comlex iw guide 2006

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NBOME

Item-Writing Guide

Copyright 2006 The National Board Of Osteopathic Medical Examiners, Inc.


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Table of Contents

Introduction 1Item Writing/Review Cycle 2Submitting an Item-Writing Assignment 3The Assignment 4

Sample Assignment Form 5How to Write an Item 6

Types of Items 6The Clinical Scenario 6The Question 7

Appropriate Item Formatting 9Inappropriate Item Formatting 9

Examples of Inappropriate Item Formats 10Differentiating By Level 12Utilizing Visuals 13Level 1 Sample Items 17Level 2 Sample Items 21Level 3 Sample Items 25

Sample Item Answer Keys 29Reference Adult Laboratory Values 30

Patient Presentation & Physician Task Requirements 34

AppendixBlooms Taxonomy of the Cognitive Domain A1Multimedia Items A2


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Introduction

The quality of the examinations produced by the National Board of Osteopathic Medical Examiners (NBOME) is dependenton the individuals who write the examination questions. You, the item writer, are the bottom line; your efforts aredirectly reflected in the examinations produced and, in turn, reflect the integrity of the osteopathic profession. Thank

you for taking your time, energy, and insight to help in this important endeavor.

Because it is important that one set of standards be applied to any examination, please familiarize yourself with theNBOMEs criteria prior to beginning your assignment. This item writing guide outlines the acceptable formats and typesof questions. Adhering to these standards ensures the continuing consistency of the NBOME exams. Please refer tothis booklet when writing items.

While writing your assignment or after you have completed it, you may have comments, questions, or suggestions. Weat the NBOME encourage and welcome your feedback. Feel free to contact your Test Administrator (773-714-0622) or Level Coordinator at any time during the item writing process.


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Item Writing/Review Cycle

Every year new items are submitted and reviewed for potential use. Each level receives approximately 1000 itemsannually.

March-May Letter of interest sent out to committee members, past item writers, and

potential item writers for the next item writing cycle

August-September Item writing assignments sent to item writers

November-December Completed item writing assignments due

Winter Items entered into databank and checked for correct format; inappropriatelyformatted items and items with an insufficient reference returned to author

Items go through a four-month review process prior to appearing on an examination. Each item is reviewed at leasthree times to ensure appropriate format and content.

February The OPP Committee (comprised of osteopathic specialists from osteopathicschools) meets to review all OPP items submitted (first-line review)

March April The New Item Review Committee meets to review all new, non-OPP itemssubmitted the prior November (first-line review)

April May The Approved Item Review Committee meets to review all items approved bythe OPP Committee and the New Item Review Committee (second-line review)

July September The Preliminary Exam Review Committee meets to review all items selected

for pretesting in the coming exam cycle (third-line review)


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Submitting an Item-Writing Assignment

Assignments may be submitted via mail, fax, or e-mail in Microsoft Word on or prior to the assignment due date.

Visuals may be submitted via mail or electronically. If desired, original visuals will be returned once they have beenscanned for possible use. (Please see page 17 for more information regarding visual submissions.)

The author of each item submitted should be noted so that CME credit may be awarded accordingly. (One hour ocategory 1B credit is awarded for every two items submitted.)

Up-to-date contact information (address, phone number, fax number, e-mail) should be included for every item

writer.

The patient presentation and etiology should be noted for all items, cases, and matching sets submitted.

A reference should be given for each item submitted with the corresponding page numbers noted. All referencesshould come from a standard source that is readily available nationwide. Websites are not an appropriate sourceunless they are a government-sponsored site or contain the on-line versions of textbooks. All items lacking anappropriate reference will be returned.


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The Assignment

Assignments are made using a standard NBOME assignment/submission form containing two sections:

Section I

To be completed with up-to-date contact information

Section II

Outlines the item type, topic, subtopics, etiologies, and physician tasks that have been assigned.

Item type: specifies the type of item that should be submitted for the given topic, subtopic, and etiologycombinationExamples: Stand Alone, Case Item, Matching (a complete description can be found on page 6)

Topic: the general nature of the patients presentation or complaintExamples: Bleeding, Masses & Edema (a complete list can be found on page 34)

Subtopic: the more specific complaint or findingExamples: hemoptysis, chest/lung masses

Etiology: the cause of the complaint or findingExamples: tuberculosis, infection

Physician task: the area of knowledge the related question should testExamples: Health Promotion/Disease Prevention, History & Physical, Management (a complete list can befound on pages 7-8 and 35)

Each line represents an item to be submitted. If you are assigned a case item or matching item, each item that is to

be part of the case or set will be listed on a separate line.

Not all items assigned will specify an etiology. In this situation, feel free to write a question related to any etiology

that is related to the subtopic assigned.

If you do not feel comfortable writing on the subtopic or etiology assigned, please contact your TestAdministrator.

Always adhere to the assigned physician task. An item should be submitted for each physician task listed. If aphysician task is listed multiple times, multiple questions should be written focusing on that area.


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How to Write an Item

Types of items

There are three types of items included in the NBOME exams:

Stand alones Include only one question related to the clinical scenario

Over 50% of each exam is comprised of stand alone items

Cases Include two to three questions related to one clinical scenario

Cases should only be written when more than one high quality item can be related to the same clinical scenario

Matching sets Include a list of similar answer choices (i.e., all management steps, diagnoses, etc.) followed by several clinical

scenarios that are associated with the answer choices provided Each clinical scenario should fall under the same general patient presentation topic and, when possible, the same

subtopic Each clinical scenario should have only one correct answer out of the answer choices provided

The answer choices provided should be plausible for each clinical scenario (e.g., if ectopic pregnancy is listed as an

answer choice, the clinical scenarios should not include a male patient or elderly female patient)

Quality matching sets should involve some degree of interpretation and/or analysis

If a visual is to be submitted with an item, the item type will be noted as w/ visual. This does not change the formatthat the item should follow; it only notes that a visual should be included with the item.

Examples of level-appropriate stand alone, case, and matching set items can be found on pages 22-38.

The Clinical ScenarioAlthough there is more than one way to construct a clinical scenario, there is a pattern that can be used to generatemultiple scenarios. This pattern involves a basic fill-in structure designed to expedite item construction.

Pattern:A [patient description] presents with [symptoms]. History reveals [historical findings]. Examination reveals [examination

findings]. Diagnostic studies reveal [imaging, electrophysiologic, or laboratory results].

Example:A [52-year-old female]presents to the office with the complaint of [generalized pruritus for the last six months and someyellowing of her complexion over the last two weeks]. Past medical history is [negative]. Physical examination reveals[jaundice and hepatomegaly]. Laboratory studies reveal [a serum alkaline phosphatase level five times that of normaand a positive antimitochondrial antibody test].

The clinical scenario should include one or more of the following:

Presenting symptoms

Historical findings Examination findings Structural findings Test results

Clinical scenarios should be brief and concise, with little to no superfluous information.

Patients should not be personalized unless the social, ethnic, or religious information to be included is crucial toanswering the associated question(s). The submission of some items constructed to test the understanding of theseconsiderations is encouraged.


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The Question

All questions are classified under one of six physician taskareas. Each question should focus on one aspect of medicaknowledge or practice.

Health Promotion/Disease Prevention Focuses on areas regarding public health issues, wellness, maintaining the health of an asymptomatic patient, and

prevention of future illness or complications

Appropriate areas to focus on include: Biostatistics and epidemiology Clinical prevention Disease transmission processes

Genomic medicine Occupational and environmental medicine

Related questions include: Which of the following may have prevented this patients condition? The most appropriate preventive measure is The most appropriate recommendation to prevent recurrence is The most appropriate immunization to administer is The most appropriate age at which to administer the next immunization is

The most appropriate screening test is The most appropriate screening program for this age group is The most appropriate age to begin screening for [associated condition] in this patient is The most appropriate dietary supplement is The predictive value of this study represents The most likely environmental factor responsible for this outbreak is The most common risk factor of this condition is The most likely cause of this condition is occupational exposure to

History & Physical

Focuses on areas regarding either the diagnosis of disease based on the clinical scenario provided or the physicafindings, including osteopathic findings when applicable, that would be related to the disease

Appropriate areas to focus on include:

Examination & recognition Gathering patient information

Related questions include: The most likely diagnosis is The most likely physical finding is The most likely osteopathic finding is

Diagnostic Technologies Focuses on diagnostic modalities and test results Appropriate areas to focus on include:

Electrophysiologic testing

Imaging Laboratory testing

Related questions include: The most appropriate diagnostic modality is The most appropriate test to order is The most likely test result is

The most likely finding on [MRI, CT scan, radiograph, etc] is The most appropriate evaluation includes Which of the following diagnostic tools would be most helpful in determining the appropriate treatment plan? The most appropriate next step in this patients work-up is Based on the test findings, the most likely diagnosis is


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Management Focuses on the standard treatment of the presenting condition Appropriate areas to focus on include:

Complementary & alternative medicine Consultation End of life Inter-disciplinary teams Manipulative treatment

Non-Pharmacological medical management Pharmacological management Psychosocial management Rehabilitation Surgery

Related questions include:

The most appropriate treatment is The most appropriate management is The most appropriate medication to prescribe is The most appropriate next step is

Scientific Understanding of Mechanisms Focuses on the underlying pathophysiology of disease processes or mechanism of the treatment prescribed

Appropriate areas to focus on include: Anatomy Biochemistry Genetics Immunology Microbiology Molecular & cell biology Pathology Pharmacology Physiology

Related questions include: The most likely pathophysiology is

The most likely etiologic organism is The primary action of the drug prescribed is The most likely affected structure is Which of the following factors was most crucial in the development of this patients disorder?

Health Care Delivery Focuses on the socioeconomic and ethical aspects of the practice of primary care medicine Appropriate areas to focus on include:

Health care system overview Information management & technology Medical ethics Medical jurisprudence Medical management

Physician-patient communication Population-based care Practice management Quality measurement & improvement Teamwork & collaboration

Related questions include: The most cost-effective management/treatment is This physician may be found liable on the basis of

Which of the following community service agencies should this patient be referred to? The most appropriate agency to contact is The most ethical course of action is


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Appropriate Item Formatting

In order for items to be considered for inclusion on the exams, certain criteria MUST be met.

All items must include:

A specific clinical scenario*

Positive wording in the question (i.e., no phrases such as all of the following except or least likely) A specific objective/focus evident in the question Five answer choices of similar length Focused answer choices (i.e., all management options OR all diagnostic tests OR all diagnoses, etc.)

Plausible answer choices An answer key A reference, including edition and page number

*The ONLY exception to including a clinical scenario is Level 1 items, which can OCCASIONALLY be straight-forwardquestions when it is not possible to create a clinical scenario to fit an important concept. All Level 2 and 3 itemsMUST include a specific clinical scenario.

When writing an item, keep in mind that:

Each answer choice should grammatically follow from the question Only non-proprietary names of medications are used When including specific laboratory values in an item, the Reference Adult Laboratory Values listing on pages 39-42

should be used as the standard Only abbreviations which are common, accepted nomenclature should be included; if they are not commonly known,

they should be spelled out

Answer choices must NOT be: Opposites

(e.g., hyperthyroidism and hypothyroidism) Too closely related to one another

(e.g., MRI with contrast and MRI without contrast)

When writing an item, you should ask yourself several questions to ascertain if it is a high-quality item: Is the information current? If it is a case, are the questions sufficiently independent from one another so as to not give away the answer to

one? Is the clinical scenario necessary to answer the associated question(s)? Are all of the answer choices plausible? Is the correct answer the best choice given? Are the incorrect answer choices sufficiently discriminating?

Inappropriate Item FormattingInappropriate item formats include:

Generalized items without a clinical scenario

Teaching in the item Negative phrasing in the question, such as except, least, and not Interrelated answer choices, such as all of the above, none of the above, and both A and B

If any of these aspects are present in a submitted item, the item will be returned for reworking and will not be consideredfor inclusion on the exam.


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Examples of Inappropriate Item Formats

Generalized items without a clinical scenario

Inappropriate formatW

hich of the following is correct regarding Hirschsprung disease?

(A) it is associated with hypokalemia

(B) it is associated with postoperative anal stricture(C) it is caused by congenital absence of the myenteric parasympathetic nerve ganglia of the distal colon(D) it is caused by partial mechanical obstruction of the lower colon, rectum, or anus(E) meconium ileus is usually presentAnswer: C

Appropriate formatA 1-week-old infant is brought to the office by his mother, who states that the child has not had a bowel movement for thepast three days. He has been breast feeding normally; however, she has noticed that his abdomen is swelling. Physicalexamination reveals the child to be afebrile, with a firm, distended abdomen and diminished bowel sounds. Rectalxamination reveals absence of feces. The most likely diagnosis ise

(A) enzyme deficiency

(B) Hirschsprung disease(C) hypothyroidism(D) imperforate anus(E) pyloric stenosisAnswer: B

Teaching in the item

Inappropriate formatUniversal precautions should be utilized by all medical personnel during the resuscitation of patients. A number of devicesare utilized to protect individuals from contracting diseases while providing this vital medical care. The most protectiveiece of equipment to prevent the spread of disease isp

(A) booties(B) face mask(C) gloves(D) goggles(E) gownAnswer: C

Appropriate formatA 30-year-old male presents to the emergency department in acute respiratory distress. You advise your staff to prepare foa possible emergent intubation. The most protective piece of equipment your staff should use to prevent the spread ocommunicable disease is

(A) booties

(B) face mask(C) gloves(D) goggles(E) gownAnswer: C


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Negative phrasing (except, least, or not'")

A 50-year-old female presents to the emergency department with right eye pain and nausea. The patient noticed thepain earlier that day in a theater. She also states that her vision is blurred, with halos seen around lights. Physicalexamination reveals a diffusely reddened and matted right eye with reduced visual acuity. The cornea is hazy and the

pupil is mid-dilated and fixed to light. Intraocular pressure is 50 mmHg.

Inappropriate formatAll of the following symptoms would be diagnostic of acute angle-closure glaucoma in this patient EXCEPT:

(A) brow pain(B) constricted pupil(C) corneal edema(D) increased intraocular pressure(E) occasional gastrointestinal symptomsAnswer: B

Appropriate formatThe most likely diagnosis is

(A) acute angle-closure glaucoma(B) acute iritis(C) central retinal artery occlusion

(D) central retinal vein occlusion(E) retrobulbar neuritisAnswer: A

Interrelated distractors(all of the above, none of the above, and both A and B)

A 57-year-old male presents to the office with progressive photophobia, blurred vision, and pain in the right eye over thelast six hours. The patient denies any trauma to the eye or previous eye problems. Physical examination reveals areddened and painful eye with the pupil constricted and direct and consensual photophobia apparent on penlightexamination. There is evidence of a ciliary flush and a diffuse reddening of the sclera at the limbus. Visual acuity andintraocular pressure are decreased in the affected eye.

Inappropriate formatThis patients symptoms are most suggestive of

(A) corneal ulcer(B) iritis(C) keratitis(D) both A and B(E) all of the aboveAnswer: E

Appropriate formatThis patients symptoms are most suggestive of

(A) conjunctivitis(B) detached retina(C) hyphema(D) iritis(E) ruptured lensAnswer: D


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Differentiating by Level

For each level, there is a candidate status requirement to register for the examination.

Level 1: two years of osteopathic medical schoolLevel 2: three to four years of osteopathic medical school

Level 3: graduate of an osteopathic medical school and registered in an internship program

Although all three levels have the same item format requirements, appropriate content varies by level. The majodistinctions between the three levels are as follows:

Level Focus Item Emphasis Physician Task Emphasis*

1Application of basic scientific andclinical principles

Basic science principlesScientific Understanding ofMechanisms

2 Interpretation of classic disorders Diagnosing disorders History & Physical

3Interpretation of classic disordersand unusual scenarios and theirsecondary complications

Determining appropriatemanagement

Management,Diagnostic Technologies

*Although there is an emphasis on these areas, each level requires questions in a variety of physician task areas. Seepage 44 foran outline of the percentages required by each level.

Items for all three levels should: Contain universally accepted terms Be based on the current standard of care Require the application of knowledge and not mere recall of facts

Address high-impact or high-frequency issues encountered by generalist physicians


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Utilizing Visuals

There are three aspects to consider when utilizing a visual in an item:

The visual must be essential to the item The clinical scenario text mustnot duplicate the information provided in the visual The visual must be of the highest quality

The following are suggestedvisual types:

Diagrams/charts/graphs (Level 1 ONLY) Microscopic slides Photographs of physical findings (the eyes will be blacked out unless instructed otherwise) 12-lead ECG Rhythm strip Fetal monitor strip Radiograph MRI CT scan

Ultrasound

Submitted visuals must be:

A high-quality copy or digital file of the visual (i.e., no photocopies); these can be returned upon request An original visual (i.e., it absolutely can not come from a published source, whether it be a publication or website,

and should not have appeared on another test or in lecture material)

Sharp and clear Level appropriate; visuals that may require discipline expertise to interpret are inappropriate

W

hen submitting a visual:

Note the top/bottom or left/right of the visual Note if the original needs to be returned

Computer files can be accepted in jpeg, tif, or Photoshop format. For all other file types, please contact the appropriateTest Administrator.


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NOTE: The visual examples have been replicated and do not represent acceptable visuaquality.

Diagrams, Charts & Graphs

Primarily used to provide information that the examinee must evaluate and draw conclusions from without being toldwhat the implications are

ExampleA 72-year-old female is hospitalized for sepsis. Blood cultures are drawn and the patient is placed on a -lactam

antibiotic. Twenty-four hours later, the laboratory reports the following growth curve for the bacteria grown from theblood cultures:

According to the chart, in which of the following phases of growth are the organisms sensitive to the effects of theantibiotics?

(A) A(B) B(C) C(D) D(E) E


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Imaging Studiese.g. radiograph, CT scan, MRI, ultrasound)(

Primarily included with items as a diagnostic tool for the examinee to use in determining the most likely diagnosis or

the most appropriate management When included with a Level 1 item, they may be used in the identification of anatomical areas

Example

A 42-year-old male is admitted to the hospital with lower left abdominal pain, fever, and anorexia of two days duration.Laboratory studies reveal a hemoglobin of 15.3 g/dL, a hematocrit of 47.4%, and a leukocyte count of 16.7 x 10 3/mcL.Colonoscopy and CT scan of the abdomen are negative. A barium enema is performed as shown below:

The most likely diagnosis is

(A) colon neoplasm(B) Crohn disease of the colon(C) mucosal ulcerative colitis(D) perforated sigmoid diverticulitis(E) regional ileitis with fistula to the colon


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ECGs

Similar to imaging studies, they are primarily included with items as a diagnostic tool for the examinee to use indetermining the most likely diagnosis or the most appropriate management

ExampleA 48-year-old male presents to the office with a history of intermittent chest pain over the past month. The pain lastsfrom a few seconds to a few minutes, but never causes the patient any significant distress. He denies shortness o

breath, diaphoresis, and other associated symptoms. The pain occurs equally at rest or while participating in vigorousactivity. Physical examination is normal, and past medical and family history are non-contributory. An ECG is obtained asshown below:

The most likely diagnosis is

(A) first-degree heart block(B) second-degree heart block(C) third-degree heart block(D) junctional rhythm(E) sinus bradycardia


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Level 1 Sample Items

Stand Alones

1. An otherwise healthy 23-year-old female at 32 weeks gestation develops intolerance, hyperventilation, anddyspnea. Although she has a mild alkalosis, no significant pulmonary abnormalities are found. The most likelycause of her respiratory changes is a decrease in

(A) inspiratory capacity(B) minute ventilation(C) tidal volume(D) total lung capacity(E) vital capacity

Patient Presentation: Pregnancy/Childbirth/Postpartum/NeonatalSubtopic: pregnancy complicationsEtiology: none specifiedPhysician Task: Scientific Understanding of Mechanisms

2. A 16-year-old male with a long history of cystic fibrosis presents to the emergency department with the suddenonset of a swollen right knee. Examination reveals a swollen joint with fluid. Numerous bruises are noted invarious stages of resolution. Further history reveals easy bruising and bleeding from the gums over the pas

month. The most likely explanation for these findings is

(A) diffuse intravascular coagulation secondary to infection(B) hypocomplementemia(C) hypofibrinogenemia(D) late-onset factor VIII deficiency(E) malabsorption of vitamins A, D, E, and K

Patient Presentation: Masses & EdemaSubtopic: knee masses/swellingEtiology: none specified

Physician Task: Scientific Understanding of Mechanisms

3. A 45-year-old female presents with unexplained hypertension. Paroxysmal episodes of headache, sweatinganxiety, nausea, and vomiting occur frequently. A CT scan reveals a left adrenal mass. Which of the followingurinary metabolites would be most helpful in establishing a diagnosis?

(A) cortisol(B) glucose(C) sodium(D) uric acid(E) vanillylmandelic acid

Patient Presentation: Masses & Edema

Subtopic: chest/lung massEtiology: none specifiedPhysician Task: Diagnostic Technologies


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4. A 62-year-old male with a history of diabetes presents with the complaint of decreasing vision in his right eyeHe states that objects appear blurred and that his vision has been declining over the last four months.Funduscopic examination reveals multiple scattered dot and blot hemorrhages as well as several hard exudates inthe macula of the right eye. The most likely diagnosis is

(A) cataract(B) open-angle glaucoma(C) refractive error(D) retinopathy(E) vitreous hemorrhage

Patient Presentation: Sensory & CNS DifficultiesSubtopic: visual disordersEtiology: diabetic retinopathyPhysician Task: History & Physical

5. A term 12-hour-old neonate develops the sudden onset of respiratory distress, apnea, and shock. Chestradiograph reveals bilateral infiltrates. Cerebrospinal fluid reveals gram-positive cocci. The most appropriateinitial treatment is

(A) ceftriaxone

(B) chloramphenicol(C) clindamycin(D) penicillin G(E) tetracycline

Patient Presentation: Pregnancy/Childbirth/Postpartum/NeonatalSubtopic: neonatal complicationsEtiology: respiratory distress syndrome

Physician Task: Management

6. A 26-year-old male presents with a cough, esophageal candidiasis, and recent weight loss. Initial screeningreveals the presence of anti-HIV antibodies. Which of the following is most appropriate to order as aconfirmatory test?

(A) complement fixation test(B) delayed hypersensitivity test(C) hemagglutination test

(D) immunofluorescence assay(E) Western blot assay

Patient Presentation: Digestive DifficultiesSubtopic: weight lossEtiology: AIDS/HIVPhysician Task: Diagnostic Technologies


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Cases

Case A

A 30-year-old female has a history of epilepsy that is well controlled on phenytoin. During a hospitalization focholecystitis, she begins to have a bizarre sequence of movements and contortions associated with unresponsivenesslasting ten minutes at a time, and recurring hourly. There is no postictal symptomatology. Her phenytoin levels aretherapeutic, and her electroencephalogram is normal. During these spells, her pupils are equal and reactive, her cornea

reflexes are intact, and her plantar reflexes are normal.Patient Presentation: Sensory & CNS DifficultiesSubtopic: seizuresEtiology: pseudoseizures

1. The most likely diagnosis is

(A) drug withdrawal seizures(B) generalized tonic-clonic seizures(C) partial complex seizures(D) pseudoseizures(E) status epilepticus

Physician Task: History & Physical

2. The most appropriate diagnostic modality is

(A) ambulatory ECG(B) ambulatory electroencephalogram (EEG)(C) lumbar puncture(D) MRI

(E) simultaneous video-EEG telemetry

Physician Task: Diagnostic Technologies

Case B

A 73-year-old hospitalized patient develops renal failure secondary to gentamicin therapy. Due to inappropriate

administration of potassium, the patient develops hyperkalemia (8.0 mEq/L).Patient Presentation: Genitourinary Disorders/IssuesSubtopic: oliguriaEtiology: renal failure

1. The earliest ECG manifestation of hyperkalemia is

(A) AV conduction delay(B) peaked T waves(C) QRS widening(D) ST segment depression(E) supraventricular arrhythmias


2. Assuming ECG changes are present, which of the following is the most appropriate immediate therapy for thispatient?

(A) calcium gluconate

(B) dialysis(C) glucose-insulin infusion(D) sodium bicarbonate(E) sodium polystyrene sulfonate



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3. The goal of this initial therapy is to

(A) antagonize the cardiac and neuromuscular effects of hyperkalemia(B) drive the potassium into the cells(C) increase intracellular protein binding of potassium

(D) increase the volume of distribution of potassium(E) promote renal potassium excretion


Matching Sets

Set A

For each numbered item (patient presentation), select the one heading (etiologic agent) most closely associatedwith it. Each lettered heading may be selected once, more than once, or not at all.

(A) Aspergillus fumigatus

(B) Blastomyces dermatitidis(C) Coccidioides immitis

(D) Pneumocystis carinii

(E) Sporothrix schenckii

Patient Presentation: Respiratory DifficultiesSubtopic: cough

Etiology: none specifiedPhysician Task: Scientific Understanding of Mechanisms

1. A 40-year-old previously healthy male presents with night sweats, chest pain, a cough, and an osteolytic lesion on themetacarpal. He is Mantoux- and histamine-negative, but has a history of travel to southern California.

2. A 9-year-old female with a severe cough and fever is one of several children with similar symptoms who presentsafter visiting a water nature preserve which contains a high population of beavers.


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Stand Alones

1. A 16-year-old female presents with a fever of unknown origin. Her parents are informed that she will need to behospitalized in order to be diagnosed. Upon questioning, the physician informs the parents that insurance wilcover the cost. The insurance company, however, refuses payment. The parents sue the insurance company

and physician for settlement of the hospital bill. Under which of the following rules of law is the physicianincluded in the case?

(A) agency law(B) captain of the ship(C) medical negligence

(D) strict liability of tort(E) vicarious liability

Patient Presentation: Fever & HypothermiaSubtopic: feverEtiology: fever of unknown originPhysician Task: Health Care Delivery

2. A 55-year-old female presents to the clinic with the complaint of progressive aching and weakness of her arms

and legs. On examination, her proximal muscles are tender to palpation and weak when compared to her distamuscles. Laboratory studies reveal an elevated serum creatine phosphokinase, antistreptolysin titer, anderythrocyte sedimentation rate. The most likely diagnosis is

(A) Duchenne dystrophy(B) myasthenia gravis(C) peripheral neuropathy(D) poliomyelitis(E) polymyositis

Patient Presentation: Fatigue & Weakness

Etiology: none specifiedPhysician Task: History & Physical

3. A 52-year-old male presents to the office with acute arthritis of the first right metatarsophalangeal joint. There isa history of four similar attacks during the past year. The most appropriate initial treatment is

(A) allopurinol(B) codeine sulfate(C) indomethacin(D) penicillin G benzathine(E) prednisone

Patient Presentation: Musculoskeletal Difficulties & Muscular Pain

Subtopic: joint painEtiology: none specifiedPhysician Task: Management


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4. A female presents with the complaint of not feeling well. She admits to consuming two glasses of wine and asix-pack of beer daily. Examination reveals scleral icterus. There is right upper quadrant tenderness and anobviously enlarged gallbladder. Acute tissue texture changes are palpated at T7-T8 on the left. A rectaexamination reveals light-colored stool. Laboratory studies reveal:

Aspartate aminotransferase: 72 U/LAlanine aminotransferase: 112 U/LAlkaline phosphatase: 1120 U/LTotal bilirubin: 7.3 mg/dL

The most appropriate diagnostic modality is

(A) endoscopic retrograde cholangiopancreatography(B) liver and spleen scan(C) liver biopsy(D) percutaneous transhepatic cholangiogram(E) ultrasound of the gallbladder and liver

Patient Presentation: Substance AbuseSubtopic: alcohol abuseEtiology: none specifiedPhysician Task: Diagnostic Technologies

5. A patient is seen with a potassium level of 2.1 mEq/L. After one week on spironolactone, her potassium is 3mEq/L. The most likely diagnosis is

(A) Addison disease(B) Cushing disease(C) pheochromocytoma(D) primary aldosteronism(E) Waterhouse-Friderichsen syndrome

Patient Presentation: Asymptomatic & General Symptoms

Subtopic: abnormal findingsEtiology: electrolyte abnormalities


6. A mother weans her infant from breast-feeding after six months. The infant should now be started on

(A) iron-fortified formula(B) lowfat milk with iron supplement(C) soy formula(D) vitamin D-fortified cows milk(E) whole milk with vitamin supplements

Patient Presentation: Pregnancy/Childbirth/Postpartum/NeonatalSubtopic: lactationEtiology: none specified

Physician Task: Health Promotion/Disease Prevention


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7. A 45-year-old female presents with a six-month history of dysphagia and pyrosis. Upper gastrointestinaradiographs reveal reflux of barium into the esophagus and a persistent mid-esophageal narrowing. Endoscopyand biopsy at the narrowed esophagus reveal tissue containing gastric-appearing mucosa. The most likelydiagnosis is

(A) Barrett esophagus(B) Boerhaave syndrome(C) diffuse esophageal spasm(D) esophageal carcinoma(E) Plummer-Vinson syndrome

Patient Presentation: Digestive DifficultiesSubtopic: dysphagia/feeding problems/odynophagiaEtiology: esophageal stricturesPhysician Task: History & Physical

Cases

Case A

A 71-year-old female presents to the emergency department with the complaint of diarrhea, wheezing, cutaneousflushing, and a right upper quadrant mass. Physical examination of the abdomen reveals an irregular nodular liverUrinary excretion of 5-HIAA is moderately elevated.

Patient Presentation: Masses & EdemaSubtopic: abdominal massesEtiology: neoplasm

1. Which of the following neoplasms is most likely responsible for this patients symptoms?

(A) adrenal adenoma(B) carcinoid(C) gastrinoma(D) pheochromocytoma

(E) thyroid carcinoma


2. The mechanism of flushing associated with this patients neoplasm is most likely attributable to which of thefollowing substances secreted by the neoplasm?

(A) adrenocorticotropic hormone(B) bradykinins(C) histamine(D) serotonin(E) tachykinins



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Matching Sets

Set A

For each numbered item (patient presentation), select the one heading (dermatologic condition) most closelyassociated with it. Each lettered heading may be selected once, more than once, or not at all.

(A) cherry hemangioma

(B) lentigo

(C) seborrheic keratosis(D) skin tag(E) venous lake

Patient Presentation: Skin, Nail, & Hair DisordersSubtopic: lesionsEtiology: none specifiedPhysician Task: History & Physical

1. An 80-year-old female presents with grey, tan, and flesh-colored papules in her axillary and groin areas.

2. An 84-year-old nursing home resident presents with variable colored, stuck-on greasy papules and plaques on thetrunk, neck, and face.

3. A 74-year-old retired truck driver presents with a red, soft, nonblanchable papule on his trunk.

4. A 76-year-old male presents with two soft, compressible, bluish-purple papules, one his lip and one on the pinna ohis ear.


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Stand Alones

1. An 8-year-old male presents to the office with a history of outbursts of cursing. His parents report that they havetried everything to get him to stop. In observing the patient, you note that he blinks his eyes excessively. Theparents state that the worst thing is that he smiles with a wide grin after he curses. The most effective treatmen

for this patient is

(A) divalproex sodium(B) haloperidol(C) lorazepam(D) methylphenidate(E) thioridazine

Patient Presentation: Cognitive DifficultiesSubtopic: behavioral disturbancesEtiology: Tourette SyndromePhysician Task: Management

2. A 76-year-old male is brought to the office by his anxious and concerned daughter. History and physicaexamination reveals that he suffers from Parkinson disease, memory loss, gait disturbance, osteoarthritis, andurinary incontinence. He has become increasingly dependent on his daughter for all of his activities of dailyliving. The daughter is extremely stressed out. The two live together in a small apartment on a fixed incomeWhich of the following local agencies should be contacted in order to identify community resources which mayhelp to support this family unit?

(A) area agency on aging(B) community health agency(C) Medicaid office(D) Medicare office(E) mental health center

Patient Presentation: Musculoskeletal Difficulties & Muscular PainSubtopic: gait disturbance/fallsEtiology: Parkinson diseasePhysician Task: Health Care Delivery

3. A 70-year-old female presents to the office with a history of weight gain and fatigue. Examination reveals thatshe has a coarse voice and hung up reflexes. She has wasting of the thenar eminence of her left hand withweakness of the hand. Chest radiograph reveals an enlarged cardiac silhouette. The most useful test in theevaluation of this patient is

(A) antinuclear antibody test(B) CT scan of the head

(C) radiograph of the hand(D) rheumatoid factor(E) thyroid-stimulating hormone level

Patient Presentation: Digestive DifficultiesSubtopic: weight gain/obesityEtiology: thyroid disturbancePhysician Task: Diagnostic Technologies


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26

Cases

Case AA 25-year-old gravida 3, para 2-0-0-2 female is admitted to the hospital in early labor. She states that the contractionsare occurring every three to four minutes and last 50-60 seconds. By dates, she is at 38 weeks gestation. The height othe uterine fundus is 40 cm above the symphysis pubis. She is 1.6 m (5'4") tall and currently weighs 85 kg (187 lb). Heprevious labors were both in excess of 12 hours, and resulted in the spontaneous delivery of infants weighing 3.7 kg (8 lb

2 oz) and 4.0 kg (8 lb 13 oz), respectively. Six hours after admission, her contractions are still mild in intensity and arenow occurring every six to seven minutes. Vaginal examination reveals the cervix to be 60% effaced and 3 cm dilatedwith the cephalus presenting at a 2 station. The fetal membranes are intact and bulging. Fetal heart tones are varyingfrom 130-150/min without decelerations.

Patient Presentation: Pregnancy/Childbirth/Postpartum/ NeonatalSubtopic: labor & delivery processEtiology: complications

1. The most likely primary diagnosis is

(A) absolute cephalopelvic disproportion(B) fetal malposition(C) obstructed labor(D) soft tissue dystocia(E) uterine inertia


2. The most appropriate management is to

(A) administer ritodrine(B) artificially rupture the membranes(C) obtain an ultrasound

(D) perform a Leopold maneuver(E) send the patient for a one-hour walk


3. Labor does NOT progress significantly in the next two hours. The fetal heart tones are varying between 132/minand 144/min without decelerations. The most appropriate next step is to

(A) administer an enema(B) augment labor with intravenous oxytocin(C) maintain the patient in a steep reverse Trendelenburg position(D) order blood to be crossmatched(E) prepare the patient for a cesarean section


4. The patient delivers an infant weighing 4.4 kg (9 lb 11 oz). The most likely complication to anticipate is

(A) cervical laceration(B) postpartum depression(C) retained placenta(D) ruptured uterus(E) uterine atony

Physician Task: Health Promotion/Disease Prevention


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Case BA 45-year-old female presents with the complaint of generalized headache, unilateral hearing loss, tinnitus, andunsteadiness for the past five months. Abnormal findings on clinical examination include decreased hearing in the righear, loss of corneal reflexes on the right, decreased sensation on the right side of the face, and right extremity ataxia.

Patient Presentation: Sensory & CNS DifficultiesSubtopic: hearing disordersEtiology: tinnitus

1. The most likely diagnosis is

(A) Benedikt syndrome(B) left convexity meningioma(C) left hemisphere cerebrovascular accident

(D) left temporal lobe glioblastoma multiforme(E) right acoustic neuroma


2. The most appropriate work-up includes

(A) cerebral angiography

(B) CT scan of the head(C) MRI of the head(D) nuclear brain scan(E) skull radiographs


Case CA 50-year-old male presents to the emergency department from his home because of ataxia. His family brought him in andthey state that his only medical problem is that he has been a heavy abuser of alcohol for many years. The patient is ataxicconfused, pale, malnourished, and has a very heavy smell of alcohol on his breath.

Patient Presentation: Substance AbuseSubtopic: alcohol abuseEtiology: non specified

1. Anemia found in this patient is due to a deficiency of

(A) erythropoietin(B) folate(C) iron(D) magnesium(E) thiamine


2. The primary pathway of ethanol oxidation in this patient's liver is via which of the following enzyme systems?

(A) alcohol dehydrogenase(B) catalase(C) citric acid (TCA) cycle(D) cytochrome P450 system(E) microsomal ethanol-oxidizing system



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28

Matching Sets

Set AFor each numbered item (patient presentation), select the one heading (procedure) most closely associated with itEach lettered heading may be selected once, more than once, or not at all.

(A) abdominoperineal resection with end colostomy

(B) laser vaporization ablation

(C) left hemicolectomy with primary anastomosis(D) sigmoid resection with diverting colostomy(E) total colectomy with ileostomy

Patient Presentation: Masses & EdemaSubtopic: rectal masses/swellingEtiology: none specifiedPhysician Task: Management

1. A 32-year-old female presents with ulcerative colitis and bleeding that has been unresponsive to conservativetherapy.

2. A 65-year-old male presents with a pelvic abscess due to sigmoid diverticular disease.

3. A 54-year-old female presents with adenocarcinoma 4 cm from the anal verge.

4. An 89-year-old male presents with a 3-cm villous adenoma extending from the anus.

5. A 75-year-old female presents with a 3-cm well-differentiated adenocarcinoma of the sigmoid colon.


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Sample Item Answer Keys

Level 1 Level 2 Level 3

Stand Alones Stand Alones Stand Alones

1. D 1. E 1. A

2. E 2. D 2. A

3. E 3. C 3. E

4. D 4. E Cases

5. D 5. D Case A

6. E 6. A 1. E

Cases 7. A 2. B

Case A Cases 3. B

1. D Case A 4. E

2. E 1. B Case B

Case B 2. C 1. E

1. B Matching Sets 2. C

2. A Set A Case C

3. A 1. D 1. B

Matching Sets 2. C 2. A

Set A 3. A Matching Sets

1. C 4. E Set A

2. B 1. E

2. D

3. A

4. B

5. C


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Reference Adult Laboratory Values

BLOOD, PLASMA, SERUM

Alanine aminotransferase (ALT, SGPT at 37C)

Male ........................ ....................... ........... ............13-40 U/L (0.22-0.68 mckat/L)Female ........................ ....................... ........... ............10-28 U/L (0.17-0.48 mckat/L)

Albumin, serum ....................... ....................... ........... ............3.5-5.2 g/dL (35-52 g/L)Amylase, serum .........................................................................27-131 U/L (0.46-2.23 mckat/L)

Aspartate aminotransferase (AST, SGOT at 37C) ........................10-59 U/L (0.17-1.00 -2 to +3 kat/L)

Bilirubin, serum (Adult)Total .........................................................................0.2-1.2 mg/dLDirect .........................................................................0.0-0.4 mg/dL

CA-125, serum .........................................................................< 35 U/mL (< 35 kU/L)Calcium, serum .........................................................................8.6-10.0 mg/dL (2.15-2.50 mmol/L)Cholesterol, serum .....................................................................< 200 mg/dL (< 5.2 mmol/L)

Cholesterol, HDL ........................................................................> 40 mg/dLCholesterol, LDL ........................................................................< 130 mg/dL (< .2 mmol/L)Cholesterol, triglycerides, serum .................................................< 150 mg/dLCortisol, plasma

8 AM .........................................................................5-23 mcg/dL (138-635 nmol/L)

4 PM .........................................................................3-16 mcg/dL (83-441 nmol/L)10 PM .........................................................................< 50% of 8 AM value (< 0.5 of 8 AM value)

Creatine kinase, serum (at 30C)Male .........................................................................15-105 U/L (0.26-1.79 mckat/L)Female .........................................................................10-80 U/L (0.17-1.36 mckat/L)

Creatinine, serum ......................................................................Male .........................................................................0.7-1.3 mg/dL (62-115 mcmol/L)Female .........................................................................0.6-1.1 mg/dL (53-97 mcmol/L)

C-Reactive protein ......................................................................< 0.5 mg/dL (< 5 mg/L)Electrolytes, serum

Sodium .........................................................................136-145 mEq/L (136-145 mmol/L)Chloride .........................................................................98-107 mmol/LPotassium ......................................................................3.5-5.1 mEq/L (3.5-5.1 mmol/L)

Bicarbonate ...................................................................22-29 mEq/L (22-29 mmol/L)Ferritin, serum

Male .........................................................................20-250 ng/mL (20-250 mcg/L)Female .........................................................................10-120 ng/mL (10-120 mcg/L)

Fibrinogen, plasma ....................................................................200-400 mg/dL (2-4 g/L)Follicle-stimulating hormone, plasma

Male .........................................................................1.4-15.4 mIU/mL (1.4-15.4 IU/L)Female

Follicular phase ..................................................1-10 mIU/mL (1-10 IU/L)Mid-cycle peak ...................................................6-17 mIU/mL (6-17 IU/L)Luteal phase ......................................................1-9 mIU/mL (1-9 IU/L)Postmenopausal ................................................19-100 mIU/mL (19-100 IU/L)

Gases, arterial blood (room air)pH .........................................................................7.35-7.45pO2 .........................................................................83-108 mmHg (11.1-14.4 kPa)PCO2

Male..................................................................35-48 mmHg (4.66-6.38 kPa)Female ..............................................................32-45 mmHg (4.26-5.99 kPa)

O2 saturation, arterial and capillary ..................................95-98% of capacity (0.95-0.98 of capacity)Glucose, serum

Fasting .........................................................................74-106 mg/dL (4.1-5.9 mmol/L)2 h postprandial .............................................................< 120 mg/dL (


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Growth hormone .......................................................................Male .........................................................................< 5 ng/mL (< 5 mcg/L)Female .........................................................................< 10 ng/mL (< 10 mcg/L)

Chorionic gonadotropin, intact (male or non-pregnant female) ......< 5.0 mIU/mL (< 5.0 IU/L)Immunoglobulins, serum

IgA .........................................................................70-400 mg/dL (0.7-4.0 g/L)IgD .........................................................................0-8 mg/dL (0-80 mg/L)IgE .........................................................................3-423 IU/mL (3-423 kIU/L)

IgG .........................................................................700-1600 mg/dL (7-16 g/L)IgM .........................................................................40-230 mg/dL (0.4-2.3 g/L)

Iron, serumMale .........................................................................65-175 mcg/dL (11.6-31.3 mcmol/L)Female .........................................................................50-170 mcg/dL (9.0-30.4 mcmol/L)

Iron binding capacity, total (TIBC), serum ...................................250-425 mcg/dL (44.8-71.6 mcmol/L)

Lactate dehydrogenase (LDH) ....................................................100-190 U/L (1.7-3.2 mckat/L)Lead, whole blood (Hep) .............................................................< 25 mcg/dL (< 0.48 mcmol/L)Lipase, serum (37C) ..................................................................23-300 U/L (0.39-5.1 mckat/L)Luteinizing hormone, serum/plasma

Male .........................................................................1.24-7.8 mIU/mL (1.24-7.8 IU/L)Female

Follicular phase .................................................1.68-15.0 mIU/mL (1.68-15.0 IU/L)

Mid-cycle peak ..................................................21.9-56.6 mIU/mL (21.9-56.6 IU/L)Luteal phase ......................................................0.61-16.3 mIU/mL (0.61-16.3 IU/L)Postmenopausal ................................................14.2-52.5 mIU/mL (14.2-52.5 IU/L)

Magnesium, serum ....................................................................1.3-2.1 mEq/L (0.65-1.07 mmol/L)Osmolality, serum ......................................................................275-295 mOsm/kg serum waterParathyroid hormone, intact ........................................................14-72 pg/mLPhosphatase (alkaline), serum (37C) ..........................................38-126 U/L (0.65-2.14 mckat/L)Phosphate (inorganic), serum .....................................................2.7-4.5 mg/dL (0.87-1.45 mmol/L)Prolactin, serum

Male .........................................................................2.5-15.0 ng/mL (2.5-15.0 mcg/L)

Female .........................................................................2.5-19.0 ng/mL (2.5-19.0 mcg/L)Prostate-specific antigen (PSA) ....................................................< 4.0 ng/mL (< 4.0 mcg/L)

Proteins, serumTotal .........................................................................6.4-8.3 g/dL (64-83 g/L)Albumin .........................................................................3.9-5.1 g/dL (39-51 g/L)Globulin

1......................................................................0.2-0.4 g/dL (2-4 g/L)2 .....................................................................0.4-0.8 g/dL (4-8 g/L) .......................................................................0.5-1.0 g/dL (5-10 g/L) .......................................................................0.6-1.3 g/dL (6-13 g/L)

Testosterone, serumMale .........................................................................280-1100 ng/dL (0.52-38.17 nmol/L)Female

Premenopausal ..................................................15-70 ng/dL (0.52-2.43 nmol/L)Pregnancy..........................................................3-4 x normal (3-4 x normal)

Postmenopausal.................................................8-35 ng/dL (0.28-1.22 nmol/L)Thyroid-stimulating hormone (TSH) ............................................0.4-4.2 mcU/mL (0.4-4.2 mU/L)Thyroxine (T4), serum ................................................................5-12 mcg/dL (65-155 nmol/L)Triiodothyronine (T3), total, serum...............................................100-200 ng/dL (1.54-3.8 nmol/L)Triiodothyronine (T3), resin uptake ..............................................25-38 relative % uptake (0.25-0.38 uptake)Troponin-I .........................................................................undetectableUrea nitrogen, serum .................................................................6-20 mg/dL (2.1-7.1 mmol urea/L)Uric acid, serum .........................................................................

Male .........................................................................4.5-8.0 mg/dL (0.27-0.47 mmol/L)Female .........................................................................2.5-6.2 mg/dL (0.15-0.37 mmol/L)

Vitamin B12, serum .....................................................................110-800 pg/mL (81-590 pmol/L)


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CEREBROSPINAL FLUIDCell count .........................................................................0-10 leukocytes/mm3

.........................................................................0 erythrocytes/mm3

Chloride .........................................................................118-132 mmol/LGamma globulin ........................................................................3-12% (0.03-0.12)IgG .........................................................................0.5-6.1 mg/dL (0.5-6.1 g/L)Glucose .........................................................................40-70 mg/dL (2.2-3.9 mmol/L)Pressure .........................................................................70-180 mm H2O

Protein .........................................................................8-32 mg/dL (80-320 mg/dL)

HEMATOLOGICBleeding time (template) ............................................................2.3-9.5 minErythrocyte count, blood

Male .........................................................................4.7-6.1 x 106/mcL (4.7-6.1 x 1012/L)

Female .........................................................................4.2-5.4 x 106/mcL (4.2-5.4 x 1012/L)Hematocrit

Male .........................................................................42-52% (0.42-0.52)Female .........................................................................37-47% (0.37-0.47)

HemoglobinMale .........................................................................14.0-18.0 g/dL (2.17-2.79 mmol/L)Female .........................................................................12.0-16.0 g/dL (1.86-2.48 mmol/L)

Hemoglobin, glycosylated............................................................4.2-5.9% (0.042-0.059)Hemoglobin, plasma ..................................................................< 3 mg/dL (< 0.47 mcmol/L)Leukocyte count and differential

Leukocyte count .............................................................4.8-10.8 x 103/mcL (4.8-10.8 x 106/L)Segmented neutrophils ...................................................54-62% (3000-5800/mcL) (3000-5800x106/L)Band neutrophils ............................................................3-5% (150-400/mcL) (150-400 x 106/L)Eosinophils ....................................................................0-0.7 x 103/mcL (0-0.7 x 109/L)Basophils .......................................................................0-0.2 x 103/mcL (0-0.2 x 109/L)Lymphocytes .................................................................20.5-51.1% (1.2-3.4 x 103/mcL) (1.2-3.4 x 109/L)Monocytes .....................................................................1.7-9.3% (0.11-0.59 x 103/mcL) (0.11-0.59 x 109/L)

Mean Corpuscular Hemoglobin ....................................................27-31 pg (0.42-0.48 fmol)Mean Corpuscular Hemoglobin Concentration ..............................33-37 g/dL (330-370 g/L)

Mean Corpuscular VolumeMale .........................................................................80-94 mcm3 (80-94 fL)Female .........................................................................81-99 mcm3 (81-99 fL)

Partial thromboplastin time (activated) ........................................< 35 secPlatelet count, blood ..................................................................130-400 x 103/mcL (130-400 x 109/L)Prothrombin time-INR ................................................................0.9-1.2Red blood cell distribution width ..................................................11.6-14.6%Reticulocyte count .....................................................................0.5-1.5% RBCs (24,000-84,000/mcL)Sedimentation rate, erythrocyte (Westergren)

Male (0-50 y)..................................................................0-15 mm/hMale (> 50 y) .................................................................0-20 mm/hFemale (0-50 y) .............................................................0-20 mm/hFemale (> 50 y)..............................................................0-30 mm/h

Thrombin time .........................................................................typically 17-25 sVolume, plasma

Male .........................................................................25-43 mL/kg body weight (0.025-0.043 L/kg body weight)Female .........................................................................28-45 mL/kg body weight (0.028-0.045 L/kg body weight)

SEMENVolume .........................................................................1.5-5.0 mL (0.0015-0.005 L)Motility ......................................................................... > 60% (> 0.60)

Count ........................................................................60-150 x 106/mL (60-150 x 109/L)


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SWEATChloride .........................................................................5-35 mmol/L

URINECalcium (usual diet, trough) ........................................................100-300 mg/24 h (2.50-7.50 nmol/24 h)Chloride .........................................................................110-250 mmol/24 h (varies greatly with Cl intake)Creatinine clearance

Male .........................................................................94-140 mL/min/1.73 m2

(0.91-1.35 mL/s/m2

)Female .........................................................................72-110 mL/min/1.73 m2 (0.69-1.06 mL/s/m2)

17-HydroxycorticosteroidsMale .........................................................................3-10 mg/24h (8.3-27.6 mcmol/24 h as cortisol)Female .........................................................................2-8 mg/24 h (5.5-22 mcmol/24 h as cortisol)

17-Ketosteroids

Male .........................................................................10-25 mg/24 h (38-87 mcmol/24 h)Female .........................................................................6-14 mg/24 h (21-52 mcmol/24 h)

Lead, 24 h .........................................................................< 80 mcg/d (< 0.39 mcmol/d)Osmolality .........................................................................50-1200 mOsm/kg water (50-1200 mmol/kg water)pH .........................................................................4.6-8.0 (depends on diet)Potassium, 24 h .........................................................................25-125 mEq/d (varies with diet) (25-125 mmol/d (varies with diet))Proteins, quantitative .................................................................50-80 mg/24 h (at rest)

Sodium, 24 h .........................................................................40-220 mEq/d (diet dependent) (40-220 mmol/d (diet dependent))Specific gravity .........................................................................1.002-1.030Uric acid .........................................................................250-750 mg/24 h (w/normal diet)(1.48-4.43 mmol/24 h (w/normal diet))


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Patient Presentations

Patient Presentations Condensed Topic Area Required

Asymptomatic/General SymptomsAsymptomatic/General Symptoms

8-16%

Digestive DifficultiesSymptoms & Disorders of Digestion

& Metabolism4-10

Cognitive Difficulties

Consciousness Alterations

Fatigue & Weakness

Sensory & CNS Difficulties

Sensory Pain

Substance Abuse

Symptoms & Disorders of SensoryFunction

23-38

Musculoskeletal Difficulties & Muscular PainSymptoms & Disorders of Motor

Function6-12

Genitourinary Disorders/IssuesSymptoms & Disorders Related toHuman Sexuality & Urination

3-8

Bleeding

Respiratory Difficulties

Symptoms & Disorders of Respiration& Circulation

8-16

Fever & HypothermiaSymptoms & Disorders of

Thermoregulation2-6

Discharge

Masses & Edema

Skin, Nail, Hair, & Tooth Disorders

Trauma

Symptoms & Disorders of theTissues and Trauma

8-16

Pregnancy/Childbirth/Postpartum/Neonatal Assessment

Symptoms & Disorders of HumanDevelopment

3-8

Every exam must contain the required percentage determined for each condensed topic area, under which the morespecific patient presentations fall.


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Physician Tasks

Level 1 Level 2 Level 3

Health Promotion/ DiseasePrevention

1-5% 15-20% 15-20%

History & Physical 5-15 30-40 10-20

Diagnostic Technologies 1-5 10-20 15-25

Management 3-7 10-20 25-40

Scientific Understanding ofMechanisms

70-85 5-15 5-10

Health Care Delivery 1-3 5-10 5-10

The emphasis of each level is reflected by the percentage of each physician task required on every examination.


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A1

Blooms Taxonomy of the Cognitive Domain

Blooms taxonomy is a method of categorizing the level of abstraction required to answer a test question. Each levesignifies the purpose of the question and a certain set of skills demonstrated by the test taker. By utilizing this system, iis possible to consider the level of difficulty of a test question.

This year, the NBOME will begin utilizing the Blooms taxonomy system to classify test questions. When writing a

question, please determine which level of taxonomy is being incorporated. Levels 3 and higher are preferable. Whensubmitting a test question, indicate the corresponding taxonomy level as dictated by the table below.

Level of Taxonomy/

Competence

Skills Demonstrated Purpose of Testing

1Knowledge

Recall of data

Knowledge of facts Mastery of subject matter

To evaluate preparedness andcomprehension

Diagnosing

Reviewing and/or summarizing

content

2Comprehension

Understanding ofmeaning

Understanding of information Translation of knowledge into new

contextfrom one medium toanother

Ordering, grouping, inferring causes

To evaluate preparedness andcomprehension

Diagnosing Reviewing and/or summarizing

content

3Application

Use of information

Use of methods, concepts, theories

in new situations Problem-solving using required

skills or knowledge

To evaluate preparedness and

comprehension Diagnosing Reviewing and/or summarizing

content

4

Analysis

Understanding oforganizational

structure

Pattern recognition Organization of parts

Recognition of hidden meanings Identification of components

To encourage students to thinkmore deeply and critically

Problem-solving

Encouraging discussions Stimulating students to seek

information on their own

5

Synthesis

Relation ofknowledge from

several areas

Use of old ideas to create new ones Generalizations from given facts

Prediction and drawing of

conclusions Combination of ideas to form a new

whole


Problem-solving Encouraging discussions

Stimulating students to seekinformation on their own

6

Evaluation

Making judgmentsabout the value of

ideas and materials

Comparison and discriminationbetween ideas

Assessment of value of theories and

presentations Choice-making based on reasoned

argument Verification of value of evidence Recognition of subjectivity


Problem-solving

Encouraging discussions Stimulating students to seek

information on their own


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Multimedia Items

Multimedia questions are a new type of item made possible by the conversion to computer-based testing. The inclusionof multimedia items will allow concepts and principles to be more effectively tested.

The following types of media are currently supported:

Video clips (example: patient with a gait abnormality or motion disturbance) Sound clips (example: heart sounds or respiratory patterns) Interactive visuals (example: images requiring identification of a particular location)

Similar to visuals, multimedia items must:

Be essential to the item Include a clinical scenario that does not duplicate the information given in the media Be of high quality

If you have any of these types of media available, please contact your Test Administrator to discuss possible inclusion inthe upcoming examinations.

comlex iw guide 2006

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