NBOME Item-Writing Guide

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

Table of Contents
Introduction Item Writing/Review Cycle Submitting an Item-Writing Assignment The Assignment Sample Assignment Form How to Write an Item Types of Items The Clinical Scenario The Question Appropriate Item Formatting Inappropriate Item Formatting Examples of Inappropriate Item Formats Differentiating By Level Utilizing Visuals Level 1 Sample Items Level 2 Sample Items Level 3 Sample Items Sample Item Answer Keys Reference Adult Laboratory Values Patient Presentation & Physician Task Requirements Appendix Blooms Taxonomy of the Cognitive Domain Multimedia Items 1 2 3 4 5 6 6 6 7 9 9 10 12 13 17 21 25 29 30 34 A1 A2

Introduction
The quality of the examinations produced by the National Board of Osteopathic Medical Examiners (NBOME) is dependent on the individuals who write the examination questions. You, the item writer, are the bottom line; your efforts are directly 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 the NBOMEs criteria prior to beginning your assignment. This item writing guide outlines the acceptable formats and types of questions. Adhering to these standards ensures the continuing consistency of the NBOME exams. Please refer to this booklet when writing items. While writing your assignment or after you have completed it, you may have comments, questions, or suggestions. We at the NBOME encourage and welcome your feedback. Feel free to contact your Test Administrator (773-7140622) or Level Coordinator at any time during the item writing process.

Item Writing/Review Cycle

Every year new items are submitted and reviewed for potential use. annually. March-May August-September November-December Winter Each level receives approximately 1000 items

Letter of interest sent out to committee members, past item writers, and potential item writers for the next item writing cycle Item writing assignments sent to item writers Completed item writing assignments due Items entered into databank and checked for correct format; inappropriately formatted 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 least three times to ensure appropriate format and content. February March April April May July September The OPP Committee (comprised of osteopathic specialists from osteopathic schools) meets to review all OPP items submitted (first-line review) The New Item Review Committee meets to review all new, non-OPP items submitted the prior November (first-line review) The Approved Item Review Committee meets to review all items approved by the OPP Committee and the New Item Review Committee (second-line review) The Preliminary Exam Review Committee meets to review all items selected for pretesting in the coming exam cycle (third-line review)

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 been scanned 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 of category 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 references should come from a standard source that is readily available nationwide. Websites are not an appropriate source unless they are a government-sponsored site or contain the on-line versions of textbooks. All items lacking an appropriate reference will be returned.

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 etiology combination Examples: Stand Alone, Case Item, Matching (a complete description can be found on page 6) Topic: the general nature of the patients presentation or complaint Examples: Bleeding, Masses & Edema (a complete list can be found on page 34) Subtopic: the more specific complaint or finding Examples: hemoptysis, chest/lung masses Etiology: the cause of the complaint or finding Examples: tuberculosis, infection Physician task: the area of knowledge the related question should test Examples: Health Promotion/Disease Prevention, History & Physical, Management (a complete list can be found 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 Test Administrator. Always adhere to the assigned physician task. An item should be submitted for each physician task listed. If a physician task is listed multiple times, multiple questions should be written focusing on that area.

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 format that 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 Scenario

Although there is more than one way to construct a clinical scenario, there is a pattern that can be used to generate multiple 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 some yellowing 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 normal and 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 to answering the associated question(s). The submission of some items constructed to test the understanding of these considerations is encouraged.

The Question
All questions are classified under one of six physician task areas. Each question should focus on one aspect of medical knowledge 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 physical findings, 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

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

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-forward questions when it is not possible to create a clinical scenario to fit an important concept. All Level 2 and 3 items MUST 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 Formatting

Inappropriate 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 considered for inclusion on the exam.

Examples of Inappropriate Item Formats

Generalized items without a clinical scenario Inappropriate format Which 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 present Answer: C Appropriate format A 1-week-old infant is brought to the office by his mother, who states that the child has not had a bowel movement for the past three days. He has been breast feeding normally; however, she has noticed that his abdomen is swelling. Physical examination reveals the child to be afebrile, with a firm, distended abdomen and diminished bowel sounds. Rectal examination reveals absence of feces. The most likely diagnosis is (A) enzyme deficiency (B) Hirschsprung disease (C) hypothyroidism (D) imperforate anus (E) pyloric stenosis Answer: B Teaching in the item Inappropriate format Universal precautions should be utilized by all medical personnel during the resuscitation of patients. A number of devices are utilized to protect individuals from contracting diseases while providing this vital medical care. The most protective piece of equipment to prevent the spread of disease is (A) booties (B) face mask (C) gloves (D) goggles (E) gown Answer: C Appropriate format A 30-year-old male presents to the emergency department in acute respiratory distress. You advise your staff to prepare for a possible emergent intubation. The most protective piece of equipment your staff should use to prevent the spread of communicable disease is (A) booties (B) face mask (C) gloves (D) goggles (E) gown Answer: 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 the pain earlier that day in a theater. She also states that her vision is blurred, with halos seen around lights. Physical examination 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 format All 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 symptoms Answer: B Appropriate format The most likely diagnosis is (A) acute angle-closure glaucoma (B) acute iritis (C) central retinal artery occlusion (D) central retinal vein occlusion (E) retrobulbar neuritis Answer: 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 the last six hours. The patient denies any trauma to the eye or previous eye problems. Physical examination reveals a reddened and painful eye with the pupil constricted and direct and consensual photophobia apparent on penlight examination. There is evidence of a ciliary flush and a diffuse reddening of the sclera at the limbus. Visual acuity and intraocular pressure are decreased in the affected eye. Inappropriate format This patients symptoms are most suggestive of (A) corneal ulcer (B) iritis (C) keratitis (D) both A and B (E) all of the above Answer: E Appropriate format This patients symptoms are most suggestive of (A) conjunctivitis (B) detached retina (C) hyphema (D) iritis (E) ruptured lens Answer: D

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Differentiating by Level
For each level, there is a candidate status requirement to register for the examination. Level 1: Level 2: Level 3: two years of osteopathic medical school three to four years of osteopathic medical school graduate of an osteopathic medical school and registered in an internship program The major

Although all three levels have the same item format requirements, appropriate content varies by level. distinctions between the three levels are as follows: Level 1 Focus Application of basic scientific and clinical principles Interpretation of classic disorders Item Emphasis Basic science principles

Physician Task Emphasis* Scientific Understanding of Mechanisms History & Physical

Diagnosing disorders

Interpretation of classic disorders and unusual scenarios and their secondary complications

Determining appropriate management

Management, Diagnostic Technologies

*Although there is an emphasis on these areas, each level requires questions in a variety of physician task areas. See page 44 for an 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 must not duplicate the information provided in the visual The visual must be of the highest quality The following are suggested visual 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 When 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 appropriate Test Administrator.

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NOTE: The visual examples have been replicated and do not represent acceptable visual quality. Diagrams, Charts & Graphs
Primarily used to provide information that the examinee must evaluate and draw conclusions from without being told what the implications are Example A 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 the blood cultures:

According to the chart, in which of the following phases of growth are the organisms sensitive to the effects of the antibiotics? (A) (B) (C) (D) (E) A B C D E

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Imaging Studies (e.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 103/mcL. Colonoscopy and CT scan of the abdomen are negative. A barium enema is performed as shown below:

The most likely diagnosis is (A) (B) (C) (D) (E) colon neoplasm Crohn disease of the colon mucosal ulcerative colitis perforated sigmoid diverticulitis 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 in determining the most likely diagnosis or the most appropriate management Example A 48-year-old male presents to the office with a history of intermittent chest pain over the past month. The pain lasts from a few seconds to a few minutes, but never causes the patient any significant distress. He denies shortness of breath, diaphoresis, and other associated symptoms. The pain occurs equally at rest or while participating in vigorous activity. Physical examination is normal, and past medical and family history are non-contributory. An ECG is obtained as shown below:

The most likely diagnosis is (A) (B) (C) (D) (E) first-degree heart block second-degree heart block third-degree heart block junctional rhythm 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, and dyspnea. Although she has a mild alkalosis, no significant pulmonary abnormalities are found. The most likely cause of her respiratory changes is a decrease in (A) (B) (C) (D) (E) inspiratory capacity minute ventilation tidal volume total lung capacity vital capacity Pregnancy/Childbirth/Postpartum/Neonatal pregnancy complications none specified Scientific Understanding of Mechanisms

Patient Presentation: Subtopic: Etiology: Physician Task: 2.

A 16-year-old male with a long history of cystic fibrosis presents to the emergency department with the sudden onset of a swollen right knee. Examination reveals a swollen joint with fluid. Numerous bruises are noted in various stages of resolution. Further history reveals easy bruising and bleeding from the gums over the past month. The most likely explanation for these findings is (A) (B) (C) (D) (E) diffuse intravascular coagulation secondary to infection hypocomplementemia hypofibrinogenemia late-onset factor VIII deficiency malabsorption of vitamins A, D, E, and K Masses & Edema knee masses/swelling none specified Scientific Understanding of Mechanisms

Patient Presentation: Subtopic: Etiology: Physician Task: 3.

A 45-year-old female presents with unexplained hypertension. Paroxysmal episodes of headache, sweating, anxiety, nausea, and vomiting occur frequently. A CT scan reveals a left adrenal mass. Which of the following urinary metabolites would be most helpful in establishing a diagnosis? (A) (B) (C) (D) (E) cortisol glucose sodium uric acid vanillylmandelic acid Masses & Edema chest/lung mass none specified Diagnostic Technologies

Patient Presentation: Subtopic: Etiology: Physician Task:

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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 eye. He 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 in the macula of the right eye. The most likely diagnosis is (A) (B) (C) (D) (E) cataract open-angle glaucoma refractive error retinopathy vitreous hemorrhage Sensory & CNS Difficulties visual disorders diabetic retinopathy History & Physical

Patient Presentation: Subtopic: Etiology: Physician Task: 5.

A term 12-hour-old neonate develops the sudden onset of respiratory distress, apnea, and shock. Chest radiograph reveals bilateral infiltrates. Cerebrospinal fluid reveals gram-positive cocci. The most appropriate initial treatment is (A) (B) (C) (D) (E) ceftriaxone chloramphenicol clindamycin penicillin G tetracycline Pregnancy/Childbirth/Postpartum/Neonatal neonatal complications respiratory distress syndrome Management

Patient Presentation: Subtopic: Etiology: Physician Task: 6.

A 26-year-old male presents with a cough, esophageal candidiasis, and recent weight loss. Initial screening reveals the presence of anti-HIV antibodies. Which of the following is most appropriate to order as a confirmatory test? (A) (B) (C) (D) (E) complement fixation test delayed hypersensitivity test hemagglutination test immunofluorescence assay Western blot assay Digestive Difficulties weight loss AIDS/HIV Diagnostic Technologies

Patient Presentation: Subtopic: Etiology: Physician Task:

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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 for cholecystitis, she begins to have a bizarre sequence of movements and contortions associated with unresponsiveness, lasting ten minutes at a time, and recurring hourly. There is no postictal symptomatology. Her phenytoin levels are therapeutic, and her electroencephalogram is normal. During these spells, her pupils are equal and reactive, her corneal reflexes are intact, and her plantar reflexes are normal. Patient Presentation: Subtopic: Etiology: 1. (A) (B) (C) (D) (E) Sensory & CNS Difficulties seizures pseudoseizures

The most likely diagnosis is drug withdrawal seizures generalized tonic-clonic seizures partial complex seizures pseudoseizures status epilepticus History & Physical

Physician Task: 2.

The most appropriate diagnostic modality is (A) (B) (C) (D) (E) ambulatory ECG ambulatory electroencephalogram (EEG) lumbar puncture MRI simultaneous video-EEG telemetry Diagnostic Technologies

Physician Task: Case B

A 73-year-old hospitalized patient develops renal failure secondary to gentamicin therapy. administration of potassium, the patient develops hyperkalemia (8.0 mEq/L). Patient Presentation: Subtopic: Etiology: (A) (B) (C) (D) (E) Genitourinary Disorders/Issues oliguria renal failure

Due to inappropriate

1. The earliest ECG manifestation of hyperkalemia is AV conduction delay peaked T waves QRS widening ST segment depression supraventricular arrhythmias Scientific Understanding of Mechanisms

Physician Task: 2.

Assuming ECG changes are present, which of the following is the most appropriate immediate therapy for this patient? (A) (B) (C) (D) (E) calcium gluconate dialysis glucose-insulin infusion sodium bicarbonate sodium polystyrene sulfonate Management

Physician Task:

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3.

The goal of this initial therapy is to (A) (B) (C) (D) (E) antagonize the cardiac and neuromuscular effects of hyperkalemia drive the potassium into the cells increase intracellular protein binding of potassium increase the volume of distribution of potassium promote renal potassium excretion Scientific Understanding of Mechanisms

Physician Task:

Matching Sets
Set A For each numbered item (patient presentation), select the one heading (etiologic agent) most closely associated with it. Each lettered heading may be selected once, more than once, or not at all. (A) (B) (C) (D) (E) Aspergillus fumigatus Blastomyces dermatitidis Coccidioides immitis Pneumocystis carinii Sporothrix schenckii Respiratory Difficulties cough none specified Scientific Understanding of Mechanisms

Patient Presentation: Subtopic: Etiology: Physician Task:

1. A 40-year-old previously healthy male presents with night sweats, chest pain, a cough, and an osteolytic lesion on the metacarpal. 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 presents after visiting a water nature preserve which contains a high population of beavers.

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Level 2 Sample Items

Stand Alones
1. A 16-year-old female presents with a fever of unknown origin. Her parents are informed that she will need to be hospitalized in order to be diagnosed. Upon questioning, the physician informs the parents that insurance will cover 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 physician included in the case? (A) (B) (C) (D) (E) agency law captain of the ship medical negligence strict liability of tort vicarious liability Fever & Hypothermia fever fever of unknown origin Health Care Delivery

Patient Presentation: Subtopic: Etiology: Physician Task: 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 distal muscles. Laboratory studies reveal an elevated serum creatine phosphokinase, antistreptolysin titer, and erythrocyte sedimentation rate. The most likely diagnosis is (A) (B) (C) (D) (E) Duchenne dystrophy myasthenia gravis peripheral neuropathy poliomyelitis polymyositis Fatigue & Weakness none specified History & Physical

Patient Presentation: Etiology: Physician Task: 3.

A 52-year-old male presents to the office with acute arthritis of the first right metatarsophalangeal joint. There is a history of four similar attacks during the past year. The most appropriate initial treatment is (A) (B) (C) (D) (E) allopurinol codeine sulfate indomethacin penicillin G benzathine prednisone Musculoskeletal Difficulties & Muscular Pain joint pain none specified Management

Patient Presentation: Subtopic: Etiology: Physician Task:

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4.

A female presents with the complaint of not feeling well. She admits to consuming two glasses of wine and a six-pack of beer daily. Examination reveals scleral icterus. There is right upper quadrant tenderness and an obviously enlarged gallbladder. Acute tissue texture changes are palpated at T7-T8 on the left. A rectal examination reveals light-colored stool. Laboratory studies reveal: Aspartate aminotransferase: Alanine aminotransferase: Alkaline phosphatase: Total bilirubin: (A) (B) (C) (D) (E) 72 U/L 112 U/L 1120 U/L 7.3 mg/dL

The most appropriate diagnostic modality is endoscopic retrograde cholangiopancreatography liver and spleen scan liver biopsy percutaneous transhepatic cholangiogram ultrasound of the gallbladder and liver Substance Abuse alcohol abuse none specified Diagnostic Technologies

Patient Presentation: Subtopic: Etiology: Physician Task: 5.

A patient is seen with a potassium level of 2.1 mEq/L. After one week on spironolactone, her potassium is 3 mEq/L. The most likely diagnosis is (A) (B) (C) (D) (E) Addison disease Cushing disease pheochromocytoma primary aldosteronism Waterhouse-Friderichsen syndrome Asymptomatic & General Symptoms abnormal findings electrolyte abnormalities Diagnostic Technologies

Patient Presentation: Subtopic: Etiology: Physician Task: 6.

A mother weans her infant from breast-feeding after six months. The infant should now be started on (A) (B) (C) (D) (E) iron-fortified formula lowfat milk with iron supplement soy formula vitamin D-fortified cows milk whole milk with vitamin supplements Pregnancy/Childbirth/Postpartum/Neonatal lactation none specified Health Promotion/Disease Prevention

Patient Presentation: Subtopic: Etiology: Physician Task:

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7.

A 45-year-old female presents with a six-month history of dysphagia and pyrosis. Upper gastrointestinal radiographs reveal reflux of barium into the esophagus and a persistent mid-esophageal narrowing. Endoscopy and biopsy at the narrowed esophagus reveal tissue containing gastric-appearing mucosa. The most likely diagnosis is (A) (B) (C) (D) (E) Barrett esophagus Boerhaave syndrome diffuse esophageal spasm esophageal carcinoma Plummer-Vinson syndrome Digestive Difficulties dysphagia/feeding problems/odynophagia esophageal strictures History & Physical

Patient Presentation: Subtopic: Etiology: Physician Task:

Cases
Case A A 71-year-old female presents to the emergency department with the complaint of diarrhea, wheezing, cutaneous flushing, and a right upper quadrant mass. Physical examination of the abdomen reveals an irregular nodular liver. Urinary excretion of 5-HIAA is moderately elevated. Patient Presentation: Subtopic: Etiology: 1. Masses & Edema abdominal masses neoplasm

Which of the following neoplasms is most likely responsible for this patients symptoms? (A) (B) (C) (D) (E) adrenal adenoma carcinoid gastrinoma pheochromocytoma thyroid carcinoma History & Physical

Physician Task: 2.

The mechanism of flushing associated with this patients neoplasm is most likely attributable to which of the following substances secreted by the neoplasm? (A) (B) (C) (D) (E) adrenocorticotropic hormone bradykinins histamine serotonin tachykinins Scientific Understanding of Mechanisms

Physician Task:

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Matching Sets
Set A For each numbered item (patient presentation), select the one heading (dermatologic condition) most closely associated with it. Each lettered heading may be selected once, more than once, or not at all. (A) (B) (C) (D) (E) cherry hemangioma lentigo seborrheic keratosis skin tag venous lake Skin, Nail, & Hair Disorders lesions none specified History & Physical

Patient Presentation: Subtopic: Etiology: Physician Task:

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 the trunk, 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 of his ear.

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Level 3 Sample Items

Stand Alones
1. An 8-year-old male presents to the office with a history of outbursts of cursing. His parents report that they have tried everything to get him to stop. In observing the patient, you note that he blinks his eyes excessively. The parents state that the worst thing is that he smiles with a wide grin after he curses. The most effective treatment for this patient is (A) (B) (C) (D) (E) divalproex sodium haloperidol lorazepam methylphenidate thioridazine Cognitive Difficulties behavioral disturbances Tourette Syndrome Management

Patient Presentation: Subtopic: Etiology: Physician Task: 2.

A 76-year-old male is brought to the office by his anxious and concerned daughter. History and physical examination reveals that he suffers from Parkinson disease, memory loss, gait disturbance, osteoarthritis, and urinary incontinence. He has become increasingly dependent on his daughter for all of his activities of daily living. The daughter is extremely stressed out. The two live together in a small apartment on a fixed income. Which of the following local agencies should be contacted in order to identify community resources which may help to support this family unit? (A) (B) (C) (D) (E) area agency on aging community health agency Medicaid office Medicare office mental health center Musculoskeletal Difficulties & Muscular Pain gait disturbance/falls Parkinson disease Health Care Delivery

Patient Presentation: Subtopic: Etiology: Physician Task: 3.

A 70-year-old female presents to the office with a history of weight gain and fatigue. Examination reveals that she has a coarse voice and hung up reflexes. She has wasting of the thenar eminence of her left hand with weakness of the hand. Chest radiograph reveals an enlarged cardiac silhouette. The most useful test in the evaluation of this patient is (A) (B) (C) (D) (E) antinuclear antibody test CT scan of the head radiograph of the hand rheumatoid factor thyroid-stimulating hormone level Digestive Difficulties weight gain/obesity thyroid disturbance Diagnostic Technologies

Patient Presentation: Subtopic: Etiology: Physician Task:

25

Cases
Case A A 25-year-old gravida 3, para 2-0-0-2 female is admitted to the hospital in early labor. She states that the contractions are occurring every three to four minutes and last 50-60 seconds. By dates, she is at 38 weeks gestation. The height of the uterine fundus is 40 cm above the symphysis pubis. She is 1.6 m (5'4") tall and currently weighs 85 kg (187 lb). Her previous 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 are now occurring every six to seven minutes. Vaginal examination reveals the cervix to be 60% effaced and 3 cm dilated, with the cephalus presenting at a 2 station. The fetal membranes are intact and bulging. Fetal heart tones are varying from 130-150/min without decelerations. Patient Presentation: Subtopic: Etiology: 1. Pregnancy/Childbirth/Postpartum/ Neonatal labor & delivery process complications

The most likely primary diagnosis is (A) (B) (C) (D) (E) absolute cephalopelvic disproportion fetal malposition obstructed labor soft tissue dystocia uterine inertia History & Physical

Physician Task: 2.

The most appropriate management is to (A) (B) (C) (D) (E) administer ritodrine artificially rupture the membranes obtain an ultrasound perform a Leopold maneuver send the patient for a one-hour walk Management

Physician Task: 3.

Labor does NOT progress significantly in the next two hours. The fetal heart tones are varying between 132/min and 144/min without decelerations. The most appropriate next step is to (A) (B) (C) (D) (E) administer an enema augment labor with intravenous oxytocin maintain the patient in a steep reverse Trendelenburg position order blood to be crossmatched prepare the patient for a cesarean section Management

Physician Task: 4.

The patient delivers an infant weighing 4.4 kg (9 lb 11 oz). The most likely complication to anticipate is (A) (B) (C) (D) (E) cervical laceration postpartum depression retained placenta ruptured uterus uterine atony Health Promotion/Disease Prevention

Physician Task:

26

Case B A 45-year-old female presents with the complaint of generalized headache, unilateral hearing loss, tinnitus, and unsteadiness for the past five months. Abnormal findings on clinical examination include decreased hearing in the right ear, loss of corneal reflexes on the right, decreased sensation on the right side of the face, and right extremity ataxia. Patient Presentation: Subtopic: Etiology: 1. Sensory & CNS Difficulties hearing disorders tinnitus

The most likely diagnosis is (A) (B) (C) (D) (E) Benedikt syndrome left convexity meningioma left hemisphere cerebrovascular accident left temporal lobe glioblastoma multiforme right acoustic neuroma History & Physical

Physician Task: 2.

The most appropriate work-up includes (A) (B) (C) (D) (E) cerebral angiography CT scan of the head MRI of the head nuclear brain scan skull radiographs Diagnostic Technologies

Physician Task: Case C

A 50-year-old male presents to the emergency department from his home because of ataxia. His family brought him in and they state that his only medical problem is that he has been a heavy abuser of alcohol for many years. The patient is ataxic, confused, pale, malnourished, and has a very heavy smell of alcohol on his breath. Patient Presentation: Subtopic: Etiology: Substance Abuse alcohol abuse non specified

1.

Anemia found in this patient is due to a deficiency of (A) (B) (C) (D) (E) erythropoietin folate iron magnesium thiamine Scientific Understanding of Mechanisms

Physician Task: 2.

The primary pathway of ethanol oxidation in this patient's liver is via which of the following enzyme systems? (A) (B) (C) (D) (E) alcohol dehydrogenase catalase citric acid (TCA) cycle cytochrome P450 system microsomal ethanol-oxidizing system Scientific Understanding of Mechanisms

Physician Task:

27

Matching Sets
Set A For each numbered item (patient presentation), select the one heading (procedure) most closely associated with it. Each lettered heading may be selected once, more than once, or not at all. (A) (B) (C) (D) (E) abdominoperineal resection with end colostomy laser vaporization ablation left hemicolectomy with primary anastomosis sigmoid resection with diverting colostomy total colectomy with ileostomy Masses & Edema rectal masses/swelling none specified Management

Patient Presentation: Subtopic: Etiology: Physician Task:

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

28

Sample Item Answer Keys

Level 1
Stand Alones 1. D 2. E 3. E 4. D 5. D 6. E Cases Case A 1. D 2. E Case B 1. B 2. A 3. A Matching Sets Set A 1. C 2. B

Level 2
Stand Alones 1. E 2. D 3. C 4. E 5. D 6. A 7. A Cases Case A 1. B 2. C Matching Sets Set A 1. D 2. C 3. A 4. E

Level 3
Stand Alones 1. A 2. A 3. E Cases Case A 1. E 2. B 3. B 4. E Case B 1. E 2. C Case C 1. B 2. A Matching Sets Set A 1. E 2. D 3. A 4. B 5. C

29

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/dL Direct .........................................................................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/dL Cholesterol, LDL ........................................................................< 130 mg/dL (< .2 mmol/L) Cholesterol, triglycerides, serum .................................................< 150 mg/dL Cortisol, 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/L Potassium ......................................................................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 .........................................................................7.35-7.45 .........................................................................83-108 mmHg (11.1-14.4 kPa) pO2 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 (<6.7 mmol/L)

30

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, serum Male .........................................................................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 water Parathyroid hormone, intact ........................................................14-72 pg/mL Phosphatase (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, serum Total .........................................................................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, serum Male .........................................................................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 .........................................................................undetectable Urea 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)

31

CEREBROSPINAL FLUID Cell count .........................................................................0-10 leukocytes/mm3 .........................................................................0 erythrocytes/mm3 Chloride .........................................................................118-132 mmol/L Gamma 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) HEMATOLOGIC Bleeding time (template) ............................................................2.3-9.5 min Erythrocyte 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) Hemoglobin Male .........................................................................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 Volume Male .........................................................................80-94 mcm3 (80-94 fL) Female .........................................................................81-99 mcm3 (81-99 fL) Partial thromboplastin time (activated) ........................................< 35 sec Platelet count, blood ..................................................................130-400 x 103/mcL (130-400 x 109/L) Prothrombin time-INR ................................................................0.9-1.2 Red 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/h Male (> 50 y) .................................................................0-20 mm/h Female (0-50 y) .............................................................0-20 mm/h Female (> 50 y)..............................................................0-30 mm/h Thrombin time .........................................................................typically 17-25 s Volume, 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) SEMEN Volume Motility Count .........................................................................1.5-5.0 mL (0.0015-0.005 L) ......................................................................... > 60% (> 0.60) ........................................................................60-150 x 106/mL (60-150 x 109/L)

32

SWEAT Chloride

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

URINE Calcium (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-Hydroxycorticosteroids Male .........................................................................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 .........................................................................1.002-1.030 Uric acid ......................................................................... 250-750 mg/24 h (w/normal diet)(1.48-4.43 mmol/24 h (w/normal diet))

33

Patient Presentations
Patient Presentations
Asymptomatic/General Symptoms Digestive Difficulties Cognitive Difficulties Consciousness Alterations Fatigue & Weakness Sensory & CNS Difficulties Sensory Pain Substance Abuse Musculoskeletal Difficulties & Muscular Pain Genitourinary Disorders/Issues Bleeding Respiratory Difficulties Fever & Hypothermia Discharge Masses & Edema Skin, Nail, Hair, & Tooth Disorders Trauma Pregnancy/Childbirth/Postpartum/ Neonatal Assessment Symptoms & Disorders of Human Development Symptoms & Disorders of the Tissues and Trauma Symptoms & Disorders of Motor Function Symptoms & Disorders Related to Human Sexuality & Urination Symptoms & Disorders of Respiration & Circulation Symptoms & Disorders of Thermoregulation 6-12 3-8 Symptoms & Disorders of Sensory Function

Condensed Topic Area

Asymptomatic/ General Symptoms Symptoms & Disorders of Digestion & Metabolism

Required
8-16% 4-10

23-38

8-16

2-6

8-16

3-8

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

34

Physician Tasks
Level 1
Health Promotion/ Disease Prevention History & Physical 1-5%

Level 2
15-20%

Level 3
15-20%

5-15

30-40

10-20

Diagnostic Technologies

1-5

10-20

15-25

Management

3-7

10-20

25-40

Scientific Understanding of Mechanisms

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.

35

Blooms Taxonomy of the Cognitive Domain

Blooms taxonomy is a method of categorizing the level of abstraction required to answer a test question. Each level signifies the purpose of the question and a certain set of skills demonstrated by the test taker. By utilizing this system, it is 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. When submitting a test question, indicate the corresponding taxonomy level as dictated by the table below. Level of Taxonomy/ Competence Skills Demonstrated Knowledge of facts Mastery of subject matter Purpose of Testing To evaluate preparedness and comprehension Diagnosing Reviewing and/or summarizing content To evaluate preparedness and comprehension Diagnosing Reviewing and/or summarizing content To evaluate preparedness and comprehension Diagnosing Reviewing and/or summarizing content To encourage students to think more deeply and critically Problem-solving Encouraging discussions Stimulating students to seek information on their own To encourage students to think more deeply and critically Problem-solving Encouraging discussions Stimulating students to seek information on their own To encourage students to think more deeply and critically Problem-solving Encouraging discussions Stimulating students to seek information on their own

1 2 3 4

Knowledge
Recall of data

Comprehension
Understanding of meaning

Understanding of information Translation of knowledge into new contextfrom one medium to another Ordering, grouping, inferring causes Use of methods, concepts, theories in new situations Problem-solving using required skills or knowledge Pattern recognition Organization of parts Recognition of hidden meanings Identification of components

Application
Use of information

Analysis
Understanding of organizational structure

Synthesis

Relation of knowledge 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 Comparison and discrimination between ideas Assessment of value of theories and presentations Choice-making based on reasoned argument Verification of value of evidence Recognition of subjectivity

Evaluation

Making judgments about the value of ideas and materials

A1

Multimedia Items
Multimedia questions are a new type of item made possible by the conversion to computer-based testing. The inclusion of 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 in the upcoming examinations.

A2