Board Review Cases

214 clinical vignettes.

Multiple-choice cases from the 8-hour board review course. Pick an answer, get rationale, review high-yield pearls.

Quiz mode — random cases
Play through cases sequentially in shuffled order.
Showing 214 of 214
S1 · NeurologyEasy

Amaurosis fugax (embolic TIA)

Older patient with sudden painless transient monocular vision loss (~5 minutes), described as a 'curtain coming down', with vascular risk factors (HTN, smoking) and a normal fundus exam.

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S1 · NeurologyMedium

Acute ischemic stroke

A 68-year-old man with hypertension presents with acute right-sided weakness and aphasia that started 2 hours ago. Non-contrast CT shows no hemorrhage.

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S1 · NeurologyMedium

Intracerebral hemorrhage

Poorly controlled hypertension + sudden focal neurologic deficit (hemiparesis, Babinski) + vomiting and confusion.

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S1 · NeurologyEasy

Idiopathic intracranial hypertension

A young obese woman presents with daily headache, transient visual obscurations, and papilledema. MRI brain is normal. LP shows opening pressure of 320 mm H₂O.

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S1 · NeurologyMedium

Subacute combined degeneration (B12 deficiency)

Vegan + progressive gait instability and falls + numbness in feet + decreased vibration sense + positive Romberg.

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S1 · NeurologyHard

Tabes dorsalis

Unsteady wide-based gait + sharp, shooting 'lightning' leg pains + history of untreated syphilis + Argyll Robertson pupils (accommodate but do not react to light).

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S1 · NeurologyEasy

Alzheimer disease

An 78-year-old man with progressive memory loss and impaired daily functioning over 2 years. MMSE 22/30. Labs (TSH, B12) and MRI rule out reversible causes.

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S1 · NeurologyMedium

Normal pressure hydrocephalus

Elderly patient with gait disturbance first, then urinary incontinence, then mild dementia. MRI shows ventriculomegaly out of proportion to cortical atrophy.

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S1 · NeurologyMedium

Lewy body dementia

Dementia + recurrent visual hallucinations + parkinsonism + REM sleep behavior disorder (acting out dreams).

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S1 · NeurologyMedium

Huntington disease

Young adult with behavioral changes, cognitive decline, choreiform movements, family history of similar disease, and MRI showing caudate atrophy.

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S1 · Infectious DiseaseMedium

Bacterial meningitis (neonatal)

A 3-week-old infant with fever, lethargy, poor feeding, and a bulging fontanelle. CSF shows neutrophilic pleocytosis, low glucose, and elevated protein.

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S1 · Infectious DiseaseEasy

Bacterial meningitis

A 72-year-old man with fever, headache, and neck stiffness. CSF: neutrophilic pleocytosis, low glucose, high protein.

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S1 · Infectious DiseaseMedium

HSV encephalitis (neonatal)

A 10-day-old infant with fever, poor feeding, and new-onset seizures. CSF shows lymphocytic pleocytosis, elevated protein, low-normal glucose, and RBCs.

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S1 · Infectious DiseaseMedium

CNS toxoplasmosis

A 35-year-old HIV-positive man with CD4 count 45 presents with headache, fever, and confusion. MRI shows multiple ring-enhancing lesions in the basal ganglia and cortex.

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S1 · OncologyHard

Primary CNS lymphoma

A 39-year-old HIV-positive man with headache, confusion, and blurry vision. MRI shows a single ring-enhancing lesion in the periventricular region. CSF reveals EBV DNA.

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S1 · Infectious DiseaseHard

Cavernous sinus thrombosis

A young adult with a facial 'danger triangle' infection, now with fever and ophthalmoplegia.

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S1 · NeurologyMedium

Brain tumor with vasogenic edema

Progressive headache + focal neurologic deficits + new-onset seizures. MRI shows a mass with vasogenic edema and midline shift.

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S1 · OncologyEasy

Brain metastases

A patient with known lung cancer presents with new headaches. MRI shows multiple ring-enhancing lesions at the gray-white matter junction with surrounding vasogenic edema.

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S1 · OncologyEasy

Meningioma

Middle-aged woman with a well-circumscribed dural-based mass on imaging found incidentally; no neurologic symptoms.

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S1 · NeurologyMedium

Vestibular schwannoma (acoustic neuroma)

Middle-aged adult with progressive unilateral sensorineural hearing loss, tinnitus, imbalance, and facial numbness.

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S1 · OncologyMedium

Glioblastoma multiforme (GBM)

Older adult with new-onset seizures, progressive headaches, and focal deficits. MRI shows a large irregular rim-enhancing mass with central necrosis crossing the corpus callosum (butterfly lesion).

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S1 · PediatricsMedium

Tuberous sclerosis complex

A 2-year-old with seizures and developmental delay. Exam shows ash leaf spots and a shagreen patch. Brain MRI shows subependymal nodules.

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S1 · PediatricsMedium

Craniopharyngioma

A child with bitemporal hemianopsia, growth delay, and increased thirst/urination. MRI shows a calcified suprasellar mass.

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S1 · NeurologyMedium

Subarachnoid hemorrhage

Sudden 'worst headache of life' (thunderclap) + photophobia/neck stiffness + transient loss of consciousness. Initial non-contrast CT is normal.

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S1 · NeurologyEasy

Subdural hematoma

Elderly alcoholic patient with a fall 2 weeks ago, now with progressive headache and confusion. CT shows a crescent-shaped bleed crossing suture lines.

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S1 · NeurologyEasy

Concussion (mild TBI)

Football player with head collision, brief LOC, transient confusion, and one episode of vomiting. Neuro exam is now normal.

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S1 · MusculoskeletalMedium

Lumbar spinal stenosis (neurogenic claudication)

Older patient with bilateral buttock/posterior thigh/calf pain when walking or standing, relieved by sitting or bending forward. Normal neuro exam.

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S1 · NeurologyMedium

Focal aware seizure

Recurrent unilateral arm tingling that gradually spreads to the face. Patient is fully alert during episodes. No loss of consciousness.

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S1 · PediatricsEasy

Absence seizure (childhood absence epilepsy)

An 8-year-old child has brief staring spells lasting seconds. The teacher reports the child becomes unresponsive then immediately returns to baseline with no postictal confusion.

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S1 · EmergencyHard

Status epilepticus

Continuous generalized tonic-clonic seizure activity for >5 minutes without return to baseline.

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S1 · NeurologyHard

Brain death

After severe intracranial hemorrhage, a patient is in coma with absent brainstem reflexes and no response to painful stimuli. All confounders are excluded.

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S1 · AnesthesiaEasy

Post-dural puncture headache

Patient develops severe headache 1–3 days after epidural anesthesia; worse when standing, improves when lying supine.

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S1 · NeurologyMedium

Optic neuritis

Young woman with acute unilateral vision loss + pain with eye movement + relative afferent pupillary defect (RAPD). MRI shows optic nerve hyperintensity.

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S1 · Infectious DiseaseHard

Spinal epidural abscess

An IV drug user with diabetes presents with fever, severe focal back pain, and new leg weakness. Spinal tenderness on exam.

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S1 · EmergencyHard

Cauda equina syndrome

A patient presents with bilateral leg weakness, urinary retention, saddle anesthesia, decreased rectal tone, and numbness in the inner thigh/buttock.

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S1 · MusculoskeletalMedium

L4 radiculopathy

Low back pain radiating to the medial leg with decreased knee extension strength and a decreased patellar reflex.

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S1 · NeurologyEasy

Essential tremor

Older patient with bilateral action tremor that worsens with movement and improves with alcohol. No rigidity or bradykinesia.

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S1 · NeurologyMedium

Myasthenia gravis

Young woman with intermittent diplopia and ptosis, proximal muscle weakness worse in the evening, normal reflexes, and improvement with an ice pack.

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S1 · NeurologyHard

Lambert-Eaton myasthenic syndrome

Older smoker with progressive proximal muscle weakness, autonomic symptoms (dry mouth, ED), and decreased reflexes that improve with brief exercise.

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S1 · OphthalmologyMedium

Central retinal artery occlusion (CRAO)

Older patient with sudden painless monocular vision loss. Fundus shows a pale retina with a cherry-red spot at the fovea. Carotid bruit on exam.

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S1 · OphthalmologyMedium

Acute angle-closure glaucoma

Older patient with sudden severe unilateral eye pain, blurred vision, nausea, red eye, hazy cornea, and a fixed mid-dilated pupil.

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S1 · OphthalmologyEasy

Hyphema

Patient with blunt eye trauma, pain, decreased vision, and blood layering in the anterior chamber on slit-lamp exam.

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S1 · OphthalmologyEasy

Viral conjunctivitis

A child with red, watery eyes, recent fever and rhinorrhea, and preauricular lymphadenopathy.

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S1 · OphthalmologyMedium

Anterior uveitis (iritis)

Young adult with eye pain, photophobia, blurred vision, ciliary injection, constricted pupil, and cells in the anterior chamber on slit-lamp.

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S1 · PediatricsMedium

Retinoblastoma

A toddler is brought in because of a white pupillary reflex (leukocoria) seen in photos and an absent red reflex on exam.

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S1 · PsychiatryMedium

PTSD

A veteran has had nightmares, hypervigilance, avoidance, and emotional detachment for 6 months after a combat experience.

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S1 · PsychiatryMedium

Anorexia nervosa

A young woman with BMI 17, amenorrhea, lanugo, bradycardia, and persistent denial of illness severity despite low weight.

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S1 · PsychiatryEasy

Bulimia nervosa

Patient with normal BMI, recurrent binge eating, self-induced vomiting, dental enamel erosion, and parotid swelling.

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S1 · PsychiatryEasy

ADHD

A 7-year-old with persistent inattention and hyperactivity at home and at school, with declining grades.

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S1 · PediatricsEasy

Autism spectrum disorder

A toddler with delayed speech, poor eye contact, minimal social interest, repetitive behaviors, and distress with routine changes.

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S1 · PsychiatryMedium

Schizophrenia

A young man has had auditory hallucinations of voices commenting and delusions of thought broadcasting for 8 months.

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S1 · PsychiatryMedium

Schizophrenia with poor adherence

A patient with chronic paranoid schizophrenia has had multiple hospitalizations because he stops his medications after discharge.

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S1 · PsychiatryMedium

Major depressive disorder (adolescent)

A 16-year-old has had 3 months of low mood, anhedonia, fatigue, academic decline, and passive suicidal ideation.

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S1 · PsychiatryHard

Treatment-resistant psychotic depression

An elderly woman has severe depression with auditory hallucinations, refusal to eat with weight loss, and failure of multiple antidepressants.

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S1 · PsychiatryHard

Severe lithium toxicity

A patient on chronic lithium has a level of 3.0 mEq/L with confusion, coarse tremor, and vomiting after starting an NSAID.

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S1 · DermatologyHard

Stevens-Johnson syndrome

New fever and widespread erythematous rash with mucosal involvement 2 weeks after starting lamotrigine.

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S1 · PsychiatryEasy

Panic disorder

Recurrent sudden episodes of palpitations and chest tightness with normal medical workup and ongoing avoidance and fear of future attacks.

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S1 · PsychiatryEasy

Generalized anxiety disorder

Persistent excessive worry about multiple domains (job, finances) for >6 months with sleep difficulty and irritability.

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S1 · PsychiatryEasy

Obsessive-compulsive disorder

Patient with repetitive compulsive handwashing for hours driven by fear of contamination, recognizing the behavior is excessive.

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S1 · PsychiatryMedium

Alcohol use disorder — medication selection

A patient with alcohol use disorder takes chronic hydrocodone-acetaminophen for chronic pain. He is now abstinent and wants medication-assisted treatment for AUD.

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S1 · ENTMedium

Ménière disease

Middle-aged patient with recurrent vertigo lasting hours, unilateral tinnitus, unilateral sensorineural hearing loss, and aural fullness.

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S1 · ENTMedium

Vestibular neuritis

Sudden persistent vertigo and nausea/vomiting after a recent URI with horizontal nystagmus and NO hearing loss.

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S1 · ENTEasy

BPPV

Recurrent brief (seconds) vertigo triggered by head movement (rolling in bed, looking up). Normal neuro exam.

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S1 · PediatricsEasy

Acute otitis media (with perforation)

A child with ear pain, fever, and sudden purulent otorrhea. Exam shows a red, bulging TM with rupture.

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S1 · ENTEasy

Otitis externa (swimmer's ear)

Swimmer with ear pain, itching, mild hearing loss, pain with manipulation of the pinna/tragus, and erythematous edematous external canal.

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S1 · Infectious DiseaseHard

Malignant (necrotizing) otitis externa

An elderly diabetic with severe ear pain (disproportionate to exam), purulent otorrhea, granulation tissue in the canal, and a CN VII palsy.

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S2 · CardiologyEasy

Endocarditis prophylaxis — no indication

A 48-year-old woman with mitral valve prolapse and mild MR is scheduled for a dental cleaning. She's allergic to penicillin.

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S2 · CardiologyMedium

Infective endocarditis (IVDU)

A 27-year-old IV drug user with fever and a new tricuspid regurgitation murmur. Blood cultures are pending.

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S2 · CardiologyHard

Perivalvular abscess

IV drug user with fever, new aortic regurgitation murmur, and new AV block on ECG.

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S2 · CardiologyEasy

Chronic stable angina

Patient with chronic stable angina, exertional chest pain relieved by rest. ECG normal at rest.

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S2 · CardiologyEasy

Stable angina — diagnostic workup

45-year-old woman with exertional pressure-like chest pain relieved by rest. ECG normal at rest. Able to exercise.

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S2 · CardiologyMedium

ST-elevation myocardial infarction

A 65-year-old man with 30 minutes of severe substernal chest pain radiating to the left arm and ST elevations in V1–V4.

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S2 · CardiologyMedium

Inferior STEMI (reperfusion strategy)

58-year-old man with 1 hour of chest pain and ST elevations in II, III, aVF. The nearest PCI center is 3 hours away.

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S2 · CardiologyHard

Prinzmetal (vasospastic) angina

Young smoker with chest pain at rest in early morning. Transient ST elevation during episode resolves. Angiography shows normal coronary arteries.

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S2 · CardiologyMedium

NSTEMI workup

58-year-old man with 2 hours of chest pain, diaphoresis, T-wave inversions inferiorly, and initial troponin normal.

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S2 · CardiologyEasy

Unstable angina

60-year-old with chest pain at rest. ECG: T-wave inversions and ST depression in lateral leads. Troponin negative.

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S2 · CardiologyMedium

Cocaine-induced MI

A 28-year-old man with chest pain after cocaine use, ST elevations, and elevated troponin.

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S2 · CardiologyHard

Papillary muscle rupture (acute MR)

3 days after an inferior MI, a patient develops sudden pulmonary edema, hypotension, and a new apical holosystolic murmur.

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S2 · CardiologyMedium

LV aneurysm

After an anterior STEMI, ECG shows persistent ST elevations and Q waves in V1–V4. Echo shows an LV wall bulge.

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S2 · CardiologyMedium

HFrEF medication management

Patient with HFrEF (EF 25%) is on enalapril, carvedilol, eplerenone, and digoxin.

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S2 · CardiologyMedium

Viral myocarditis → dilated cardiomyopathy

20-year-old with recent flu-like illness, now with dyspnea, orthopnea, S3, and echo showing biventricular dilation with EF 35%.

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S2 · OncologyMedium

Trastuzumab-induced cardiomyopathy

55-year-old woman with HER2-positive breast cancer on trastuzumab develops new dyspnea and orthopnea. Echo shows reduced EF.

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S2 · CardiologyMedium

Restrictive cardiomyopathy

Patient with Hodgkin lymphoma history (treated with chest radiation) presents with dyspnea, preserved EF (65%), and low-voltage QRS on ECG.

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S2 · CardiologyHard

Constrictive pericarditis

60-year-old from TB-endemic region with dyspnea, elevated JVP, ascites, pericardial knock, and calcified pericardium on CXR.

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S2 · CardiologyEasy

Acute pericarditis

32-year-old man with sharp pleuritic chest pain, scratchy high-pitched sound on auscultation, and ECG showing diffuse ST elevations with PR depressions.

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S2 · CardiologyHard

Cardiac tamponade

48-year-old man with metastatic lung cancer has dizziness, hypotension, JVD, muffled heart sounds, BP drop >10 mmHg on inspiration, and clear lungs.

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S2 · CardiologyHard

Torsades de pointes

35-year-old woman with syncope, ECG showing polymorphic VT and prolonged QT, recently started erythromycin.

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S2 · PediatricsHard

Kawasaki disease — coronary complications

A 4-year-old with progressive dyspnea, fatigue, tachycardia, and hepatomegaly. One month ago he had 6 days of high fever, bilateral conjunctivitis, cracked lips, and a polymorphous rash.

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S2 · TraumaMedium

Myocardial contusion

After blunt chest trauma, patient has elevated troponin but normal ECG.

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S2 · CardiologyMedium

Beta-blocker overdose

Symptomatic bradycardia after beta-blocker overdose.

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S2 · CardiologyMedium

Severe aortic stenosis

58-year-old man with aortic stenosis, BP 100/84 (narrow pulse pressure), late-peaking systolic murmur, and delayed carotid upstroke.

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S2 · CardiologyMedium

Marfan syndrome with aortic regurgitation

Tall thin man with long limbs, scoliosis, high-arched palate, joint hypermobility, and an early diastolic decrescendo murmur at left sternal border.

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S2 · CardiologyMedium

AFib with RVR — rate control with asthma

40-year-old man with AFib (HR 154) and known asthma.

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S2 · CardiologyMedium

AFib stroke prevention

67-year-old woman with AFib, HTN, and diabetes; rate-controlled on bisoprolol.

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S2 · CardiologyHard

WPW syndrome

50-year-old man with WPW (delta wave on ECG) and history of paroxysmal AFib.

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S2 · CardiologyMedium

Stable VT

58-year-old man with ischemic heart disease and stable VT.

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S2 · CardiologyMedium

Asymptomatic HOCM

Asymptomatic patient with echo-confirmed HOCM.

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S2 · CardiologyMedium

Digoxin toxicity

Patient on digoxin presents with nausea, vomiting, and yellow vision with halos.

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S2 · RenalMedium

Hyperkalemia

Patient on spironolactone presents with weakness and ECG showing tall peaked T waves.

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S2 · PediatricsMedium

Croup (laryngotracheobronchitis) — moderate/severe

A 2-year-old with barking cough, inspiratory stridor at rest, hoarseness, and suprasternal retractions.

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S2 · PediatricsHard

Epiglottitis

Unvaccinated child with high fever, drooling, tripod position, and muffled voice.

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S2 · PediatricsEasy

Bronchiolitis

An 8-month-old with viral URI followed by wheezing and crackles.

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S2 · PediatricsMedium

Foreign body aspiration

A toddler with sudden onset of unilateral wheezing and hyperinflation, unresponsive to albuterol.

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S2 · PediatricsMedium

Neonatal respiratory distress syndrome

Premature infant born at 29 weeks with respiratory distress, nasal flaring, intercostal retractions, and diffuse reticulogranular (ground-glass) opacities with air bronchograms on CXR.

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S2 · CardiologyMedium

Amiodarone toxicity

Patient on amiodarone develops pulmonary infiltrates, hypothyroidism symptoms, and blue-gray skin discoloration.

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S2 · Infectious DiseaseEasy

Acute bacterial rhinosinusitis

Patient with sinus symptoms for 14 days, severe facial pain, fever, and 'double worsening' after initial improvement.

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S2 · Infectious DiseaseMedium

Pertussis

Patient with paroxysmal cough, posttussive vomiting, and minimal fever for 2 weeks.

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S2 · Infectious DiseaseMedium

Lung abscess (aspiration)

Alcoholic with foul-smelling sputum and a cavitary lesion with air-fluid level on CXR.

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S2 · PulmonaryMedium

Empyema

Patient with pneumonia and now frank pus in the pleural space (thoracentesis shows pH 7.0, glucose 30, positive Gram stain).

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S2 · Infectious DiseaseMedium

Latent TB

Patient has a positive PPD and a normal chest X-ray.

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S2 · Infectious DiseaseMedium

Active TB

Patient with hemoptysis, night sweats, and apical cavitary lesions on CXR.

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S2 · Infectious DiseaseMedium

Pneumocystis pneumonia (PJP)

HIV+ patient with CD4 of 150 presents with hypoxia and bilateral interstitial infiltrates.

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S2 · PulmonaryHard

Allergic bronchopulmonary aspergillosis (ABPA)

Asthmatic patient with brown sputum, eosinophilia, high IgE, and central bronchiectasis.

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S2 · PulmonaryMedium

Alpha-1 antitrypsin deficiency

A 38-year-old with progressive dyspnea and basilar emphysema on CT, with minimal smoking history.

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S2 · PulmonaryEasy

Asthma

Young woman with recurrent chest tightness, wheezing, and SOB. PFTs show decreased FEV₁ with 15% improvement after bronchodilator.

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S2 · PulmonaryMedium

Severe acute asthma exacerbation

Adolescent with known asthma, severe SOB, PEF <40% baseline, SpO₂ 88%, and no relief after albuterol.

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S2 · PulmonaryMedium

Samter triad (AERD)

Patient with asthma, nasal polyps, and wheezing after taking NSAIDs.

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S2 · OncologyMedium

Pancoast tumor

Smoker with apical lung mass, shoulder pain, and Horner syndrome (ptosis, miosis, anhidrosis).

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S2 · HematologyMedium

TRALI

Patient develops acute hypoxia and bilateral infiltrates within 6 hours of a blood transfusion.

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S2 · EmergencyMedium

Carbon monoxide poisoning

Patient with headache, confusion, after exposure to a fire in an enclosed space. SpO₂ is normal.

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S2 · PulmonaryMedium

Idiopathic pulmonary fibrosis

Patient with progressive dyspnea, dry cough, basilar peripheral honeycombing on HRCT.

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S3 · GastroenterologyHard

Variceal hemorrhage

A 54-year-old man with alcoholic cirrhosis presents with hematemesis. BP 84/52, HR 128. Jaundice, spider angiomata, ascites. Hgb 7.4, INR 2.1.

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S3 · GastroenterologyMedium

Zenker diverticulum

Elderly patient with dysphagia, halitosis, regurgitation of undigested food hours after eating, and a gurgling neck mass.

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S3 · GastroenterologyEasy

GERD (uncomplicated)

Patient with substernal burning chest pain, regurgitation, worsens after meals/lying down, no alarm features, age <60.

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S3 · GastroenterologyMedium

Barrett esophagus with low-grade dysplasia

Patient with Barrett esophagus and low-grade dysplasia on biopsy, now post-Nissen fundoplication.

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S3 · GastroenterologyMedium

Oropharyngeal dysphagia

Post-stroke patient with coughing/choking during swallowing and nasal regurgitation.

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S3 · GastroenterologyMedium

Achalasia

Progressive dysphagia to solids AND liquids from onset, regurgitation of undigested food, no oropharyngeal symptoms.

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S3 · Infectious DiseaseMedium

HIV infectious esophagitis

HIV+ patient with dysphagia, odynophagia, and substernal chest pain.

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S3 · GastroenterologyEasy

Pill esophagitis

Acute dysphagia and substernal pain after recent alendronate use; shallow ulcers with normal surrounding mucosa on EGD.

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S3 · EmergencyHard

Caustic alkali ingestion

Suicide attempt with liquid drain cleaner ingestion. Gray oral exudate, epigastric tenderness.

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S3 · GastroenterologyEasy

Dyspepsia — H. pylori workup

Chronic epigastric pain, no weight loss/bleeding/anemia, age 35.

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S3 · GastroenterologyMedium

H. pylori eradication confirmation

Patient completed quadruple therapy for H. pylori 4 weeks ago, now asymptomatic. Initial diagnosis was via serology.

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S3 · GastroenterologyEasy

Duodenal ulcer (H. pylori)

A 28-year-old man with 3 months of epigastric pain occurring 2–3 hours after meals and at night, improving with eating. Recent dark stools.

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S3 · EmergencyHard

Perforated peptic ulcer

Patient with PUD develops sudden severe epigastric pain with a rigid board-like abdomen. Upright CXR shows free air under diaphragm.

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S3 · GastroenterologyMedium

Celiac disease

Chronic diarrhea, weight loss, and bloating after consuming wheat-containing foods.

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S3 · Infectious DiseaseHard

Whipple disease

Middle-aged man with chronic diarrhea/malabsorption, arthralgias, and neurologic findings.

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S3 · GastroenterologyMedium

Crohn disease

Young patient with chronic diarrhea, abdominal pain, weight loss, and skip lesions on colonoscopy with transmural inflammation and fistulas.

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S3 · EmergencyHard

Toxic megacolon

UC patient with severe colitis, abdominal distention, fever, and colon diameter 7 cm on imaging.

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S3 · Infectious DiseaseMedium

C. difficile colitis

Patient develops watery diarrhea 1 week after a course of clindamycin. Stool PCR positive for C. difficile toxin.

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S3 · GastroenterologyMedium

Postoperative ileus

Post-operative patient day 3 with abdominal distention, no bowel sounds, no flatus or stool. KUB shows diffuse gas in small and large bowel without transition point.

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S3 · GastroenterologyMedium

Small bowel obstruction

Patient with prior abdominal surgery presents with crampy abdominal pain, vomiting, distention, and no flatus. CT shows transition point with proximal dilation.

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S3 · EmergencyEasy

Acute appendicitis

An 18-year-old with periumbilical pain migrating to RLQ, fever, anorexia, and rebound tenderness.

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S3 · GastroenterologyEasy

Acute diverticulitis

Older patient with LLQ pain, low-grade fever, and tenderness. CT shows pericolic fat stranding around the sigmoid.

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S3 · GastroenterologyEasy

Acute cholecystitis

Patient with RUQ pain, fever, Murphy sign positive. US shows gallstones, wall thickening, and pericholecystic fluid.

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S3 · GastroenterologyMedium

Ascending cholangitis

Patient with RUQ pain, fever, jaundice (Charcot triad), confusion, and hypotension (Reynolds pentad). Elevated bilirubin and alk phos.

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S3 · GastroenterologyEasy

Acute pancreatitis

Patient with epigastric pain radiating to back, lipase 5× ULN, after binge drinking.

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S3 · GastroenterologyMedium

Pancreatic pseudocyst

Patient 6 weeks after acute pancreatitis develops abdominal pain and a palpable epigastric mass. CT shows a 6 cm fluid collection.

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S3 · PediatricsMedium

Intussusception

A 1-year-old with intermittent severe crampy abdominal pain, vomiting, and currant jelly stools. Sausage-shaped mass on exam.

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S3 · PediatricsMedium

Hypertrophic pyloric stenosis

A 5-week-old with projectile non-bilious vomiting after feeds. Olive-shaped epigastric mass. Labs: hypochloremic hypokalemic metabolic alkalosis.

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S3 · PediatricsMedium

Hirschsprung disease

Newborn with delayed meconium passage (>48 hours), abdominal distention, and forceful expulsion of stool on rectal exam.

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S3 · PediatricsHard

Necrotizing enterocolitis

Premature neonate with feeding intolerance, bloody stools, abdominal distention. KUB shows pneumatosis intestinalis.

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S3 · PediatricsHard

Midgut volvulus (malrotation)

Neonate with bilious emesis. Upper GI series shows abnormal duodenal position with corkscrew appearance.

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S3 · Infectious DiseaseEasy

Acute hepatitis A

Patient returned from travel with acute jaundice, fatigue, nausea. Labs: elevated AST/ALT >1000, positive HAV IgM.

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S3 · Infectious DiseaseMedium

Chronic hepatitis B

Patient with chronic hepatitis B (HBsAg positive >6 months), elevated ALT, and elevated HBV DNA.

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S3 · Infectious DiseaseMedium

Chronic hepatitis C

Patient with chronic hepatitis C (HCV RNA positive, genotype 1).

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S3 · GastroenterologyMedium

Severe alcoholic hepatitis

Heavy alcohol use + fever, jaundice, hepatomegaly, AST/ALT ratio >2:1 (both <500). Maddrey discriminant function 35.

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S3 · GastroenterologyMedium

Hepatic encephalopathy

Cirrhotic patient with confusion, asterixis, and recent GI bleed.

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S3 · Infectious DiseaseMedium

Spontaneous bacterial peritonitis

Cirrhotic patient with ascites develops fever and abdominal pain. Paracentesis: PMN count 400, gram stain negative.

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S3 · OncologyEasy

HCC surveillance

Patient with compensated cirrhosis from hepatitis C.

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S3 · GastroenterologyEasy

Irritable bowel syndrome

Young woman with 6 months of abdominal pain relieved by defecation, alternating diarrhea and constipation, no weight loss, normal labs.

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S3 · OncologyEasy

Colorectal cancer screening

Average-risk asymptomatic patient turning 45.

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S3 · OncologyMedium

Pancreatic adenocarcinoma

Patient with painless jaundice, weight loss, and pruritus. CT shows pancreatic head mass.

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S3 · EndocrineEasy

Diabetic gastroparesis

Long-standing diabetic with early satiety, nausea, bloating, and vomiting of undigested food hours after meals.

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S3 · GastroenterologyEasy

Mallory-Weiss tear

Young patient with retching and vomiting after binge drinking, now with hematemesis.

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S3 · EmergencyHard

Boerhaave syndrome

After severe vomiting, patient develops sudden chest pain, dyspnea, and subcutaneous emphysema. CXR: pneumomediastinum.

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S3 · GastroenterologyHard

Wilson disease

Young adult with hepatitis, neuropsychiatric symptoms (tremor, dystonia, mood changes), and Kayser-Fleischer rings.

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S3 · GastroenterologyMedium

Hereditary hemochromatosis

Middle-aged man with fatigue, bronze skin, diabetes, hepatomegaly, and arthralgias.

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S3 · GastroenterologyMedium

Primary biliary cholangitis

Middle-aged woman with fatigue, pruritus, jaundice. Labs: elevated alk phos and IgM; positive AMA.

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S3 · GastroenterologyMedium

Primary sclerosing cholangitis

Young man with ulcerative colitis develops jaundice and pruritus. MRCP shows beaded biliary strictures.

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S3 · OncologyHard

Carcinoid syndrome

Patient with flushing, diarrhea, wheezing, and right-sided valvular heart disease. Elevated 24-hour urine 5-HIAA.

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S3 · GastroenterologyEasy

Anal fissure

Patient with severe sharp pain during defecation and bright red blood on toilet paper. Linear posterior anal tear on exam.

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S3 · GastroenterologyEasy

Hemorrhoids

Patient with painless bright red blood per rectum on toilet paper and anal pruritus.

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S1 · NutritionMedium

Refeeding syndrome

A 45-year-old man with alcohol use disorder and 10 days of minimal food intake is admitted (BMI 17). IV dextrose and enteral nutrition are started. Two days later he develops weakness, dyspnea, palpitations, mild edema. Labs: phosphate 1.2, K 3.3, Mg 1.5 (all low).

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S1 · NeurologyMedium

Wernicke encephalopathy

Pregnant woman with hyperemesis gravidarum brought in confused, swaying side-to-side, with horizontal nystagmus.

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S1 · EndocrineEasy

Metformin-induced B12 deficiency

Long-standing T2DM patient on chronic high-dose metformin has fatigue, paresthesias, MCV 105, and macrocytic anemia.

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S1 · NutritionHard

Copper deficiency

Patient with prior Roux-en-Y gastric bypass develops progressive numbness, gait instability, ↓ vibration/proprioception, positive Romberg. B12 level is normal. CBC shows mild anemia and NEUTROPENIA.

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S1 · EndocrineEasy

GLP-1 agonist contraindication

Patient started semaglutide for obesity. Family history reveals medullary thyroid carcinoma in a sibling.

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S1 · DermatologyMedium

Vitamin A toxicity (pseudotumor cerebri)

Patient on chronic isotretinoin develops severe headache, blurred vision, and papilledema. MRI brain is normal.

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S1 · PsychiatryMedium

Anorexia nervosa — leading cause of death

A 19-year-old with anorexia nervosa (BMI 13) collapses suddenly. Cause of death?

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S2 · OB/GYNMedium

Pregnancy with IUD in place

Patient with copper IUD is pregnant; strings are still visible.

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S2 · OB/GYNHard

Uterine rupture

A 36-year-old G3P2 at 40 weeks in labor (5 hours in) suddenly develops severe abdominal pain and vaginal bleeding. Prior C-sections × 2. Exam: tender uterus, contractions cease, vertex was −1 station 1 hour ago, now −3 station. Fetal HR: late decelerations + absent variability. BP 95/60, HR 110.

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S2 · OB/GYNMedium

Placental abruption

Cocaine user at 32 weeks develops sudden severe abdominal pain, painful vaginal bleeding, and a firm rigid (hypertonic) uterus. Contractions are present. Fetal HR shows distress.

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S2 · OB/GYNEasy

Placenta previa

A 34-year-old G3P2 at 30 weeks has painless bright-red vaginal bleeding. Uterus is soft and nontender. No contractions. US shows placenta covering the cervical os.

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S2 · OB/GYNHard

Vasa previa

Patient with rupture of membranes immediately has bright-red vaginal bleeding and sudden fetal bradycardia. Mom is stable.

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S2 · OB/GYNMedium

Hydatidiform mole

A 28-year-old at 14 weeks has hypertension, proteinuria, hyperemesis, and uterine size at level of umbilicus. β-hCG is dramatically elevated.

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S2 · CardiologyHard

Peripartum cardiomyopathy

A 28-year-old woman, 3 months postpartum, presents with dyspnea, orthopnea, bilateral crackles. Echo: EF 30%.

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S2 · OB/GYNEasy

Chorioamnionitis (intra-amniotic infection)

Laboring patient with prolonged ROM (24 hours) develops maternal fever, uterine tenderness, and fetal tachycardia.

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S2 · OB/GYNEasy

Postpartum endometritis

Day 3 after C-section, patient has fever 39°C, chills, lower abdominal pain, and uterine tenderness on exam.

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S2 · OB/GYNMedium

Preterm labor management

Patient at 30 weeks with regular contractions and cervical change. No infection signs.

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S2 · OB/GYNMedium

Active phase arrest

Primigravida at 7 cm dilation × 5 hours with adequate contractions (250 Montevideo units), ruptured membranes, no cervical change.

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S2 · OB/GYNEasy

Postpartum hemorrhage — uterine atony

Primigravida immediately after vaginal delivery has profuse vaginal bleeding. Uterus is soft and boggy above the umbilicus.

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S2 · OB/GYNMedium

HIV in pregnancy — delivery planning

Pregnant patient with HIV at 36 weeks. Viral load is 1,500 copies/mL despite ART.

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S2 · OB/GYNMedium

Oligohydramnios from uteroplacental insufficiency

26-year-old at 32 weeks with chronic uncontrolled hypertension is found to have oligohydramnios on US.

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S2 · OB/GYNEasy

Post-term pregnancy with placental insufficiency

Pregnant woman at 43 weeks with decreased fetal movements and oligohydramnios on US.

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S2 · OB/GYNMedium

Rh isoimmunization prevention

Rh-negative pregnant woman at 7 weeks has a miscarriage. Antibody screen is negative.

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S2 · OB/GYNEasy

Pregnancy vaccinations

Pregnant woman at 28 weeks asks which vaccines she should receive.

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S2 · OB/GYNMedium

Hyperthyroidism in pregnancy

Pregnant woman at 8 weeks with newly diagnosed Graves disease.

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S2 · OB/GYNEasy

GDM screening

30-year-old at 24 weeks for routine prenatal visit.

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S2 · OB/GYNMedium

Trisomy 21 — first-trimester screening

35-year-old at 10 weeks gestation: ↑ β-hCG, ↓ PAPP-A, ↑ nuchal translucency.

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S2 · OB/GYNMedium

Hyperemesis gravidarum

Pregnant woman in twin gestation with severe nausea, vomiting, weight loss, dehydration.

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S2 · OB/GYNHard

Preeclampsia with severe features (HELLP overlap)

30-year-old at 32 weeks with BP 165/110, platelets 80,000, AST 200 (3× ULN), and RUQ pain.

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S2 · OB/GYNMedium

Eclampsia

Patient at 36 weeks with known preeclampsia develops a generalized tonic-clonic seizure.

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S2 · OB/GYNEasy

Antepartum fetal surveillance

Pregnant patient reports decreased fetal movements at 34 weeks.

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S2 · OB/GYNHard

Shoulder dystocia

During delivery of a 4,500 g infant, the head is delivered but the anterior shoulder fails to deliver after gentle downward traction.

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S2 · OB/GYNMedium

Retained placenta

Patient delivered vaginally; 45 minutes later the placenta has not been delivered.

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S2 · OB/GYNHard

Monochorionic-monoamniotic twin pregnancy

Monochorionic-monoamniotic (MoMo) twins are identified at 12 weeks.

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S2 · OB/GYNMedium

Postmenopausal bleeding workup

62-year-old postmenopausal woman with vaginal bleeding for 2 months.

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S2 · OB/GYNEasy

Lichen sclerosus

Postmenopausal woman with vulvar pruritus, white atrophic patches on vulva and perianal area in a figure-of-eight pattern.

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S2 · EndocrineEasy

Polycystic ovary syndrome

22-year-old with irregular menses (q6 weeks), hirsutism, acne, and BMI 32.

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S2 · OB/GYNMedium

Endometriosis

28-year-old with chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia, and infertility.

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S2 · OB/GYNEasy

Uterine leiomyomas (fibroids)

35-year-old with heavy menstrual bleeding, anemia, and enlarged irregular uterus on bimanual exam.

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S2 · OB/GYNHard

Ovarian torsion

25-year-old with sudden severe unilateral lower abdominal pain, nausea, vomiting. Tender adnexal mass on exam. US shows ovarian mass with reduced Doppler flow.

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S2 · Infectious DiseaseMedium

Pelvic inflammatory disease

22-year-old with lower abdominal pain, fever 38.5°C, mucopurulent cervical discharge, and cervical motion tenderness.

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S3 · OncologyHard

Gastrointestinal stromal tumor (GIST)

Patient with gastric mass on EGD biopsy showing spindle cells positive for CD117 (c-KIT).

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