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All Questions
40 clinical practice questions — click to reveal answers and explanations
Q1
A 16-year-old boy with a seizure disorder presents to the hospital with a history of severe joint pain, fever, and fatigue. On examination, he has a low-grade fever, and his vitals are blood pressure 135/85 mmHg, heart rate 89 bpm, and respiratory rate 19 breaths/min. His seizures have been controlled with phenytoin for the past few years. The autoimmune assay is positive for ssDNA, anti-histones, and ANA. What is the most likely diagnosis? A. Drug-induced lupus erythematosus B. Systemic lupus erythematosus C. Purple glove syndrome D. Rheumatoid arthritis
Correct answer
Drug-induced lupus erythematosus
Why: Phenytoin is a classic cause of drug-induced lupus (DIL). Anti-histone antibodies are positive in ~95% of DIL cases. Unlike SLE, symptoms resolve when the offending drug is stopped.
Q2
A 32-year-old woman presents with 10 days of intense redness and hives on the hands, face, and abdomen. The patient was recently exposed to a cosmetic cream. Physical examination findings include erythematous raised wheals on the hands, face, and abdomen. What is the most likely diagnosis? A. Contact urticaria B. Anaphylaxis to the cream C. Staphylococcal skin infection D. Dermatographism
Correct answer
Contact urticaria
Why: Contact urticaria is a localized IgE-mediated or non-immunological reaction at the contact site. Resolution on days away from the allergen confirms occupational/contact etiology.
Q3
A 65-year-old woman presents with a four-month history of pain and stiffness in her neck, shoulders, and hips worse in the morning lasting 2 hours, low-grade fever, fatigue, and weight loss. No headache, blurred vision, scalp tenderness, or jaw claudication. Prescribed low-dose corticosteroid therapy. Which of the following tests were more likely elevated? A. ANA, rheumatoid factor, and uric acid B. CRP and ESR C. Anti-histone antibodies and anti-dsDNA D. CPK and aldolase
Correct answer
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
Why: Polymyalgia rheumatica (PMR) elevates CRP and ESR. Corticosteroids are first-line. ANA, RF, and anti-dsDNA are not typically elevated. CPK/aldolase elevation would suggest myositis instead.
Q4
A 55-year-old woman presents with a rash extending from abdomen to whole body, fevers, chills, decreased appetite, diffuse erythema with exfoliation and nodules, and diffuse lymphadenopathy. She takes amlodipine for hypertension. Family history of lymphoma. What is the next best step? A. CBC, blood chemistries, and CT chest/abdomen/pelvis B. Excisional lymph node biopsy C. PET scan D. Skin biopsy
Correct answer
Order a skin biopsy
Why: With erythroderma, lymphadenopathy, and lymphoma family history, cutaneous T-cell lymphoma must be excluded. Skin biopsy is the first diagnostic step before CT or PET.
Q5
A 67-year-old woman with 15-year history of type 2 diabetes presents with recurrent syncope. Symptoms occur when transitioning from lying to standing. BP seated 138/92, HR 82; after standing BP 102/73, HR 83. Which feature is most consistent with diabetic autonomic neuropathy? A. Age 67 B. Symptoms triggered by positional changes C. Single syncopal episode with chest pain D. BP decreases after standing but HR remains relatively unchanged
Correct answer
BP decreases significantly after standing but HR remains relatively unchanged
Why: Diabetic autonomic neuropathy impairs the reflex tachycardia that normally compensates for orthostatic hypotension. BP drops but HR fails to increase — the hallmark finding.
Q6
A 26-year-old man presents with recurrent episodes of rotational vertigo for 10 hours, followed by unilateral tinnitus, decreased hearing, hyperacusis, and sensation of fullness that waxes and wanes. What type of hearing loss will the patient most likely have? A. All frequencies B. High-frequency C. Mid-frequency D. Low-frequency
Correct answer
Low-frequency hearing loss
Why: Ménière's disease presents with low-frequency sensorineural hearing loss, tinnitus, aural fullness, and episodic vertigo. Low-frequency loss is the earliest and most characteristic audiometric finding.
Q7
A 3-year-old boy presents with a limp for 48 hours. Pain on internal rotation of left hip. Ibuprofen markedly reduces the limp. Normal WBC, CRP, and hip x-ray. What is the most likely diagnosis? A. Legg-Calve-Perthes disease B. Septic arthritis C. Transient synovitis D. Osteomyelitis
Correct answer
Transient synovitis
Why: Transient synovitis is the most common cause of acute hip pain in children aged 3–10. Normal labs (WBC, CRP) and x-ray, with pain relief from NSAIDs, distinguish it from septic arthritis.
Q8
A 39-year-old woman with 5-year history of episodic dizziness lasting up to 2 hours, right ear fullness and tinnitus. Head thrust test shows corrective saccades worse with rightward thrusts; audiometry shows low-frequency hearing loss in right ear. What is the most appropriate treatment in addition to a sodium-restricted diet? A. Loop diuretic B. Thiazide diuretic C. Intravenous aminoglycoside D. Aldosterone receptor antagonist
Correct answer
Thiazide diuretic
Why: Ménière's disease is managed with a low-sodium diet and thiazide diuretics (hydrochlorothiazide) to reduce endolymphatic pressure. Loop diuretics are not standard first-line for Ménière's.
Q9
A 68-year-old man presents after a generalized tonic-clonic seizure, with intermittent fever and headaches for a week. Drowsy and disoriented, bilateral papilledema, positive nuchal rigidity, bilateral Babinski sign, and leukocytosis. What is the next best step? A. Lumbar puncture B. MRI brain with contrast C. CT brain without contrast D. Electroencephalogram
Correct answer
CT of the brain without contrast
Why: Papilledema and nuchal rigidity with fever suggest elevated ICP from meningoencephalitis. CT without contrast must precede lumbar puncture to rule out herniation risk from mass lesion.
Q10
A 4-year-old child with epilepsy develops severe gingival hyperplasia after 1 year of anticonvulsive therapy. What is the therapeutic range for the medication that likely caused this side effect? A. 5-10 mcg/mL B. 10-15 mcg/mL C. 10-20 mcg/mL D. 20-30 mcg/mL
Correct answer
10 to 20 mcg/mL
Why: Gingival hyperplasia is a classic side effect of phenytoin. Therapeutic range for phenytoin is 10–20 mcg/mL. Above this range, toxicity (nystagmus, ataxia, CNS depression) occurs.
Q11
A 62-year-old woman with progressive forgetfulness, getting lost on familiar routes, frequent confusion, excessive daytime sleepiness, visual hallucinations, paranoid behavior, masked facies, soft voice, postural instability, slow gait, MMSE 24/30. Haloperidol worsens symptoms with limb and neck stiffness. What is the most likely diagnosis? A. Alzheimer dementia B. Dementia with Lewy bodies C. Bipolar disorder with psychosis D. Major depression with psychosis
Correct answer
Dementia with Lewy bodies
Why: Dementia with Lewy bodies features visual hallucinations, parkinsonism (masked facies, postural instability), REM sleep behavior disorder, and neuroleptic sensitivity — haloperidol worsened symptoms.
Q12
A 55-year-old man presents after head trauma with intermittent rotatory dizziness. Dix-Hallpike reveals transient upbeating positional nystagmus with left torsion. No neurological deficits. What is the cause? A. Left posterior semicircular canal canalithiasis B. Left posterior semicircular canal cupulolithiasis C. Right posterior semicircular canal cupulolithiasis D. Right posterior semicircular canal canalithiasis
Correct answer
Left posterior semicircular canal canalithiasis
Why: In the Dix-Hallpike test, upbeating torsional nystagmus with left torsion indicates left posterior semicircular canal BPPV. Canalithiasis (free-floating otoconia) causes a transient burst of nystagmus.
Q13
A 29-year-old woman presents with difficulty concentrating, bilateral headache most of the time, and diffuse body aches. Family history of SLE. Physical exam and inflammatory markers are normal. Which medication has been most studied in RCTs for this patient's likely condition? A. Lamotrigine B. Amitriptyline C. Lorazepam D. Sertraline
Correct answer
Amitriptyline
Why: The presentation describes fibromyalgia — diffuse pain, fatigue, cognitive symptoms, normal inflammatory markers. Amitriptyline (TCA) has the most evidence in RCTs for fibromyalgia pain.
Q14
A 75-year-old man with history of CAD, hypertension, COPD, and diabetes presents with memory impairment and behavioral problems. Heart rate 52/min. Alzheimer dementia is suspected. Which condition precludes treatment with donepezil? A. Hypertension B. Type 2 second-degree heart block C. COPD D. Uncontrolled diabetes mellitus
Correct answer
Type 2 second-degree heart block
Why: Donepezil (acetylcholinesterase inhibitor) increases vagal tone and can cause bradycardia and heart block. It is contraindicated in patients with significant cardiac conduction abnormalities including second-degree AV block.
Q15
An 18-year-old fully vaccinated college student whose dormitory roommate was diagnosed with invasive meningococcal disease 4 days ago. What is the most appropriate treatment? A. Chemoprophylaxis is unnecessary B. Too late to administer chemoprophylaxis C. Oral rifampicin or ciprofloxacin for chemoprophylaxis D. Nasopharyngeal swab; treat if positive
Correct answer
Oral rifampicin or oral ciprofloxacin for meningococcal chemoprophylaxis
Why: Vaccination does not eliminate the need for post-exposure prophylaxis. Close contacts of confirmed IMD cases require chemoprophylaxis with rifampicin, ciprofloxacin, or ceftriaxone regardless of vaccination status.
Q16
A 16-year-old lacrosse player with a prior concussion 2 weeks ago is diagnosed with another concussion but insists on returning to athletics early. What is the most dangerous potential neurologic complication? A. Second impact syndrome B. Development of migraine disorder C. Post-concussion syndrome D. Intracranial bleeding
Correct answer
Second impact syndrome
Why: Second impact syndrome occurs when a second concussion happens before the first has fully healed. The result can be rapid, catastrophic cerebral edema — potentially fatal. Return-to-play protocols exist to prevent this.
Q17
A 42-year-old man presents with profound dizziness worse with head movement after a low-speed rear-end collision. No gait instability, but movement provokes dizziness and nausea. Which clinical feature is consistent with the most likely diagnosis? A. Positional dizziness with severe unilateral throbbing head pain B. Spinning sensation with tinnitus and hearing loss C. Torsional nystagmus that does not fatigue D. Brief episodes of intense dizziness triggered by head position change
Correct answer
Brief episodes of intense dizziness triggered by a change in head position
Why: The clinical picture describes BPPV after minor trauma — brief intense dizziness triggered by head position change. Ménière's would have hearing loss and tinnitus; vertebrobasilar TIA would have other neurological signs.
Q18
A 68-year-old man with epilepsy controlled on lamotrigine reports adherence but takes medication at different times when he remembers. What is the most appropriate strategy to check adherence? A. Take the patient's word for it B. Diaries C. Direct observation D. Pill counts
Correct answer
Pill counts
Why: Pill counts are a validated method for assessing adherence in epilepsy management. Diaries rely on self-report. Direct observation is impractical outpatient. Taking the patient's word has the lowest reliability.
Q19
A 17-year-old presents with intense anxiety in movie theaters, lines, and large crowds for almost a year, turning down invitations and preferring to stay home. He wants to avoid medications. What is the most appropriate intervention? A. Alprazolam prescription B. Sertraline prescription C. Referral for cognitive behavioral therapy D. Referral for exposure and response prevention therapy
Correct answer
Referral for cognitive behavioral therapy
Why: Agoraphobia with no prior panic disorder history is best treated with CBT as first-line. Exposure and response prevention is used for OCD. Alprazolam is not recommended for long-term anxiety management.
Q20
A 35-year-old woman has not left her home in 6 months due to severe fear of crowds, subway, parking garages, and large buildings. What is the next best step? A. Clonazepam or diazepam B. Amitriptyline or imipramine C. Sertraline or fluoxetine D. Propranolol or prazosin
Correct answer
Initiate sertraline or fluoxetine
Why: Agoraphobia — severe avoidance of situations where escape might be difficult — is treated with SSRIs (first-line) plus CBT. Benzodiazepines are not recommended as first-line due to dependence risk.
Q21
A 21-year-old nurse develops hives on her palms and hands that resolve on days off and reappear at work. No medical history or medications. What is the best next step? A. Avoid natural rubber latex gloves B. Avoid hand sanitizers, increase handwashing C. Use skin barrier cream D. Premedicate with H1 antihistamine
Correct answer
Avoid natural rubber latex gloves
Why: Latex allergy is the most common occupational allergen for healthcare workers. Symptoms clearing on days off and returning at work is the classic occupational pattern. Latex-free gloves are the primary intervention.
Q22
A 32-year-old woman with regular menses presents with fatigue, lethargy, weakness, and pallor. She is being treated for generalized tonic-clonic seizures. What will be seen in the blood picture? A. Hypersegmented neutrophils B. Howell-Jolly bodies C. Schistocytes D. Sideroblasts
Correct answer
Hypersegmented neutrophils
Why: Phenytoin and other antiepileptics can cause folate deficiency. Folate deficiency leads to megaloblastic anemia with hypersegmented neutrophils (5+ lobes) — a key blood smear finding.
Q23
A 64-year-old man with hypertension, hyperlipidemia, and diabetes presents with 2 days of continuous progressive dizziness and loss of balance. Spontaneous and vertical nystagmus, positive test of skew, negative head impulse test. BP 152/90. What is the best next step? A. Increase lisinopril B. Decrease lisinopril C. Epley maneuver D. Brain MRI
Correct answer
Order brain magnetic resonance imaging
Why: Spontaneous vertical nystagmus, positive test of skew, and NEGATIVE head impulse test point to a central vestibular lesion (brainstem/cerebellum), not BPPV. MRI is required to exclude stroke.
Q24
A 75-year-old man with moderate Alzheimer dementia on donepezil 5 mg daily has MMSE decline from 18/30 to 15/30 over one year. TSH is normal. What is the appropriate next step? A. Continue donepezil 5 mg B. Increase donepezil to 10 mg C. Continue donepezil 5 mg, add rivastigmine D. Increase donepezil to 20 mg
Correct answer
Increase the donepezil dose to 10 mg daily
Why: Progression on MMSE (18→15) indicates worsening Alzheimer dementia. The next step is increasing donepezil from 5 mg to 10 mg daily. Adding a second cholinesterase inhibitor is not evidence-based.
Q25
A 75-year-old man with mild Alzheimer dementia on donepezil 5 mg nightly has frequent nightmares over the last two months but stable memory. What is the most appropriate next step? A. Increase donepezil to 10 mg B. Stop donepezil C. Add prazosin D. Change donepezil to morning dosing
Correct answer
Change donepezil dosing to the morning
Why: Donepezil taken in the evening commonly causes vivid dreams and nightmares. Switching to morning administration is the simple intervention before considering dose change or discontinuation.
Q26
A 65-year-old woman with atrioventricular block has a 10-year history of repeatedly checking electrical appliances and washing hands multiple times. What neurotransmitter is most affected by first-line medication for her psychiatric disorder? A. Dopamine B. Serotonin C. Norepinephrine D. Acetylcholine
Correct answer
Serotonin
Why: OCD (compulsive checking and handwashing for 10 years) is treated first-line with SSRIs (serotonin reuptake inhibitors). SSRIs work by blocking serotonin reuptake, making serotonin the key neurotransmitter.
Q27
A 16-year-old male presents after a concussion during football. Only symptom is a mild improving headache. What should the parents be advised regarding recovery? A. Complete cognitive and physical rest until symptoms resolve B. Symptoms usually resolve within weeks; start gradual stepwise return to activity C. Return to athletics as quickly as possible D. Symptoms likely to persist for months
Correct answer
Symptoms usually resolve within the first few weeks; gradual stepwise return to previous activities
Why: Concussion recovery typically follows a staged return-to-play protocol: rest → light aerobic exercise → sport-specific exercise → non-contact drills → full contact practice → return to competition.
Q28
A 65-year-old woman falls and hits her head, complaining of dizziness and headache. No loss of consciousness. Normal neurological exam and CT excludes bleed. What is the most common complication of her neurological condition? A. Post-concussion symptoms B. Second-impact syndrome C. Post convulsive syndrome D. Migraine
Correct answer
Post-concussion symptoms
Why: Post-concussion syndrome — headache, dizziness, cognitive difficulty, mood changes — is the most common complication after concussion, occurring in up to 30% of patients and lasting weeks to months.
Q29
An 88-year-old woman with vascular dementia is oriented to self and location, recognizes family members, no cognitive progression, intermittent diarrhea from IBS, heart rate in low 60s, no behavioral concerns. What is the next best step? A. Prescribe donepezil B. Prescribe aripiprazole C. Encourage cognitive stimulation and socialization D. Reassess in 3 months
Correct answer
Encouraging cognitive stimulation and socialization
Why: In vascular dementia with no behavioral concerns, no cognitive decline, and bradycardia, cholinesterase inhibitors have limited evidence. Non-pharmacological approaches (cognitive stimulation, socialization) are first-line.
Q30
A 66-year-old truck driver with hypertension, diabetes, and hyperlipidemia presents with recurrent syncope. Holter monitor shows asystole for 9 seconds coinciding with syncope. What is of greatest concern? A. Concomitant diabetes B. Occupation C. Family history D. Obesity
Correct answer
Occupation
Why: Asystole during syncope in a truck driver is a safety-critical finding. His occupation puts others at risk. This supersedes all other concerns and requires immediate driving restriction and cardiology referral.
Q31
A 70-year-old male presents with difficulty sleeping, binge eating, no sympathy towards animals, inappropriate behavior, and need for assistance with finances. Only taking amlodipine. What is the next appropriate step? A. EEG B. MMSE C. MRI brain D. Trial of lithium
Correct answer
Mini-Mental State Examination (MMSE)
Why: Behavioral and personality changes (disinhibition, binge eating, lack of empathy) in an elderly patient suggest frontotemporal dementia. MMSE is the first cognitive screening step before imaging.
Q32
A 15-year-old boy presents with fever, myalgia, photophobia, vomiting, headache, neck rigidity, and gram-negative diplococci in CSF. Which vaccination schedule is most likely to have prevented this condition? A. 2, 4, 6, and 12-15 months B. 2 and 4 months C. 11-12 years D. 12-15 months and 4-6 years
Correct answer
11 to 12 years
Why: Gram-negative diplococci in CSF = Neisseria meningitidis. Meningococcal conjugate vaccine (MenACWY) is given at age 11–12 years with a booster at 16. This schedule matches option C.
Q33
A 49-year-old woman presents with hazy vision in the right eye, mild diplopia with extreme lateral gaze, bilateral horizontal nystagmus, prominent intention tremor on right hand, and scanning speech. No motor weakness or sensory loss. What is the most probable diagnosis? A. Multiple sclerosis B. Parkinson's disease C. Wilson's disease D. Systemic lupus erythematosus
Correct answer
Multiple sclerosis
Why: Multiple sclerosis presents with optic neuritis, internuclear ophthalmoplegia (diplopia with lateral gaze), nystagmus, intention tremor, and scanning speech — the classic Charcot triad (nystagmus + intention tremor + scanning speech).
Q34
A 16-year-old girl is afraid to leave home because she fears she might suffer a panic attack in malls or grocery stores. No other medical problems. What is the most likely diagnosis? A. Panic disorder B. Agoraphobia C. Social anxiety D. Specific phobia
Correct answer
Agoraphobia
Why: Agoraphobia is fear of situations where escape might be difficult or help unavailable during a panic attack — avoiding malls, public transport, crowds. Panic disorder requires recurrent unexpected panic attacks.
Q35
A 69-year-old woman presents with behavioral changes, short-term memory loss, mood changes, difficulty performing complex tasks, and getting lost in familiar neighborhoods. Reversible causes excluded. What medication class is most likely beneficial? A. Cholinesterase inhibitors B. Decarboxylase inhibitors C. Atypical antipsychotics D. SSRIs
Correct answer
Cholinesterase inhibitors
Why: Alzheimer dementia — memory loss, getting lost, behavioral changes — is treated with cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild-to-moderate disease.
Q36
A 65-year-old woman with hypertension has short-term memory trouble for one year, requires assistance to walk, and has incontinence. MMSE 24/30 with 0/3 recall. Wide-based gait with short steps. CT head shows dilated ventricles. What is the next best step? A. High-volume lumbar puncture B. Urinalysis C. Thyroid function tests D. MRI brain without contrast
Correct answer
High-volume lumbar puncture
Why: Classic normal pressure hydrocephalus (NPH) triad: cognitive decline + gait apraxia (wide-based, short steps) + urinary incontinence. Dilated ventricles on CT. High-volume LP (30–50 mL) is both diagnostic and therapeutic.
Q37
Which of the following is the most common type of dementia? A. Frontotemporal dementia B. Alzheimer disease C. Lewy body dementia D. Vascular dementia
Correct answer
Alzheimer disease
Why: Alzheimer disease accounts for approximately 60–80% of all dementia cases, making it the most common type. Vascular dementia is second, followed by Lewy body dementia and frontotemporal dementia.
Q38
A 31-year-old woman with 7 months of heart palpitations, anxiety at home and work, poor sleep, persistent fear that something bad will happen, concentration issues, fatigue, and increased alcohol use. Normal vitals and ECG shows NSR with HR 102. What is the most appropriate next step? A. Start disulfiram B. Prescribe an SSRI C. Administer the CAGE questionnaire D. Refer for DBT
Correct answer
Prescribe a selective serotonin reuptake inhibitor
Why: The presentation describes generalized anxiety disorder (GAD) — excessive worry for 7 months affecting multiple domains, somatic symptoms, sleep disturbance. SSRIs are first-line pharmacotherapy for GAD.
Q39
A 10-month-old baby has brief sudden jerking spells causing extension of limbs and trunk while flexing the neck, with 3 episodes. The baby cannot sit or speak. What is the next best step? A. EEG B. MRI brain C. Genetic studies D. Sodium valproate therapy
Correct answer
Electroencephalogram
Why: Flexion-extension spasms in an infant with developmental regression are infantile spasms (West syndrome). EEG is the immediate next step to confirm the diagnosis (hypsarrhythmia pattern).
Q40
A patient has been taking extra diazepam doses. Which factor accounts for the greater abuse liability of diazepam compared with lorazepam? A. Increased potency B. First-pass effect C. Rapid onset of action D. Long half-life
Correct answer
Rapid onset of action
Why: Diazepam has a rapid onset of action due to high lipophilicity, leading to fast CNS entry and euphoria — the key driver of abuse liability. Long half-life actually reduces abuse compared to short-acting agents.
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