Patient scenarios for any Single Item or Sequential Item Set may be provided in either Vignette (paragraph) format, or in Chart/Tabular format. Test items using the chart/tabular format are designed to resemble patient charts but are not intended to be an exact representation of a patient chart. Questions written in chart/tabular format will contain relevant patient information in list form, organized in clearly marked sections for ease of review. Familiar medical abbreviations may be used within chart/tabular format questions.
A single patient-centered vignette is associated with one question followed by four or more response options. The response options are lettered (ie, A, B, C, D, E). A portion of the questions involves interpretation of graphic or pictorial materials. You are required to select the best answer to the question. Other options may be partially correct, but there is only ONE BEST answer. This is the traditional, most frequently used multiple-choice question format on the examination.
A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure over the past 2 years. She is not yet on dialysis. Examination shows no abnormalities. Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and mean corpuscular volume is 94 m3. A blood smear shows normochromic, normocytic cells. Which of the following is the most likely cause?
(A) Acute blood loss
(B) Chronic lymphocytic leukemia
(C) Erythrocyte enzyme deficiency
(D) Erythropoietin deficiency
(E) Immunohemolysis
(F) Microangiopathic hemolysis
(G) Polycythemia vera
(H) Sickle cell disease
(I) Sideroblastic anemia
(J) β-Thalassemia trait
(Answer: D)
Patient Information
Age: 18 years
Gender: F, self-identified
Ethnicity: unspecified
Site of Care: emergency department
History
Reason for Visit/Chief Concern: "My roommate took a lot of pills and said she wanted to die."
History of Present Illness:
• patient brought by ambulance 2 hours after a suspected acetaminophen overdose
• roommate had returned to their dorm and found the patient distraught; patient was holding an empty bottle of acetaminophen and said, "I just want to die."
• roommate estimates patient consumed 20 to 30 tablets of 500-mg acetaminophen
Past Medical History:
• generalized anxiety disorder
• major depressive disorder
Medications:
• citalopram
Allergies:
• no known drug allergies
Family History:
• noncontributory
Physical Examination
| Temp | Pulse | Resp | BP | O2 Sat | Ht | Wt | BMI |
| 36.8°C (98.2°F) |
89/min | 16/min | 108/59 mm Hg | 99% on RA | 170 cm 5 ft 7 in |
63 kg 140 lb |
22 kg/m2 |
• Appearance: awake and alert but distraught and fearful; patient says, "This was totally stupid."
• Pulmonary: clear lung fields
• Cardiac: regular rhythm; S1 and S2, with an early systolic murmur
• Abdominal: soft and nontender; liver and spleen cannot be palpated
• Neurologic: no abnormalities; fully oriented
Question: In addition to obtaining serum acetaminophen concentration, which of the following is the most appropriate next step in management?
(A) Administer N-acetylcysteine
(B) Arrange hemodialysis
(C) Gastric lavage
(D) Initiate sodium bicarbonate infusion
(Answer: A)
A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. Each question is associated with the initial patient vignette but is testing a different point. You are required to select the ONE BEST answer to each question. Questions are designed to be answered in sequential order. You must click “Proceed to Next Item” to view the next item in the set; once you click on this button, the next question will be displayed, and you will not be able to change the answer to the previous question.
A 35-year-old woman is brought to the emergency department because of worsening pain and swelling of her right knee for the past 2 days. She has been taking acetaminophen for the knee pain during the past 2 days, but the pain is worse today. She has not had any trauma to the knee or any previous problems with her joints. She is otherwise healthy and she currently takes an oral contraceptive. She is sexually active and has a 10-year-old son who lives with her. She is a receptionist at a local hotel and she tells you she must stand often while working. She is 160 cm (5 ft 3 in) tall and weighs 52 kg (115 lb); BMI is 20 kg/m2. Temperature is 37.9°C (98.9°F). The right knee is erythematous, swollen, and tender; there is pain on movement. No other joints are affected. X-ray of the knee shows an effusion but no structural abnormalities of the joint.
Which of the following is the most appropriate next step in diagnosis?
(A) Arthrocentesis of the knee
(B) Blood cultures
(C) MRI of the knee
(D) Urine cultures
(Answer: A)
Arthrocentesis is done. The synovial fluid is cloudy. Gram stain is negative. Analysis of the synovial fluid shows a leukocyte count of 120,000/mm3 and 90% neutrophils. Which of the following is the most appropriate additional test on the synovial fluid?
(A) Culture for bacteria
(B) Glucose measurement
(C) Polarized light microscopy
(D) Protein level
(Answer: A)
The abstract item format includes a summary of an experiment or clinical investigation presented in a manner commonly encountered by a physician, eg, as an abstract that accompanies a research report in a medical journal. Examinees must interpret the abstract in order to answer questions on various topics, including