EMERGENCY; empiric BROAD-SPECTRUM IV antibiotics immediately (anti-pseudomonal beta-lactam: cefepime, piperacillin-tazobactam, or carbapenem); do NOT wait for culture results; add vancomycin if suspected MRSA/catheter infection

C. Drug fever from chemotherapy; diphenhydramine and observation

D. Typhlitis; CT scan required before antibiotics

Q66  |  Integrated

A 35-year-old male recreational tennis player has acute onset of left posterior heel pain after lunging for a wide ball. He heard a "pop" and cannot push off. Thompson test is positive (squeezing the calf does NOT plantarflex the foot). He can walk with a flat-footed gait. What is the diagnosis and management?

A. Posterior tibial tendon rupture; medial heel pain; flat foot deformity; surgical repair

B. Achilles tendon RUPTURE; Thompson test positive = diagnostic (no plantarflexion with calf squeeze = tendon is disrupted); palpable gap proximal to calcaneal insertion; management = surgical repair for active patients (lower re-rupture rate) OR functional rehabilitation in cast/brace for lower-demand patients (similar outcomes in some studies)

C. Peroneal tendon subluxation; lateral ankle; snapping with eversion

D. Ankle sprain; ATFL most commonly injured; RICE protocol

Q67  |  Integrated

A 42-year-old female presents with a 3-month history of worsening grip weakness, difficulty writing, and occasional dropping of objects. She has bilateral hand symptoms in the median nerve distribution. She is a computer programmer who types 8 hours daily. EMG/NCS shows prolonged median nerve conduction velocity bilaterally. Initial conservative management has failed after 4 months. What is the next step?

A. Cervical MRI; rule out C6 radiculopathy before any further treatment

B. Carpal tunnel syndrome refractory to conservative management; next step = SURGICAL CARPAL TUNNEL RELEASE (carpal tunnel release — open or endoscopic) — section of the transverse carpal ligament to decompress the median nerve; thenar atrophy is a sign of severe/chronic disease

C. Switch to a different wrist splint and reassess in 6 months

D. Continue conservative management indefinitely; surgery is contraindicated in bilateral CTS

Q68  |  Integrated

A 52-year-old male presents to the ED agitated and confused, with dilated pupils, dry flushed skin, and urinary retention. He is hyperthermic at 39.2°C. His wife reports he may have taken an unknown number of his adult son's antipsychotic medications mixed with his own medications. Which toxidrome is most consistent and what medications are MOST likely responsible?

A. Cholinergic toxidrome; organophosphate exposure; profuse secretions, miosis, bradycardia

B. ANTICHOLINERGIC TOXIDROME: Hot, Dry, Red, Blind, Mad + urinary retention; MOST likely = ANTIPSYCHOTICS (many have anticholinergic properties — olanzapine, clozapine, quetiapine), TRICYCLIC ANTIDEPRESSANTS, antihistamines, GI antispasmodics; treatment = supportive; physostigmine for severe cases (reversible AChE inhibitor)

C. Serotonin syndrome; hyperthermia + clonus/myoclonus + agitation; cyproheptadine; caused by serotonergic excess

D. NMS (neuroleptic malignant syndrome); hyperthermia + lead-pipe rigidity + altered consciousness; caused by dopamine antagonists

Q69  |  Integrated

A 38-year-old male with alcohol use disorder has been sober for 2 days after a 10-year drinking history. He presents tremulous, diaphoretic, with visual hallucinations (seeing insects on the wall), HR 128, BP 168/104, and temperature 38.6°C. He is confused. What syndrome is this, what medication class is contraindicated, and what is the definitive treatment?

A. Alcohol intoxication; supportive care; IV fluids

B. DELIRIUM TREMENS (DTs); life-threatening alcohol withdrawal syndrome (typically 48–96h after last drink); ANTIPSYCHOTICS (haloperidol) do NOT prevent seizures and do NOT treat the underlying GABA dysregulation — do NOT use as monotherapy; definitive treatment = HIGH-DOSE BENZODIAZEPINES (GABA-A agonist, cross-tolerant with alcohol); give THIAMINE BEFORE GLUCOSE; ICU monitoring

C. Wernicke encephalopathy; confusion + ataxia + ophthalmoplegia; thiamine only needed

D. Hepatic encephalopathy; elevated ammonia; lactulose and rifaximin

Q70  |  Integrated

A 19-year-old female college student presents after being found unconscious at a party. Witnesses report she consumed alcohol and a pill someone gave her. She has slurred speech, ataxia, and respiratory rate of 8. Pupils are mid-sized and reactive. Naloxone is given with no response. Blood alcohol level is 0.31 g/dL. What is the most likely cause of respiratory depression and management?

A. Opioid overdose; repeat higher-dose naloxone

B. POLYSUBSTANCE intoxication — ALCOHOL + BENZODIAZEPINE (or GHB/barbiturate); CNS and respiratory depression synergistic; pupils mid-sized/reactive (benzodiazepines — unlike opioids which cause MIOSIS); naloxone ineffective; FLUMAZENIL can reverse benzodiazepines (use cautiously — can precipitate seizures in chronic users); supportive care: airway management, respiratory support; NO emesis induction

C. Methamphetamine overdose; dilated pupils, tachycardia, hypertension

D. Serotonin syndrome; hyperthermia, clonus, diaphoresis

Q71  |  Integrated

A 44-year-old female with SLE presents with a 3-week history of increasing fatigue, facial swelling, 3+ pitting edema to the knees, and 8 lbs of weight gain. UA shows 4+ protein, red cell casts, and dysmorphic RBCs. 24-hour urine protein is 4.8g. Anti-dsDNA is markedly elevated. Complement C3 and C4 are low. What is this complication and what does low complement indicate?

A. Drug-induced lupus; hydralazine or procainamide; histone antibodies; stop the offending drug

B. LUPUS NEPHRITIS; glomerulonephritis from immune complex deposition; RBC CASTS + DYSMORPHIC RBCS = NEPHRITIC; PROTEINURIA = nephrotic component (mixed nephritic-nephrotic pattern = class IV most common/severe); LOW COMPLEMENT = active disease (complement consumption from immune complex deposition); anti-dsDNA correlates with disease activity; treatment = mycophenolate mofetil or cyclophosphamide + corticosteroids

C. Minimal change disease; normal complement; podocyte effacement; steroids

D. Diabetic nephropathy; no RBC casts; proteinuria progressive over years

Q72  |  Integrated

A 29-year-old male has bilateral knee pain for 3 months that is worse with sitting for prolonged periods, climbing stairs, and kneeling. He is a competitive cyclist. Pain is described as a diffuse aching behind and around the patella. No swelling or instability. Clarke test (compression of patella against femur elicits pain) is positive. X-ray shows mild lateral patellar tilt. What is the diagnosis and treatment?

A. Meniscus tear; McMurray positive; arthroscopic repair

B. Patellofemoral pain syndrome (chondromalacia patellae / runner's knee); pain arising from the patellofemoral joint; Clarke test (patellar grind test) positive; worse with prolonged knee flexion (movie sign), stairs, and running/cycling; treatment = PHYSICAL THERAPY (VMO strengthening, hip abductor strengthening, patellar taping), NSAIDs, activity modification; surgery rarely needed

C. Patellar tendonitis (jumper's knee); inferior pole of patella tenderness; eccentric squats

D. IT band syndrome; lateral knee pain; Ober test positive

Q73  |  Integrated

A 31-year-old female presents after several months of fatigue, weight gain, constipation, cold intolerance, and hair loss. Her menstrual cycles have become irregular. TSH is 18.2 mIU/L (elevated). Free T4 is 0.6 ng/dL (low). Anti-TPO antibodies are markedly elevated. What is the diagnosis, underlying mechanism, and treatment?

A. Graves disease; TSH low, T4/T3 elevated; anti-TSH receptor antibodies; propylthiouracil or radioiodine

B. HASHIMOTO THYROIDITIS (autoimmune hypothyroidism); anti-TPO antibodies (most sensitive marker) + anti-thyroglobulin antibodies; lymphocytic infiltration and destruction of thyroid; ELEVATED TSH + LOW FREE T4; treatment = LEVOTHYROXINE (synthetic T4) — goal TSH 0.5–2.5 mIU/L; titrate every 6–8 weeks; take on empty stomach

C. Subacute (de Quervain) thyroiditis; painful thyroid + ESR elevated; triphasic course (hyper → hypo → normal); NSAIDs

D. Central hypothyroidism; low TSH + low T4; pituitary pathology; MRI brain

Q74  |  Integrated

A 55-year-old male smoker has insidious onset of fatigue, night sweats, unintentional 20-lb weight loss over 3 months, and painless cervical lymphadenopathy. A cervical lymph node biopsy shows Reed-Sternberg cells: large binucleated cells with prominent "owl-eye" nucleoli in a background of inflammatory cells. What is the diagnosis and classic biopsy finding?

A. Non-Hodgkin lymphoma; no Reed-Sternberg cells; more aggressive; multiple subtypes; CHOP chemotherapy

B. HODGKIN LYMPHOMA; REED-STERNBERG CELLS (large binucleated with prominent owl-eye nucleoli) = PATHOGNOMONIC; bimodal age distribution (young adults 15–35 and >55); B symptoms = fever + night sweats + >10% weight loss; staging by PET/CT; treatment = ABVD chemotherapy ± radiation; EXCELLENT prognosis (80–90% cure rate for early-stage)

C. Multiple myeloma; clonal plasma cells; M-spike on SPEP; bony lytic lesions

D. CLL; smudge cells on peripheral smear; indolent; CD5+/CD23+

Q75  |  Integrated

A PA student is preparing for CAM III boards. Which of the following clinical presentations is CORRECTLY matched with its diagnosis, key diagnostic finding, and first-line treatment?

A. Scaphoid fracture — anatomical snuffbox tenderness + initial X-ray positive — cast for 2 weeks

B. PTSD — intrusive symptoms + avoidance + hyperarousal >1 month — trauma-focused CBT (Prolonged Exposure/CPT) + SSRI (sertraline or paroxetine)

C. Osteoid osteoma — nocturnal pain relieved by elevation — MRI gold standard — surgical excision only

D. ITP — pancytopenia + hypercellular bone marrow — immediate splenectomy

PART II — ANSWER KEY WITH CLINICAL RATIONALES

Q1  Answer: B  [ORTHO — Hip & Pelvis]

AVN (osteonecrosis) of the hip results from disrupted blood supply — primarily the medial circumflex femoral artery — to the femoral head. Classic risk factors include alcoholism, corticosteroids, trauma, SCD, SLE, radiation, and HIV. MRI is most sensitive early; X-ray shows flattening/collapse later. Pain is in the groin/thigh, worsens with weight-bearing and IR/ER. Treatment ranges from conservative (non-weight-bearing, bisphosphonates) to core decompression to total hip arthroplasty depending on stage.

Q2  Answer: B  [ORTHO — Hip & Pelvis]

Positive Trendelenburg sign: patient stands on one leg (stance side); the pelvis drops on the OPPOSITE unsupported leg (swing side). This indicates weakness of the hip ABductors — gluteus medius and minimus — on the STANCE side. In this case, standing on the right leg → left pelvis drops → right gluteus medius/minimus weakness. Causes include hip OA, AVN, superior gluteal nerve injury, and prolonged immobilization. The Trendelenburg gait is the compensatory waddling gait seen with bilateral abductor weakness.

Q3  Answer: C  [ORTHO — Hip & Pelvis]

Greater trochanteric bursitis (now called trochanteric pain syndrome) presents with lateral hip pain over the greater trochanter, worsening with lying on the affected side, climbing stairs, and cross-body adduction. Tenderness on direct palpation of the greater trochanter is the key exam finding. FABER test assesses the SI joint and hip joint — negative here. First-line: NSAIDs, PT, activity modification. If refractory: corticosteroid injection. Ober test evaluates the IT band specifically. Lateral thigh pain generally → trochanteric bursitis; buttock pain → referred from spine; groin pain → true hip pathology.

Q4  Answer: B  [ORTHO — Hip & Pelvis]

Femoral neck fractures risk AVN of the femoral head because the blood supply travels along the femoral neck (retinacular vessels from the medial circumflex femoral artery). Fracture displacement tears these vessels, cutting off perfusion to the femoral head. Shortened + externally rotated leg = classic femoral neck or intertrochanteric fracture presentation. Treatment: surgical — hemiarthroplasty or total hip arthroplasty for displaced femoral neck fractures in elderly; internal fixation for non-displaced or younger patients. DVT is also a concern but AVN is the more specific complication of femoral neck fractures.

Q5  Answer: B  [ORTHO — Hip & Pelvis]

SCFE is the most common hip disorder in adolescents, classically in obese males age 10–16. The femoral epiphysis slips posteriorly and inferiorly. Key: Klein line (drawn along the superior femoral neck on AP film) should intersect the epiphysis — if it does not, SCFE is present. Medial knee pain is a classic referred pain pattern from hip pathology. IMMEDIATE management: NON-WEIGHT-BEARING + surgical pinning in situ. Do NOT attempt closed reduction (increases AVN risk). Transient synovitis has normal labs and resolves spontaneously. Perthes is ages 4–10.

Q6  Answer: B  [ORTHO — Hip & Pelvis]

Legg-Calvé-Perthes (LCP): idiopathic AVN of the femoral head in children ages 4–10, males > females (4:1). Painless limp is classic. Labs: mildly elevated ESR, normal WBC — key distinction from septic arthritis (toxic, febrile, WBC/ESR/CRP all markedly elevated). X-ray: increased joint space, subchondral sclerosis, "crescent sign" on MRI. Treatment: containment (keeping femoral head within acetabulum) — Petrie casts, abduction bracing, or surgery for severe cases. Prognosis depends on age at onset (younger = better) and degree of involvement.

Q7  Answer: D  [ORTHO — Shoulder & Elbow]

AC joint injuries (Rockwood Classification): Type I = AC ligament sprain, no instability. Type II = AC ligament torn, AC instability, CC intact. Type III = both AC AND CC ligaments torn, instability present — CC distance 1–3× normal. Types IV-VI = progressive displacement. CC distance 3cm with ability to still elevate arm suggests Type III. Type III management is controversial — many treat conservatively (sling 2–4 weeks) for lower-demand patients; surgical reconstruction for athletes or manual laborers. Type V has CC distance >3× normal with severe droop requiring surgery. Cross-body adduction test + step-off + direct blow to lateral shoulder = classic AC joint injury mechanism.

Q8  Answer: B  [ORTHO — Shoulder & Elbow]

Adhesive capsulitis (frozen shoulder): hallmark is loss of BOTH active AND passive ROM in ALL planes (external rotation most severely restricted first). Pathology = glenohumeral joint capsule inflammation → fibrosis and contracture. Three phases: freezing (painful, ROM decreasing), frozen (less pain, ROM stuck), thawing (gradual recovery over 1–3 years). Risk factors: diabetes (most common), hypothyroidism, female, age 40–60, prior immobilization. X-ray normal. Treatment: PT, corticosteroid injections, manipulation under anesthesia, arthroscopic capsular release for refractory cases. Key distinction: rotator cuff tear = active ROM worse than passive ROM (passive preserved).

Q9  Answer: B  [ORTHO — Shoulder & Elbow]

Shoulder impingement syndrome: compression of the supraspinatus tendon (and subacromial bursa) under the acromion, especially with overhead activities. Neer and Hawkins-Kennedy are the key provocative tests. Painful arc: 60–120° (supraspinatus passing under acromion). MRI shows tendinosis without full-thickness tear. Conservative management first: NSAIDs, PT focusing on rotator cuff strengthening and scapular stabilization, activity modification. Corticosteroid subacromial injection if refractory. Surgery (subacromial decompression/acromioplasty) reserved for failure after ≥3–6 months conservative care. Rotator cuff = SITS: Supraspinatus (most common injury), Infraspinatus, Teres minor, Subscapularis.

Q10  Answer: A  [ORTHO — Shoulder & Elbow]

Drop arm sign: examiner passively abducts the arm to 90° and asks the patient to slowly lower it. Positive if the arm drops suddenly or the patient cannot maintain the position — indicates full-thickness rotator cuff tear (most commonly supraspinatus). Supraspinatus initiates the first 15° of abduction; without it, patients cannot initiate abduction smoothly. Full-thickness tears in active patients → surgical repair. Partial tears → conservative initially. Wrist drop = radial nerve palsy (Saturday night palsy). Popeye deformity = distal biceps tendon rupture. Speed test and Yergason test = biceps tendinopathy.

Q11  Answer: C  [ORTHO — Shoulder & Elbow]

Cubital tunnel syndrome: ulnar nerve compression at the elbow (cubital tunnel = between medial epicondyle and olecranon). Presents with medial elbow pain, paresthesias in ulnar nerve distribution (ring and small fingers, medial palm), and intrinsic hand weakness (grip). Positive Tinel at the cubital tunnel (tapping reproduces symptoms). In overhead throwing athletes (pitchers), this often coexists with UCL (medial collateral ligament) insufficiency — the valgus stress of throwing stretches the ulnar nerve. Lateral epicondylitis: pain with wrist extension, lateral elbow, common extensor origin. Medial epicondylitis: pain with wrist flexion, medial elbow, common flexor origin — but no ulnar nerve symptoms.

Q12  Answer: B  [ORTHO — Shoulder & Elbow]

Nursemaid's elbow (pulled elbow/radial head subluxation): classic mechanism = longitudinal traction on a pronated extended arm (pulling up, swinging child by arms). Annular ligament slips over/under the radial head. Age 1–5 years. Child holds arm pronated at side, refuses to move it. X-ray is NORMAL. Treatment: hyperpronation maneuver (now preferred — quicker resolution) OR supination-flexion maneuver. A palpable/audible click at the radial head confirms reduction; child typically resumes use of the arm within minutes. No imaging required if history is classic. Supracondylar fracture: posterior fat pad sign on X-ray, neurovascular compromise risk (anterior interosseous nerve, radial pulse).

Q13  Answer: B  [ORTHO — Shoulder & Elbow]

Lateral epicondylitis (tennis elbow): overuse tendinopathy of the common extensor origin at the lateral epicondyle — ECRB (extensor carpi radialis brevis) most commonly involved. Cozen's test: patient resists wrist extension with elbow extended → reproduces lateral epicondyle pain. Also: Mill's test (passive wrist flexion with elbow extended). Treatment: RICE, NSAIDs, PT (eccentric strengthening), counterforce brace, corticosteroid injection (short-term relief), PRP (emerging). Surgery if >12 months conservative failure. Medial epicondylitis (golfer's elbow): pain with resisted wrist FLEXION, medial epicondyle, common FLEXOR origin — opposite side.

Q14  Answer: B  [ORTHO — Wrist & Hand]

Scaphoid fracture: most common carpal bone fracture; mechanism = FOOSH. Anatomical snuffbox tenderness (between EPL and EPB/APL tendons) is the classic finding. Key: up to 20% of scaphoid fractures are OCCULT on initial X-ray. NEVER dismiss based on normal X-ray alone. Treatment: empirically place in thumb spica cast and repeat imaging (X-ray at 10–14 days; MRI most sensitive early; CT also used). Untreated scaphoid fractures risk AVN of the proximal pole (blood supply enters distally) and nonunion. Displaced or proximal pole fractures → surgical fixation. Colles = distal radius DORSAL displacement (dinner fork); Smith = VOLAR displacement (garden spade).

Q15  Answer: B  [ORTHO — Wrist & Hand]

CTS: compression of the median nerve at the carpal tunnel. Distribution: thumb, index, middle, and radial half of ring finger (classic). Nocturnal and activity-provoked. Thenar atrophy = severe/chronic. Phalen test (wrists flexed 60 sec → reproduces symptoms) and Tinel test (tapping over carpal tunnel → tingling in median nerve distribution) are clinical tests. Gold standard: EMG/NCS showing prolonged sensory and/or motor latency across the carpal tunnel. Treatment: night splints, NSAIDs, steroid injection, surgical carpal tunnel release for refractory or severe cases. CTS distribution = "thumb to 3½ fingers" — everything EXCEPT the small finger and ulnar half of ring finger.

Q16  Answer: B  [ORTHO — Wrist & Hand]

De Quervain's tenosynovitis: stenosing tenosynovitis of the 1st dorsal compartment tendons (APL and EPB). Classic in new mothers (repetitive lifting of infant) and those with repetitive thumb/wrist use. Finkelstein test: patient makes fist with thumb inside fingers, then ulnar deviate the wrist → reproduces pain over first dorsal compartment = POSITIVE. Treatment: thumb spica splint, NSAIDs, corticosteroid injection into the first dorsal compartment (very effective), surgery if refractory. Trigger finger: clicking/locking of finger flexor tendon in A1 pulley — different location and mechanism.

Q17  Answer: B  [ORTHO — Wrist & Hand]

Boxer's fracture: 5th (most common) or 4th metacarpal neck fracture, typically from a closed-fist punch. Dorsally angulated. Acceptable angulation limits: ring finger ≤30–40°, small finger ≤40–70° (more mobility at 4th/5th CMC joints allows remodeling). Treatment within acceptable angulation: ulnar gutter splint in intrinsic plus position (MCPs 70–90° flexion, IPs extended). Orthopedic referral if beyond threshold, rotational deformity, or neurovascular compromise. Bennett: intra-articular base of 1st metacarpal (thumb); requires ORIF. Rolando: comminuted Bennett; ORIF. Nightstick: isolated ulnar shaft fracture from blocking a blow.

Q18  Answer: B  [ORTHO — Wrist & Hand]

Ganglion cyst: most common soft tissue mass of the hand and wrist; fluid-filled cyst arising from joint capsule (most common: dorsal scapholunate ligament) or tendon sheath. Smooth, compressible, transilluminates, may fluctuate in size. Usually painless but can ache with use. Treatment: observation (50% spontaneously resolve), aspiration (high recurrence), surgical excision (lowest recurrence). Flexor tenosynovitis (Kanavel's signs): fusiform swelling of the finger, flexed resting posture, pain with passive extension, tenderness along flexor sheath — surgical emergency requiring IV antibiotics and irrigation. Felon: abscess of the distal finger pulp → I&D.

Q19  Answer: B  [ORTHO — Wrist & Hand]

Flexor tenosynovitis is a surgical emergency — infection within the closed flexor tendon sheath rapidly destroys the tendon. Kanavel's 4 cardinal signs: (1) fusiform (sausage) finger swelling, (2) semiflexed resting posture, (3) tenderness along the flexor tendon sheath, (4) PAIN WITH PASSIVE EXTENSION (most sensitive). Mechanism: penetrating trauma (fish hook, nail, bite). Treatment: IV antibiotics (broad-spectrum: cover gram-positive cocci and anaerobes) + URGENT surgical irrigation and debridement. Delay → tendon necrosis, permanent finger dysfunction. Paronychia = nail fold infection. Felon = distal pulp abscess (tense, painful, no Kanavel signs).

Q20  Answer: B  [ORTHO — Lower Extremity (Knee)]

ACL tear: classic mechanism = non-contact deceleration/rotation (pivoting, cutting) or valgus force. Immediate hemarthrosis (within 2 hours) strongly suggests ACL tear (vs. meniscus = delayed swelling 12–24h). Anterior drawer (knee at 90°) and Lachman (knee at 20–30°) both test anterior translation — Lachman is MORE SENSITIVE for ACL. MRI confirms. Ottawa Knee Rules determine need for X-ray. Management: PT for non-athletes/older patients; surgical reconstruction (patellar tendon or hamstring autograft) for young active patients. PCL: posterior sag, posterior drawer. McMurray = joint line pain/click with knee ROM = meniscus.

Q21  Answer: B  [ORTHO — Lower Extremity (Knee)]

Knee OA: most common joint disorder. Risk factors: age, obesity, prior injury, repetitive loading. Morning stiffness <30 minutes (vs. RA >1 hour). Bony crepitus, joint line tenderness, bony enlargement. X-ray: joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts. Treatment ladder: exercise + weight loss (first-line for all); acetaminophen; topical NSAIDs; oral NSAIDs (with GI protection); intra-articular corticosteroids; hyaluronic acid injections; joint replacement for end-stage. RA: symmetric, MCP/PIP joints, prolonged morning stiffness, RF/anti-CCP positive, periarticular erosions on X-ray.

Q22  Answer: B  [ORTHO — Lower Extremity (Knee)]

Prepatellar bursitis: swelling ANTERIOR to the patella (not in the joint space). Aseptic: trauma/overuse (wrestler's knee); Septic: S. aureus most common (penetrating wound or hematogenous). KEY: aspiration of bursal fluid with cell count, crystals, gram stain, culture is essential to distinguish. Synovial fluid analysis: WBC >50,000 = likely septic joint (knee joint); bursal fluid WBC thresholds differ but >20,000 raises concern for infection. Septic bursitis: antibiotics (dicloxacillin/cephalexin for MSSA; vancomycin if MRSA concern) ± I&D. Aseptic: NSAIDs, aspiration for relief, compression, avoid kneeling. Pes anserine bursitis: medial knee pain below joint line, especially in obese patients with OA.

Q23  Answer: B  [ORTHO — Lower Extremity (Knee)]

IT band syndrome: overuse injury from repetitive friction of the IT band over the lateral femoral epicondyle, especially with repetitive knee flexion/extension (running, cycling). Lateral knee pain that starts after a fixed distance and resolves with rest. Noble compression test: tenderness at lateral femoral epicondyle. Ober test: assesses IT band/TFL tightness (patient side-lying, abduct and extend hip, then let drop — failure to adduct = positive IT band tightness). Treatment: activity modification, stretching (IT band and hip abductors/flexors), foam rolling, NSAIDs, corticosteroid injection if refractory. Surgery rare.

Q24  Answer: B  [ORTHO — Lower Extremity (Knee)]

Acute compartment syndrome: increased pressure within a closed fascial compartment compromises perfusion. 6 Ps: Pain (disproportionate, with passive stretch = EARLIEST/MOST SENSITIVE), Pressure (compartment pressure >30mmHg or within 30mmHg of diastolic), Paresthesias, Paralysis, Pallor, Pulselessness (LATE). Do NOT wait for pulse loss. TREATMENT = IMMEDIATE FASCIOTOMY. Elevation and tight dressings are CONTRAINDICATED (increase compartment pressure). Causes: fractures (especially tibial shaft), crush injuries, burns, tight casts, reperfusion injury. Irreversible muscle/nerve damage begins within 6 hours.

Q25  Answer: B  [ORTHO — Lower Extremity (Foot & Ankle)]

Ottawa Ankle Rules (X-ray required if): tenderness over posterior 6 cm of fibula (lateral malleolus zone) OR posterior 6 cm of tibia (medial malleolus zone) OR navicular OR base of 5th metatarsal, OR inability to bear weight 4 steps. This patient meets NONE of these criteria → X-ray not required. Lateral ankle sprains: ATFL (anterior talofibular ligament) most commonly injured (inversion injury), then CFL, then PTFL. Grades I (sprain), II (partial tear), III (complete tear). Treatment: RICE (rest, ice, compression, elevation), NSAIDs, early functional rehabilitation, proprioceptive training. Grade III may need immobilization or surgical repair.

Q26  Answer: B  [ORTHO — Lower Extremity (Foot & Ankle)]

Jones fracture: transverse fracture at the metaphyseal-diaphyseal junction (Zone 2) of the 5th metatarsal — approximately 1.5–2 cm from the tip. Located in a vascular watershed zone → HIGH RISK OF NONUNION. Treatment: non-weight-bearing short leg cast 6–8 weeks; surgical fixation (intramedullary screw) for athletes, active patients, or delayed unions/nonunions. Avulsion fracture (Zone 1) = peroneus brevis avulsion at the base tip → better blood supply → walking boot, generally heals well. Stress fracture (Zone 3, diaphysis) = competitive athletes. Lisfranc: tarsometatarsal disruption — often missed; look for 2nd MT base fracture or widening between 1st and 2nd metatarsals.

Q27  Answer: B  [ORTHO — Lower Extremity (Foot & Ankle)]

Plantar fasciitis: most common cause of plantar heel pain. Inflammation/degeneration at origin of plantar fascia on medial calcaneal tubercle. Classic: worst pain with FIRST STEPS IN THE MORNING (after overnight inactivity) or after prolonged sitting, improves after walking a few minutes (but worsens again with prolonged activity). Heel spur on X-ray is a CONSEQUENCE, not the CAUSE. Risk factors: obesity, prolonged standing, flat feet, tight Achilles. First-line: calf/plantar fascia stretching, supportive footwear with arch support, NSAIDs, ice. Next: corticosteroid injection, night splints, PT. Surgery (plantar fascia release) rare. Tarsal tunnel = tibial nerve posterior to medial malleolus.

Q28  Answer: B  [ORTHO — Neoplasms]

Osteoid osteoma: most common benign osteoid tumor (10% of benign bone tumors). Peak: males in 2nd decade. Location: proximal femur (most common), long tubular bones. CLASSIC: dull, aching NOCTURNAL pain COMPLETELY RELIEVED by aspirin/NSAIDs (prostaglandin-mediated pain). Radiographic: central lytic nidus ≤1 cm with dense sclerotic rim. CT: imaging of choice (best defines nidus). Treatment: Stage 1 = ASA/NSAIDs until spontaneous resolution. Gold standard: RADIOFREQUENCY ABLATION (RFA) — same success rate as surgery, less invasive. Surgery must remove entire nidus + 2–3mm margin. Osteosarcoma: sunburst pattern, Codman triangle, metaphyseal, chemotherapy + surgery.

Q29  Answer: B  [ORTHO — Neoplasms]

Ewing sarcoma: 2nd most common primary bone malignancy in children/adolescents (after osteosarcoma). Ages 10–20. DIAPHYSEAL location in long bones. Classic X-ray: 'onion-skin' periosteal reaction (layers of reactive periosteum). Constitutional symptoms common (fever, weight loss, malaise). Elevated LDH, ESR. Histology: small round blue cells (t[11;22] translocation — EWS-FLI1). Treatment: multidrug chemotherapy + radiation ± surgical resection. Osteosarcoma: METAPHYSEAL, sunburst/Codman triangle, around the knee most common (distal femur/proximal tibia), peaks 10–20 years. Chondrosarcoma: cartilaginous matrix, adults, chemotherapy-RESISTANT → surgery is primary treatment.

Q30  Answer: B  [ORTHO — Neoplasms]

Osteochondroma: MOST COMMON BENIGN BONE TUMOR OVERALL. Cartilage-capped bony projection; cortex and medullary cavity continuous with host bone; grows AWAY from joint. Stops growing at skeletal maturity. Usually asymptomatic/painless. Hereditary multiple exostoses (HME) = autosomal dominant, multiple lesions. KEY CONCERN: malignant transformation to CHONDROSARCOMA (rare in solitary [<1%], higher in HME [5–25%]). Red flags for transformation: growth in adulthood, pain, cartilage cap >2cm on MRI. Resect if: symptomatic (nerve/vessel compression), cosmetically bothersome, cartilage cap >2cm. Giant cell tumor: epiphyseal, 'soap bubble' on X-ray, adults 20–40, locally aggressive, treat with curettage + bone graft.

Q31  Answer: B  [PSYCH — Somatic Symptom & Related Disorders]

Somatic symptom disorder (formerly somatization disorder): ≥1 somatic symptom causing distress + at least ONE of: disproportionate/persistent thoughts about seriousness, persistently high anxiety about health, excessive time/energy devoted to symptoms. Duration >6 months. DIAGNOSIS OF EXCLUSION — patient's suffering is authentic. Most common psychiatric comorbidities: anxiety and depression (80% have a comorbid mental disorder). Illness anxiety disorder (IAD): PRIMARY feature is fear of having a serious illness; minimal or no actual somatic symptoms. Factitious disorder: INTENTIONAL production/feigning of symptoms to assume the sick role — no external gain. Malingering: symptoms produced for EXTERNAL GAIN (money, disability, avoiding jail) — NOT a mental disorder.

Q32  Answer: B  [PSYCH — Somatic Symptom & Related Disorders]

Functional neurological symptom disorder (conversion disorder): neurological symptoms (weakness, paralysis, sensory loss, seizures, blindness) with objective evidence of INCOMPATIBILITY with neurological disease. Key: symptoms are NOT intentionally produced (vs. factitious = intentional, no gain; vs. malingering = intentional, external gain). Clinical signs supporting functional: Hoover sign (weakness of hip extension resolves when asked to flex contralateral hip), give-way weakness, tremor entrainment. Often triggered by psychological stressor. More common in women. Treatment: PT, OT, psychotherapy. Factitious disorder by proxy (Munchausen by proxy): caregiver induces illness in another person (usually child) to assume caregiver/sick role.

Q33  Answer: B  [PSYCH — Eating Disorders]

Anorexia nervosa: restriction of caloric intake → significantly low body weight + intense fear of weight gain + distorted body image. Physical findings: bradycardia, lanugo, amenorrhea, orthostatic hypotension, cold intolerance, muscle wasting, bone loss. LEADING CAUSE OF DEATH: CARDIAC ARRHYTHMIA from electrolyte imbalances (hypokalemia, hypophosphatemia) + prolonged QT. Highest mortality of any psychiatric disorder. REFEEDING SYNDROME: rapid nutritional rehabilitation → intracellular shift of phosphate → hypophosphatemia → life-threatening cardiac and respiratory failure. Prevent by: gradual caloric increase, phosphate monitoring and supplementation. Treatment: medical stabilization, nutritional rehab, CBT/FBT, ± olanzapine for weight gain.

Q34  Answer: B  [PSYCH — Eating Disorders]

Bulimia nervosa: recurrent binge eating + compensatory behaviors (purging, laxatives, fasting, excessive exercise). Normal or slightly low body weight. PURGING (vomiting) → loss of HCl from stomach → HYPOKALEMIA + METABOLIC ALKALOSIS (elevated bicarb). Dental erosions on LINGUAL surfaces (acid from vomiting). Parotid gland enlargement, calluses on dorsal hand (Russell sign). First-line: CBT (most effective) + FLUOXETINE 60 mg (only FDA-approved medication for bulimia — higher dose than for MDD). Lisdexamfetamine (Vyvanse) is FDA-approved for BINGE EATING DISORDER (not bulimia). Distinction: bulimia = compensatory behaviors after binge; binge eating disorder = recurrent binges without compensation.

Q35  Answer: B  [PSYCH — Somatic & Eating]

Factitious disorder imposed on another (Munchausen syndrome by proxy): a caregiver deliberately induces, fabricates, or exaggerates illness in another person (most often a child) in order to assume the caregiver/sick role — there is no external gain (distinguishes from malingering). The caregiver appears highly attentive, the child's symptoms resolve when separated from the caregiver, and symptoms cannot be explained medically. ACTION: MANDATORY REPORT TO CPS (child protective services) immediately; child safety is the priority; separate child from caregiver; multidisciplinary team (social work, pediatrics, psychiatry, law enforcement). This is child abuse. Factitious disorder (on self): person produces symptoms in themselves.

Q36  Answer: B  [PSYCH — Somatic & Eating]

KEY DISTINCTION: MALINGERING = intentional symptom production for EXTERNAL GAIN (money, drugs, avoiding jail/military duty). NOT a mental disorder in DSM-5 — it is a V-code (condition for clinical attention). FACTITIOUS DISORDER = intentional production/feigning of symptoms to assume the sick role — NO external gain. Both are intentional (vs. somatic symptom disorder and conversion disorder = NOT intentional). This patient explicitly states he's not in pain and wants opioids for his legal case = external gain = MALINGERING. Management of malingering: do not prescribe requested medications; address secondary gain; consider legal/social work consultation. Factitious: confrontation is nuanced; psychotherapy; protect against unnecessary medical interventions.

Q37  Answer: B  [PSYCH — Substance Use Disorders]

Alcohol withdrawal timeline: 6–24h = tremors, anxiety, diaphoresis, tachycardia; 24–48h = seizures (generalized tonic-clonic); 48–72h = DELIRIUM TREMENS (peak severity) = tremor + autonomic instability (tachycardia, hypertension, hyperthermia, diaphoresis) + confusion + hallucinations (visual most common) + agitation. Life-threatening without treatment. FIRST-LINE: BENZODIAZEPINES (GABA-A agonists, cross-tolerant with alcohol) — diazepam (long-acting, preferred) or lorazepam (liver disease). CIWA-Ar scale guides dosing. THIAMINE BEFORE GLUCOSE (Wernicke encephalopathy prevention). Naltrexone = long-term alcohol use disorder maintenance. Disulfiram = aversion therapy.

Q38  Answer: B  [PSYCH — Substance Use Disorders]

Key pharmacology: naloxone (Narcan) half-life = 30–90 minutes, SHORTER than most opioids (heroin ~4–6h, fentanyl longer). Re-narcotization = opioid effects return as naloxone wears off. Requires repeat dosing q20–60 minutes or continuous infusion. Observation for ≥4 hours after last naloxone dose. LONG-TERM: Medication-Assisted Treatment (MAT) is GOLD STANDARD for opioid use disorder. BUPRENORPHINE/NALOXONE (Suboxone): partial mu-agonist; can prescribe in office setting (DATA 2000 waiver); reduces cravings, withdrawal. METHADONE: full agonist; dispensed only at licensed opioid treatment programs (OTPs). NALTREXONE (Vivitrol): opioid antagonist; for motivated patients after full detox; injection preferred for adherence.

Q39  Answer: B  [PSYCH — Substance Use Disorders]

Suboxone (buprenorphine/naloxone) abuse-deterrent design: SUBLINGUAL use (as prescribed) → buprenorphine absorbed sublingually (partial mu-agonist effect; reduces cravings and withdrawal); naloxone has POOR sublingual bioavailability → essentially inactive. IV INJECTION (misuse) → both absorbed systemically; naloxone blocks opioid receptors and PRECIPITATES ACUTE WITHDRAWAL in opioid-dependent person → deterrent to injection. Buprenorphine's ceiling effect on respiratory depression makes it safer than full agonists (methadone) in overdose. Buprenorphine monotherapy (Subutex) used in pregnancy (naloxone potentially harmful to fetus — though evidence limited). SCREENING tool for alcohol: CAGE, AUDIT. For opioids: DAST.

Q40  Answer: B  [PSYCH — Substance Use Disorders]

Benzodiazepine withdrawal: dangerous — potentially life-threatening. Similar to alcohol withdrawal (both GABA-A) but withdrawal may take LONGER (weeks to months for long-acting agents). Mechanism: chronic BZD use → GABA-A receptor downregulation/desensitization → abrupt discontinuation = CNS hyperexcitability → SEIZURES, DELIRIUM, autonomic instability. Management: GRADUAL TAPER — convert to long-acting equivalent (diazepam) and reduce by 10%/week or slower. Never abrupt discontinuation in physically dependent patients. Distinguish from opioid withdrawal (rarely life-threatening but intensely uncomfortable — muscle aching, GI distress, piloerection, yawning). Alcohol + benzodiazepine + barbiturate withdrawal = life-threatening (GABA withdrawal syndromes). Opioid withdrawal = miserable but rarely lethal.

Q41  Answer: B  [PSYCH — Substance Use Disorders]

Pharmacotherapy for alcohol use disorder: NALTREXONE (ReVia oral; Vivitrol monthly IM injection) — mu-opioid receptor antagonist; alcohol triggers endogenous opioid release mediating reward; blocking this reduces craving and drinking. Contraindicated in current opioid use or acute hepatitis/liver failure. Monthly injection (Vivitrol) improves adherence. ACAMPROSATE — glutamate/GABA modulator; reduces protracted withdrawal discomfort; good for patients already abstinent; safe in liver disease (renal excretion). DISULFIRAM — aldehyde dehydrogenase inhibitor → acetaldehyde accumulates → flushing/nausea/vomiting (disulfiram reaction); deterrent only; requires motivation and compliance; avoid in cardiovascular disease.

Q42  Answer: B  [PSYCH — Trauma & Stressor-Related Disorders]

PTSD diagnostic criteria: exposure to actual/threatened death, serious injury, or sexual violence → symptoms in 4 clusters lasting >1 MONTH: (1) INTRUSION (flashbacks, nightmares, psychological/physiological reactivity to cues), (2) AVOIDANCE (of trauma-related thoughts or external reminders), (3) NEGATIVE COGNITION/MOOD (persistent negative beliefs, distorted blame, emotional numbing, anhedonia), (4) HYPERAROUSAL (hypervigilance, exaggerated startle, sleep disturbance, irritability, reckless behavior). First-line: TRAUMA-FOCUSED CBT (Prolonged Exposure, CPT) + SSRI (sertraline or paroxetine — FDA-approved). Prazosin for trauma nightmares. Acute stress disorder = same symptoms but 3 days to 1 month. Adjustment disorder = disproportionate response to identifiable stressor, resolves within 6 months after stressor ends.

Q43  Answer: B  [PSYCH — Trauma & Stressor-Related Disorders]

Acute Stress Disorder vs. PTSD: same symptom clusters (intrusion, avoidance, negative cognition/mood, hyperarousal + dissociative symptoms). KEY DISTINCTION: ASD = symptoms lasting 3 DAYS TO 1 MONTH after trauma; PTSD = symptoms >1 MONTH. ASD predicts PTSD in ~50% of cases. Treatment for ASD: trauma-focused CBT (Prolonged Exposure) is most effective — early intervention reduces PTSD development. SSRIs are not first-line for ASD. Normal stress response: symptoms present but do not cause significant impairment, resolve within days. Adjustment disorder: identifiable stressor + disproportionate emotional/behavioral response + clinically significant distress OR functional impairment; onset within 3 months of stressor; resolves within 6 months after stressor ends.

Q44  Answer: B  [PSYCH — Sleep Disorders]

OSA: repetitive upper airway obstruction during sleep → hypoxia + arousals. Classic: obese male, loud snoring, witnessed apneas, morning headaches, daytime sleepiness, nocturia. GOLD STANDARD: Overnight POLYSOMNOGRAPHY (PSG) — measures AHI (apnea-hypopnea index). AHI 5–15 = mild; 15–30 = moderate; >30 = severe. Diagnosis: AHI ≥5/h with symptoms OR AHI ≥15/h regardless. First-line: CPAP — most effective. Alternatives: weight loss, positional therapy, oral appliances (mandibular advancement), surgery (UPPP). Untreated OSA: HTN, atrial fibrillation, heart failure, stroke, MVA risk. Narcolepsy: cataplexy (sudden muscle weakness with emotion) + excessive daytime sleepiness + sleep paralysis + hypnagogic hallucinations; MSLT shows short sleep latency + ≥2 SOREMPs.

Q45  Answer: B  [PSYCH — Sleep Disorders]

Insomnia disorder: difficulty initiating sleep (>30 min sleep onset latency), maintaining sleep, or early awakening, occurring ≥3 nights/week for ≥3 months, causing significant daytime impairment. GOLD STANDARD: CBT-I (Cognitive Behavioral Therapy for Insomnia) — components: (1) STIMULUS CONTROL (bed only for sleep/sex), (2) SLEEP RESTRICTION (reduce time in bed to actual sleep time, gradually extend), (3) RELAXATION techniques, (4) SLEEP HYGIENE. CBT-I is superior to medications both short- and long-term and has no side effects. Pharmacotherapy: used short-term if CBT-I unavailable; options = zolpidem (Z-drugs), doxepin (low-dose), lemborexant/suvorexant (orexin antagonists), melatonin receptor agonists (ramelteon). Benzodiazepines: avoid long-term (dependence risk).

Q46  Answer: B  [PSYCH — Sleep Disorders]

Delayed sleep phase syndrome (DSPS): a circadian rhythm sleep-wake disorder in which the internal clock is shifted LATER than the desired/societal schedule. Patient can sleep fine — but only if allowed to sleep on their delayed schedule (e.g., 2 AM to 11 AM). When forced to wake early: sleep deprivation, daytime sleepiness, academic/occupational failure. Most common in adolescents and young adults. Treatment: MORNING BRIGHT LIGHT THERAPY (suppresses melatonin at the wrong time, advances clock) + LOW-DOSE MELATONIN in the EVENING (2–5 mg given 3–6 hours before target sleep time) + CHRONOTHERAPY (gradually shifting sleep time earlier). Screen time avoidance before bed.

Q47  Answer: B  [PSYCH — Personality Disorders]

BPD hallmarks: pervasive instability in interpersonal relationships, self-image, and affect with marked impulsivity (DSM-5: ≥5 of 9 criteria). Defense mechanism: SPLITTING (all-or-nothing thinking — people are idealized or devalued). Suicidal gestures and self-harm are common (distinguish from genuine suicidal intent — requires thorough assessment). Chronic emptiness, identity disturbance, intense abandonment fears, transient paranoia/dissociation under stress. TREATMENT: DIALECTICAL BEHAVIOR THERAPY (DBT) — gold standard; combines CBT with mindfulness and distress tolerance. Pharmacotherapy adjunctive (mood stabilizers, low-dose antipsychotics). Cluster B: Borderline, Antisocial, Narcissistic, Histrionic (dramatic/impulsive/erratic).

Q48  Answer: B  [PSYCH — Personality Disorders]

NPD: grandiosity (real or fantasized) + need for admiration + lack of empathy. Key features: sense of entitlement, exploits others, envious, arrogant, fantasies of unlimited success/power. EGO-SYNTONIC — traits are comfortable/acceptable to the patient, who tends to blame others. DISTINCTION FROM BPD: NPD = stable GRANDIOSITY; BPD = unstable self-image, identity disturbance, splitting (oscillates between idealization/devaluation), marked impulsivity, self-harm, abandonment fears. NPD patients rarely seek treatment voluntarily (don't see themselves as having a problem). Antisocial PD: conduct disorder before 15, criminal/rights-violating behavior, callousness — more behavioral violations; NPD = more grandiosity/entitlement. Both lack empathy.

Q49  Answer: B  [PSYCH — Personality Disorders]

Personality disorder clusters: CLUSTER A (Odd/Eccentric): Paranoid, Schizoid, Schizotypal. CLUSTER B (Dramatic/Impulsive/Erratic): Borderline, Antisocial, Narcissistic, HISTRIONIC. CLUSTER C (Anxious/Fearful): Avoidant, Dependent, Obsessive-Compulsive. Histrionic PD: excessive emotionality + attention-seeking. Features: uncomfortable when not center of attention, sexually provocative behavior, shallow rapidly shifting emotions, uses physical appearance to draw attention, theatrical/dramatic speech, suggestible (easily influenced), considers relationships more intimate than they are. Ego-syntonic. More common in women. Treatment: psychotherapy (long-term); patients often seek treatment for depression/anxiety rather than the PD itself.

Q50  Answer: B  [PSYCH — Personality Disorders]

Paranoid PD: pervasive DISTRUST and SUSPICIOUSNESS — people's motives are interpreted as malevolent. Key features: suspects exploitation/harm without basis, questions loyalty of friends, reluctant to confide (fears misuse of info), reads hidden demeaning meanings into benign remarks, bears grudges, perceives attacks, suspects partner of infidelity. NOT psychotic (no true hallucinations or delusions — distinguishes from schizophrenia and delusional disorder). Cluster A: Paranoid (suspicious), Schizoid (detached, emotionally cold, no desire for relationships), Schizotypal (odd beliefs/magical thinking, odd perceptions, eccentric behavior, social isolation — most closely related to schizophrenia). Memory: Cluster A = 'Weird'; B = 'Wild'; C = 'Worried.'

Q51  Answer: B  [PSYCH — Personality Disorders]

ASPD: Cluster B. REQUIRED: (1) age ≥18; (2) evidence of CONDUCT DISORDER before age 15. Pattern of pervasive disregard for and violation of rights of others: deceitfulness (repeated lying, use of aliases, conning), impulsivity, aggressiveness (fights/assaults), disregard for safety of self and others, irresponsibility (fails to sustain work or honor obligations), LACK OF REMORSE. Ego-syntonic — does not see behavior as problematic. 'Psychopathy' and 'sociopathy' are colloquial terms related to ASPD. Treatment: extremely difficult; DBT shows some benefit; address comorbid substance use. High recidivism. Conduct disorder: same behavior pattern in children/adolescents <18 (aggression, theft, rule violations, cruelty to animals).

Q52  Answer: B  [Rheumatology — Inflammatory Arthritis]

RA: symmetric inflammatory arthritis, MCP and PIP joints (DIP spared — opposite of OA). Morning stiffness >1 hour. Extra-articular: rheumatoid nodules, lung disease (ILD), vasculitis, episcleritis, Felty syndrome (RA + splenomegaly + neutropenia). LABS: RF (sensitive, not specific); ANTI-CCP = MOST SPECIFIC (also predicts erosive/severe disease). X-ray: periarticular osteopenia → marginal erosions → joint space narrowing → deformities (ulnar deviation, swan-neck, boutonniere, Z-thumb). Treatment: METHOTREXATE (anchor DMARD — preferred first-line); folic acid supplementation. Inadequate response: add biologic (TNF-alpha inhibitors: etanercept, adalimumab; non-TNF: abatacept, rituximab, tocilizumab, JAK inhibitors).

Q53  Answer: B  [Rheumatology — Crystal Arthropathy]

GOUT: hyperuricemia → MSU crystal deposition in joints/soft tissue. Podagra (1st MTP) classic; also: ankle, knee, wrist. NEGATIVELY birefringent NEEDLE-SHAPED crystals under polarized light. Acute flare: NSAIDs (indomethacin — first-line), colchicine, corticosteroids. NEVER start urate-lowering therapy during acute attack (can prolong/worsen). Start allopurinol (or febuxostat) for prevention after acute attack resolves; cover with colchicine prophylaxis for first 3–6 months. Risk factors: thiazide diuretics (↓ uric acid excretion), purine-rich diet, alcohol, obesity, renal disease. Tophaceous gout: chronic deposits in soft tissue. PSEUDOGOUT: calcium pyrophosphate crystals — POSITIVELY birefringent, RHOMBOID-shaped; chondrocalcinosis on X-ray (menisci, triangular fibrocartilage of wrist); treat same as gout acutely.

Q54  Answer: B  [Rheumatology — Spondyloarthropathy]

Ankylosing spondylitis: seronegative spondyloarthropathy. HLA-B27 in 90%. Inflammatory back pain criteria (ASAS): insidious onset, age <40, duration >3 months, morning stiffness >1 hour, IMPROVES WITH EXERCISE (unlike mechanical LBP), may awaken in 2nd half of night. Sacroiliitis on MRI → bamboo spine (complete ankylosis) in late disease. Extra-articular: UVEITIS (most common — acute anterior; painful red eye, photophobia), aortic regurgitation, IBD, psoriasis, apical pulmonary fibrosis. Schober test: measures lumbar flexion (<5cm expansion = abnormal). Treatment: NSAIDs first-line; PT essential; TNF inhibitors (adalimumab, etanercept) or IL-17 inhibitors for refractory disease.

Q55  Answer: B  [Rheumatology — Connective Tissue Disease]

SLE: multisystem autoimmune disease, women of childbearing age, AA > other groups. Mnemonic for SLICC criteria: DOPAMINE RASH or ACR: Malar rash (spares nasolabial folds), Discoid rash, Photosensitivity, Oral ulcers, Arthritis (non-erosive), Serositis, Renal (proteinuria/casts), Neuro (seizures/psychosis), Hematologic (hemolytic anemia, leukopenia, thrombocytopenia), Immunologic, ANA. ANTIBODIES: ANA = sensitive (~95%), not specific. Anti-dsDNA = specific + correlates with disease activity and nephritis. ANTI-SM = MOST SPECIFIC (pathognomonic). Anti-phospholipid = antiphospholipid syndrome (thrombosis, recurrent miscarriage). Treatment: hydroxychloroquine (ALL patients), NSAIDs, corticosteroids, mycophenolate/belimumab for lupus nephritis.

Q56  Answer: B  [Rheumatology — Vasculitis]

Giant cell arteritis (GCA): most common systemic vasculitis in adults >50 (peak age 70). Large/medium vessel. Classic: temporal headache + scalp tenderness + jaw claudication + visual symptoms. MOST FEARED: PERMANENT BLINDNESS from anterior ischemic optic neuropathy. START HIGH-DOSE PREDNISONE IMMEDIATELY (1 mg/kg/day) — do NOT delay for biopsy. Temporal artery biopsy: gold standard (segments can be skipped — take ≥2cm). ESR >50 (often >100), markedly elevated CRP. Association with PMR (polymyalgia rheumatica) in 50% — proximal girdle pain/stiffness. Treatment: prednisone; taper over 1–2 years; tocilizumab (IL-6 inhibitor) for steroid-sparing. Takayasu: young women, <50, large vessel (aorta/branches), 'pulseless disease.'

Q57  Answer: B  [Rheumatology — Fibromyalgia & Osteoporosis]

Fibromyalgia: central sensitization syndrome. 2016 ACR criteria: widespread pain index (WPI ≥7 + symptom severity ≥5) OR WPI 3–6 + symptom severity ≥9, present ≥3 months, no other explanation. Labs: NORMAL ESR, CRP, ANA, RF, CBC, metabolic panel. Physical exam: no synovitis, no muscle weakness. MANAGEMENT: AEROBIC EXERCISE (most robust evidence — first-line), CBT, sleep hygiene, stress management. Pharmacotherapy: DULOXETINE (Cymbalta), MILNACIPRAN (Savella), PREGABALIN (Lyrica) — all FDA-approved. AVOID opioids (worsen central sensitization long-term). Avoid: muscle relaxants as monotherapy, long-term opioids. Comorbidities: IBS, interstitial cystitis, headache, mood disorders.

Q58  Answer: B  [Rheumatology — Osteoporosis]

Osteoporosis: T-score ≤-2.5 at spine, hip, or femoral neck. Osteopenia: T-score -1.0 to -2.5. Treatment threshold: T-score ≤-2.5, OR prior fragility fracture, OR FRAX 10-year risk ≥20% for major osteoporotic fracture (or ≥3% for hip). First-line: BISPHOSPHONATES (alendronate 70mg weekly PO most commonly used; risedronate; zoledronate 5mg IV annually). Calcium 1200mg/day + Vitamin D 800–1000 IU/day for all. Side effects: bisphosphonates — esophageal irritation (take with full glass of water, remain upright 30–60 min), atypical femoral fractures (rare, long-term use), osteonecrosis of jaw. Alternatives: denosumab (RANK-L inhibitor), teriparatide (anabolic, severe osteoporosis/intolerant), romosozumab. DEXA every 1–2 years to monitor.

Q59  Answer: B  [Hematology — Anemia]

B12 deficiency vs folate deficiency: BOTH cause macrocytic megaloblastic anemia + hypersegmented neutrophils. KEY: METHYLMALONIC ACID (MMA) — elevated in B12 deficiency ONLY (not folate). Homocysteine elevated in BOTH. Always check MMA when B12 is low to confirm true deficiency vs. lab error. Causes of B12 deficiency: strict veganism, pernicious anemia (autoimmune anti-IF Ab + anti-parietal cell Ab), metformin (↓ IF function), gastrectomy/ileal resection, bacterial overgrowth. Neurologic consequences: subacute combined degeneration (posterior and lateral column degeneration — proprioception/vibration loss + spasticity). Treatment: IM cyanocobalamin (monthly) or high-dose oral B12 (1000mcg/day — passive absorption in pernicious anemia). Folate: supplement during pregnancy (prevents NTDs).

Q60  Answer: B  [Hematology — Anemia]

Iron deficiency anemia (IDA): most common anemia worldwide. Causes: blood loss (GI, menstrual), poor intake, malabsorption (celiac, gastrectomy), increased demand (pregnancy). Labs: low Hgb, low MCV, high RDW, low serum iron, HIGH TIBC (body increases transferrin production to scavenge iron), LOW FERRITIN (most sensitive/specific test for iron stores). Smear: hypochromic microcytic, pencil cells, target cells. Treatment: oral ferrous sulfate 325 mg TID; take on empty stomach (better absorption), with vitamin C; avoid antacids, calcium, tea. Reticulocytosis in 7–10 days = response; Hgb normalizes in 4–8 weeks; continue 3–6 months to replete stores. IDA in a male or postmenopausal female = ALWAYS evaluate for GI blood loss (colonoscopy/EGD).

Q61  Answer: B  [Hematology — Hemoglobinopathies]

Acute Chest Syndrome: vaso-occlusion in the pulmonary vasculature → lung injury. Can be triggered by infection, fat embolism from bone marrow infarction, or in situ sickling. DIAGNOSTIC REQUIREMENT: NEW INFILTRATE ON CXR — without this finding, the diagnosis cannot be made. Features: fever, chest pain, cough, dyspnea, hypoxia. Treatment: O₂ (maintain sat ≥95%), IV fluids, analgesia, BROAD-SPECTRUM ANTIBIOTICS (atypical coverage: azithromycin + beta-lactam; covers Mycoplasma and Chlamydia which trigger ACS), bronchodilators, EXCHANGE TRANSFUSION for severe ACS (rapidly reduces HbS to <30%). ACS is the LEADING CAUSE OF DEATH in SCD patients. Hydroxyurea reduces ACS frequency (increases HbF).

Q62  Answer: B  [Hematology — Malignant]

ALL: most common childhood cancer (peak age 2–5 years). Lymphoblasts (TdT+, B-cell markers: CD10/CALLA, CD19; or T-cell markers). Pancytopenia (bone marrow replaced) + lymphadenopathy + hepatosplenomegaly + bone pain (periosteal involvement). CNS involvement common → LP with intrathecal prophylaxis. Prognosis in CHILDREN: EXCELLENT (>90% long-term cure). Adult ALL: worse prognosis. High-risk features: age <1 or >10, WBC >50,000, T-cell phenotype, Ph+ chromosome (t[9;22]), CNS disease at diagnosis. Treatment: induction (vincristine, prednisone, asparaginase, anthracycline), consolidation, maintenance (2–3 years), CNS prophylaxis. AML: myeloblasts + AUER RODS (pathognomonic) — cytogenetics crucial (t[15;17] = APL; treat with ATRA). CLL: smudge cells; indolent; adults.

Q63  Answer: B  [Hematology — Malignant]

Multiple myeloma: clonal plasma cell malignancy. CRAB: Hypercalcemia (bone destruction → Ca²⁺ release), Renal failure (light chain cast nephropathy, hypercalcemia), Anemia (marrow infiltration), Bone lesions (punched-out lytic lesions, NOT blastic — distinguishes from prostate met). M-spike on SPEP (IgG most common, then IgA). Bence Jones proteins = free light chains in urine. Bone marrow: ≥10% clonal plasma cells. Workup: SPEP + UPEP, serum free light chains, bone marrow biopsy, PET/CT or skeletal survey. Treatment: bortezomib (proteasome inhibitor) + lenalidomide (immunomodulator) + dexamethasone (VRd) → autologous SCT for eligible. Waldenstrom: IgM paraprotein + hyperviscosity syndrome (vision changes, bleeding, neurological symptoms) → plasmapheresis.

Q64  Answer: B  [Hematology — Platelet & Coagulation]

ITP: autoimmune destruction of platelets (IgG autoantibodies coat platelets → Fc receptor-mediated splenic phagocytosis). Primary (idiopathic) or secondary (post-viral most common in children, H. pylori, HIV, SLE, CLL). ISOLATED thrombocytopenia — WBC and Hgb NORMAL (key distinction from aplastic anemia or leukemia). Large platelets (young/activated). Bone marrow: normal/increased megakaryocytes (increased production attempting to compensate). CHILDREN: often post-viral, 80–85% self-resolve within 6 months. Management: observation if platelet count >20,000–30,000 and no significant bleeding. Treatment if <20,000 or active bleeding: IVIG (fastest response, 1–2 days), corticosteroids, anti-D (Rh+). Chronic ITP (>12 months): splenectomy or TPO receptor agonists (eltrombopag). TTP: MAHA + thrombocytopenia + neuro/renal/fever → plasma exchange EMERGENTLY.

Q65  Answer: B  [Hematology — Neutropenia & Transfusions]

Febrile neutropenia: FEVER (≥38.3°C once or ≥38.0°C for 1 hour) + ANC <500 cells/μL (or <1000 expected to decrease). ANC = Total WBC × (% segs + % bands) ÷ 100. MEDICAL EMERGENCY — mortality from sepsis without prompt treatment. EMPIRIC IV ANTIBIOTICS WITHIN 1 HOUR — do NOT wait for cultures. First-line: ANTI-PSEUDOMONAL BETA-LACTAM (cefepime, piperacillin-tazobactam, imipenem, or meropenem). ADD VANCOMYCIN for: suspected MRSA, hemodynamic instability, catheter-related infection, skin/soft tissue infection, gram-positive bacteremia. G-CSF (filgrastim) reduces duration of neutropenia. Risk stratification (MASCC score) determines inpatient vs outpatient management — most high-risk patients require inpatient IV antibiotics. Lowest-risk patients: fluoroquinolone prophylaxis.

Q66  Answer: B  [Integrated]

Achilles tendon rupture: most common in 30–50-year-old 'weekend warriors.' Mechanism: sudden eccentric loading (lunging, jumping). Classic: audible 'pop' + inability to push off + palpable gap above calcaneal insertion. THOMPSON TEST: patient prone, knee bent, squeeze calf → POSITIVE if no plantarflexion (tendon disrupted). Negative Thompson = intact Achilles. Can walk with flat-footed gait (extrinsic toe flexors partially compensate). MRI or ultrasound confirms if clinical doubt. Treatment: SURGICAL (primary repair) for young, active patients — lower re-rupture rate; conservative (functional rehabilitation in equinus cast/boot) for sedentary/elderly or surgical risk. Achilles tendinopathy (chronic, no rupture): eccentric strengthening, NSAIDs, shockwave therapy.

Q67  Answer: B  [Integrated]

CTS management ladder: (1) Conservative: night splints (neutral wrist position), activity modification, NSAIDs, ergonomic changes. (2) Corticosteroid injection (transient relief, may delay surgery). (3) SURGICAL CARPAL TUNNEL RELEASE for: failure of conservative management after 3–6 months, severe symptoms, thenar atrophy, EMG/NCS confirmation. Surgical release (sectioning the flexor retinaculum/transverse carpal ligament) = definitive treatment with >90% success. Thenar atrophy = severe/chronic compression of recurrent motor branch of median nerve — may not fully recover after surgery. Bilateral CTS is NOT a contraindication to surgery (done staged). C6 radiculopathy: arm/shoulder pain + biceps reflex loss + thumb/index symptoms — different presentation; Spurling positive.

Q68  Answer: B  [Integrated]

Anticholinergic toxidrome: classic mnemonic = Hot as a Hare (hyperthermia), Dry as a Bone (dry skin, mucous membranes), Red as a Beet (flushing), Blind as a Bat (mydriasis), Mad as a Hatter (delirium/agitation) + urinary retention, tachycardia, decreased bowel sounds. Many atypical antipsychotics have significant anticholinergic activity. TCAs = significant anticholinergic + Na-channel blockade (widened QRS) + hypotension. Treatment: supportive (cooling, benzodiazepines for agitation, monitoring QRS/QTc); PHYSOSTIGMINE (reversible AChE inhibitor) for severe cases (reverses central + peripheral symptoms). NMS: lead-pipe RIGIDITY + hyperthermia + AMS + autonomic instability from antipsychotics (dopamine antagonism) — treated with dantrolene + bromocriptine. Serotonin syndrome: clonus + hyperreflexia + diaphoresis (differs from anticholinergic — moist, not dry).

Q69  Answer: B  [Integrated]

Delirium Tremens: most severe form of alcohol withdrawal. Onset typically 48–96 hours after last drink. Features: delirium + autonomic instability (tachycardia, hypertension, hyperthermia, diaphoresis) + hallucinations (visual most common — insects/'formication') + tremor + agitation. Mortality: up to 5–15% untreated. TREATMENT: HIGH-DOSE IV BENZODIAZEPINES (diazepam or lorazepam — GABA-A agonists, cross-tolerant with alcohol); CIWA-Ar scale for symptom-triggered dosing. ICU monitoring required. ANTIPSYCHOTICS (haloperidol) are CONTRAINDICATED as monotherapy — lower seizure threshold, do not treat GABA dysregulation. THIAMINE BEFORE ANY GLUCOSE — prevents Wernicke encephalopathy (confusion + ataxia + ophthalmoplegia). Wernicke → Korsakoff (confabulation, anterograde amnesia) if untreated.

Q70  Answer: B  [Integrated]

Polysubstance toxicology: Alcohol + benzodiazepine (or GHB) synergistically depress CNS and respiration. PUPILS: opioids → MIOSIS (pinpoint); benzodiazepines → mid-sized/reactive (important distinction). Naloxone reverses ONLY opioids — no effect here confirms non-opioid CNS depressant. FLUMAZENIL: competitive benzodiazepine antagonist — reverses sedation; use CAUTIOUSLY in chronic BZD users (precipitates ACUTE WITHDRAWAL and SEIZURES). Management: AIRWAY FIRST (jaw thrust, positioning), supplemental O₂, intubation if needed, monitor, supportive care. GHB: short-acting, no reversal agent — supportive. Activated charcoal: only if awake and protecting airway within 1 hour. Gastric lavage: rarely used, risk of aspiration in obtunded patient.

Q71  Answer: B  [Integrated]

Lupus nephritis: renal involvement in SLE from immune complex deposition in glomeruli. ISN/RPS classes I–VI. Class IV (diffuse) = most common and most severe — nephritic + nephrotic picture, RBC casts, massive proteinuria. Biomarkers of ACTIVE DISEASE: elevated anti-dsDNA (double-stranded DNA antibody — most specific for SLE and correlates with activity), LOW C3 AND C4 (complement CONSUMED by immune complexes). Urine findings: RBC CASTS + DYSMORPHIC RBCS = glomerulonephritis (nephritic); heavy proteinuria (nephrotic). Treatment for class III/IV: MYCOPHENOLATE MOFETIL (preferred in US; less toxic than cyclophosphamide) + corticosteroids. Cyclophosphamide for severe/refractory. Hydroxychloroquine in ALL SLE patients. Monitor: anti-dsDNA, complement, urinalysis, GFR.

Q72  Answer: B  [Integrated]

Patellofemoral pain syndrome (PFPS): most common knee pain in young active adults, especially runners and cyclists. Pain is retropatellar (behind the kneecap), diffuse, aching. 'Movie sign': pain worsening with prolonged knee flexion (sitting in a theater). Clarke test: examiner pushes patella inferiorly against femur and asks patient to contract quadriceps — positive if pain reproduced. Lateral tilt on X-ray may be present. Mechanism: abnormal patellar tracking (VMO weakness, hip abductor weakness, foot pronation). Treatment: PT (FIRST-LINE) — VMO (vastus medialis obliquus) strengthening, hip strengthening, patellar taping/bracing, orthotics; NSAIDs; activity modification. Surgery (lateral release) rarely needed.

Q73  Answer: B  [Integrated]

Hashimoto thyroiditis: most common cause of hypothyroidism in developed countries. Autoimmune — lymphocytic infiltration + anti-TPO antibodies (most sensitive test) + anti-thyroglobulin antibodies destroy thyroid tissue. Primary hypothyroidism: ELEVATED TSH (pituitary compensating) + LOW FREE T4. Symptoms: fatigue, weight gain, cold intolerance, constipation, hair loss, bradycardia, dry skin, myxedema (severe), delayed DTRs, menstrual irregularity. TREATMENT: LEVOTHYROXINE (synthetic T4, once daily) — empty stomach, 30–60 min before food; interactions with antacids/calcium/iron (take 4h apart). Target TSH: 0.5–2.5 mIU/L; in pregnancy, target 0.1–2.5. Titrate dose every 6–8 weeks. Subacute thyroiditis: PAINFUL thyroid + elevated ESR; triphasic: hyperthyroid → hypothyroid → normal.

Q74  Answer: B  [Integrated]

Hodgkin lymphoma: B-cell malignancy. BIMODAL distribution: young adults (15–35) and older adults (>55). B SYMPTOMS: unexplained fever, drenching night sweats, >10% weight loss in 6 months. Painless lymphadenopathy (usually starts cervical/mediastinal). Contiguous spread. REED-STERNBERG CELLS: PATHOGNOMONIC — large binucleated (owl-eye nucleoli), CD15+/CD30+, background of inflammatory cells. Staging: PET/CT (Ann Arbor system: I–IV). Subtypes: nodular sclerosis (most common in US, young women, mediastinal), mixed cellularity, lymphocyte-predominant, lymphocyte-depleted. Treatment: ABVD (Adriamycin/doxorubicin, Bleomycin, Vinblastine, Dacarbazine) ± radiation. PROGNOSIS: EXCELLENT (80–90% cure in early stage). NHL: no RS cells, non-contiguous spread, variable (indolent to aggressive).

Q75  Answer: B  [Integrated]

B is correct — PTSD: ≥1 month of intrusion + avoidance + negative cognition/mood + hyperarousal after trauma exposure = PTSD. First-line = trauma-focused CBT (Prolonged Exposure or CPT) + FDA-approved SSRIs (sertraline/paroxetine). All other options contain errors: A — Scaphoid fractures are frequently OCCULT on initial X-ray (not 'positive'); treat empirically with thumb spica cast and repeat imaging. C — Osteoid osteoma = nocturnal pain relieved by ASA/NSAIDs (not elevation); CT is imaging of choice (not MRI); gold standard treatment = radiofrequency ablation (RFA), not exclusively surgical excision. D — ITP = ISOLATED thrombocytopenia (not pancytopenia); bone marrow shows increased megakaryocytes; management for mild pediatric ITP = observation, not immediate splenectomy (splenectomy is for chronic refractory adult ITP).

CAM III PAS 5