Differential Diagnosis

Question 1

0A 70-year-old male presents with a persistent productive cough with yellowish sputum, shortness of breath on exertion, and a history of smoking. He has no fever, and his lung examination reveals wheezing and decreased breath sounds. Which of the following is the most likely diagnosis?

A) Pneumonia
B) COPD
C) Heart Failure
D) Tuberculosis

Answer 1

Answer: B) COPD

Rationale: COPD is highly associated with a smoking history, productive cough, and wheezing or decreased breath sounds on auscultation.

Incorrect choices:

A) Pneumonia – Pneumonia generally presents with fever, acute onset of symptoms, and may have crackles rather than wheezes on lung exam. Patients with pneumonia also often experience chest pain and acute shortness of breath.
C) Heart Failure – Heart failure commonly presents with symptoms like shortness of breath, especially when lying flat (orthopnea), leg swelling (edema), and fatigue. Auscultation often reveals crackles or rales rather than wheezes due to fluid accumulation in the lungs.
D) Tuberculosis – Tuberculosis may present with night sweats, unexplained weight loss, and chronic cough, which often becomes productive and may include hemoptysis. It also typically involves constitutional symptoms that are absent here.

Question 2

A patient reports chronic fatigue, significant shortness of breath on mild exertion, and a persistent cough. On physical exam, there are fine crackles at the lung bases. Which diagnostic test is most appropriate to confirm the suspected diagnosis?
A) Spirometry
B) High-Resolution CT (HRCT)
C) Chest X-ray
D) Tuberculin Skin Test (TST)

Answer 2

Answer: B) High-Resolution CT (HRCT)

Rationale: HRCT is the most sensitive test for diagnosing Interstitial Lung Disease (ILD), which can cause chronic fatigue, progressive dyspnea, and fine crackles. HRCT can reveal characteristic patterns of lung fibrosis, which help confirm ILD.

Incorrect choices:
A) Spirometry – Although helpful for detecting obstructive lung disease (e.g., COPD), spirometry does not reveal detailed structural lung changes characteristic of ILD.
C) Chest X-ray – While a chest X-ray can sometimes show fibrotic changes, it is less sensitive for diagnosing ILD than HRCT and often misses early disease stages.
D) Tuberculin Skin Test (TST) – TST is specific for tuberculosis but would not detect ILD, and the patient lacks other symptoms, like night sweats, to suggest tuberculosis.

Question 3

A 65-year-old woman presents with fever, chills, productive cough, and sharp chest pain. Her oxygen saturation is 88%, and she has crackles and bronchial breath sounds on auscultation. Which condition should be ruled out immediately?

A) COPD
B) Emphysema
C) Pneumonia
D) Interstitial Lung Disease

Answer 3

Answer: C) Pneumonia

Rationale: Pneumonia is often indicated by fever, cough with sputum, low oxygen saturation, and sharp pleuritic chest pain. Crackles and bronchial breath sounds are typical on auscultation, suggesting lung infection and inflammation.

Incorrect choices:

A) COPD – COPD usually presents without fever or acute pleuritic chest pain and more frequently includes chronic symptoms like productive cough and dyspnea. Auscultation findings would more likely include wheezing and decreased breath sounds.
B) Emphysema – Emphysema, a type of COPD, typically presents with chronic dyspnea and barrel chest but is not usually associated with fever or acute symptoms unless there is a superimposed infection.
D) Interstitial Lung Disease (ILD) – ILD usually presents with progressive shortness of breath and crackles but lacks acute fever, pleuritic chest pain, and productive cough.

Question 4

A 55-year-old patient presents with chronic shortness of breath and cough. Imaging reveals hyperinflation of the lungs. Which of the following conditions is most likely?

A) Emphysema
B) Heart Failure
C) Tuberculosis
D) Pneumonia

Answer 4

Answer: A) Emphysema

Rationale: Emphysema often shows lung hyperinflation on imaging due to alveolar damage. Symptoms include chronic cough, dyspnea, and a history of smoking, with decreased lung elasticity leading to hyperinflation.

Incorrect choices:

B) Heart Failure – Heart failure often involves symptoms of shortness of breath and swelling but does not typically cause hyperinflation on imaging. Heart failure imaging would more commonly show pulmonary edema or pleural effusion.
C) Tuberculosis – Tuberculosis can cause chronic cough but is more likely to show localized lung consolidation or cavitation rather than hyperinflation.
D) Pneumonia – Pneumonia would likely show focal consolidation, not hyperinflation, and often has an acute presentation with fever and productive cough.

More info.
Is it related to inhalation?
Not directly. While inhalation causes the diaphragm to contract and move downward in a healthy person, flattened diaphragms in COPD remain in this low position at baseline, even when the person is not actively inhaling. This chronic flattening is a sign of permanent lung changes rather than a momentary phase of breathing.

Why is this finding significant?
Flattened diaphragms are a hallmark of diseases like emphysema and provide clues about the degree of lung hyperinflation and chronic respiratory compromise. This, combined with the patient’s smoking history, cough, wheezing, and weight loss, strongly points to COPD, particularly emphysema, as the most likely diagnosis.

Question 5

A 50-year-old man reports a worsening cough, wheezing, and frequent infections. He has also experienced occasional hemoptysis. Which condition should be prioritized for evaluation?
A) COPD
B) Chronic Bronchitis
C) Bronchiectasis
D) Interstitial Lung Disease

Answer 5

Answer: C) Bronchiectasis

Rationale: Bronchiectasis is characterized by recurrent infections, chronic productive cough, hemoptysis, and wheezing due to dilated airways, commonly worsened by infections.

Incorrect choices:

A) COPD – COPD commonly involves wheezing and chronic cough but lacks the frequent infections and hemoptysis seen in bronchiectasis.
B) Chronic Bronchitis – Chronic bronchitis involves chronic cough and mucus production but typically does not present with hemoptysis or recurrent infections unless complications arise.
D) Interstitial Lung Disease (ILD) – ILD usually presents with progressive dyspnea, fatigue, and fine crackles rather than frequent infections or hemoptysis.

more info
In bronchiectasis, the airways are persistently inflamed due to repeated or chronic infections. This inflammation damages the bronchial walls and their associated blood vessels.
Chronic infection promotes the formation of fragile blood vessels (neovascularization) within the damaged bronchial walls, making them more prone to rupture.

Question 6

. A 45-year-old woman reports a flu-like illness following a recent hiking trip. She noticed a circular red rash on her thigh with a clear center that has grown over the past week. She also has joint pain and fatigue. Which diagnosis is most likely?

A) Rocky Mountain Spotted Fever
B) Lyme Disease
C) Systemic Lupus Erythematosus
D) Chronic Fatigue Syndrome

Answer 6

Answer: B) Lyme Disease

Rationale: The characteristic “bullseye” or erythema migrans rash is specific to Lyme disease. The patient’s recent outdoor activity in an endemic area, along with flu-like symptoms, joint pain, and fatigue, is highly indicative of Lyme disease.
Incorrect choices:
A) Rocky Mountain Spotted Fever (RMSF) – Although RMSF can present with fever, fatigue, and rash, it usually lacks the classic bullseye appearance and is commonly found on the wrists and ankles.
C) Systemic Lupus Erythematosus (SLE) – SLE may cause fatigue and joint pain, but the rash in SLE is typically a butterfly-shaped rash on the face, not a circular lesion.
D) Chronic Fatigue Syndrome (CFS) – CFS presents with chronic fatigue but lacks characteristic skin changes such as an erythema migrans rash.

Question 7

A 50-year-old male presents with high fever, severe headache, nausea, and a non-itchy rash on his wrists and ankles after a camping trip. Which diagnosis should be considered first?

A) Lyme Disease
B) Systemic Lupus Erythematosus
C) Rocky Mountain Spotted Fever
D) Fibromyalgia

Answer 7

Answer: C) Rocky Mountain Spotted Fever

Rationale: RMSF often presents with a high fever, headache, nausea, and a characteristic rash that begins on the wrists and ankles and then migrates toward the trunk. The history of recent tick exposure and flu-like symptoms makes RMSF the most likely diagnosis.Answer: C) Rocky Mountain Spotted Fever

Incorrect choices:
A) Lyme Disease – Lyme disease can cause fever and rash, but the rash usually appears as a bullseye and does not start on the wrists and ankles.
B) Systemic Lupus Erythematosus – SLE can present with fever and fatigue but typically has a butterfly rash on the face and lacks a tick exposure history.
D) Fibromyalgia – Fibromyalgia primarily causes widespread musculoskeletal pain and fatigue rather than acute fever, rash, or headache.

More information:
Rocky Mountain Spotted Fever (RMSF), the rash often becomes petechial as the disease progresses, although it may initially appear as small, pink macules. The petechial rash is a key feature of more advanced RMSF and suggests increased severity, as it reflects damage to small blood vessels caused by Rickettsia rickettsii.

Question 8

A 60-year-old woman presents with a painful, red, swollen area on her lower leg following a minor cut. The area is warm and tender, with red streaking towards her groin. What is the most likely diagnosis?

A) Rocky Mountain Spotted Fever
B) Lyme Disease
C) Cellulitis
D) Systemic Lupus Erythematosus

Answer 8

Answer: C) Cellulitis

Rationale: Cellulitis commonly presents as a painful, red, warm area of skin with irregular borders following skin trauma. The presence of red streaking (lymphangitis) is also a common finding in cellulitis.
Incorrect choices:
A) Rocky Mountain Spotted Fever – RMSF causes a generalized rash on the wrists and ankles, not localized redness and swelling.
B) Lyme Disease – Lyme disease may present with erythema migrans but not with the warmth, pain, or lymphangitic spread typical of cellulitis.
D) Systemic Lupus Erythematosus – SLE can involve rashes but typically presents as a butterfly rash on the face or photosensitive rash, not localized swelling, redness, and tenderness.

Question 9

A 45-year-old woman presents with widespread pain affecting her shoulders, lower back, and thighs. She reports fatigue, trouble sleeping, and frequent “brain fog” or difficulty concentrating. She also has heightened sensitivity to bright lights and loud noises. Her symptoms have persisted for over 6 months. What is the most likely diagnosis?

A) Systemic Lupus Erythematosus (SLE)
B) Rheumatoid Arthritis
C) Fibromyalgia
D) Chronic Fatigue Syndrome (SEID)

Answer 9

Answer: C) Fibromyalgia

Rationale: Fibromyalgia often presents with multisite pain (defined as pain in at least 6 out of 9 possible pain sites), along with fatigue or sleep problems persisting for at least 3 months. Additional supportive features include dyscognition (brain fog) and environmental sensitivity (e.g., sensitivity to lights and sounds). The patient’s long-standing, multisite pain and other symptoms fit the AAPT criteria for fibromyalgia.

Multisite pain defined as 6 or more pain sites from a total of 9 possible sites (head, left arm, right arm, chest, abdomen, upper back and spine, lower back and spine including buttocks, left leg, and right leg)

Incorrect choices:

A) Systemic Lupus Erythematosus (SLE) – SLE can involve joint pain and fatigue but typically has additional systemic signs, such as a butterfly-shaped facial rash or organ involvement.
B) Rheumatoid Arthritis – RA generally presents with joint swelling and morning stiffness rather than widespread pain and cognitive issues.
D) Chronic Fatigue Syndrome (SEID) – SEID causes fatigue and cognitive impairment, but widespread musculoskeletal pain and environmental sensitivity are more characteristic of fibromyalgia.

Question 10

A 40-year-old male presents with extreme fatigue, muscle pain, headaches, and sore throat persisting over the past eight months without an apparent cause. Physical exam reveals normal vital signs. Which diagnosis should be considered?
A) Systemic Lupus Erythematosus
B) Chronic Fatigue Syndrome
C) Rocky Mountain Spotted Fever
D) Fibromyalgia

Answer 10

Answer: B) Chronic Fatigue Syndrome

Rationale: Chronic Fatigue Syndrome is defined by persistent, severe fatigue lasting more than six months without an identifiable cause, along with symptoms like muscle pain, cognitive impairment, and sore throat.

Incorrect choices:

A) Systemic Lupus Erythematosus – SLE can cause fatigue and muscle pain, but it usually presents with other systemic features such as a butterfly rash, photosensitivity, or organ involvement.
C) Rocky Mountain Spotted Fever – RMSF is an acute, rather than chronic, condition and would present with high fever, rash, and muscle pain shortly after tick exposure.
D) Fibromyalgia – Fibromyalgia also involves chronic fatigue and muscle pain but typically includes tender points, which are absent in this patient.

Question 11

A 32-year-old female presents with fatigue, joint pain, a low-grade fever, and a butterfly-shaped rash across her cheeks and nose. She reports that her symptoms worsen after being in the sun. She has no history of recent tick bites or infections and denies recent travel. What is the most likely diagnosis?

A) Lyme Disease
B) Rocky Mountain Spotted Fever
C) Systemic Lupus Erythematosus
D) Dermatomyositis

Answer: C) Systemic Lupus Erythematosus

Answer 11

Answer: C) Systemic Lupus Erythematosus

Rationale: Systemic Lupus Erythematosus (SLE) is characterized by systemic symptoms such as fatigue, fever, and joint pain, often accompanied by a butterfly-shaped (malar) rash that worsens with sun exposure (photosensitivity). The absence of recent tick exposure or travel reduces the likelihood of tick-borne illnesses, making SLE the most likely diagnosis in this case.

Incorrect choices:

A) Lyme Disease – Lyme disease can cause fatigue and joint pain but is usually associated with a history of tick exposure and typically presents with an erythema migrans (“bullseye”) rash, not a malar rash.

B) Rocky Mountain Spotted Fever – RMSF may present with fever and a rash, but it typically starts on the wrists and ankles and spreads inward, eventually becoming petechial. Additionally, a history of tick exposure is usually present.

D) Dermatomyositis – Dermatomyositis can cause a similar facial rash and photosensitivity, but it is more commonly associated with proximal muscle weakness (e.g., difficulty climbing stairs or raising arms) and may show Gottron’s papules on the knuckles, which are absent here.

Question 12

A 65-year-old woman presents with severe morning stiffness, fatigue, and leg swelling. Her physical exam reveals decreased oxygen saturation and jugular vein distention. Which diagnosis should be considered first?

A) Chronic Myofascial Pain Syndrome
B) Systemic Lupus Erythematosus
C) Polymyalgia Rheumatica
D) Heart Failure

Answer 12

D Heart Failure
Rationale: Heart failure is suggested by symptoms such as fatigue, leg swelling, jugular vein distention, and decreased oxygen saturation, which are classic signs of worsening cardiac function.

Incorrect choices:

A) Chronic Myofascial Pain Syndrome – This primarily involves localized pain and stiffness at trigger points rather than systemic findings like oxygen saturation and jugular distention.
B) Systemic Lupus Erythematosus – While SLE can cause fatigue, it typically doesn’t present with leg swelling or jugular vein distention, which are signs of heart failure.
C) Polymyalgia Rheumatica – This is characterized by morning stiffness and pain in the shoulders and hips but usually does not include severe leg swelling or signs of cardiac decompensation.

Question 13

A 45-year-old female reports worsening fatigue, joint pain, and episodes of unexplained low-grade fever. She has recently noticed a butterfly-shaped rash on her face that worsens with sun exposure. What diagnosis should be prioritized?

A) Hypothyroidism
B) Rheumatoid Arthritis
C) Systemic Lupus Erythematosus (SLE)
D) Chronic Myofascial Pain Syndrome

Answer 13

Answer: C) Systemic Lupus Erythematosus (SLE)

Rationale: SLE is associated with fatigue, joint pain, fever, and a characteristic butterfly rash that is photosensitive, making it the most likely diagnosis.

Incorrect choices:

A) Hypothyroidism – Although fatigue and joint pain can occur in hypothyroidism, it doesn’t usually cause a photosensitive rash or fever.
B) Rheumatoid Arthritis – RA may present with joint pain and fatigue, but it typically does not include fever or a butterfly rash.
D) Chronic Myofascial Pain Syndrome – This condition is characterized by localized muscle pain rather than systemic symptoms like fever and rash.

Question 14

A 52-year-old male presents with rapidly worsening shortness of breath, night sweats, and hemoptysis. He recently moved to an area where tick-borne diseases are prevalent. What diagnosis should be considered first?

A) Lyme Disease
B) Tuberculosis
C) Polymyalgia Rheumatica
D) Chronic Viral Infection

Answer 14

Answer: B) Tuberculosis

Rationale: Tuberculosis commonly presents with symptoms like night sweats, hemoptysis, and worsening dyspnea. The red flags for TB are evident in his presentation.

Incorrect choices:

A) Lyme Disease – While Lyme disease can cause fatigue and flu-like symptoms, it doesn’t typically cause hemoptysis or night sweats.
C) Polymyalgia Rheumatica – This often presents with stiffness and pain but does not usually involve respiratory symptoms.
D) Chronic Viral Infection – Viral infections can cause fatigue and muscle aches but do not typically cause hemoptysis or night sweats.

Question 15

A 39-year-old woman presents with progressive muscle weakness, fatigue, and numbness in her feet and hands. She also reports difficulty concentrating. What is the most likely diagnosis?

A) Small Fiber Neuropathy
B) Polymyalgia Rheumatica
C) Fibromyalgia
D) Hypothyroidism

Answer 15

Answer: A) Small Fiber Neuropathy

Rationale: Small Fiber Neuropathy is associated with neuropathic pain, numbness, and burning sensations in the extremities, as well as sensory symptoms that fit this presentation.

Incorrect choices:

B) Polymyalgia Rheumatica – This condition typically presents with pain and stiffness in the shoulders and hips rather than neuropathy.
C) Fibromyalgia – Fibromyalgia often includes widespread musculoskeletal pain but does not usually involve numbness or tingling in the hands and feet.
D) Hypothyroidism – Although hypothyroidism can cause fatigue and cognitive impairment, it doesn’t commonly lead to numbness in the hands and feet.

Question 16

A 44-year-old male presents with severe fatigue, muscle pain, cognitive impairment, and a history of tick exposure. He has also developed a circular “bullseye” rash on his arm. Which diagnosis is most likely?

A) Chronic Myofascial Pain Syndrome
B) Lyme Disease
C) Systemic Lupus Erythematosus
D) Small Fiber Neuropathy

Answer 16

Answer: B) Lyme Disease

Rationale: Lyme disease is suggested by a “bullseye” rash (erythema migrans), history of tick exposure, and symptoms like fatigue and cognitive impairment.

Incorrect choices:

A) Chronic Myofascial Pain Syndrome – This condition involves muscle pain localized to trigger points rather than systemic symptoms or rashes.
C) Systemic Lupus Erythematosus – While SLE can cause fatigue and joint pain, it typically doesn’t present with a bullseye rash or a history of tick exposure.
D) Small Fiber Neuropathy – Small Fiber Neuropathy causes neuropathic symptoms but doesn’t involve a bullseye rash or systemic symptoms.

Question 17

A 50-year-old female presents with severe morning fatigue, weight gain, and difficulty concentrating. On physical examination, she has dry skin and coarse hair. Which diagnosis should be considered?

A) Fibromyalgia
B) Systemic Lupus Erythematosus
C) Hypothyroidism
D) Multiple Sclerosis

Answer 17

Answer: C) Hypothyroidism

Rationale: Hypothyroidism commonly presents with fatigue, weight gain, dry skin, coarse hair, and cognitive issues. These symptoms, along with physical exam findings, align with thyroid dysfunction.

Incorrect choices:

A) Fibromyalgia – Fibromyalgia may include fatigue, but it lacks the classic signs of dry skin and weight gain associated with hypothyroidism.
B) Systemic Lupus Erythematosus – SLE may present with fatigue but often includes a butterfly rash and other systemic signs, which are absent here.
D) Multiple Sclerosis – MS could cause fatigue and cognitive impairment, but it usually also involves neurological symptoms like numbness or tingling.

Question 18

A 30-year-old male reports chronic fatigue, muscle pain, and recent unintentional weight loss. His lab work reveals a Vitamin D deficiency. What should be considered first?

A) Chronic Viral Infection
B) Vitamin Deficiency
C) Systemic Lupus Erythematosus
D) Small Fiber Neuropathy

Answer 18

Answer: B) Vitamin Deficiency

Rationale: A Vitamin D deficiency can result in fatigue, muscle pain, and sometimes weight changes. Addressing the deficiency can often improve these symptoms.

Incorrect choices:

A) Chronic Viral Infection – While chronic infections can cause fatigue and weight loss, this patient’s Vitamin D deficiency better explains his symptoms.
C) Systemic Lupus Erythematosus – SLE could present with fatigue and weight loss but often includes additional signs, such as a rash or joint involvement.
D) Small Fiber Neuropathy – This usually presents with pain or burning in the extremities rather than systemic symptoms like fatigue and weight loss.

Question 19

A 55-year-old woman complains of persistent pain in her neck, shoulders, and hips, especially in the morning, along with new difficulties sleeping. She denies joint swelling. What is the likely diagnosis?

A) Rheumatoid Arthritis
B) Polymyalgia Rheumatica
C) Hypothyroidism
D) Fibromyalgia

Answer 19

Answer: B) Polymyalgia Rheumatica

Rationale: Polymyalgia Rheumatica commonly presents with pain and stiffness in the neck, shoulders, and hips, particularly in the morning, and is more common in individuals over 50.

Incorrect choices:

A) Rheumatoid Arthritis – RA often involves joint swelling and younger age groups.
C) Hypothyroidism – Hypothyroidism may cause fatigue but does not typically present with localized pain in the shoulders and hips.
D) Fibromyalgia – While fibromyalgia may present with diffuse pain, it typically affects more areas and does not localize to the shoulders and hips in the same way.

Question 20

A 28-year-old male presents with fatigue, sore throat, and diffuse muscle aches for the past three months. He recalls an infection with a flu-like illness two years ago. What diagnosis should be considered?

A) Systemic Lupus Erythematosus
B) Chronic Viral Infection
C) Hypothyroidism
D) Small Fiber Neuropathy

Answer 20

Answer: B) Chronic Viral Infection

Rationale: Chronic viral infections, such as Epstein-Barr Virus (EBV), can cause prolonged symptoms of fatigue, sore throat, and muscle aches, especially if there was a prior flu-like illness.

Incorrect choices:

A) Systemic Lupus Erythematosus – SLE could cause fatigue, but typically involves other symptoms such as rash or joint pain.
C) Hypothyroidism – Hypothyroidism may cause fatigue, but sore throat and muscle aches are not typical.
D) Small Fiber Neuropathy – This condition presents with neuropathic pain rather than generalized fatigue or sore throat.

Question 21

A 46-year-old woman presents with fatigue, muscle spasms at night, and frequent waking. Her spouse reports she snores loudly. Which diagnosis should be prioritized?

A) Systemic Lupus Erythematosus
B) Sleep Apnea
C) Multiple Sclerosis
D) Fibromyalgia

Answer 21

B) Sleep Apnea
Rationale: Sleep apnea often involves symptoms such as frequent waking, snoring, and fatigue, which align with her presentation.

Incorrect choices:

A) Systemic Lupus Erythematosus – SLE may present with fatigue, but it does not typically cause sleep disruptions or snoring.
C) Multiple Sclerosis – MS could cause fatigue but would more likely present with neurological deficits.
D) Fibromyalgia – Fibromyalgia could cause fatigue and muscle pain but does not cause snoring or frequent waking related to breathing issues.

Question 22

A 35-year-old female reports persistent fatigue, widespread muscle pain, and cognitive issues for the past year. Physical exam reveals tenderness at specific points on her body. What is the most likely diagnosis?

A) Chronic Fatigue Syndrome
B) Systemic Lupus Erythematosus
C) Fibromyalgia
D) Lyme Disease

Answer 22

Answer: C) Fibromyalgia

Rationale: Fibromyalgia is characterized by widespread musculoskeletal pain, chronic fatigue, and cognitive issues (“fibro fog”). The presence of tender points on physical exam is a classic finding.
Incorrect choices:
A) Chronic Fatigue Syndrome (CFS) – CFS also causes fatigue, but it does not typically include tender points or widespread musculoskeletal pain.
B) Systemic Lupus Erythematosus (SLE) – SLE can cause fatigue and muscle pain but usually presents with a rash, photosensitivity, or other systemic symptoms.
D) Lyme Disease – Lyme disease can cause fatigue and joint pain but often involves a history of tick exposure and erythema migrans rash in the early stages.

Question 23

A 38-year-old woman has experienced severe fatigue, unrefreshing sleep, and cognitive difficulties for the past 8 months. She reports intermittent muscle aches but no specific joint pain or swelling. Physical examination reveals no significant findings, and routine labs are normal. Which condition is most likely?

A) Fibromyalgia
B) Systemic Exertion Intolerance Disease (SEID)
C) Rheumatoid Arthritis
D) Small Fiber Neuropathy

Answer 23

Answer: B) Systemic Exertion Intolerance Disease (SEID)

Rationale: SEID (also known as Chronic Fatigue Syndrome) is primarily characterized by severe fatigue, unrefreshing sleep, and cognitive difficulties persisting for over 6 months, often without other physical findings. Muscle aches may occur, but widespread musculoskeletal pain is not as prominent as in fibromyalgia.

Incorrect choices:

A) Fibromyalgia – Although fatigue and cognitive issues are common in fibromyalgia, it typically involves widespread musculoskeletal pain across multiple body sites, which is less pronounced in this case.
C) Rheumatoid Arthritis – RA usually involves joint inflammation and pain, often with visible swelling and morning stiffness.
D) Small Fiber Neuropathy – Small fiber neuropathy may cause pain and sensory disturbances but does not typically present with profound fatigue or cognitive symptoms.

Question 24

A 56-year-old woman presents with symmetric joint pain and stiffness that is worse in the morning and lasts over an hour. On physical examination, you note swelling in the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. Which of the following is the most likely diagnosis?
A) Osteoarthritis
B) Rheumatoid Arthritis
C) Fibromyalgia
D) Psoriatic Arthritis

Answer 24

B) Rheumatoid Arthritis: Correct. RA involves symmetric joint pain, morning stiffness lasting over an hour, and swelling of MCP and PIP joints.

A) Osteoarthritis: Incorrect. Osteoarthritis involves asymmetric joint pain and stiffness that improves with rest. It typically affects the distal interphalangeal (DIP) joints, not the MCP or PIP joints.
C) Fibromyalgia: Incorrect. Fibromyalgia is characterized by widespread pain and fatigue without joint swelling or prolonged morning stiffness.
D) Psoriatic Arthritis: Incorrect. Psoriatic arthritis can involve dactylitis and skin plaques, which are absent in this case.

More information on why movement helps RA:
Nature of Inflammation: RA pain is primarily due to systemic inflammation of the synovium (synovitis), rather than mechanical stress. Inflammation is more pronounced during periods of inactivity because:
Prolonged rest allows inflammatory fluid to accumulate in the joint, causing stiffness and pain.
Movement helps redistribute fluid and reduces joint stiffness.
Joint Lubrication: Movement promotes the production and circulation of synovial fluid, which helps reduce friction and ease pain.
Immune Modulation: Physical activity may have mild anti-inflammatory effects by improving circulation and reducing local inflammatory cytokines in the joint.

The hour is because it takes longer to move the fluids compared to OA which doesn’t have that extra fluid

Question 25

A 45-year-old man presents with sudden onset of severe pain in his right great toe, accompanied by redness and swelling. He reports consuming alcohol the night before. What is the most likely diagnosis?
A) Rheumatoid Arthritis
B) Gout
C) Septic Arthritis
D) Reactive Arthritis

Answer 25

B) Gout: Correct. Gout commonly affects the first MTP joint (great toe) and is associated with alcohol intake.

A) Rheumatoid Arthritis: Incorrect. RA typically presents as symmetric polyarthritis involving small joints, not acute monoarthritis.
C) Septic Arthritis: Incorrect. Septic arthritis involves fever and purulent synovial fluid, which is not mentioned here.
D) Reactive Arthritis: Incorrect. Reactive arthritis usually follows a genitourinary or gastrointestinal infection and is not localized to the great toe.

Question 26

A 60-year-old woman presents with proximal muscle stiffness, primarily in her shoulders and hips, accompanied by fatigue and morning stiffness lasting over an hour. Her ESR is markedly elevated, but her creatine kinase is normal. Which condition should you suspect?
A) Polymyalgia Rheumatica
B) Fibromyalgia
C) Rheumatoid Arthritis
D) Scleroderma

Answer 26

A) Polymyalgia Rheumatica: Correct. PMR presents with proximal muscle stiffness, elevated ESR, and normal creatine kinase.
B) Fibromyalgia: Incorrect. Fibromyalgia does not cause elevated ESR or muscle stiffness confined to proximal areas.
C) Rheumatoid Arthritis: Incorrect. RA involves joint swelling and inflammatory markers but not isolated proximal muscle stiffness.
D) Scleroderma: Incorrect. Scleroderma involves skin changes (e.g., sclerodactyly) and systemic manifestations, which are absent here.

Question 27

A 35-year-old man with a history of psoriasis presents with dactylitis (“sausage fingers”), nail pitting, and joint pain primarily affecting his knees and fingers. What is the most likely diagnosis?
A) Rheumatoid Arthritis
B) Psoriatic Arthritis
C) Osteoarthritis
D) Systemic Lupus Erythematosus

Answer 27

B) Psoriatic Arthritis: Correct. PsA presents with dactylitis, nail pitting, and joint involvement, often with a history of psoriasis.

A) Rheumatoid Arthritis: Incorrect. RA does not typically cause nail pitting or dactylitis.
C) Osteoarthritis: Incorrect. OA is not associated with nail pitting or dactylitis.
D) Systemic Lupus Erythematosus: Incorrect. SLE involves multi-organ symptoms and does not present with dactylitis or nail changes.

Question 28

A 70-year-old man presents with fever, severe monoarthritis of the knee, and an elevated white blood cell count. Synovial fluid analysis reveals purulent fluid with a high neutrophil count. What is the most likely diagnosis?
A) Gout
B) Reactive Arthritis
C) Septic Arthritis
D) Osteoarthritis

Answer 28

C) Septic Arthritis: Correct. Septic arthritis involves fever, severe monoarthritis, and purulent synovial fluid with a high neutrophil count.
A) Gout: Incorrect. Gout presents with non-purulent synovial fluid containing monosodium urate crystals.
B) Reactive Arthritis: Incorrect. Reactive arthritis is associated with preceding infections and does not typically cause purulent synovial fluid.
D) Osteoarthritis: Incorrect. OA is a non-inflammatory condition that does not present with fever or purulent synovial fluid.

Question 29

A 28-year-old sexually active female presents with joint pain, swelling, and tenderness in her wrists and knees. She also reports a fever and a few small pustules on her forearm. What is the most likely diagnosis?
A) Septic arthritis
B) Osteoarthritis
C) Gonococcal arthritis
D) Rheumatoid arthritis

Answer 29

Correct Answer: C) Gonococcal arthritis
Rationale: Migratory joint pain, fever, and pustular skin lesions are classic signs of gonococcal arthritis.
Incorrect Options:
A) Septic arthritis: Typically involves one joint with more severe systemic symptoms.
B) Osteoarthritis: Does not present acutely or with fever or pustules.
D) Rheumatoid arthritis: Unlikely to present with pustules or fever.

Question 30

A 65-year-old male presents with chronic knee pain that worsens with activity and improves with rest. On examination, you notice crepitus in the knee joint. What is the most likely diagnosis?
A) Septic arthritis
B) Gonococcal arthritis
C) Osteoarthritis
D) Rheumatoid arthritis

Answer 30

Correct Answer: C) Osteoarthritis
Rationale: Pain worsens with activity and improves with rest, and crepitus is a classic sign of osteoarthritis.
Incorrect Options:
A) Septic arthritis: Presents acutely with fever, redness, and systemic signs.
B) Gonococcal arthritis: Often involves systemic symptoms or multiple joints.
D) Rheumatoid arthritis: Pain and stiffness improve with activity.

More information on OA:
In osteoarthritis, morning stiffness typically lasts less than 30 minutes. It tends to resolve quickly after starting daily activities. This brief stiffness occurs due to limited overnight movement and resolves as the synovial fluid is redistributed within the joint with movement.

Question 31

A 33-year-old male presents with acute pain, redness, and swelling in his right knee. He reports a recent fever and a painful sexual encounter two weeks ago. What is the most appropriate next step in diagnosis?
A) Perform an X-ray
B) Obtain synovial fluid analysis and NAAT
C) Prescribe non-steroidal anti-inflammatory drugs (NSAIDs)
D) Order rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies

Answer 31

Correct Answer: B) Obtain synovial fluid analysis and NAAT
Rationale: This is the most accurate way to confirm a diagnosis of gonococcal arthritis or rule out other causes.
Incorrect Options:
A) X-ray: May show joint damage but will not confirm the diagnosis.
C) NSAIDs: Should not be started until infection is ruled out.
D) RF and anti-CCP: These are used for rheumatoid arthritis, which is less likely in this scenario.

Why NSAIDs shouldn’t be started:

Masking Symptoms:
NSAIDs can reduce pain, fever, and swelling, which may temporarily alleviate symptoms. This could delay diagnosis and proper treatment of an infectious cause, such as septic arthritis or gonococcal arthritis.

Risk of Complications:
Septic arthritis and gonococcal arthritis require immediate antibiotic therapy to prevent permanent joint damage or systemic infection. Delayed treatment increases the risk of complications such as osteomyelitis, sepsis, or permanent joint deformity.

Question 32

What is the most likely diagnosis for Isabelle M. given her symptoms of cyclic pelvic pain, dysmenorrhea, dyspareunia, and tenderness on adnexal and posterior fornix palpation?
A) Pelvic Inflammatory Disease (PID)
B) Endometriosis
C) Irritable Bowel Syndrome (IBS)
D) Uterine Fibroids

Answer 32

Correct Answer: B) Endometriosis

B) Endometriosis: Correct. Cyclic pelvic pain, dysmenorrhea, dyspareunia, and tenderness on adnexal and posterior fornix palpation strongly suggest endometriosis. More red flags for this condition: severe cyclic pelvic pain, dysmenorrhea, and dyspareunia, reports of infertility and painful defecation during menstruation.

A) Pelvic Inflammatory Disease (PID): Incorrect. While PID can cause pelvic pain and adnexal tenderness, it typically involves systemic symptoms like fever or abnormal discharge, which Isabelle does not report.

C) Irritable Bowel Syndrome (IBS): Incorrect. IBS is less likely as Isabelle’s symptoms correlate more strongly with her menstrual cycle, and she denies significant bowel habit changes.
D) Uterine Fibroids: Incorrect. While fibroids can cause pelvic pain, they are more associated with heavy menstrual bleeding, which Isabelle does not report.

Question 33

Which symptom would most strongly suggest uterine fibroids as the primary diagnosis?
A) Cyclical pelvic pain associated with menstruation
B) Persistent heavy menstrual bleeding
C) Pain during bowel movements around the menstrual cycle
D) Tenderness upon palpation of the adnexa

Answer 33

Correct Answer: B) Persistent heavy menstrual bleeding

A) Cyclical pelvic pain associated with menstruation: Incorrect. This symptom is more characteristic of endometriosis than fibroids.
B) Persistent heavy menstrual bleeding: Correct. This is a hallmark symptom of uterine fibroids and would make them a more likely diagnosis.
C) Pain during bowel movements around the menstrual cycle: Incorrect. This symptom is more suggestive of endometriosis.
D) Tenderness upon palpation of the adnexa: Incorrect. While tenderness may occur with fibroids, it is not a primary symptom.

Question 34

A 45-year-old woman presents with postcoital bleeding, intermittent pelvic pain, and a foul-smelling vaginal discharge. Which condition should be the most urgent to rule out?
A) Pelvic Inflammatory Disease (PID)
B) Cervical Cancer
C) Endometrial Hyperplasia
D) Adenomyosis

Answer 34

Correct Answer: B) Cervical Cancer

A) PID: Often includes fever and purulent cervical discharge.
C) Endometrial Hyperplasia: Rarely causes postcoital bleeding.
D) Adenomyosis: More associated with heavy menstrual bleeding and dysmenorrhea.

Question 35

A 32-year-old woman with persistent bloating, early satiety, and unintentional weight loss is most likely to have:
A) Ovarian Cancer
B) Polycystic Ovary Syndrome (PCOS)
C) Primary Dysmenorrhea
D) Uterine Fibroids

Answer 35

Correct Answer: A) Ovarian Cancer

B) PCOS: Causes irregular cycles and hirsutism but lacks the hallmark of early satiety and bloating.
C) Primary Dysmenorrhea: Presents with pain, not weight loss or satiety.
D) Uterine Fibroids: Typically causes heavy bleeding rather than bloating.

Question 36

A patient presents with severe depression and irritability before her menstrual cycle. These symptoms interfere with her work and relationships. What is the most likely diagnosis?
A) Premenstrual Syndrome (PMS)
B) Premenstrual Dysphoric Disorder (PMDD)
C) Endometriosis
D) Ovarian Cyst

Answer 36

Correct Answer: B) Premenstrual Dysphoric Disorder (PMDD)

A) PMS: Symptoms are milder and do not disrupt daily life.
C) Endometriosis: More linked to pelvic pain and infertility.
D) Ovarian Cyst: Pain may occur but is not cyclical with mood changes.

Question 37

A 28-year-old presents with thick, white, curdy discharge and severe vulvar itching. Her pH is less than 4.5, and she recently completed a course of antibiotics. What is the most likely diagnosis?
A) Trichomoniasis
B) Vulvovaginal Candidiasis (VVC)
C) Atrophic Vaginitis
D) Irritant/Allergic Vaginitis

Answer 37

Correct Answer: B) Vulvovaginal Candidiasis (VVC)
Rationale: Thick, white, curdy discharge, severe vulvar itching, and a low pH (<4.5) are hallmark features of VVC. The history of recent antibiotic use is a significant risk factor.
Incorrect Options:

A) Trichomoniasis: Typically presents with green/yellow frothy discharge, a foul odor, and inflammation.
C) Atrophic Vaginitis: Occurs in postmenopausal women and presents with vaginal dryness, thin walls, and possible dyspareunia.
D) Irritant/Allergic Vaginitis: Would involve a history of exposure to an irritant or allergen, not mentioned here.

Question 38

A 50-year-old postmenopausal woman reports heavy vaginal bleeding and pelvic pain. Physical examination reveals an enlarged uterus. What is the most likely diagnosis?
A) Endometrial Cancer
B) Adenomyosis
C) Uterine Fibroids
D) Ovarian Cancer

Answer 38

Correct Answer: A) Endometrial Cancer

B) Adenomyosis: More common in premenopausal women.
C) Uterine Fibroids: Rarely cause postmenopausal bleeding.
D) Ovarian Cancer: Symptoms include bloating rather than heavy bleeding.

Question 39

A young adult male presents with persistent joint pain, bilateral auricular redness, and nasal bridge tenderness. What condition is most likely?
A) Rheumatoid Arthritis (RA)
B) Relapsing Polychondritis
C) Osteoarthritis
D) Systemic Lupus Erythematosus (SLE)

Answer 39

Correct Answer: B) Relapsing Polychondritis

A) RA: Does not affect cartilage-specific areas like the ears or nasal bridge.
C) Osteoarthritis: Pain worsens with movement; no auricular or nasal involvement.
D) SLE: May cause systemic symptoms but lacks localized cartilage involvement.

Question 40

A 40-year-old woman presents with a boggy, tender uterus and severe dysmenorrhea unresponsive to NSAIDs. Heavy menstrual bleeding is noted. What condition is likely?
A) Endometriosis
B) Adenomyosis
C) Ovarian Cyst
D) Cervical Cancer

Answer 40

Correct Answer: B) Adenomyosis

A) Endometriosis: Typically involves infertility and dyspareunia.
C) Ovarian Cyst: Would present as a mass or with acute pain.
D) Cervical Cancer: Not associated with a boggy uterus.

Question 41

A 22-year-old female presents with a history of irregular menstrual cycles, obesity, and acanthosis nigricans. She has been trying to conceive for one year without success. What is the most likely diagnosis?
A) Polycystic Ovary Syndrome (PCOS)
B) Premenstrual Syndrome (PMS)
C) Endometriosis
D) Primary Dysmenorrhea

Answer 41

Correct Answer: A) Polycystic Ovary Syndrome (PCOS)
A) PCOS: Irregular cycles and hirsutism are typical.

B) PMS: Does not cause infertility or insulin resistance.
C) Endometriosis: Infertility is possible but not linked to irregular cycles or obesity.
D) Primary Dysmenorrhea: Painful periods, no infertility or irregular cycles.

Question 42

A 60-year-old woman reports postmenopausal bleeding, pelvic discomfort, and fatigue. She has a history of obesity and late menopause. Which condition should be investigated first?
A) Endometrial Cancer
B) Ovarian Cancer
C) Uterine Fibroids
D) Adenomyosis

Answer 42

Correct Answer: A) Endometrial Cancer

B) Ovarian Cancer: Less likely with postmenopausal bleeding alone.
C) Uterine Fibroids: Rare in postmenopausal women.
D) Adenomyosis: Occurs in premenopausal women.

Question 43

A 34-year-old woman presents with thin, white discharge with a fishy odor but no inflammation. Microscopic examination shows clue cells. What is the most likely diagnosis?
A) Bacterial Vaginosis (BV)
B) Vulvovaginal Candidiasis (VVC)
C) Trichomoniasis
D) Pelvic Inflammatory Disease (PID)

Answer 43

Correct Answer: A) Bacterial Vaginosis (BV)

Rationale:
Thin, white, homogeneous discharge and a fishy odor are hallmark features of BV. The absence of inflammation (e.g., itching or redness) further supports this diagnosis.
Clue cells on microscopic examination are a diagnostic finding for BV.
Incorrect Options:

B) Vulvovaginal Candidiasis (VVC): This condition typically presents with thick, white, curdy discharge and vulvar itching or burning, which are not described here.
C) Trichomoniasis: This condition usually presents with green or yellow frothy discharge, inflammation, and occasionally a “strawberry cervix.” These features are absent in the case described.
D) Pelvic Inflammatory Disease (PID): PID involves systemic symptoms like fever and significant pelvic pain, neither of which are described here.

Question 44

A 45-year-old postmenopausal woman reports vaginal dryness, dyspareunia, and a thin, clear discharge. Examination reveals thin vaginal walls. What condition is most likely?
A) Atrophic Vaginitis
B) Pelvic Inflammatory Disease (PID)
C) Bacterial Vaginosis (BV)
D) Irritant/Allergic Vaginitis

Answer 44

Correct Answer: A) Atrophic Vaginitis
Rationale: Symptoms of vaginal dryness, dyspareunia, and thin vaginal walls are classic for atrophic vaginitis, which results from estrogen deficiency in postmenopausal women.
Incorrect Options:

B) Pelvic Inflammatory Disease (PID): Typically involves fever, pelvic pain, and cervical motion tenderness, not dryness or dyspareunia.
C) Bacterial Vaginosis (BV): Associated with thin, white, malodorous discharge without the dryness or thinning of vaginal walls.
D) Irritant/Allergic Vaginitis: Would require exposure to an irritant or allergen, not present here.

Question 45

A 24-year-old woman with a history of douching presents with foul-smelling, purulent vaginal discharge, fever, and dyspareunia. Wet prep is inconclusive. What is the most likely diagnosis?
A) Inflammatory Vaginitis
B) Bacterial Vaginosis (BV)
C) Irritant/Allergic Vaginitis
D) Pelvic Inflammatory Disease (PID)

Answer 45

Correct Answer: D) Pelvic Inflammatory Disease (PID)

Rationale: PID typically presents with systemic signs (e.g., fever), foul-smelling discharge, and dyspareunia. A history of risk factors like douching further increases the likelihood.
Incorrect Options:

A) Inflammatory Vaginitis: This condition involves purulent discharge but lacks systemic symptoms such as fever.
B) Bacterial Vaginosis (BV): BV would have a characteristic fishy odor and discharge but does not cause systemic symptoms like fever or dyspareunia.
C) Irritant/Allergic Vaginitis: Typically associated with burning and irritation but not purulent discharge or systemic symptoms.

Question 46

A 22-year-old presents with recurrent right lower quadrant pain and diarrhea, which worsens with stress. She denies fever or weight loss. What is the most likely diagnosis?
A) Irritable Bowel Syndrome (IBS)
B) Appendicitis
C) Diverticulitis
D) Pelvic Inflammatory Disease (PID)

Answer 46

Correct Answer: A) Irritable Bowel Syndrome (IBS)

Rationale: IBS often involves abdominal pain and altered bowel habits (e.g., diarrhea) that are exacerbated by stress. The absence of systemic symptoms (fever, weight loss) helps rule out more serious conditions.
Incorrect Options:

B) Appendicitis: Appendicitis causes acute, localized pain, often accompanied by fever or rebound tenderness, which are absent here.
C) Diverticulitis: This typically causes LLQ pain and fever, which are inconsistent with the presentation.
D) Pelvic Inflammatory Disease (PID): PID would involve systemic symptoms and pelvic pain, not localized RLQ pain or stress-induced worsening.

Question 47

A 30-year-old woman presents with sharp, intermittent left lower quadrant pain and fever. She reports a recent history of constipation and occasional rectal bleeding. What is the most likely diagnosis?
A) Diverticulitis
B) Appendicitis
C) Irritable Bowel Syndrome (IBS)
D) Atrophic Vaginitis

Answer 47

A 30-year-old woman presents with sharp, intermittent left lower quadrant pain and fever. She reports a recent history of constipation and occasional rectal bleeding. What is the most likely diagnosis?
Correct Answer: A) Diverticulitis

Rationale: Diverticulitis is characterized by LLQ pain, fever, and a history of bowel irregularities such as constipation or rectal bleeding.
Incorrect Options:

B) Appendicitis: Presents with RLQ pain and does not commonly involve rectal bleeding.
C) Irritable Bowel Syndrome (IBS): IBS lacks systemic symptoms like fever or bleeding.
D) Atrophic Vaginitis: This is primarily a vaginal condition with symptoms like dryness or dyspareunia, not LLQ pain or fever.

Question 48

A 40-year-old presents with vaginal burning, purulent discharge, and dyspareunia. She has a history of allergies and recently switched to a new brand of soap. What is the most likely diagnosis?
A) Irritant/Allergic Vaginitis
B) Inflammatory Vaginitis
C) Vulvovaginal Candidiasis (VVC)
D) Bacterial Vaginosis (BV)

Answer 48

Revised Answer: B) Inflammatory Vaginitis
Rationale: Inflammatory vaginitis can present with purulent discharge, burning, and dyspareunia. Although there is no systemic inflammation in this case, inflammatory vaginitis could explain all of the symptoms, particularly when other infectious causes (e.g., bacterial vaginosis or trichomoniasis) do not align with the presentation.
Revised Incorrect Options:

A) Irritant/Allergic Vaginitis: Typically causes burning and irritation but not purulent discharge.
C) Vulvovaginal Candidiasis (VVC): Characterized by thick, cheesy discharge, not purulent discharge.
D) Bacterial Vaginosis (BV): Presents with thin, fishy-smelling discharge and lacks the associated burning or dyspareunia.

Question 49

A 33-year-old presents with sudden onset of right lower quadrant pain and nausea. She denies vaginal discharge but has mild fever and guarding on abdominal examination. What is the most likely diagnosis?
A) Appendicitis
B) Diverticulitis
C) Pelvic Inflammatory Disease (PID)
D) Irritable Bowel Syndrome (IBS)

Answer 49

Correct Answer: A) Appendicitis

Rationale: Acute RLQ pain, nausea, fever, and guarding are classic signs of appendicitis.
Incorrect Options:

B) Diverticulitis: Involves LLQ pain and is less common in younger patients.
C) Pelvic Inflammatory Disease (PID): Would present with pelvic pain, fever, and vaginal discharge, which are absent here.
D) Irritable Bowel Syndrome (IBS): IBS lacks fever, guarding, and acute RLQ pain.

Question 50

A 56-year-old male presents with sudden onset chest pain, shortness of breath, and tachycardia. His pain worsens with deep breathing, and oxygen saturation is 89% on room air. What is the most likely diagnosis?
A) Pulmonary Embolism (PE)
B) Angina
C) Deep Vein Thrombosis (DVT)
D) Peripheral Artery Disease (PAD)

Answer 50

Correct Answer: A) Pulmonary Embolism (PE)

Rationale: Sudden-onset pleuritic chest pain, hypoxia, and tachycardia are classic red flags for PE. The worsening pain with breathing suggests pleural involvement.
B) Incorrect: Angina presents with exertional chest pain but is not typically pleuritic or associated with hypoxia.
C) Incorrect: DVT does not directly cause chest symptoms but can be a precursor to PE.
D) Incorrect: PAD primarily causes leg pain (claudication) and does not involve respiratory symptoms.

More information about (PE):
Pulmonary Embolism Red flags 🚩 also include tachycardia, tachypnea, hypotension, hypoxemia unrelieved by oxygen and high fever

1. Tachycardia (Fast Heart Rate)
   Cause: PE leads to a sudden increase in pulmonary vascular resistance because of a blood clot obstructing the pulmonary arteries. This puts strain on the right ventricle, which must pump harder to overcome the resistance.
   Compensation: The body responds to decreased oxygenation and reduced cardiac output by increasing heart rate to maintain blood flow and oxygen delivery to vital organs.
2. Tachypnea (Fast Breathing)
   Cause: The embolus causes a mismatch between ventilation and perfusion (V/Q mismatch) in the lungs, leading to hypoxemia (low blood oxygen).
   Compensation: The body responds by increasing respiratory rate to improve oxygen uptake and eliminate excess carbon dioxide, even though the effort may not fully correct the oxygen deficit.
3. Hypotension (Low Blood Pressure)
   Cause: Large emboli can obstruct blood flow in the pulmonary arteries, leading to reduced left ventricular preload (less blood returning to the heart). This reduces cardiac output and systemic blood pressure.
   Right Heart Strain: In severe cases, acute right ventricular failure due to the increased afterload can further contribute to hypotension.
4. Fever (High Temperature)
   Cause: PE can cause a systemic inflammatory response. The embolus damages the pulmonary blood vessels, releasing inflammatory mediators like cytokines.
   Fever may also result from necrosis (tissue death) in the lung caused by ischemia due to the obstruction.
   Distinction from Infection: While fever is less common than in infections, mild fever can still occur as part of this inflammatory response.
   Pathophysiology Overview
   When a clot obstructs a pulmonary artery:

Gas exchange is impaired, leading to hypoxemia and hypercapnia.
The heart and lungs respond with increased effort to compensate (tachycardia, tachypnea).
The right heart may fail under the strain of increased afterload, leading to hypotension.

Why is hypoxemia in PE unrelieved by
oxygen?

Ventilation-Perfusion (V/Q) Mismatch
Mechanism: In PE, the embolus obstructs blood flow to parts of the lung. These areas become well-ventilated but under-perfused (high V/Q ratio). The blood cannot pick up oxygen in these regions because perfusion is severely impaired or absent.
Supplemental Oxygen: While supplemental oxygen increases the partial pressure of oxygen (PaO₂) in the ventilated alveoli, it cannot restore blood flow to the obstructed areas. Thus, it has limited effectiveness in improving oxygenation.
2. Shunting and Redistribution
Mechanism: Blood flow is redirected to other lung regions still receiving perfusion. However, this can overwhelm these areas, causing them to become poorly ventilated relative to perfusion (low V/Q ratio or even right-to-left shunt).
Impact: The poorly oxygenated blood from these regions mixes with the oxygenated blood, leading to persistent hypoxemia.
3. Impaired Gas Exchange
The embolus disrupts normal diffusion of oxygen into the bloodstream in affected areas.
Dead space ventilation: Portions of the lung become ventilated but do not participate in gas exchange due to the absence of blood flow. This increases the physiologic dead space, further impairing oxygen uptake.
4. Right-to-Left Shunt via Patent Foramen Ovale (PFO)
In some patients with a PFO or other intracardiac shunts, the increased pressure in the right heart caused by PE can force deoxygenated blood directly into the left atrium, bypassing the lungs altogether. This worsens hypoxemia and cannot be corrected with oxygen therapy.
Why Oxygen Alone Isn’t Enough
Supplemental oxygen:

Only addresses ventilation: It improves the oxygen content in ventilated alveoli but doesn’t correct the perfusion problem caused by the embolus.
Doesn’t resolve V/Q mismatch: Oxygen cannot “fix” the lack of blood flow to parts of the lung or the redistribution issues in other lung regions.
Clinical Implications
Persistent hypoxemia despite oxygen is a red flag for PE.
Addressing the underlying issue (e.g., with anticoagulation or thrombolysis) is critical for restoring normal perfusion and resolving hypoxemia.

Question 51

A 65-year-old female complains of leg pain that worsens with activity and resolves with rest. Her skin appears pale and cool to the touch, and pedal pulses are weak. What is the most likely diagnosis?
A) Peripheral Artery Disease (PAD)
B) Peripheral Venous Disease (PVD)
C) Pulmonary Embolism (PE)
D) Angina

Answer 51

Correct Answer: A) Peripheral Artery Disease (PAD)

Rationale: Pain relieved by rest (claudication), weak pulses, and cool, pale skin suggest arterial insufficiency typical of PAD.
B) Incorrect: PVD involves venous insufficiency with symptoms like leg swelling and varicose veins but no pulse deficits.
C) Incorrect: PE primarily causes respiratory symptoms, not limb-specific issues.
D) Incorrect: Angina affects the chest and is unrelated to peripheral symptoms.

Question 52

A 48-year-old male presents with swelling and pain in his left calf. He reports that the pain is worse when standing and relieved with elevation. A recent long-haul flight is noted in his history. What is the most likely diagnosis?
A) Deep Vein Thrombosis (DVT)
B) Peripheral Artery Disease (PAD)
C) Pulmonary Embolism (PE)
D) Peripheral Venous Disease (PVD)

Answer 52

Correct Answer: A) Deep Vein Thrombosis (DVT)

Rationale: Localized calf pain, swelling, and a history of immobility are classic features of DVT. The relief with elevation supports venous etiology.
B) Incorrect: PAD causes ischemic pain during activity but not swelling.
C) Incorrect: PE might follow a DVT but does not cause isolated leg pain or swelling.
D) Incorrect: PVD causes more chronic leg swelling and skin changes rather than acute pain.

Question 53

A 58-year-old female reports aching, swollen legs that worsen by the evening. She also has skin discoloration and varicose veins. What is the most likely diagnosis?
A) Peripheral Venous Disease (PVD)
B) Peripheral Artery Disease (PAD)
C) Deep Vein Thrombosis (DVT)
D) Pulmonary Embolism (PE)

Answer 53

Correct Answer: A) Peripheral Venous Disease (PVD)

Rationale: PVD is characterized by leg swelling, aching, varicose veins, and skin discoloration due to chronic venous insufficiency.
B) Incorrect: PAD presents with cool, pale extremities and claudication but not swelling or varicosities.
C) Incorrect: DVT is more acute with localized pain and swelling.
D) Incorrect: PE causes respiratory symptoms, not leg-related chronic changes.

Question 54

A 60-year-old male with a history of smoking presents with chest pressure radiating to his jaw and left arm during exertion, relieved by rest. What is the most likely diagnosis?
A) Angina
B) Pulmonary Embolism (PE)
C) Peripheral Artery Disease (PAD)
D) Deep Vein Thrombosis (DVT)

Answer 54

Correct Answer: A) Angina

Rationale: Classic angina presents with exertional chest pressure radiating to the jaw or arm, relieved by rest. This is due to myocardial ischemia.
B) Incorrect: PE causes sudden respiratory symptoms and pleuritic pain, not exertional chest pressure.
C) Incorrect: PAD causes peripheral symptoms, not central chest pain.
D) Incorrect: DVT involves localized limb symptoms, not chest pain.

Question 55

A 72-year-old male presents with acute chest pain that radiates to the left arm and is accompanied by nausea and diaphoresis. His symptoms began at rest and have lasted for 30 minutes. What is the most likely diagnosis?

A) Pulmonary Embolism (PE)
B) Stable Angina
C) Unstable Angina
D) Myocardial Infarction

Answer 55

Correct Answer: D) Myocardial Infarction (MI)

A) Pulmonary Embolism (PE): Incorrect. PE often presents with pleuritic chest pain, shortness of breath, and hypoxia, but not typically with radiating pain or diaphoresis.

B) Stable Angina: Incorrect. Stable angina is relieved by rest and lasts less than 15 minutes, unlike the prolonged and severe symptoms described here.

C) Unstable Angina: Incorrect. Unstable angina is similar but lacks the myocardial necrosis that characterizes MI.

D) Myocardial Infarction (MI): Correct. The prolonged chest pain, radiation to the arm, nausea, and diaphoresis are classic for MI.

Question 56

A 65-year-old woman reports intermittent chest pain lasting 5-15 minutes, particularly during physical activity or emotional stress. The pain resolves with rest. She denies shortness of breath or other systemic symptoms. What is the most likely diagnosis?

A) Pulmonary Embolism (PE)
B) Stable Angina
C) Unstable Angina
D) Esophageal Spasm

Answer 56

Correct Answer: B) Stable Angina

A) Pulmonary Embolism (PE): Incorrect. PE typically presents with sudden, unexplained dyspnea, chest pain, and hypoxia. Intermittent pain relieved by rest is not characteristic of PE.

B) Stable Angina: Correct. Stable angina is triggered by exertion or stress and relieved with rest, consistent with this patient’s description of her symptoms.

C) Unstable Angina: Incorrect. Unstable angina presents with chest pain that is more prolonged, occurs at rest, or is new and worsening in intensity.

D) Esophageal Spasm: Incorrect. While esophageal spasm can mimic angina, it is often associated with dysphagia or regurgitation, which are not mentioned here.

Question 57

Here is what to look for when in doubt of MI or Unstable Angina

Answer 57

1. Clinical Presentation
   Unstable Angina:

Chest pain occurs at rest, is new in onset, or has worsened in severity or frequency.
Pain is typically relieved by rest or nitroglycerin (but less effectively over time).
No associated symptoms like significant nausea, sweating, or severe shortness of breath.
Myocardial Infarction (MI):

Chest pain is more severe, lasts longer (>20 minutes), and is not relieved by rest or nitroglycerin.
Often accompanied by symptoms such as:
Sweating (diaphoresis).
Nausea/vomiting.
Shortness of breath.
Feeling of impending doom.
2. Cardiac Biomarkers
Unstable Angina:

Troponin levels are normal because no necrosis has occurred.
Other markers of heart damage (e.g., CK-MB) are also within normal ranges.
Myocardial Infarction (MI):

Troponin levels are elevated, indicating heart muscle damage.
CK-MB and other cardiac enzymes may also rise.
These markers increase within hours of the event and remain elevated for days.
3. Electrocardiogram (ECG)
Unstable Angina:

ECG may show ischemic changes, such as:
ST depression (partial blockage).
T-wave inversion.
No evidence of ST-segment elevation or Q waves.
Myocardial Infarction (MI):

ST-Elevation MI (STEMI): Characterized by ST elevation in specific leads.
Non-ST-Elevation MI (NSTEMI): May show ST depression or T-wave inversion, but with elevated troponins.
Q waves may develop later, indicating irreversible damage.
4. Imaging
Unstable Angina:

Coronary angiography may reveal partial blockages in coronary arteries without complete occlusion.
Myocardial Infarction (MI):

Imaging may show complete occlusion of a coronary artery (e.g., on angiography).
Echocardiography may detect areas of the heart with reduced movement due to necrosis.
Key Differentiator
The most reliable methods for differentiation are cardiac biomarkers (troponins) and the ECG pattern, alongside clinical assessment.

If in doubt, treat chest pain as a potential MI until proven otherwise to avoid delaying life-saving interventions.

Question 58

A 45-year-old woman presents with a hard, immovable lump in her left breast, dimpling of the overlying skin, and bloody nipple discharge. What is the most likely diagnosis?

A) Breast Cancer
B) Fibroadenoma
C) Breast Cyst
D) Mastitis

Answer 58

Correct Answer: A) Breast Cancer

Rationale:
A) Breast Cancer: A hard, immovable lump, skin dimpling, and bloody discharge are classic red flags for breast cancer.
B) Fibroadenoma: Usually presents as a smooth, mobile lump without skin changes or nipple discharge.
C) Breast Cyst: Typically a fluid-filled lump that may fluctuate in size and cause pain but does not usually cause bloody discharge.
D) Mastitis: Often occurs in breastfeeding women, presenting with redness, swelling, and tenderness, not a hard, immovable lump or bloody discharge.

Question 59

A 25-year-old woman notices a smooth, mobile, painless lump in her right breast during a self-exam. She denies nipple discharge or skin changes. What is the most likely diagnosis?

A) Fibroadenoma
B) Breast Cancer
C) Fat Necrosis
D) Intraductal Papilloma

Answer 59

Correct Answer: A) Fibroadenoma

Rationale:
A) Fibroadenoma: Presents as a smooth, mobile, painless lump, especially in younger women, with no associated skin or nipple changes.
B) Breast Cancer: A hard, immovable lump, often with skin or nipple changes, is more suspicious for malignancy.
C) Fat Necrosis: Typically occurs after trauma and may mimic cancer but is less common in young women.
D) Intraductal Papilloma: Often causes bloody nipple discharge but does not usually present as a palpable lump.

Question 60

A breastfeeding woman develops a swollen, red, and painful area on her right breast accompanied by fever. What is the most likely diagnosis?

A) Mastitis
B) Breast Cancer
C) Breast Abscess
D) Fibrocystic Changes

Answer 60

Correct Answer: A) Mastitis

Rationale:
A) Mastitis: Presents with redness, swelling, pain, and systemic symptoms like fever, especially in breastfeeding women.
B) Breast Cancer: Rarely presents with acute inflammation and fever; inflammatory breast cancer might cause redness but lacks systemic infection signs.
C) Breast Abscess: May present similarly but is usually more localized, with a pocket of pus that can be drained.
D) Fibrocystic Changes: Typically cause lumpiness and tenderness but not redness, fever, or systemic symptoms.

Question 61

A 50-year-old woman has a scaly, red, itchy patch on her left nipple and areola. She reports no lumps or significant pain. What is the most likely diagnosis?

A) Paget’s Disease of the Breast
B) Eczema
C) Psoriasis
D) Breast Cancer

Answer 61

Correct Answer: A) Paget’s Disease of the Breast

Rationale:
A) Paget’s Disease of the Breast: A rare form of breast cancer that presents with scaly, red, itchy changes to the nipple and areola.
B) Eczema: Affects both breasts and does not typically involve the nipple.
C) Psoriasis: May cause scaly patches but is not localized to the nipple.
D) Breast Cancer: Though Paget’s disease is a form of breast cancer, the presentation described is specific to Paget’s disease.

Question 62

A 40-year-old man notices swelling and tenderness under his right nipple. He is on spironolactone for hypertension. What is the most likely diagnosis?

A) Gynecomastia
B) Breast Cancer
C) Fat Necrosis
D) Intraductal Papilloma

Answer 62

Correct Answer: A) Gynecomastia

Rationale:
A) Gynecomastia: Common in men and often linked to medications like spironolactone. Presents with swelling and tenderness under the nipple.
B) Breast Cancer: Rare in men, and symptoms typically include a hard, immovable lump without tenderness.
C) Fat Necrosis: Unlikely without a history of trauma; presents as a hard lump and is not tender.
D) Intraductal Papilloma: Rare in men and primarily associated with nipple discharge, not swelling.

More info. for clarification:
Gynecomastia occurs in men taking spironolactone due to the drug’s effects on hormonal balance. Spironolactone is a potassium-sparing diuretic that also acts as an androgen receptor antagonist and inhibits testosterone synthesis. Here’s why it happens:

Decreased Testosterone Activity: Spironolactone blocks androgen receptors and reduces the production of testosterone, leading to a lower androgen-to-estrogen ratio.

Increased Estrogen Effect: The reduced testosterone allows estrogen to have a more pronounced effect on breast tissue, stimulating growth.

Hormonal Imbalance: The imbalance between androgens (male hormones) and estrogens (female hormones) leads to the development of breast tissue, causing swelling and tenderness under the nipple, which is characteristic of gynecomastia.

This condition is generally benign, but it can cause discomfort or distress. If significant symptoms occur, the medication may need to be reviewed or substituted.

Question 63

A 65-year-old smoker presents with a chronic cough, weight loss, and hemoptysis. A chest X-ray shows a right upper lobe mass. Which of the following is the most likely diagnosis?

A) Lung Cancer
B) Tuberculosis
C) COPD
D) Pulmonary Embolism

Answer 63

Correct Answer: A) Lung Cancer

Rationale:

A) Lung Cancer: Chronic cough, unexplained weight loss, hemoptysis, and a mass on imaging are hallmark signs of lung cancer. Smoking history adds to the suspicion.
B) Tuberculosis: While TB may cause weight loss and hemoptysis, it is typically accompanied by fever, night sweats, and a history of exposure or travel. Imaging often shows cavitations or upper lobe infiltrates, not a solitary mass.
C) COPD: COPD presents with chronic cough and shortness of breath but rarely causes hemoptysis or a mass on imaging. It would more likely show hyperinflation or flattened diaphragms on imaging.
D) Pulmonary Embolism: PE can cause hemoptysis, but it usually presents with acute symptoms like sudden shortness of breath and pleuritic chest pain. A mass would not be seen on imaging.

Question 64

A 58-year-old man with a history of rheumatoid arthritis presents with shortness of breath, a non-productive cough, and clubbing of his fingers. Imaging reveals bilateral interstitial infiltrates. What is the most likely diagnosis?

A) Interstitial Lung Disease (ILD)
B) Sarcoidosis
C) Pneumonia
D) Bronchiectasis

Answer 64

Correct Answer: A) Interstitial Lung Disease (ILD)

Rationale:
A) ILD: Non-productive cough, progressive shortness of breath, and clubbing of fingers are consistent with ILD, especially given the bilateral interstitial infiltrates on imaging. ILD is a known complication of rheumatoid arthritis.
B) Sarcoidosis: Sarcoidosis may present with similar symptoms but typically involves bilateral hilar lymphadenopathy rather than interstitial infiltrates.
C) Pneumonia: Pneumonia usually causes fever, productive cough, and localized consolidation on imaging, which is absent here.
D) Bronchiectasis: Bronchiectasis involves chronic cough with copious sputum and recurrent infections. Clubbing can occur but is usually associated with extensive mucus production.

More info.
Why is ILD a known complication of rheumatoid arthritis (RA)?

1. Autoimmune inflammation targeting the lungs:
   Rheumatoid arthritis (RA) is an autoimmune condition that primarily affects the joints but can also involve other organs, including the lungs. The systemic inflammation associated with RA can target the lung tissue, leading to progressive scarring (fibrosis) and the development of interstitial lung disease (ILD).
2. Types of lung involvement in RA:
   RA-related lung complications can include:

Interstitial Lung Disease (ILD): Chronic inflammation damages the lung’s interstitium (the area around alveoli), leading to fibrosis, decreased lung elasticity, and impaired gas exchange.
Rheumatoid nodules in the lungs: These nodules may form but are less common.
Pleuritis: Inflammation of the pleura, causing chest pain and effusion.
Bronchiolitis: Inflammation of small airways.
ILD is among the most serious because it is progressive and can lead to respiratory failure.

3. Risk factors for ILD in RA:
   Chronic inflammation: Long-standing or poorly controlled RA increases the risk.
   Smoking history: Amplifies the likelihood of lung complications in RA.
   Genetics: Certain genetic markers (e.g., HLA-DR4) are linked to both RA and ILD.
   RA medications: Drugs like methotrexate can occasionally worsen lung inflammation but are not the primary cause of ILD.
4. Symptoms and imaging findings of RA-ILD:

Symptoms: Non-productive cough, progressive shortness of breath, and sometimes fatigue or clubbing of fingers.
Imaging: Chest X-rays or high-resolution CT scans often show bilateral interstitial infiltrates, reflecting lung fibrosis.
Differential Diagnosis:
Sarcoidosis: Involves granuloma formation and lymphadenopathy, not commonly seen in RA-ILD.
Pneumonia: Causes acute symptoms like fever and productive cough, which contrast with ILD’s chronic progression.
Bronchiectasis: Associated with chronic cough and large sputum production, different from ILD’s dry cough and breathlessness.

Question 65

A 70-year-old patient with a history of diabetes and smoking presents with calf pain while walking, relieved by rest, and absent pedal pulses on examination. What is the most likely diagnosis?

A) Peripheral Artery Disease (PAD)
B) Deep Vein Thrombosis (DVT)
C) Chronic Obstructive Pulmonary Disease (COPD)
D) Pulmonary Embolism (PE)

Answer 65

Correct Answer: A) Peripheral Artery Disease (PAD)

Rationale:

A) Peripheral Artery Disease (PAD): Calf pain relieved by rest (claudication) and absent pedal pulses indicate arterial insufficiency, typical of PAD. Risk factors include diabetes and smoking.
B) Deep Vein Thrombosis (DVT): DVT causes pain and swelling in the leg but is not relieved by rest. Pulses are typically normal unless there is severe swelling.
C) Chronic Obstructive Pulmonary Disease (COPD): COPD involves respiratory symptoms like shortness of breath and chronic cough, not leg pain.
D) Pulmonary Embolism (PE): PE would present with respiratory symptoms and possibly calf pain from a preceding DVT, but rest does not relieve the pain, and there are no absent pulses

Question 66

Chest pain during exercise could indicate all of the following EXCEPT:
a) Musculoskeletal injuries
b) Gastroesophageal reflux disease (GERD)
c) Carotid artery dissection
d) Exercise-induced asthma

Answer 66

Chest pain during exercise could indicate all of the following EXCEPT:
Correct Answer: c) Carotid artery dissection
A) Musculoskeletal injuries: Incorrect. Chest pain can result from strains or muscle injuries.
B) Gastroesophageal reflux disease (GERD): Incorrect. GERD can cause chest discomfort, especially during exercise.
C) Carotid artery dissection: Correct. This condition affects the carotid arteries and does not typically present with chest pain during exercise.
D) Exercise-induced asthma: Incorrect. Chest tightness is a common symptom of asthma.

Question 67

A 45-year-old male presents with a sudden onset of persistent vertigo, nausea, vomiting, and a sensation of fullness in the right ear for the past two days. He denies hearing loss but reports constant ringing (tinnitus) in the same ear. Gait is unsteady, veering to the right. A head-thrust test is positive, and the Dix-Hallpike maneuver is negative. What is the most likely diagnosis?

A) Vestibular Neuritis
B) Ménière’s Disease
C) Benign Paroxysmal Positional Vertigo (BPPV)
D) Central Vertigo (Posterior Circulation Stroke)

Answer 67

Rationale:

A) Vestibular Neuritis - Correct.
The patient’s symptoms—persistent vertigo worsened by head movements, positive head-thrust test, absence of hearing loss, and unsteady gait—strongly suggest vestibular neuritis. A negative Dix-Hallpike maneuver rules out positional causes like BPPV.

B) Ménière’s Disease - Incorrect.
Ménière’s typically involves episodic vertigo (lasting minutes to hours), fluctuating hearing loss, tinnitus, and aural fullness. This patient denies hearing loss and has persistent, rather than episodic, vertigo.

C) Benign Paroxysmal Positional Vertigo (BPPV) - Incorrect.
BPPV is characterized by brief episodes of vertigo triggered by positional changes and a positive Dix-Hallpike maneuver, neither of which are present here.

D) Central Vertigo (Posterior Circulation Stroke) - Incorrect.
While unsteady gait and persistent vertigo can occur in a stroke, the absence of focal neurological deficits and purely vertical or direction-changing nystagmus makes this less likely.

Question 68

A 45-year-old male reports sudden, persistent vertigo with constant ringing in his right ear and a sense of fullness. His hearing test is normal, and he has no recent head trauma or infections. Which of the following is a red flag for a central cause of vertigo (e.g., stroke)?

A) Positive head-thrust test
B) Persistent vertigo unrelieved by fixation
C) Absence of hearing loss
D) Gait instability with veering to the right

Answer 68

A) Positive head-thrust test - Incorrect.
A positive head-thrust test is a hallmark of peripheral vestibular dysfunction, such as vestibular neuritis or labyrinthitis, and is not considered a central red flag.

B) Persistent vertigo unrelieved by fixation - Correct.
Persistent vertigo that does not reduce with visual fixation is a key red flag for central causes of vertigo, such as a posterior circulation stroke.

C) Absence of hearing loss - Incorrect.
While hearing loss can help differentiate between peripheral and central causes, its absence is not a central red flag.

D) Gait instability with veering to the right - Incorrect.
Gait instability is a common feature of both central and peripheral vertigo and is not specific enough to indicate a central cause alone.

Question 69

A 45-year-old male presents with persistent vertigo, tinnitus, and aural fullness in the right ear but denies hearing loss. His symptoms began suddenly two days ago and have not improved. What feature would most strongly suggest a diagnosis of Ménière’s disease?

A) Persistent vertigo lasting for days
B) Fluctuating hearing loss
C) Positive head-thrust test
D) Negative Dix-Hallpike maneuver

Answer 69

Rationale:

A) Persistent vertigo lasting for days - Incorrect.
Ménière’s disease is characterized by episodic vertigo lasting minutes to hours, not persistent vertigo lasting days.

B) Fluctuating hearing loss - Correct.
Fluctuating hearing loss, along with tinnitus and aural fullness, is a hallmark of Ménière’s disease. The absence of hearing loss in this patient makes Ménière’s unlikely.

C) Positive head-thrust test - Incorrect.
A positive head-thrust test suggests a peripheral vestibular cause, such as vestibular neuritis or labyrinthitis, but is not specific to Ménière’s disease.

D) Negative Dix-Hallpike maneuver - Incorrect.
A negative Dix-Hallpike maneuver rules out positional vertigo (e.g., BPPV) but does not point specifically to Ménière’s disease.

Question 70

A patient presents with sudden-onset vertigo, tinnitus, and hearing loss in one ear. They have a history of head trauma from a fall a few days ago. What is the most likely diagnosis?

A) Vestibular Neuritis
B) Perilymph Fistula
C) Benign Paroxysmal Positional Vertigo (BPPV)
D) Acoustic Neuroma

Answer 70

Rationale:

A) Vestibular Neuritis - Incorrect.
Vestibular neuritis is not associated with hearing loss or a history of trauma.

B) Perilymph Fistula - Correct.
The combination of vertigo, tinnitus, hearing loss, and recent head trauma strongly suggests a perilymph fistula, where a tear in the inner ear membranes leads to symptoms.

C) Benign Paroxysmal Positional Vertigo (BPPV) - Incorrect.
BPPV does not cause hearing loss or tinnitus and is not typically associated with recent head trauma.

D) Acoustic Neuroma - Incorrect.
Acoustic neuroma presents with progressive, rather than sudden, hearing loss and is not linked to trauma.