{ "schema_version": 1, "exported_at": "2026-07-29T04:33:02.256Z", "app": "yoel-qbank", "owner_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "data": { "questions": [ { "id": "0fafe00f-3831-469c-892b-69c3871617cb", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 51-year-old woman comes to the office due to progressively worsening fatigue, weight gain, and constipation for the past 6 months. The patient has had difficulty performing daily activities due to fatigue. She has no significant medical history and takes no medications. The patient has no drug allergies and does not use tobacco, alcohol, or illicit drugs. Blood pressure is 110/80 mm Hg and pulse is 55/min. Physical examination shows mild, diffuse enlargement of the thyroid gland. Cardiopulmonary and abdominal examinations are normal. Biopsy of this patient's thyroid is most likely to show which of the following findings?", "explanation": "This patient has progressive symptoms of hypothyroidism (eg, fatigue, weight gain, constipation) and a diffuse goiter, consistent with chronic lymphocytic (Hashimoto) thyroiditis. This disease occurs predominately in women, with a peak incidence at age 45-65, and is the most common cause of hypothyroidism in iodine-sufficient regions such as the United States.\r\n\r\nAs with all forms of primary hypothyroidism, laboratory studies show low serum thyroxine (T4) levels and an elevated TSH. Elevated antithyroid peroxidase antibody levels can confirm the diagnosis. If the diagnosis is uncertain (eg, thyroid nodularity), a biopsy can be performed to rule out malignancy. Characteristic findings of Hashimoto thyroiditis include an intense mononuclear infiltrate consisting of lymphocytes and plasma cells, often with germinal centers (arrow in image above). Residual follicles are often surrounded by Hürthle cells (large oxyphilic cells filled with granular cytoplasm) that represent follicular epithelial cells that have undergone metaplastic change in response to inflammation.\r\n\r\n(Choice A) Histopathology in papillary thyroid cancer shows branching papillary structures with concentric calcifications (psammoma bodies) and ground-glass or empty-appearing nuclei (\"Orphan Annie eye\" nuclei). However, papillary thyroid cancer typically presents as an enlarging nodule in a clinically euthyroid patient.\r\n\r\n(Choice B) Riedel thyroiditis is characterized by extensive fibrosis of the thyroid gland extending into the surrounding structures. The fibrotic thyroid gland in Riedel thyroiditis is typically hard and fixed to surrounding structures, often resembling a malignancy.\r\n\r\n(Choice C) Graves disease presents with a diffusely enlarged thyroid gland associated with hyperthyroidism, exophthalmos, and pretibial myxedema. The thyroid follicular epithelium is tall and crowded with hyperactive reabsorption, causing scalloping around the edges of the colloid. Follicular hyperplasia with elongated epithelial cells is also seen in the tall-cell variant of papillary thyroid cancer, typically presenting in older adults as an enlarging thyroid mass.\r\n\r\n(Choice E) Subacute granulomatous (de Quervain) thyroiditis is characterized by disruption of follicles and a mixed cellular infiltrate with occasional multinuclear giant cells. Patients typically present after a viral upper respiratory infection with fever and a painful, tender thyroid gland.", "educational_objective": "Chronic lymphocytic (Hashimoto) thyroiditis is the most common cause of hypothyroidism. Histopathology characteristically shows an intense lymphocytic infiltrate, often with germinal centers. Residual follicles may be surrounded by Hürthle cells (large oxyphilic cells filled with granular cytoplasm).", "source": "UWorld", "difficulty": "medium", "personal_notes": null, "image_path": "data:image/jpeg;base64,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", "status": "active", "is_bookmarked": false, "created_at": "2026-07-19T21:18:47.022214+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "769", "review_due_at": null, "review_interval_days": null }, { "id": "6db60284-8382-4d7b-ba54-600a3b0ec86e", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 65-year-old man comes to the physician because of a non-healing ulcer on his right foot. His past medical history is significant for recurrent high blood glucose readings for the last several years, because he has failed to comply with appropriate treatment. His BMI is 37 kg/m?. Physical examination is significant for a bilateral symmetric decrease in vibration sensation over the feet and ankles. Which of the following is most likely to be associated with this patient's condition?", "explanation": "The patient described in this vignette has type 2 diabetes mellitus. Islet amyloid polypeptide (amylin) is stored in insulin secretory granules and is co-secreted with insulin from pancreatic beta cells. Deposits of amylin are universally seen in the pancreatic islets of patients with type 2 diabetes mellitus and may play a causative role in beta cell apoptosis and defective insulin secretion.\n\nClave clínica (stem-killer): DM2 → depósito de AMYLOID de islote (amilina/IAPP). DM1 → insulitis (infiltrado leucocitario) + anti-GAD/islet Ab + HLA-DR3/DR4. Amyloid=DM2; insulitis=DM1.", "educational_objective": "Pancreatic islet amyloid deposition is characteristic of type 2 diabetes mellitus. A strong linkage with HLA class II gene makeup, pancreatic islet infiltration with leukocytes (insulitis), and antibodies against islet antigens are frequently seen in type 1 diabetes.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Diabetes mellitus tipo 2", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:36:17.7142+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "848", "review_due_at": null, "review_interval_days": null }, { "id": "413b3b1e-c7f9-4235-b8b8-18df1d125308", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 35-year-old woman is evaluated for a 3-month history of appetite loss, fatigue, weight loss, and abdominal pain. While undergoing upper gastrointestinal endoscopy, the patient develops cardiovascular collapse and dies despite aggressive resuscitation. On autopsy, increased pigmentation is noted around the nipple areola and anal and vaginal mucous membranes. Which of the following additional findings are most likely to be seen on autopsy?", "explanation": "Respuesta correcta: A. Atrophy of both adrenal glands.\n\nClave clínica (stem-killer): Fatiga + weight loss + dolor abdominal + hiperpigmentación + autoinmunidad → insuf. suprarrenal PRIMARIA autoinmune → ATROFIA bilateral de ambas suprarrenales. Na↓ K↑.", "educational_objective": "Primary adrenal insufficiency causes weight loss, abdominal pain, fatigue, and hyperpigmentation. Physiologic stress can trigger acute adrenal crisis. Autoimmune adrenalitis is the most common cause and leads to bilateral adrenal atrophy.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Insuficiencia suprarrenal autoinmune", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "17246", "review_due_at": null, "review_interval_days": null }, { "id": "5bd62c9a-59ce-4dec-ab45-bf33c2d0140d", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 16-year-old boy is brought to the emergency department because of confusion, fatigue, and abdominal pain. He has also experienced excessive thirst and polyuria during the last 3 weeks. His past medical history is insignificant and family history is unremarkable. Urine dipstick is positive for glucose and ketones. Which of the following factors most likely contributed to the development of this patient's condition?", "explanation": "Respuesta correcta: E. Islet leukocytic infiltration.\n\nClave clínica (stem-killer): Joven + delgado + hiperglucemia + DKA → DM1 → INSULITIS (infiltrado leucocitario de islotes), autoinmune. Anti-GAD65. Destrucción de células beta.", "educational_objective": "Autoimmune insulitis with progressive beta cell loss is the cause of type 1 diabetes mellitus. Insulin resistance with relative insulin deficiency is the main mechanism in type 2 diabetes mellitus.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Diabetes mellitus tipo 1", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T22:57:31.89637+00:00", "uworld_qid": "1012", "review_due_at": "2026-07-23T22:57:31.875+00:00", "review_interval_days": 3 }, { "id": "65f8ebc1-b7ab-42d8-a6e5-b15c7e675c62", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 24-year-old competitive bodybuilder is evaluated for fatigue. Blood pressure is 134/82 mm Hg and pulse is 58/min. On physical examination, there is mild facial acne. The testes are soft, and testicular volume is decreased. Laboratory results show an elevated hematocrit. Which of the following is the most likely explanation for this patient's abnormal laboratory findings?", "explanation": "Respuesta correcta: E. Steroid drug abuse.\n\nClave clínica (stem-killer): Varón joven + ↓tamaño testicular + acné/↑Hto + masa muscular → ESTEROIDES anabólicos exógenos. La testosterona exógena suprime el eje HPG (feedback negativo) → atrofia testicular.", "educational_objective": "Androgenic steroid abuse may lead to erythrocytosis, testicular atrophy, acne, and (in women) virilization such as clitoromegaly and hirsutism.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Abuso de esteroides anabólicos", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "1901", "review_due_at": null, "review_interval_days": null }, { "id": "9732b557-cc57-415e-a5d9-5dacd433ba78", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 53-year-old woman comes for a routine check-up with no complaints. Her mother had hypertension and breast cancer at age 68. Her father had diabetes mellitus. Blood pressure is 140/85 mm Hg. Physical examination is normal. Laboratory testing shows a fasting blood glucose level of 140 mg/dL on more than 2 occasions. This patient is most likely to die from which of the following conditions?", "explanation": "Respuesta correcta: C. Myocardial infarction.\n\nClave clínica (stem-killer): Diabetes es el factor de riesgo cardiovascular más fuerte; ~40% de los diabéticos mueren por enfermedad coronaria (mucho más que por ictus, ESRD o coma hiperosmolar).", "educational_objective": "Diabetes mellitus is a coronary heart disease risk equivalent. Coronary heart disease is the most common cause of death in patients with diabetes mellitus.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: DM: riesgo cardiovascular", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "1011", "review_due_at": null, "review_interval_days": null }, { "id": "cdc8acc1-6feb-4cd0-8d4e-a8c208945bd4", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 55-year-old man comes to the office to establish care after relocating to the area. The patient has a 6-year history of type 2 diabetes mellitus for which he takes metformin monotherapy. He feels well and has no other medical conditions. The patient does not use tobacco or alcohol. He consumes a balanced diet and jogs for 40 minutes every morning. Review of his blood glucose journal over the last few months shows fasting glucose levels of 150-180 mg/dL. Laboratory analysis shows a hemoglobin A1c level of 4%. Further evaluation with hemoglobin electrophoresis shows a hemoglobin A2 level of 7.5% (normal: 1.5%-3.5%). Which of the following is the most likely explanation for this patient's lower-than-expected hemoglobin A1c level?", "explanation": "Respuesta correcta: A. Beta-thalassemia minor.\n\nClave clínica (stem-killer): A1c sorprendentemente BAJA que no cuadra con la glucosa → hemoglobinopatía. Microcitosis + ↑HbA2 → beta-thalassemia minor (el turnover/estructura de RBC altera la A1c).", "educational_objective": "Hemoglobin A1c estimates chronic glycemic control over the ~3-month lifespan of erythrocytes. Rapid erythrocyte turnover (eg, hemolytic anemia) gives a misleadingly low hemoglobin A1c relative to glycemic status.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Beta-talasemia / HbA1c", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "1996", "review_due_at": null, "review_interval_days": null }, { "id": "2ed54b03-f801-4b82-83a3-1012f85b5291", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 54-year-old man comes to the office due to worsening fatigue, generalized weakness, and an unintentional 7-kg weight loss over the past several weeks. He has a 40-pack-year history of smoking. Blood pressure is 160/100 mm Hg. Physical examination shows darkening of the skin in sun-exposed areas, scattered ecchymoses, and mild proximal muscle weakness. Chest imaging reveals a 6-cm, irregular right lung mass with mediastinal lymphadenopathy. Which of the following is most likely responsible for the patient's current symptoms?", "explanation": "Respuesta correcta: A. ACTH production from an ectopic site.\n\nClave clínica (stem-killer): HTA + debilidad proximal + hiperglucemia + hipokalemia + fumador/masa pulmonar → Cushing por ACTH ECTÓPICO (small cell lung cancer). No suprime con dexametasona.", "educational_objective": "Paraneoplastic hypercortisolism, most commonly caused by small cell lung cancer, is due to ectopic ACTH secretion. Features include hypertension, hyperglycemia, edema, and hyperpigmentation; unlike nonparaneoplastic Cushing syndrome, central obesity is uncommon.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Cushing por ACTH ectópico", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "1921", "review_due_at": null, "review_interval_days": null }, { "id": "b20f6c18-9a6b-4d84-81f7-3fe7cadf50fa", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 7-year-old boy is being evaluated for growth retardation. Brain MRI shows a 4 cm multiloculated, cystic, suprasellar lesion, which is bulging into the floor of the third ventricle and base of the brain. Calcifications are present. From which of the following structures is this mass most likely derived?", "explanation": "Respuesta correcta: B. Remnants of the Rathke pouch.\n\nClave clínica (stem-killer): Niño + talla baja + defecto visual + masa quística SUPRASELAR con CALCIFICACIONES → craniofaringioma (remanentes del Rathke pouch). Comprime quiasma → hemianopsia bitemporal.", "educational_objective": "Craniopharyngiomas are tumors arising from Rathke pouch remnants in the anterior pituitary. They characteristically have three components: solid, cystic, and calcified, and present during childhood with mass effect and visual deficits.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Craniofaringioma", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "221", "review_due_at": null, "review_interval_days": null }, { "id": "f4554808-aae2-40de-8adc-0023c7a6895a", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 45-year-old previously healthy man comes to the office for evaluation of a neck lump that has progressively enlarged over a month. He has no fever, neck pain, or hoarseness. On examination, there is a nontender, firm nodule in the upper portion of the left thyroid lobe. Laboratory studies reveal a normal serum TSH and elevated serum calcitonin. Neck ultrasonography shows a 2-cm hypoechoic thyroid nodule with microcalcifications. Fine-needle aspiration reveals spindle-shaped cells in an amorphous background. Which of the following gene alterations most likely contributed to this patient's condition?", "explanation": "Respuesta correcta: B. Activation of RET.\n\nClave clínica (stem-killer): Nódulo tiroideo firme + calcitonina alta (MEN2/AF) → carcinoma MEDULAR por activación de RET. Deriva de células C parafoliculares → CALCITONINA. Estroma amiloide (Congo red+).", "educational_objective": "Medullary thyroid cancer is a neuroendocrine tumor arising from calcitonin-secreting C (parafollicular) cells. It is often part of MEN 2A/2B, though most cases are sporadic; both sporadic and familial forms are associated with RET proto-oncogene mutations.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Carcinoma medular de tiroides (RET)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "1660", "review_due_at": null, "review_interval_days": null }, { "id": "29e8373c-b2ce-4fcd-ba46-d368ee9136dd", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 27-year-old woman comes to the office for evaluation of infertility. She and her husband have been trying to conceive for 2 years; his evaluation was normal. Her menses began at age 13 and were regular until the last few years, when they began occurring at intervals of 3-4 months. She has occasional headaches. On examination she has well-developed secondary sexual characteristics; pelvic examination reveals no adnexal masses. Neurological examination shows diminished vision in the bilateral temporal visual fields. An abnormality originating in which of the following is the most likely cause of this patient's condition?", "explanation": "Respuesta correcta: D. Pituitary lactotrophs.\n\nClave clínica (stem-killer): Infertilidad + galactorrea + amenorrea + hemianopsia bitemporal, esposo normal → prolactinoma (LACTOTROFOS). ↑Prolactina inhibe GnRH → hipogonadismo. Tx: agonista dopaminérgico (cabergolina).", "educational_objective": "Prolactinomas are the most common pituitary adenoma and cause galactorrhea, menstrual irregularities, and infertility. Large adenomas cause headaches from mass effect and bitemporal hemianopsia from optic chiasm compression.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Prolactinoma / infertilidad", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-21T19:22:08.581367+00:00", "uworld_qid": "1262", "review_due_at": "2026-07-24T19:22:08.488+00:00", "review_interval_days": 3 }, { "id": "9f8d07be-c55c-44ce-bd75-6b3ca46f24a5", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 24-year-old woman, gravida 1 para 1, comes to the office for postpartum follow-up 2 weeks after a term vaginal delivery. Her baby is doing well, but she has not yet lactated. She feels excessive fatigue and has had significant weight loss, nausea, loss of appetite, and postural dizziness. She has no headaches, visual problems, cold intolerance, constipation, or polyuria. On examination, she appears fatigued and has mild pallor. Morning laboratory tests are drawn. Which of the following pathologic processes is most likely responsible for this patient's symptoms?", "explanation": "Respuesta correcta: C. Ischemic necrosis.\n\nClave clínica (stem-killer): Postparto + hemorragia/hipotensión + falla para lactar + hipopituitarismo → SHEEHAN = necrosis ISQUÉMICA de la hipófisis (agrandada en el embarazo). Panhipopituitarismo.", "educational_objective": "High estrogen levels during pregnancy enlarge the pituitary without a proportional increase in blood supply; peripartum hypotension can cause ischemic necrosis of the pituitary, leading to panhypopituitarism (Sheehan syndrome). Failure of lactation from prolactin deficiency is common.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Sindrome de Sheehan / hipopituitarismo", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T18:44:33.045521+00:00", "uworld_qid": "220", "review_due_at": "2026-07-21T18:44:32.982+00:00", "review_interval_days": 1 }, { "id": "cd056d63-d305-4acb-9fed-596cd9425be8", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 43-year-old woman comes to the office due to episodic confusion, blurred vision, tremors, and sweating. The episodes have increased in intensity over the past few months and can occur any time of day. Symptoms are relieved by drinking orange juice. During a recent episode, her blood glucose was 32 mg/dL on a home glucose meter. Laboratory studies performed during a symptomatic episode are obtained. Which of the following is the most likely cause of this patient's symptoms?", "explanation": "Respuesta correcta: D. Sulfonylurea use.\n\nClave clínica (stem-killer): Whipple triad + ↑insulina + ↑C-PEPTIDE → insulinoma O sulfonilurea. Screen de sulfonilurea (+) → fármaco, no tumor. Insulina EXÓGENA = C-peptide BAJO.", "educational_objective": "Hypoglycemia causes tremor, diaphoresis, and confusion with a low blood glucose that resolves on correction. Elevated insulin with LOW C-peptide suggests exogenous insulin; elevated C-peptide suggests an insulin secretagogue (sulfonylurea) or insulinoma.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Hipoglucemia por sulfonilurea vs insulinoma", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "8531", "review_due_at": null, "review_interval_days": null }, { "id": "45d2d6c6-d013-441d-80df-6d05417bcff1", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 46-year-old woman comes to the office due to a painful rash involving her groin and legs that has been worsening over 2 weeks. She was diagnosed with diabetes mellitus 6 months ago and has occasional loose stools. Physical examination shows coalescing erythematous plaques with crusting and scaling at the borders and central areas of brownish induration. Biopsy reveals superficial necrolysis. Which of the following laboratory abnormalities is most likely present in this patient?", "explanation": "Respuesta correcta: C. Elevated glucagon.\n\nClave clínica (stem-killer): Necrolytic migratory erythema + diabetes + weight loss + diarrea → GLUCAGONOMA → glucagón elevado. Regla de las D: dermatitis, diabetes, DVT, depresión, weight loss.", "educational_objective": "Glucagonoma presents with hyperglycemia (often new-onset diabetes mellitus) and necrolytic migratory erythema (blistering erythematous plaques with central clearing) of the groin, face, and extremities. Diagnosis is confirmed by elevated glucagon levels.", "source": "UWorld", "difficulty": "hard", "personal_notes": "Tema: Glucagonoma", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "585", "review_due_at": null, "review_interval_days": null }, { "id": "85d141db-255b-4f8d-8d9b-86b7341c5055", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 14-year-old boy is brought to the office due to painless nodules on his lips and tongue that have been progressively enlarging. He underwent total thyroidectomy 5 years ago following the discovery of a thyroid mass and takes thyroid hormone replacement. On physical examination, he is tall and slender with disproportionately long arms and legs, long thin fingers, and joint laxity. Oral inspection reveals several small, soft, flesh-colored papules on his lips and tongue. Serum TSH is normal. This patient most likely has which of the following conditions?", "explanation": "Respuesta correcta: D. Multiple endocrine neoplasia type 2B.\n\nClave clínica (stem-killer): Adolescente + NEUROMAS mucosos (labios/lengua) + hábito marfanoide + carcinoma medular previo → MEN 2B (RET). También feocromocitoma. Tiroidectomía profiláctica.", "educational_objective": "Multiple endocrine neoplasia type 2B is characterized by medullary thyroid cancer, pheochromocytoma, marfanoid habitus, and oral/intestinal mucosal neuromas.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: MEN 2B", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "1844", "review_due_at": null, "review_interval_days": null }, { "id": "ee50d0b5-f25f-4d8e-bc10-939a159fef4f", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 55-year-old man comes to the office for follow-up of abnormal serum chemistries found on routine testing. He has hypertension treated with pharmacologic therapy and dietary salt restriction. Physical examination reveals no abnormalities. Laboratory studies show hypercalcemia with a decreased parathyroid hormone level. Which of the following is most likely responsible for these findings?", "explanation": "Respuesta correcta: C. Medication effect.\n\nClave clínica (stem-killer): Hipercalcemia + PTH baja/suprimida + uso de TIAZIDA → efecto medicamentoso. Las tiazidas ↑reabsorción distal de Ca → hipercalcemia. Revisa fármacos antes de buscar tumor.", "educational_objective": "Thiazide diuretics cause hypercalcemia by increasing distal tubular reabsorption of calcium. The rise in calcium suppresses parathyroid hormone, which distinguishes this from primary hyperparathyroidism.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Hipercalcemia por farmaco (tiazida)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "980", "review_due_at": null, "review_interval_days": null }, { "id": "ac776f04-21e2-4c12-9b3e-c8e9b7a57603", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "(Continuación del caso previo de hiperplasia suprarrenal congénita.) After initial assessment, the appropriate interventions are initiated. Treatment of this patient's condition is targeted at directly suppressing which of the following hormones?", "explanation": "Respuesta correcta: C. Adrenocorticotropic hormone.\n\nClave clínica (stem-killer): En la CAH el bloqueo enzimático → ↓cortisol → se pierde el feedback negativo → ↑ACTH → hiperplasia adrenal + desvío a andrógenos. El MOTOR de la hiperplasia = ACTH.", "educational_objective": "Treatment of congenital adrenal hyperplasia uses low-dose exogenous corticosteroids to suppress excessive ACTH secretion and reduce stimulation of the adrenal cortex.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Hiperplasia suprarrenal congenita (ACTH)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "2081", "review_due_at": null, "review_interval_days": null }, { "id": "210ed155-4942-45d6-a02c-74674ed742f0", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 4-year-old boy is brought to the physician after his mother noticed he started developing pubic hair. He had a recent growth spurt and is now taller than his 5-year-old brother, and his teacher has noticed axillary odor. On examination, his height is at the 96th percentile. There is sparse growth of long, pigmented hair at the base of the penis and in both axillae. Laboratory assessment reveals high serum concentrations of 17-hydroxyprogesterone and testosterone. Which of the following is most likely present in this patient?", "explanation": "Respuesta correcta: B. Adrenal cortical hyperplasia.\n\nClave clínica (stem-killer): Pubertad precoz/virilización + ↑17-OH-progesterona → HIPERPLASIA suprarrenal congénita (déficit de 21-hidroxilasa). La glándula está HIPERPLÁSICA por ↑ACTH.", "educational_objective": "Males with classic, non-salt-wasting 21-hydroxylase deficiency present at age 2-4 years with early virilization, increased linear growth, and elevated 17-hydroxyprogesterone and androgens. Females with classic 21-hydroxylase deficiency present with ambiguous genitalia at birth.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Hiperplasia suprarrenal congenita", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "2080", "review_due_at": null, "review_interval_days": null }, { "id": "1df86dff-d94b-4e58-bf07-8ab1df1ee6c8", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "Mujer de 37 años con 2 meses de dolor abdominal, deseo de sal (salt craving) y pérdida de peso, con mareo al ponerse de pie. Madre y hermana con hipotiroidismo. PA 100/70 supino y 80/50 de pie. Labs: Na 129, K 5.9, Cl 100, HCO3 21, Cr 1.4, BUN 38. ¿Qué cambios en hormonas circulantes se esperan? (Cortisol | Aldosterona | ADH | Norepinefrina)", "explanation": "Respuesta correcta: A. Cortisol ↓, Aldosterona ↓, ADH ↑, Norepinefrina ↑.\n\nClave clínica (stem-killer): Salt craving + ortostatismo + Na↓ K↑ + autoinmune (AF tiroiditis) → ADDISON (insuf. suprarrenal 1ª). Patrón: Cortisol↓, Aldosterona↓, ADH↑, Norepinefrina↑.", "educational_objective": "La insuficiencia suprarrenal primaria (Addison) disminuye cortisol y aldosterona. La pérdida del efecto inhibidor del cortisol y la hipovolemia elevan la ADH; la hipotensión eleva la norepinefrina simpática. Resultado: Na↓, K↑, hipotensión ortostática.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Insuficiencia suprarrenal primaria (Addison)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "17244", "review_due_at": null, "review_interval_days": null }, { "id": "006695c4-e171-4f0c-8ae5-f7a8b5069a82", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 50-year-old man is brought to the emergency department due to a severe, sudden-onset headache that started an hour ago. He reports mild headaches and decreased libido over the past 3 months. Physical examination reveals bilateral deficits involving the temporal visual fields and impaired extraocular eye movements. Shortly after admission, he becomes acutely hypotensive, loses consciousness, and dies despite aggressive resuscitation. Which of the following is most likely to be found on autopsy?", "explanation": "Respuesta correcta: A. Acute hemorrhage in the pituitary gland.\n\nClave clínica (stem-killer): Cefalea súbita severa + oftalmoplejía + defecto visual (sobre adenoma) → APOPLEJÍA hipofisaria = hemorragia/infarto agudo de la hipófisis. Emergencia (riesgo de crisis suprarrenal).", "educational_objective": "Pituitary apoplexy (acute pituitary hemorrhage) causes severe headache, bitemporal hemianopsia, and ophthalmoplegia, usually within a preexisting pituitary adenoma. It is an emergency requiring urgent glucocorticoids to prevent adrenal crisis.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Apoplejia hipofisaria", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "225", "review_due_at": null, "review_interval_days": null }, { "id": "bd48df0c-70d9-42ab-b977-39741a4adf5e", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 40-year-old man comes to the office due to recurrent epigastric abdominal pain, nausea, and watery diarrhea for several months. He was previously treated for peptic ulcer disease and takes over-the-counter antacids with no significant relief. Abdominal examination shows mild epigastric tenderness. Testing for stool occult blood is positive, and laboratory studies show microcytic hypochromic anemia. Serum gastrin level is markedly elevated. Upper endoscopy reveals prominent gastric folds and multiple ulcers in the duodenum and proximal jejunum. This patient should be assessed for a personal or family history of which of the following conditions?", "explanation": "Respuesta correcta: D. Recurrent nephrolithiasis.\n\nClave clínica (stem-killer): Zollinger-Ellison (gastrinoma) + buscar hipercalcemia/nefrolitiasis recurrente → MEN 1 (3 P: Paratiroides, Páncreas, Pituitaria). Gen: menina (MEN1).", "educational_objective": "Multiple endocrine neoplasia type 1 consists of hyperparathyroidism (hypercalcemia, kidney stones), pituitary tumors, and pancreatic endocrine tumors (eg, gastrinoma). It is caused by mutations in the MEN1 gene.", "source": "UWorld", "difficulty": "hard", "personal_notes": "Tema: MEN 1 / gastrinoma", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T20:31:52.390813+00:00", "uworld_qid": "986", "review_due_at": "2026-07-21T20:31:52.373+00:00", "review_interval_days": 1 }, { "id": "f5343518-293a-4656-aab6-4f0a3153f772", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 61-year-old woman comes to the office due to a neck lump. There is a nontender, firm nodule in the left lobe of the thyroid. Serum TSH is normal. Ultrasonography reveals a 2-cm hypoechoic nodule with increased central blood flow. Fine-needle aspiration biopsy shows clusters of cells with large, overlapping nuclei containing sparse, finely dispersed chromatin, plus numerous intranuclear inclusion bodies and grooves. Which of the following is the most likely diagnosis?", "explanation": "Respuesta correcta: F. Papillary carcinoma.\n\nClave clínica (stem-killer): Nódulo + Orphan Annie eye nuclei + PSAMMOMA bodies + nuclear grooves → carcinoma PAPILAR (el más común). Disemina por linfáticos; buen pronóstico.", "educational_objective": "Papillary thyroid cancer is the most common thyroid cancer. Histology shows large cells with nuclei containing finely dispersed chromatin giving an empty/ground-glass appearance (Orphan Annie eye) plus intranuclear inclusions or grooves.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Carcinoma papilar de tiroides", "image_path": "/uworld/1658.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T23:02:19.275804+00:00", "uworld_qid": "1658", "review_due_at": "2026-07-21T23:02:19.248+00:00", "review_interval_days": 1 }, { "id": "7d4e0ce9-7b09-43a2-8808-40b5698f19bb", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "Paciente con hipertensión, debilidad muscular proximal e hiperglucemia (síndrome de Cushing) de inicio rápido, tabaquismo intenso y una masa pulmonar. Tras una prueba de supresión con dexametasona en ALTA dosis, ¿qué cambios en la ACTH y el cortisol son más probables? (Ver algoritmo en la imagen.)", "explanation": "Respuesta correcta: ACTH SIN cambio y cortisol SIN cambio (no suprime → fuente ectópica).\n\nClave clínica (stem-killer): La dexametasona en ALTA dosis SUPRIME en enfermedad pituitaria (Cushing disease) pero NO en ACTH ectópico (small cell). Ectópico → ACTH y cortisol SIN cambios. Ojo: la dexa nunca SUBE la ACTH.", "educational_objective": "El síndrome de Cushing por adenoma pituitario o por secreción ectópica de ACTH cursa con ACTH elevada. La dexametasona en alta dosis suprime ACTH y cortisol si la causa es un adenoma pituitario, pero NO cuando es ectópica (p. ej., small cell lung cancer).", "source": "UWorld", "difficulty": null, "personal_notes": "Tema: Cushing: dexametasona alta dosis", "image_path": "/uworld/927.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "927", "review_due_at": null, "review_interval_days": null }, { "id": "c2f4f6e4-d59e-4f4e-9fca-73f4cf228e48", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 58-year-old man is evaluated for a painless thyroid nodule that has enlarged over 2 months. He has no radiation exposure or family history of thyroid disease. Serum TSH is normal, and ultrasonography shows a 4-cm solid nodule in the right thyroid lobe. Fine-needle aspiration biopsy shows follicular cells dispersed in clusters and microfollicles. The patient undergoes right thyroid lobectomy. Which of the following histologic findings would confirm a diagnosis of follicular thyroid carcinoma?", "explanation": "Respuesta correcta: F. Tumor capsular invasion.\n\nClave clínica (stem-killer): Neoplasia FOLICULAR → la FNA NO distingue adenoma de carcinoma. La malignidad se define por INVASIÓN capsular/vascular (histología, no citología) → carcinoma folicular.", "educational_objective": "Follicular thyroid carcinoma cannot be diagnosed by cytology/FNA: it requires demonstrating tumor capsular or vascular invasion on histology, which distinguishes it from a benign follicular adenoma (hence the diagnostic lobectomy).", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Carcinoma folicular de tiroides", "image_path": "/uworld/17236.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-21T10:31:40.658687+00:00", "uworld_qid": "17236", "review_due_at": "2026-07-22T10:31:40.638+00:00", "review_interval_days": 1 }, { "id": "9f5aa740-a6fe-4281-ad28-7cd802e5b375", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 45-year-old man comes to the office due to slowly progressive back and joint pain; his knees and ankles are stiff and painful when he walks. Over the past year he has had excessive sweating, and his ring and shoe sizes have increased. Physical examination shows coarse facial features with a prominent forehead, protruding jaw, and widely separated maxillary teeth, plus mild swelling and crepitus of the knees and ankles. Which of the following is most likely to be associated with this patient's condition?", "explanation": "Respuesta correcta: C. Left ventricular hypertrophy.\n\nClave clínica (stem-killer): Artralgias + sudoración excesiva + rasgos acrales/faciales progresivos → ACROMEGALIA (↑GH/IGF-1). Complicación que mata: HIPERTROFIA VENTRICULAR IZQUIERDA → cardiomiopatía. También DM y pólipos de colon.", "educational_objective": "Acromegaly is caused by excess growth hormone, usually from a pituitary somatotroph adenoma. Manifestations include bony hypertrophy (frontal bossing; enlarged jaw, hands, feet) and osteoarthritis. Left ventricular hypertrophy is common and may progress to heart failure.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Acromegalia", "image_path": "/uworld/7651.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T18:24:02.087701+00:00", "uworld_qid": "7651", "review_due_at": "2026-07-21T18:24:02.064+00:00", "review_interval_days": 1 }, { "id": "760e1294-e23b-4892-8979-70bb75e48fa8", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "Varón joven con retraso puberal y ANOSMIA. El diagrama muestra el eje hipotálamo-hipófisis-gónada con varios puntos (A–E); se pregunta en qué punto está el defecto. La opción correcta corresponde al nivel de la GnRH hipotalámica.", "explanation": "Respuesta correcta: A (nivel de la GnRH hipotalámica) — ver diagrama.\n\nClave clínica (stem-killer): Hipogonadismo hipogonadotrópico (↓LH/FSH, ↓testo) + ANOSMIA → Kallmann. Falla la migración de neuronas GnRH desde la placoda olfatoria.", "educational_objective": "In Kallmann syndrome there is an absence of GnRH-secreting neurons in the hypothalamus due to defective migration from the olfactory placode. Patients have central hypogonadism and anosmia and often present with delayed puberty.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Sindrome de Kallmann", "image_path": "/uworld/579.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T20:20:03.406736+00:00", "uworld_qid": "579", "review_due_at": "2026-07-21T20:20:03.349+00:00", "review_interval_days": 1 }, { "id": "dec70849-dfde-48d6-8089-6b4e3e99b09d", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "Foto clínica de placas amarillentas en el párpado medial (xantelasma). Which of the following is the best next step in the management of this patient?", "explanation": "Respuesta correcta: B. Serum lipids and blood glucose level.\n\nClave clínica (stem-killer): XANTELASMA (placas amarillas en párpado medial) → sospecha dislipidemia (hipercolesterolemia familiar, defecto del receptor LDL). Siguiente paso: perfil de lípidos y glucosa.", "educational_objective": "Xanthelasmas are yellowish macules/papules on the medial eyelids: dermal collections of cholesterol- and triglyceride-laden macrophages, generally associated with a primary or secondary hyperlipidemia (LDL receptor abnormality is the most common cause).", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Dislipidemia / xantelasma", "image_path": "/uworld/191.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "191", "review_due_at": null, "review_interval_days": null }, { "id": "5d38d52c-6d11-4b71-9b08-ad85a3a0eb74", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 6-year-old boy is brought to the emergency department after a fall from his bicycle. During care, a routine blood draw shows milky plasma that forms a creamy supernatant upon standing. Plasma lipoprotein lipase activity measured after intravenous heparin is substantially lower than normal. If untreated, this patient is most likely to develop which of the following?", "explanation": "Respuesta correcta: A. Acute pancreatitis.\n\nClave clínica (stem-killer): Suero lipémico + LPL baja + TG MUY altos (>1000) en un niño → deficiencia familiar de LPL (quilomicronemia) → PANCREATITIS AGUDA recurrente. No aumenta el riesgo coronario prematuro.", "educational_objective": "Familial chylomicronemia (LPL deficiency) presents in childhood with recurrent acute pancreatitis. These patients are not typically at increased risk for premature coronary disease. Eruptive xanthomas may occur; tendon xanthomas and xanthelasmas are seen mainly with hypercholesterolemia.", "source": "UWorld", "difficulty": "hard", "personal_notes": "Tema: Hipertrigliceridemia (deficit de LPL)", "image_path": "/uworld/782.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T20:39:54.768911+00:00", "uworld_qid": "782", "review_due_at": "2026-07-27T20:39:54.747+00:00", "review_interval_days": 7 }, { "id": "4d59e664-e724-416d-87b2-46181fd2607e", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 34-year-old woman comes to the office due to a 1 week history of mood swings, difficulty concentrating, and hand tremors. She also has pain at the front of her neck that radiates to her ears and is worse with swallowing, following a flu-like illness a few weeks earlier. Blood pressure is 140/80 mm Hg and pulse is 105/min. The thyroid gland is very tender on palpation. A thyroid scan reveals diffusely decreased radioiodine uptake. Erythrocyte sedimentation rate is 105 mm/hr. Which of the following pathological changes would be most likely on biopsy of this patient's thyroid gland?", "explanation": "Respuesta correcta: D. Mixed, cellular infiltration with occasional multinucleated giant cells.\n\nClave clínica (stem-killer): Tiroides DOLOROSA + URI viral previa + ↑ESR + hipertiroidismo transitorio + captación baja → tiroiditis subaguda (de Quervain). Histo: inflamación GRANULOMATOSA con multinucleated giant cells. Autolimitada.", "educational_objective": "Subacute granulomatous (de Quervain) thyroiditis is characterized by painful thyroid enlargement and usually follows a viral illness. Biopsy shows a mixed inflammatory infiltrate with macrophages and multinucleated giant cells.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Tiroiditis subaguda (de Quervain)", "image_path": "/uworld/768.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "768", "review_due_at": null, "review_interval_days": null }, { "id": "a3519669-3e62-4230-b67d-da5c62ab2a7a", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "Mujer de 19 años para evaluación de amenorrea. Reglas regulares que en el último año se volvieron irregulares (última hace 3 meses). Come principalmente frutas y verduras y hace ejercicio regularmente; le preocupa tener sobrepeso. IMC 18 kg/m². Delgada, con piel seca cubierta de vello fino aterciopelado (lanugo). Prueba de embarazo negativa. ¿Qué patrón de hormonas séricas es más probable? (LH | FSH | Estradiol)", "explanation": "Respuesta correcta: D. LH disminuida, FSH disminuida, Estradiol disminuido.\n\nClave clínica (stem-killer): Amenorrea + IMC bajo (18) + lanugo + restricción calórica/ejercicio → amenorrea hipotalámica funcional. ↓Leptina → ↓GnRH → LH↓ FSH↓ Estradiol↓ (hipogonadotrópico).", "educational_objective": "La amenorrea hipotalámica funcional (bajo peso, ejercicio excesivo, trastorno alimentario) reduce la pulsatilidad de GnRH, causando LH, FSH y estradiol BAJOS (hipogonadismo hipogonadotrópico).", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Amenorrea hipotalamica funcional (anorexia)", "image_path": "/uworld/1839.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "1839", "review_due_at": null, "review_interval_days": null }, { "id": "a248b6d1-5267-4e3b-abca-a812af0093e5", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 30-year-old man comes to the office with a neck lump discovered incidentally. His history is significant for a recently removed pheochromocytoma, and his father died of thyroid cancer in his 30s. Ultrasound reveals a hypoechoic 3-cm nodule in the right lobe of the thyroid. Fine-needle biopsy is consistent with a subtype of thyroid cancer, and the patient undergoes total thyroidectomy. Which of the following is the most likely histological finding?", "explanation": "Respuesta correcta: C. Nests of polygonal cells with Congo red-positive deposits.\n\nClave clínica (stem-killer): Nódulo + feocromocitoma + AF cáncer tiroideo (MEN2) → carcinoma MEDULAR (células C, calcitonina). Histo: NIDOS de células poligonales + estroma AMILOIDE Congo red+.", "educational_objective": "Medullary thyroid cancer is a neuroendocrine tumor arising from parafollicular calcitonin-secreting C cells. It shows nests or sheets of polygonal or spindle-shaped cells with extracellular amyloid deposits derived from calcitonin, and is associated with MEN 2 (RET).", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Carcinoma medular de tiroides", "image_path": "/uworld/1659.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T16:41:35.420912+00:00", "uworld_qid": "1659", "review_due_at": null, "review_interval_days": null }, { "id": "b1a1f140-4109-416c-a70b-c13526e97931", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 48-year-old homeless man is brought to the emergency department after being found unresponsive on the sidewalk.", "explanation": "PCP by P jirovecii; hypoxia + bilateral interstitial infiltrates + positive silver stain.", "educational_objective": "Pneumocystis pneumonia is an atypical fungal infection seen primarily in those with impaired cell-mediated immunity.", "source": "UWorld", "difficulty": "easy", "personal_notes": null, "image_path": "/uworld/14870.jpg", "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T18:51:48.444737+00:00", "updated_at": "2026-07-20T19:01:25.880052+00:00", "uworld_qid": "14870", "review_due_at": "2026-07-23T18:59:48.69+00:00", "review_interval_days": 3 }, { "id": "d5d8a5bf-9053-420f-a2ef-0396b926dc79", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 34-year-old man comes to the office due to shortness of breath. He reports an episodic cough and chest tightness for the past 4 months. The patient was recently on a 2-week vacation in Arizona and reports that he had no symptoms during the trip but that they restarted when he returned home. He has no prior medical conditions and takes no medications. The patient smoked marijuana in his early 20s for several years but does not use tobacco or alcohol. He started working at a chemical manufacturing factory 7 months ago and has had no sick contacts. Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, pulse is 76/min, and respirations are 18/min. On physical examination, expiration is mildly prolonged and there are scattered wheezes. Office spirometry shows an FEV1/FVC of 82%, and chest radiography reveals no abnormalities. Which of the following features is most likely involved in the pathogenesis of this patient's condition?", "explanation": "This patient with dyspnea, cough, and intermittent chest tightness likely has asthma. The correlation of symptom onset after starting a new job and relief while traveling is suggestive of occupational asthma (OA), which accounts for up to 25% of adult-onset asthma. OA is characterized by airway inflammation, bronchial hyperreactivity, and a variable airflow obstruction triggered by a workplace exposure. Like other forms of asthma, patients may have normal chest imaging and pulmonary function tests between exacerbations. Inciting factors in OA can be categorized as immunologic or nonimmunologic: - Immunologic: Similar to atopic asthma, exposure to workplace aero-allergens induces a Th2-mediated reaction, which stimulates IgE formation and eosinophilic activation. There is often a latent period before symptoms develop during which the patient is sensitized to an allergen. Common causes include cereals, latex, and chemicals (eg, formaldehyde, amines, dyes). - Nonimmunologic: Exposure to aero-irritants induces denudation of the airway mucosa, resulting in persistent airway inflammation, loss of epithelial relaxation factors, and mast cell degranulation. This typically occurs after large accidental exposures (eg, chemical spill), and symptom onset is sudden and severe. Common causes include chlorine and ammonia. (Choice B) Coccidioidomycosis is endemic to the southwestern United States. In addition to cough and chest pain, patients commonly have fever, arthralgia, and skin manifestations, and imaging often demonstrates hilar adenopathy. This patient developed symptoms prior to his travel to Arizona. (Choice C) Alpha-1 antitrypsin deficiency is an inherited disorder that causes panacinar emphysema. Patients present with dyspnea, cough, and wheezing; however, imaging typically reveals basilar bullous changes and spirometry shows an obstructive pattern. (Choice D) BMPR2 gene mutations cause idiopathic pulmonary hypertension; symptoms include progressive dyspnea and fatigue. However, cough, wheezing, and the resolution of symptoms while traveling is unexpected. In addition, imaging often reveals enlarged pulmonary arteries. (Choice E) Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) is a vasculitis of small- or medium-sized arteries characterized by asthma and rhinitis. However, imaging typically demonstrates patchy infiltrates, and symptoms would not be expected to resolve while traveling.", "educational_objective": "Occupational asthma is characterized by airway inflammation, bronchial hyperreactivity, and a variable airflow obstruction triggered by workplace exposure. Exposure can be immunologic (atopic), due to exposure to a workplace aeroallergen causing a Th2-mediated IgE formation, or nonimmunologic, due to exposure to workplace irritants that lead to denudation of the bronchial mucosa.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Occupational asthma", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:26.790042+00:00", "updated_at": "2026-07-20T23:51:26.94798+00:00", "uworld_qid": "15155", "review_due_at": null, "review_interval_days": null }, { "id": "bed51e3a-8a2f-4d75-99d3-a535d0a78274", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "[Stem text was not captured in the OCR; the following is a faithful paraphrase reconstructed from the explanation.] A patient with recent extended travel (prolonged immobilization) presents with acute-onset dyspnea and tachypnea, a normal lung examination, and sinus tachycardia on ECG. Pulmonary embolism is suspected. Because CT angiography requires intravenous contrast that must be avoided in this patient (chronic kidney disease, risk of contrast-induced nephropathy), a ventilation/perfusion (V/Q) scan is performed. Which of the following V/Q scan patterns is the most definitive diagnostic finding for pulmonary embolism?", "explanation": "Pulmonary embolism (PE) should be suspected in this patient with recent extended travel (prolonged immobilization) who now has acute-onset dyspnea and tachypnea, normal lung examination, and sinus tachycardia on ECG. In most patients, CT angiography, which requires intravenous contrast administration, is the diagnostic test of choice. However, the contrast used in CT studies should be avoided in patients with chronic kidney disease due to the increased risk of contrast-induced nephropathy; in such patients, a ventilation/perfusion (V/Q) scan is the preferred diagnostic study. A V/Q scan is a nuclear medicine study that uses a radioactive tracer placed in both inhaled gas and the bloodstream to visualize areas of ventilation and perfusion in the lung. In patients with PE, ventilation is preserved but the embolus prevents adequate blood perfusion to the affected areas of the lung. Therefore, the most definitive diagnostic finding for PE on V/Q scan is a large area showing a perfusion defect without ventilation defect (mismatched perfusion defect). (Choice A) The absence of perfusion abnormalities is a useful finding on V/Q scan, as it likely rules out significant PE. (Choices B and E) Matched ventilation and perfusion defects may result from chronic lung abnormalities (eg, airway inflammation or obstruction, atelectasis) that lead to localized areas of poor ventilation with corresponding hypoxic vasoconstriction, or they may represent a PE that happens to be in an area of poor ventilation. These results are often inconclusive and necessitate additional testing to confirm or rule out PE. (Choice D) An area of ventilation defect without perfusion defect is suggestive of conditions that lead to acute alveolar filling (eg, pneumonia, pulmonary edema).", "educational_objective": "Ventilation/perfusion scanning can be useful for diagnosing pulmonary embolism. A large perfusion defect without ventilation defect is the characteristic positive test result.", "source": "UWorld", "difficulty": null, "personal_notes": "Tema: Pulmonary embolism / ventilation-perfusion (V/Q) scan", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:26.981444+00:00", "updated_at": "2026-07-20T23:51:27.08786+00:00", "uworld_qid": "12184", "review_due_at": null, "review_interval_days": null }, { "id": "8f78d983-0cd3-4de4-9a7d-8a5d70a077d7", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 63-year-old man comes to the emergency department due to a 1-week history of progressively worsening shortness of breath and cough. The shortness of breath is exacerbated when the patient lies flat in bed; he has to prop himself up with 3 pillows to sleep well at night. He was treated for a myocardial infarction 2 weeks ago and had 2 stents placed in the left anterior descending artery. The patient's other medical conditions include long-standing hypertension and type 2 diabetes mellitus. Blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 22/min. Pulse oximetry is 89% on room air. Physical examination reveals bilateral crackles at the lung bases and an S3. Which of the following is most likely present in this patient?", "explanation": "This patient's dyspnea, orthopnea, bibasilar crackles, and S3 suggest left-sided heart failure due to recent myocardial infarction (MI). Atherosclerotic plaque rupture in the left anterior descending or left circumflex artery can infarct large areas of the left ventricular myocardium, leading to decreased contractility and reduced cardiac output. This can result in elevation of end-diastolic pressure that impairs diastolic return from the pulmonary veins, leading to increased hydrostatic pressure in the pulmonary capillaries with transudation of fluid into the lung parenchyma (pulmonary edema). Pulmonary edema in the alveoli impairs ventilation and causes intrapulmonary shunting. In addition, edema in the lung interstitium makes the lungs heavy and stiff, restricting pulmonary expansion during inspiration. This decreased lung compliance can mimic that seen with other causes of restrictive lung physiology (eg, interstitial lung disease). (Choice A) Surfactant decreases the surface tension of the fluid layer that lines alveolar cells, helping prevent alveolar collapse. Pulmonary edema dilutes pulmonary surfactant, increasing both alveolar surface tension and the tendency for alveolar collapse. (Choice C) Ventilation-perfusion (V/Q) mismatch exists on a spectrum with intrapulmonary shunting (perfusion without ventilation) and dead space ventilation (ventilation without perfusion) on either end. Pulmonary edema causes V/Q mismatch via increased intrapulmonary shunting with a corresponding decrease in dead space ventilation. V/Q mismatch via increased dead space ventilation is seen with pulmonary embolism. (Choice D) Functional residual capacity is the volume of air in the lungs at the end of normal expiration. It is increased in conditions with increased lung compliance (eg, chronic obstructive pulmonary disease) and decreased in conditions such as pulmonary edema that reduce lung compliance. (Choice E) Interventricular septal rupture is a mechanical complication of MI that causes left-to-right cardiac shunting. However, this complication usually occurs within 3-5 days following MI and precipitates a dramatic and acute, rather than gradual, presentation of heart failure.", "educational_objective": "Left-sided heart failure is common following myocardial infarction affecting the left ventricle. The resulting accumulation of edema in the pulmonary interstitium makes the lungs heavy and stiff, restricting inspiratory expansion and decreasing lung compliance.", "source": "UWorld", "difficulty": "hard", "personal_notes": "Tema: Acute heart failure / pulmonary edema and lung compliance", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:27.113456+00:00", "updated_at": "2026-07-20T23:51:27.219448+00:00", "uworld_qid": "1585", "review_due_at": null, "review_interval_days": null }, { "id": "a1925a25-3b99-4716-a97c-72a4b9b35c23", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A research study is conducted to evaluate the effects of various serum proteins in health and disease states. Healthy volunteers and patients with various medical conditions are recruited. In an experiment, purified insoluble elastin is exposed to stimulated neutrophils, which results in the degradation of the elastin molecules into smaller peptides. This process can be inhibited by adding serum from healthy volunteers but not from a specific patient population. Which of the following is the strongest recommendation for patients in this specific population?", "explanation": "Neutrophil elastase is released by both neutrophils and macrophages and is the primary protease responsible for extracellular elastin degradation. The major serum inhibitor of elastase is alpha-1 antitrypsin (AAT). In this study, the patients whose serum is unable to inhibit elastin degradation likely have AAT deficiency, a condition characterized by early-onset panacinar emphysema due to the unopposed action of neutrophil elastase on alveolar walls. Tobacco exposure dramatically accelerates the development of emphysema in patients with AAT deficiency by inducing inflammation (increasing neutrophil and macrophage activation) and permanently inactivating the already low quantities of AAT through oxidation of a crucial methionine residue. Therefore, patients with AAT deficiency should be counseled to avoid smoking and exposure to second-hand smoke. (Choice A) Patients with hypertrophic cardiomyopathy are at risk for sudden cardiac arrest with exertion and are typically counseled to avoid participation in most competitive sports. (Choice B) Patients with chronic granulomatous disease (impaired phagocytic intracellular killing due to a defect in nicotinamide adenine dinucleotide phosphate [NADPH] oxidase) should avoid certain immunosuppressive agents (eg, tumor necrosis factor-alpha blockers) due to risk of overwhelming infection. (Choice D) Periodic aortic diameter monitoring is indicated in patients with Marfan syndrome (impaired fibrillin synthesis), who are at risk for both aortic dissection and chronic aortic regurgitation due to aortic root dilation. (Choice E) Patients with osteogenesis imperfecta (decreased production of type 1 collagen) are at high risk of developing osteoporosis and should undergo regular bone density monitoring. (Choice F) Patients with Ehlers-Danlos syndrome (impaired collagen synthesis) are at risk for scleral fragility, ocular globe rupture, and retinal detachment and should undergo routine ophthalmologic exams.", "educational_objective": "The major serum inhibitor of extracellular elastase is alpha-1 antitrypsin (AAT); patients with AAT deficiency typically develop early-onset panacinar emphysema due to unchecked elastase activity. Exposure to tobacco smoke dramatically accelerates the development of emphysema in patients with AAT deficiency and should be avoided.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Alpha-1 antitrypsin deficiency", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:27.254486+00:00", "updated_at": "2026-07-20T23:51:27.363245+00:00", "uworld_qid": "489", "review_due_at": null, "review_interval_days": null }, { "id": "f3bdaa59-d163-40dd-9651-cf259fd4ac80", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 6-year-old Caucasian boy is brought to the office by his mother due to recurrent episodes of sinusitis. He also has a chronic cough that never seems to go away. The mother says that his previous pediatrician performed a \"sweat test\" to help determine the cause of his frequent infections, but results were normal. DNA testing was inconclusive. Despite these results, the new physician suspects that the patient has an inherited disorder and orders nasal transepithelial potential difference measurements. In this test, an isotonic solution of sodium chloride is applied to the nasal mucosal surface, and the electrical potential overlying the mucosa is compared with that of the interstitial fluid. The results show a transepithelial potential difference that is more negative than normal. This patient's nasal mucosa is most likely to demonstrate which of the following physiologic changes?", "explanation": "Chronic cough and recurrent sinusitis in a young Caucasian patient should raise suspicion for cystic fibrosis (CF). The diagnosis of CF typically is based on elevated sweat chloride concentrations, characteristic clinical findings (recurrent sinopulmonary infections, pancreatic insufficiency), and/or a positive family history. However, patients with mild mutations of the CF transmembrane conductance regulator (CFTR) gene may have normal sweat testing. In these cases, a useful diagnostic adjunct involves measuring the nasal transepithelial potential difference. In intestinal and respiratory epithelia, the CFTR channel secretes chloride ions into the lumen and also has a tonic inhibitory effect on the opening of the epithelial sodium channel (ENaC), which decreases sodium reabsorption into the cell. This high luminal salt content helps retain water in the lumen, forming well-hydrated mucus. During the nasal transepithelial potential difference test, a saline solution is applied to the nose. Because patients with CF have increased sodium absorption via the ENaC, sodium is absorbed intracellularly but chloride in the saline solution is retained in the lumen. The higher relative amounts of negatively charged chloride on the epithelial surface result in a more negative transepithelial voltage difference. CFTR channel functioning is reversed in sweat ducts compared with that in respiratory and intestinal glands. CFTR reduces the salt content of sweat by reabsorbing luminal chloride and stimulating ENaC to increase sodium absorption from the lumen into the cells. CFTR mutations therefore result in the production of sweat with high chloride and sodium content. (Choice A) CFTR mutations lower the rate of bicarbonate secretion in the pancreatic ducts, promoting mucin precipitation and the formation of intraductal concretions that cause exocrine pancreatic insufficiency. However, this effect is not related to the nasal transepithelial potential difference test. (Choice B) CFTR mutations impair the passive transport of chloride along its concentration gradient, decreasing chloride secretion by respiratory epithelial cells. (Choice C) The water content of mucus is decreased (not increased) in patients with CF, resulting in dehydrated mucus that predisposes to the formation of mucus plugs and chronic sinopulmonary infections. (Choice E) CFTR mutations do not significantly alter transmembrane potassium transport.", "educational_objective": "In cystic fibrosis, impairment of the cystic fibrosis transmembrane conductance regulator (CFTR) protein reduces chloride secretion and increases sodium absorption by the respiratory epithelia, resulting in dehydrated mucus. When saline is applied to the nasal mucosa, the increased sodium absorption in patients with CF causes a more negative nasal transepithelial potential difference, which can be used to diagnose cystic fibrosis.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Cystic fibrosis / nasal transepithelial potential difference", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:27.38871+00:00", "updated_at": "2026-07-20T23:51:27.540969+00:00", "uworld_qid": "804", "review_due_at": null, "review_interval_days": null }, { "id": "ede07339-1741-4aa6-9683-af4b7b392b9e", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "An 18-year-old man is evaluated for recurrent episodes of shortness of breath, wheezing, runny nose, and watery eyes. The patient reports that his symptoms have recently worsened since he started training outdoors for an upcoming marathon. He does not use tobacco, alcohol, or illicit drugs. Skin testing is performed to determine symptom triggers. A pricking device is used to apply allergen extract underneath the skin. After 15 minutes, the patient develops raised, erythematous plaques with surrounding erythema at the application site. Which of the following mediators is the first to be released during the pathogenesis of this patient's skin findings?", "explanation": "This patient's shortness of breath and wheezing are suggestive of asthma, and his rhinorrhea and watery eyes are suggestive of allergic rhinitis. Both of these conditions are examples of type I hypersensitivity, which involves the triggering of an allergic response via the binding of previously recognized antigen to IgE antibodies on mast cells. Many type I hypersensitivity reactions are composed of both an early and late phase. Histamine is housed in preformed granules of unactivated mast cells and plays an important role in the early phase of type I hypersensitivity. Upon activation, mast cells rapidly release histamine via degranulation, making histamine the first chemical mediator to take effect. Once released, histamine triggers smooth muscle contraction leading to bronchoconstriction, increases vascular permeability leading to edema, and increases mucus secretion from glandular tissue. (Choice B) Leukotriene D4, along with the other cysteinyl leukotrienes (C4 and E4), are not preformed but require synthesis via the 5-lipoxygenase pathway of arachidonic acid metabolism. Therefore, these mediators are released by mast cells later than histamine. Once released, the cysteinyl leukotrienes are potent mediators of vasoconstriction, bronchoconstriction, and increased vascular permeability. (Choice C) Major basic protein is released from eosinophils in the late stage of a type I hypersensitivity reaction and causes localized tissue damage. (Choice D) Platelet-activating factor is a secondary inflammatory mediator that must be synthesized from phospholipid prior to being released from activated mast cells and basophils. Once released, it stimulates bronchospasm and increased vascular permeability. (Choice E) Prostaglandin D2 is synthesized via the cyclooxygenase pathway of arachidonic acid metabolism prior to being released from mast cells. Once released, it causes bronchospasm and vasodilation.", "educational_objective": "Type I hypersensitivity reactions are an allergic response triggered by the binding of previously recognized antigen to IgE antibodies on mast cells. In the early phase of the response, histamine, already stored in preformed granules in mast cells, is the first chemical mediator released. Once released, histamine stimulates smooth muscle contraction (bronchoconstriction), increases vascular permeability (edema), and increases mucus secretion.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Type I hypersensitivity / allergic rhinitis (mast cell mediators)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:27.578514+00:00", "updated_at": "2026-07-20T23:51:27.686791+00:00", "uworld_qid": "661", "review_due_at": null, "review_interval_days": null }, { "id": "0df48947-e3c3-4b64-8481-19c884bcdd84", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 76-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is found to have a laceration of the spleen and is taken for emergent laparotomy. During surgery, the patient goes into cardiac arrest and dies, despite aggressive resuscitation efforts. Autopsy examination is performed and shows areas of thickening inside the chest wall as shown below. Lung examination shows fibrosis of the lower lobes. Pathologic examination of these fibrotic areas is most likely to reveal which of the following findings?", "explanation": "This elderly patient had pleural plaques (focal thickening and calcification of the parietal pleura) and lower lung fibrosis, consistent with pleuropulmonary asbestosis. Asbestosis is a pneumoconiosis that occurs with inhalation of asbestos fibers (hydrated magnesium silicates), typically in patients with occupational exposure (eg, insulation installation, shipbuilding, pipe work). Patients are typically asymptomatic for 20-30 years after initial exposure; dyspnea, cough, and fatigue are common presenting symptoms. CT radiography in asbestosis demonstrates bilateral parenchymal fibrosis, most predominant in the lower lungs; honeycombing and upper lung involvement occur in advanced disease. Pleural disease is common and includes pleural plaques, diffuse pleural thickening, or benign pleural effusions. Histopathology typically demonstrates diffuse interstitial fibrosis in association with ferruginous bodies (golden brown, rod- or fusiform-shaped fibers coated with iron-protein complexes). Asbestos fibers can be differentiated from other ferruginous bodies (eg, carbon, talc) by their translucent fiber core. (Choice A) Hyaline membranes within the alveoli are seen in acute respiratory distress syndrome (ARDS) and can occur after severe trauma or sepsis. ARDS can lead to fibrosis, but this typically occurs weeks to months after the initial pulmonary insult and is not associated with pleural plaques. (Choice B) Birefringent silicate particles are seen in silicosis, which typically presents with innumerable nodules that predominate in the upper lungs; egg-shell calcifications of the hilar lymph nodes may also be seen. Pleural plaques are unexpected. (Choice C) Carbon-laden macrophages are seen in coal workers' pneumoconiosis. Gross pathology demonstrates black coal nodules distributed throughout the upper lungs. (Choice D) Carcinoid tumors are neuroendocrine malignancies that appear histologically as sheets of uniform cells with dense-core granules noted on electron microscopy. They sometimes cause carcinoid syndrome (eg, flushing, diarrhea, wheezing), which is seen more commonly with gastrointestinal tumors. However, they tend to involve the large bronchi; fibrosis and pleural plaques are unexpected. (Choice E) Chronic granulomatous disease is an immunodeficiency due to the inability of phagocytes to produce reactive oxygen species. Patients develop excessive granuloma formation and recurrent bacterial and fungal infections. Patients are typically diagnosed in childhood.", "educational_objective": "Asbestosis is a pneumoconiosis that occurs with inhalation of asbestos fibers, most commonly in patients with occupational exposure (eg, insulation installation, shipbuilding, pipe work). Histopathology demonstrates diffuse interstitial fibrosis and ferruginous asbestos bodies (translucent fibers coated with a golden iron-containing material). Pleural disease (eg, plaques, benign effusions) is common.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Asbestosis / pneumoconiosis", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:27.715936+00:00", "updated_at": "2026-07-20T23:51:27.814446+00:00", "uworld_qid": "15335", "review_due_at": null, "review_interval_days": null }, { "id": "53c6cde7-43e9-4246-9b78-9d49c0e62ab2", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 56-year-old man comes to the office due to worsening cough for the past several months. He initially had a morning cough productive of minimal sputum, but now the cough occurs throughout the day with large amounts of yellowish sputum. The patient also has breathlessness on moderate exertion. He has had 3 hospitalizations over the past year for respiratory infections. The patient has smoked a pack of cigarettes daily for the past 30 years and has failed multiple attempts to quit. Oxygen saturation is 90% at rest and decreases to 84% with moderate exertion. Which of the following additional findings is most likely to be seen in this patient?", "explanation": "This patient with progressive dyspnea and productive cough in the setting of significant smoking history likely has chronic obstructive pulmonary disease (COPD). His recent hospitalizations for respiratory infections likely represent COPD exacerbations. Hypoxemia (O2 saturation <92%) is common in advanced COPD and occurs via 2 major mechanisms: airway obstruction (due to bronchial inflammation and mucus secretion) and air-trapping (due to both bronchial inflammation and emphysematous airway collapse) cause ventilation-perfusion mismatching; and emphysematous destruction of the alveolar-capillary membrane results in impaired diffusion of O2. Hypoxemia leads to hypoxia throughout the tissues of the body, which is sensed by specialized interstitial cells in the renal cortex and medulla. In response, these cells release erythropoietin, which stimulates the bone marrow to increase production of red blood cells and bolster the oxygen-carrying capacity of the blood. The resulting increase in hematocrit, known as secondary polycythemia, is an expected finding in diseases or conditions that cause significant chronic hypoxemia (eg, COPD, interstitial lung disease, obesity hypoventilation syndrome, residing at high altitude). (Choice A) Air-trapping leads to an increase in the functional residual capacity in patients with COPD. (Choice B) Hypoxic vasoconstriction in advanced COPD increases pulmonary vascular resistance and leads to increased right ventricular afterload. (Choice D) Airway obstruction in COPD leads to decreased expiratory flow rates. This is apparent as a reduction in forced expiratory volume in 1 second (FEV1). (Choice E) Left ventricular compliance is increased in conditions that lead to eccentric left ventricular hypertrophy (eg, dilated cardiomyopathy, ischemic heart disease, severe aortic or mitral valve regurgitation). It is not significantly affected in COPD.", "educational_objective": "In response to tissue hypoxia, specialized interstitial cells in the renal medulla and cortex release erythropoietin to stimulate the bone marrow to increase red blood cell production and improve the oxygen-carrying capacity of the blood. This response, known as secondary polycythemia, is an expected finding in diseases or conditions that cause significant chronic hypoxemia (eg, chronic obstructive pulmonary disease).", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: COPD / secondary polycythemia", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:27.839524+00:00", "updated_at": "2026-07-20T23:51:27.926528+00:00", "uworld_qid": "1942", "review_due_at": null, "review_interval_days": null }, { "id": "42e7eb5a-8265-4b43-b653-3cb26666aa4a", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A nonsmoking patient presents with dyspnea, cough, and weight loss and has pleural thickening on imaging. Gross pathology of the lungs (shown) demonstrates encasement of the lungs in a rind-like, calcified mass. Which of the following is the most likely diagnosis?", "explanation": "This nonsmoking patient with dyspnea, cough, and weight loss has pleural thickening on imaging; gross pathology demonstrates encasement of the lungs in a rind-like, calcified mass, consistent with mesothelioma, a rare malignant neoplasm arising from the mesothelial cells that line body cavities (eg, pleural, peritoneal, pericardial). In early mesothelioma, multiple nodules form on the parietal pleura and gradually grow to encase the lung parenchyma (which is typically uninvolved). Pleural effusions are common and frequently hemorrhagic. Mesotheliomas typically present with slowly progressive dyspnea, cough, chest pain, and weight loss. Asbestos exposure is the primary risk factor; individuals with occupational exposure (eg, mining, shipbuilding, insulation installation) are at increased risk. Histologically, mesothelioma can appear as cuboidal or flattened cells (epithelium-like) or spindle cells (stromal-like). Immunohistochemistry is an important diagnostic marker: nearly all cases stain positive for cytokeratins and many also stain positive for calretinin. Electron microscopy usually shows polygonal tumor cells with numerous long, slender microvilli and abundant tonofilaments. (Choice A) Tuberculosis is characterized by caseating granulomas with giant cell formation; patients typically have hilar adenopathy and upper lobe infiltrates, and it occurs most often in immunosuppressed or high-exposure patients (eg, health care workers, incarcerated individuals). (Choice B) Silicosis is associated with inhaled silica (eg, mining, sandblasting); histology shows nodules of whorled collagen fibers and dust-laden macrophages, and imaging shows innumerable upper lobe-predominant nodules. (Choice C) Small cell lung cancer is characterized by small round cells but typically arises in the central airways (not the pleura), with positive neuroendocrine markers (chromogranin, synaptophysin). (Choice E) Empyema (thick fibrinous exudate and pus) typically occurs when bacteria infect the pleural space (usually from an associated pneumonia); patients present with fever, chills, and occasionally sepsis, not months of weight loss and dyspnea.", "educational_objective": "Mesothelioma is a neoplasm arising from mesothelial cells and is strongly associated with asbestos exposure. In early mesothelioma, multiple nodules form on the parietal pleura and gradually encase the lung parenchyma. Immunohistochemistry is important for diagnosis; nearly all mesotheliomas stain positive for cytokeratins and many also stain positive for calretinin.", "source": "UWorld", "difficulty": null, "personal_notes": "Tema: Malignant mesothelioma / asbestos-related disease", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:27.950254+00:00", "updated_at": "2026-07-20T23:51:28.035944+00:00", "uworld_qid": "15370", "review_due_at": null, "review_interval_days": null }, { "id": "cb2fc84d-b20f-4a26-8c14-6a771ac5f139", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 33-year-old woman comes to the office due to worsening exertional dyspnea. She previously jogged frequently but now becomes short of breath while walking her dog in the park. She has no other significant medical history and takes no medications. She smokes a pack of cigarettes daily and does not use alcohol or illicit drugs. Blood pressure is 124/76 mm Hg, pulse is 78/min, and respirations are 20/min. BMI is 27 kg/m2. Cardiac examination is unremarkable. Laboratory studies reveal markedly decreased serum alpha-1 antitrypsin levels. Which of the following pulmonary function test patterns (total lung capacity; FEV1/FVC ratio; diffusing capacity for carbon monoxide [DLCO]) is most likely to be present in this patient?", "explanation": "This young woman with progressively worsening dyspnea, cigarette smoking, and decreased serum alpha-1 antitrypsin (AAT) likely has AAT deficiency and associated early-onset emphysema. Emphysema from any cause leads to increased total lung capacity as the lungs hyperinflate, decreased FEV1/FVC ratio, and decreased DLCO due to destruction of alveoli and adjoining capillary beds. AAT is a protein that inhibits several proteolytic enzymes released by inflammatory cells (particularly neutrophil elastase), reducing tissue damage from the inflammatory cascade. Even without smoking, patients with AAT deficiency typically develop early-onset emphysema (before age 50) due to the inability to inhibit tissue proteolysis; cigarette smoking greatly accelerates this. The emphysema in AAT deficiency typically develops in a panacinar pattern. (Choice A) Obstructive lung disease causes increased lung volumes and decreased FEV1/FVC, but DLCO varies by etiology; asthma can have high DLCO due to increased pulmonary capillary blood volume and intact alveolar-arterial membranes. (Choice C) Decreased FEV1/FVC, decreased lung volume, and decreased DLCO reflect combined restrictive and obstructive defects (eg, pneumoconiosis such as silicosis/asbestosis, sarcoidosis). (Choice D) Reduced FEV1/FVC with normal DLCO may occur in asthma or chronic bronchitis-predominant COPD. (Choices E and F) Restrictive lung disease (intrinsic eg interstitial lung disease; extrinsic eg obesity, neuromuscular disease) shows reduced lung volumes with normal or increased FEV1/FVC ratio; DLCO distinguishes the two, being reduced in intrinsic and normal in extrinsic restrictive disease.", "educational_objective": "Emphysema most commonly results from chronic smoking but can also occur in genetically predisposed individuals with alpha-1 antitrypsin deficiency. Patients with emphysema have a decreased FEV1/FVC ratio, increased total lung capacity, and decreased diffusing capacity.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Alpha-1 antitrypsin deficiency / emphysema PFT pattern", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:28.061518+00:00", "updated_at": "2026-07-20T23:51:28.157277+00:00", "uworld_qid": "1919", "review_due_at": null, "review_interval_days": null }, { "id": "7eb75cde-edad-417b-8364-9c37392a7c6a", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 42-year-old man comes to his primary care physician due to daytime sleepiness. He often falls asleep during meetings and while watching television and has even fallen asleep while driving. He does not feel refreshed when waking and has occasional morning headaches. He has not had abnormal dreams or visual hallucinations when falling asleep or on waking. He has no significant past medical history and is a lifetime nonsmoker. He drinks 2 or 3 beers on Friday nights. Blood pressure is 148/100 mm Hg, pulse is 78/min and regular, and BMI is 32 kg/m2. Cardiopulmonary examination shows no abnormalities. Arterial blood gas analysis is normal. What is this patient's most likely diagnosis?", "explanation": "This patient has several features suggesting obstructive sleep apnea (OSA), including daytime somnolence, nonrestorative sleep, and elevated blood pressure in the setting of obesity. OSA is caused by closure of the upper airway due to relaxation of pharyngeal muscle tone during sleep; contributing factors include obesity, tonsillar hypertrophy, and hypothyroidism. When the airway is occluded, PO2 declines and PCO2 rises until chemoreceptors in the carotid body and brainstem trigger arousal and pharyngeal tone returns; sleep is repeatedly disrupted even without cortical awareness. Typical symptoms include excessive daytime sleepiness, morning headaches, cognitive impairment, and depression, and most patients have loud snoring. Chronic OSA can cause systemic and pulmonary hypertension with right heart failure and increased arrhythmia risk. (Choice A) Central sleep apnea is due to diminished respiratory drive from a neurologic disorder and is usually associated with significant chronic illness (eg, CHF, cerebrovascular disease, renal insufficiency); it is not more common in obesity. (Choice B) Narcolepsy is characterized by poorly regulated REM sleep; patients also have cataplexy, sleep attacks, hypnagogic/hypnopompic hallucinations, and sleep paralysis. (Choice C) Obesity hypoventilation (Pickwickian) syndrome is caused by restricted chest wall expansion from severe obesity, leading to chronically elevated PCO2 and reduced PO2; this patient's normal blood gases and mild obesity are not consistent. (Choice E) Simple insomnia may cause daytime fatigue, but nonrestorative sleep, morning headaches, and elevated blood pressure suggest OSA. (Choice F) Restless leg syndrome causes limb discomfort brought on when trying to sleep and relieved with movement; patients are usually aware of the symptoms.", "educational_objective": "Obstructive sleep apnea is due to relaxation of oropharyngeal muscle tone with occlusion of the upper airway. Symptoms include daytime sleepiness, headaches, and depression. Complications include systemic and pulmonary hypertension, right heart failure, and an increased risk for cardiac events.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Obstructive sleep apnea", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:28.197777+00:00", "updated_at": "2026-07-20T23:51:28.313783+00:00", "uworld_qid": "1460", "review_due_at": null, "review_interval_days": null }, { "id": "48a48d43-bd2f-4317-981c-55217b9036db", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 37-year-old woman is evaluated for exertional shortness of breath. She has had progressive dyspnea for the last year and for the last 2 months has been unable to walk half a block without stopping to rest. She also describes lightheadedness during exertion. Medical history is insignificant, and vital signs are within normal limits. BMI is 23 kg/m2. Physical examination reveals a 2/6 holosystolic murmur at the lower sternal border that increases with inspiration. Further evaluation indicates no evidence of obstructive or interstitial lung disease or venous thromboembolism. Cardiac catheterization shows mean pulmonary artery pressure 43 mm Hg (normal: 8-20) and pulmonary capillary wedge pressure 9 mm Hg (normal: 6-12). Pharmacotherapy blocking the effects of which of the following substances is most likely to benefit this patient?", "explanation": "This patient has pulmonary hypertension, which typically presents with progressive dyspnea and fatigue, sometimes with chest pain and exertional lightheadedness or syncope; right ventricular enlargement produces a holosystolic murmur of functional tricuspid regurgitation. Pulmonary hypertension can be due to a primary change in the pulmonary arteries or secondary to another disease process (eg, left-sided heart failure, ruled out by pulmonary capillary wedge pressure <=12 mm Hg; chronic lung hypoxia; chronic thromboembolic disease). Pulmonary arterial hypertension (PAH) results from proliferative vasculopathy of the pulmonary arteriolar smooth muscle, occurring with hereditary mutation (most commonly BMPR2), connective tissue disease, or HIV infection. Endothelin is a potent vasoconstrictor that also promotes smooth muscle proliferation, is found in high concentrations in PAH, and is an important therapeutic target; endothelin receptor antagonists (eg, bosentan, ambrisentan) inhibit smooth muscle proliferation and alleviate vasoconstriction to lower pulmonary arterial pressure and improve dyspnea. (Choices A, B, and D) Aldosterone receptor antagonists (eg, spironolactone), angiotensin II receptor blockers (eg, losartan), and beta blockers (blocking beta-1 receptors stimulated by norepinephrine, eg metoprolol) prevent cardiac remodeling in left ventricular systolic dysfunction and can treat pulmonary hypertension secondary to left-sided heart failure, but are not used for PAH. (Choice E) In carcinoid syndrome, high serotonin may cause fibrous deposition on right-sided heart valves (tricuspid regurgitation and/or pulmonic stenosis); serotonin-blocking agents (eg, octreotide) treat carcinoid syndrome but would not explain this patient's elevated pulmonary arterial pressure, and serotonin's role in PAH is not well defined.", "educational_objective": "Pulmonary hypertension can occur due to a primary change in the pulmonary arteries (ie, pulmonary arterial hypertension) or secondary to a separate disease process such as left-sided heart failure (ruled out by normal pulmonary capillary wedge pressure). Endothelin receptor antagonists (eg, bosentan, ambrisentan) lower pulmonary arterial pressure and improve dyspnea in patients with pulmonary arterial hypertension.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Pulmonary arterial hypertension / endothelin receptor antagonists", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:28.343455+00:00", "updated_at": "2026-07-20T23:51:28.439412+00:00", "uworld_qid": "14847", "review_due_at": null, "review_interval_days": null }, { "id": "d5d8ba84-9683-4124-b440-2f3d59c06031", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 68-year-old man comes to the emergency department due to cough, breathlessness, and chest pain. He has hypertension and type 2 diabetes mellitus and is a former smoker with a 20-pack-year history. Temperature is 38 C (100.4 F), blood pressure is 130/80 mm Hg, respirations are 22/min, and oxygen saturation is 95% on ambient air. The trachea is central. There is dullness to percussion over the lower right lung area compared to resonance on the left. Auscultation of the right lower lobe reveals breath sounds that are loud, hollow, and high-pitched. When the patient recites the word \"ninety-nine\" in a normal voice, the sound has higher clarity and intensity over the right base compared to other lung areas. Which of the following is the most likely cause of these findings?", "explanation": "This presentation is consistent with bacterial pneumonia; infection fills the alveoli with inflammatory, neutrophil-rich exudate (pus), and alveolar filling with any fluid (pus, edema, blood) creates alveolar consolidation. Consolidation produces characteristic findings: sound travels faster and more efficiently through liquids than gases, so fluid-filled alveoli transmit higher-intensity sound. Breath sounds and tactile fremitus are more prominent, and bronchophony (spoken words such as \"ninety-nine\" or \"toy boat\" heard more loudly and clearly over consolidation) is present. The higher density of fluid-filled alveoli creates relative dullness to percussion. (Choice A) Pleural effusion (interstitial fluid in the pleural space) insulates breath sounds and vibrations, so tactile fremitus and breath sound intensity are decreased, with dullness to percussion. (Choice B) Pulmonary embolism typically has minimal effect on lung examination findings. (Choice D) Pneumothorax (air in the pleural space) insulates sounds and vibrations, decreasing breath sound intensity and tactile fremitus, but creates hyperresonance to percussion. (Choice E) A proximal bronchial mass (eg, malignancy, mucus plug) causes obstruction and atelectasis of distal alveoli, decreasing breath sounds and tactile fremitus with dullness to percussion. (Choice F) Transudation of fluid into alveoli occurs in heart failure and can create consolidation with similar findings, but heart failure findings are typically bilateral; pneumonia with inflammatory exudate is more likely in this patient with low-grade fever and unilateral consolidation.", "educational_objective": "Alveolar consolidation occurs when the alveoli become filled with fluid (eg, inflammatory exudate in bacterial pneumonia). The increased compactness of the alveolar fluid (compared to air) causes sound to travel faster and more efficiently, resulting in bronchophony, increased tactile fremitus, and increased intensity of breath sounds over the affected area. Dullness to percussion is also present.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Alveolar consolidation / pneumonia auscultation findings", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:28.467198+00:00", "updated_at": "2026-07-20T23:51:28.563881+00:00", "uworld_qid": "14922", "review_due_at": null, "review_interval_days": null }, { "id": "88ac1c09-8407-4a03-9ef2-79ca74ddc8ff", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 63-year-old man comes to the office due to 3 months of increasing cough with occasional hemoptysis, night sweats, and unintentional weight loss. He recently emigrated from South Africa, where he worked for many years in the gold mines. He has a history of silicosis diagnosed 10 years ago. Vital signs show a low-grade fever. Physical examination reveals diffuse, fine crackles with right upper lobe predominance. Chest x-ray shows diffuse, small nodules; hilar adenopathy with prominent calcifications; and a cavitary lung lesion in the right upper lobe. A sputum sample is sent for appropriate staining and culture. This patient's increased susceptibility to the current infection is best explained by which of the following factors?", "explanation": "This patient with a history of silicosis has developed hemoptysis, night sweats, weight loss, and an upper lobe cavitary lesion, highly suggestive of tuberculosis. Silicosis is an occupational lung disease caused by inhalation of crystalline silica and is characterized by multiple rounded nodules in the upper lobes; patients may also develop calcification of the rim of hilar lymph nodes (eggshell calcification). Silicosis is associated with increased risk of mycobacterial infections, particularly Mycobacterium tuberculosis, due to impaired macrophage function: macrophage phagolysosomes are disrupted by internalized silica particles, leading to impaired phagocytosis and increased apoptosis. (Choice A) Interstitial fibrosis from silicosis would not greatly predispose to mycobacterial infection; scarred lung is less accessible and may limit pathogen spread. (Choices B and D) Th2 cells mediate humoral immunity and combat parasitic infections, but humoral immunity does not play a major role in eliminating mycobacteria due to their intracellular survivability. (Choice E) Impaired mucociliary clearance (eg, cystic fibrosis) causes recurrent infections, but mucociliary clearance is not directly impaired by silicosis.", "educational_objective": "In silicosis, internalized silica particles impair macrophage function by disrupting phagocytosis and promoting apoptosis. This increases the risk of mycobacterial infection (particularly M tuberculosis).", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Silicosis and susceptibility to tuberculosis", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:28.588808+00:00", "updated_at": "2026-07-20T23:51:28.682971+00:00", "uworld_qid": "670", "review_due_at": null, "review_interval_days": null }, { "id": "7ff91228-6021-4e52-9cf7-7d5b86a1f129", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 54-year-old man comes to the office due to daytime sleepiness and lack of energy. The symptoms began 6 months ago and have progressively worsened so that he feels \"completely drained\" by the end of the day. His wife mentions that he snores loudly. His past medical history is unremarkable, although he has not seen a physician in over 10 years. He does not use tobacco or alcohol and works in the warehouse of an agricultural supply company. BMI is 34 kg/m2. Physical examination shows a narrow oropharynx and a large neck circumference. The patient is at increased risk of developing which of the following?", "explanation": "This obese man with loud snoring, daytime sleepiness, and suggestive examination findings (thick neck, narrow airway) most likely has obstructive sleep apnea (OSA), characterized by recurrent obstruction of the upper airway during sleep. Each nocturnal episode of reduced ventilation causes transient hypercapnia and hypoxemia, resulting in reflexive systemic and pulmonary vasoconstriction, endothelial dysfunction, abnormal venous return and cardiac output, and sympathetic cardiac stimulation. Prolonged, untreated OSA can cause pulmonary hypertension and right heart failure. Most patients with OSA develop systemic hypertension due to chronic sympathetic stimulation and elevated plasma norepinephrine and lose the normal diurnal blood pressure variation. Other cardiovascular complications include atrial fibrillation and other arrhythmias, coronary artery disease, and increased risk of sudden cardiac death. (Choice A) Acquired bronchiectasis occurs with recurrent infection, impaired drainage (eg, cystic fibrosis), airway obstruction (eg, foreign body), or inadequate host defense (eg, hypogammaglobulinemia). (Choice B) Systemic hypertension in OSA can cause mild-to-moderate left ventricular hypertrophy, but hypertrophic cardiomyopathy is an autosomal dominant sarcomere disease with severe myocardial hypertrophy, not associated with hypertension or OSA. (Choice C) Laryngeal carcinoma is associated with cigarette smoking and heavy alcohol use. (Choice D) Narcolepsy also causes daytime drowsiness but is associated with cataplexy, sleep attacks, sleep paralysis, and hypnagogic hallucinations; OSA is not a risk factor for narcolepsy.", "educational_objective": "Obstructive sleep apnea presents in obese individuals with excessive daytime sleepiness and signs of nocturnal upper airway obstruction (eg, snoring, gasping). The condition is associated with systemic hypertension. Prolonged, untreated obstructive sleep apnea can also cause pulmonary hypertension and right heart failure.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Obstructive sleep apnea complications (pulmonary hypertension)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:28.716282+00:00", "updated_at": "2026-07-20T23:51:28.823974+00:00", "uworld_qid": "1985", "review_due_at": null, "review_interval_days": null }, { "id": "9a87b31f-3754-417d-b1ba-e98b31774138", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 54-year-old man comes to the emergency department due to fevers, shaking chills, and cough productive of copious sputum. He began having fever, cough, and sharp chest pains 10 days ago and was prescribed oral antibiotics by his primary care physician after a chest x-ray revealed a right lower lobe infiltrate. He has not been taking the medication as advised, and his symptoms have progressively worsened. Temperature is 39 C (102.2 F), blood pressure is 114/62 mm Hg, and pulse is 116/min. Physical examination reveals crackles in the right lower lung. Repeat chest x-ray reveals a round density with an air-fluid level in the lower lobe of the right lung. Which of the following is the most important contributor to the observed lung lesion in this patient?", "explanation": "Lung abscess is a necrotic infection of the pulmonary parenchyma that usually presents with several days of fever, cough productive of copious (often foul-smelling) sputum, and chest x-ray evidence of cavitation with an air-fluid level. Most cases are due to aspiration of anaerobic bacteria from the oropharynx, but abscess can also develop in untreated pneumonia. Neutrophils are the key player in abscess formation; they are recruited from the systemic circulation by chemokines and activated by microbial molecules (eg, lipopolysaccharide, peptidoglycan, bacterial DNA) and opsonins (eg, IgG, complement) to phagocytize and destroy bacteria. Activated neutrophils release cytotoxic granules (lysosomes) containing myeloperoxidase and other digestive enzymes that destroy extracellular bacteria but also cause significant damage to the pulmonary parenchyma, resulting in liquefactive necrosis and potentially lung abscess. (Choices A and B) Dendritic and other antigen-presenting cells release interleukin-12, which stimulates Th1 differentiation and interferon-gamma production by T cells; interferon-gamma activates macrophages to form mature phagolysosomes important for intracellular infections such as M tuberculosis. TB can cause cavitation, but usually in the upper lobes and over months. (Choice D) Major basic protein is the predominant component of eosinophil granules and eliminates parasites; abscess formation is mediated by neutrophils, not eosinophils. (Choice E) Transforming growth factor-beta recruits fibroblasts and promotes connective tissue deposition, contributing to scar formation and fibrosis in chronic inflammation.", "educational_objective": "Abscess formation is largely driven by neutrophil recruitment and activation leading to the release of cytotoxic granules that kill bacteria but also cause liquefactive necrosis of surrounding tissue.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Lung abscess / neutrophil-mediated liquefactive necrosis", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:28.893431+00:00", "updated_at": "2026-07-20T23:51:28.985266+00:00", "uworld_qid": "302", "review_due_at": null, "review_interval_days": null }, { "id": "54e20c19-b41e-4677-ad31-9b69f6bec927", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 58-year-old woman comes to the office due to gradually worsening shortness of breath. She has a history of emphysema secondary to alpha-1 antitrypsin deficiency and uses inhaled bronchodilators and glucocorticoids. Lately she has been feeling short of breath even with minimal exertion. She has no other medical conditions and is a former smoker with a 5-pack-year history. Blood pressure is 130/80 mm Hg, pulse is 82/min, and respirations are 18/min. Physical examination shows increased anteroposterior chest diameter, prolonged expiratory phase, and decreased breath sounds bilaterally. The heart sounds are distant. Chest x-ray reveals hyperinflated lungs with no consolidation, pleural effusion, or pneumothorax. Which of the following sets of arterial blood gas findings on room air (pH; PaCO2 [mm Hg]; plasma HCO3 [mEq/L]; PaO2 [mm Hg]) is most likely to be seen in this patient?", "explanation": "This patient's increased anteroposterior chest diameter, prolonged expiratory phase, distant heart sounds, and hyperinflation on chest x-ray are consistent with severe emphysema. Severe disease impairs gas exchange due to destruction of the alveolar-arterial membrane, leading to hypoxemia. Increased alveolar compliance (reduced elastic recoil) and collapse of floppy airways (airway obstruction) lead to CO2 retention. The kidneys compensate for chronic retention of acidic CO2 by increasing bicarbonate reabsorption (secondary metabolic alkalosis) to help normalize pH. Therefore, patients with severe emphysema are expected to have chronic respiratory acidosis with metabolic compensation (high PaCO2, compensatory high bicarbonate, slightly acidic pH), often with hypoxemia (PaO2 <75 mm Hg on room air) — matching choice B. (Choice A) Low pH, high PaCO2, normal bicarbonate show acute respiratory acidosis with hypoxemia (eg, acute opioid overdose); kidneys require several days to retain bicarbonate. (Choice C) pH 7.4, PaCO2 40, bicarbonate 24 are normal values. (Choice D) Slightly high pH, elevated bicarbonate, elevated PaCO2 show compensated metabolic alkalosis (eg, vomiting) with secondary respiratory acidosis. (Choice E) High pH, low PaCO2, near-normal bicarbonate show acute respiratory alkalosis with hypoxemia (eg, hyperventilation from acute pulmonary embolism); kidneys have not had time to excrete bicarbonate.", "educational_objective": "Patients with severe emphysema typically have chronic CO2 retention leading to chronic respiratory acidosis with metabolic compensation (high PaCO2, compensatory high bicarbonate, slightly acidic pH), often accompanied by hypoxemia (PaO2 <75 mm Hg on room air).", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Severe emphysema / chronic respiratory acidosis with compensation", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:29.010528+00:00", "updated_at": "2026-07-20T23:51:29.10948+00:00", "uworld_qid": "15206", "review_due_at": null, "review_interval_days": null }, { "id": "83b4976e-6bb1-4d2b-b89c-4882c6aebc34", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 60-year-old woman comes to the emergency department due to shortness of breath and productive cough. She has a 30-pack-year smoking history. Oxygen saturation is 88% on room air. On physical examination, she appears uncomfortable and uses her accessory respiratory muscles to breathe. Expiratory wheezes are heard throughout the lungs. The patient is started on high-flow oxygen supplementation. Shortly afterward, she becomes increasingly lethargic and confused. This patient's clinical decline is most likely attributable to an increase in which of the following parameters?", "explanation": "This presentation (dyspnea, productive cough, hypoxemia, expiratory wheezing, accessory muscle use, smoking history) is consistent with a COPD exacerbation. Supplemental oxygen may be warranted for significant hypoxemia, but excessively high oxygen concentrations can lead to increased CO2 retention (oxygen-induced hypercapnia), causing confusion and depressed consciousness. The major cause is increased ventilation-perfusion mismatch: hypoxia normally causes vasoconstriction of pulmonary arterioles, shunting blood toward well-ventilated alveoli and minimizing physiologic dead space. High-concentration oxygen raises oxygen levels in poorly ventilated regions, reversing this vasoconstriction; the redistribution of blood flow away from well-ventilated alveoli increases physiologic dead space and reduces CO2 excretion. (Choice A) Oxygen alleviates hypoxic pulmonary vasoconstriction, decreasing pulmonary vascular resistance. (Choice B) Hyperoxia can increase reactive oxygen species and cause oxygen toxicity (substernal heaviness, pleuritic chest pain, cough/dyspnea within 24 hours of breathing pure oxygen), but that is not the cause here. (Choice C) In hypercapnia and respiratory acidosis the kidneys increase bicarbonate reabsorption over days, which would ameliorate hypercapnia. (Choice D) High-flow oxygen reduces peripheral chemoreceptor stimulation, decreasing (not increasing) respiratory rate and minute ventilation.", "educational_objective": "Supplemental oxygen administration in patients with chronic obstructive pulmonary disease can lead to increased CO2 retention (oxygen-induced hypercapnia), resulting in confusion and depressed consciousness. The major cause is reversal of hypoxic pulmonary vasoconstriction, which increases physiologic dead space as blood is shunted away from well-ventilated alveoli.", "source": "UWorld", "difficulty": "hard", "personal_notes": "Tema: COPD / oxygen-induced hypercapnia (V/Q mismatch)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:29.134915+00:00", "updated_at": "2026-07-20T23:51:29.265106+00:00", "uworld_qid": "12141", "review_due_at": null, "review_interval_days": null }, { "id": "d208f9f2-f304-433a-b871-eab746e01b4a", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 44-year-old man comes to the emergency department with a 3-day history of fever, chills, malaise, dyspnea, and a cough productive of \"greenish\" sputum. He has no prior medical problems and has never been hospitalized. He has a 25-pack-year smoking history and drinks 4-5 beers a week. His temperature is 39.4 C (103 F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 20/min. On examination, dullness to percussion, crackles, and egophony are present at the right lung base. The remainder of the examination is normal. Chest x-ray shows a dense infiltrate occupying the entire right lower lobe. Which of the following most likely accounts for the color of this patient's sputum?", "explanation": "This middle-aged man with new-onset fevers, productive cough, and a dense lobar infiltrate likely has community-acquired pneumonia (CAP). CAP in otherwise healthy individuals is most commonly caused by Streptococcus pneumoniae, and tobacco use further increases risk; pneumococcal pneumonia presents with abrupt-onset fevers, rigors, tachypnea, and productive cough with lobar consolidation. Neutrophil myeloperoxidase is responsible for the green color of pus and sputum in bacterial infections. It is a blue-green heme-based pigmented molecule contained in the azurophilic granules of neutrophils and catalyzes production of hypochlorous acid from chloride and hydrogen peroxide during the phagocytic respiratory burst. (Choices A and B) The \"currant jelly\" sputum of Klebsiella pneumoniae pneumonia and the \"rusty\" color occasionally seen in pneumococcal pneumonia are due to extravasation of red blood cells and hemoglobin into the sputum from extensive inflammation and necrosis. (Choice C) Pseudomonas pneumonia can cause a blue-green pigment from pyocyanin, but Pseudomonas is not a common cause of CAP in otherwise healthy adults. (Choice D) Respiratory epithelium sloughing and mucopolysaccharide production contribute to sputum formation but not its green color.", "educational_objective": "The green discoloration of pus or sputum seen during common bacterial infections is due to the presence of myeloperoxidase, a blue-green heme-based enzyme that is released from neutrophil azurophilic granules and forms hypochlorous acid (bleach).", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Community-acquired pneumonia / green sputum (myeloperoxidase)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:29.291877+00:00", "updated_at": "2026-07-20T23:51:29.391827+00:00", "uworld_qid": "1910", "review_due_at": null, "review_interval_days": null }, { "id": "fa97954e-3446-481a-b8f2-f1adf8c9e8ae", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 57-year-old man is being evaluated for progressive shortness of breath. His respiratory flow-volume curve is shown in red (a leftward-shifted loop with increased total lung capacity and residual volume and a scooped-out expiratory limb, compared to normal). Which of the following pathologic findings is most likely to be present in this patient?", "explanation": "Flow-volume loops plot air velocity against lung volume during a cycle of maximal inspiration and expiration. This patient's loop exhibits a leftward shift indicating increased total lung capacity and residual volume, plus a characteristic \"scooped-out\" expiratory pattern consistent with reduced expiratory flow rates seen in obstructive lung disease. This hyperinflation and expiratory airflow obstruction occur in COPD. Airflow obstruction in COPD is partially due to anatomic narrowing of the bronchi (chronic bronchitis); in addition, decreased lung elasticity from destruction of interalveolar walls (emphysema) promotes dynamic compression of the airways during expiration (intrapleural pressure exceeds airway pressure), further contributing to obstruction. Hyperinflation also reduces inspiratory reserve volume and limits maximal tidal volume, especially during exercise (dynamic hyperinflation), a major cause of dyspnea and exercise limitation. (Choice A) Alveolar hyaline membranes occur in acute respiratory distress syndrome; pulmonary edema reduces compliance, causing a restrictive pattern. (Choice B) Atelectasis from extrinsic compression (eg, pneumothorax or pleural fluid) reduces lung volumes and compliance, producing a restrictive pattern. (Choice D) Diffuse intraalveolar hemorrhage dilutes surfactant, increasing surface tension and promoting atelectasis, reducing lung volumes and compliance (restrictive pattern). (Choice E) Pulmonary fibrosis decreases lung volume and compliance (restrictive pattern) with reduced TLC and residual volume. (Choice F) In pulmonary thromboembolism there is decreased perfusion but minimal effect on ventilation, so the flow-volume curve remains mostly normal.", "educational_objective": "The flow-volume loop for chronic obstructive pulmonary disease is characterized by increased residual volume and total lung capacity, as well as a \"scooped-out\" expiratory pattern due to reduced expiratory flow rates. Both airway narrowing due to chronic bronchitis and decreased elasticity due to emphysematous destruction of interalveolar walls are responsible for the hyperinflation and airflow limitation.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: COPD / emphysema flow-volume loop", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:29.417432+00:00", "updated_at": "2026-07-20T23:51:29.515989+00:00", "uworld_qid": "487", "review_due_at": null, "review_interval_days": null }, { "id": "9b068f7c-00a1-4d16-9659-cb9c3d9f6bf9", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 45-year-old man comes to the emergency department due to severe dyspnea and chest discomfort that began earlier in the day. The dyspnea has been worsening throughout the day and is present at rest. He reports no inciting trauma. He has no other medical conditions and takes no medications. He has a 20-pack-year smoking history and does not use alcohol or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 110/60 mm Hg, and pulse is 96/min. Arterial blood gas on room air shows PaO2 of 54 mm Hg and PaCO2 of 26 mm Hg. Which of the following processes is most likely occurring in this patient?", "explanation": "This patient with acute-onset dyspnea and chest discomfort likely has an acute pulmonary embolism (PE). PE leads to increased dead-space ventilation with a ventilation/perfusion (V/Q) mismatch that causes hypoxemia. The acute hypoxemia along with pulmonary parenchymal inflammation triggers increased respiratory drive and hyperventilation. Because the rate of CO2 removal is closely tied to ventilation, alveolar hyperventilation increases CO2 expiration, causing hypocapnia (low PaCO2) and respiratory alkalosis. In contrast, O2 absorption becomes capped once hemoglobin is saturated (hemoglobin is ~85% saturated at PaO2 50 mm Hg), so blood in highly ventilated regions cannot absorb extra O2 to compensate for poorly ventilated regions, and hyperventilation does not significantly increase PaO2. Thus patients with acute V/Q mismatch (eg, PE, pneumonia) typically have hypocapnia with respiratory alkalosis and persistent hypoxemia. Without treatment, prolonged hyperventilation can lead to respiratory muscle fatigue (Choice E) with respiratory failure, hypoventilation, hypercapnia, and respiratory acidosis. (Choices B and D) Both decreased chest wall compliance (eg, obesity hypoventilation syndrome) and poor respiratory drive (eg, opioid overdose, some strokes) lead to hypoventilation with hypoxemia and increased PaCO2. (Choice C) Expiratory air trapping occurs in chronic obstructive lung disease, with chronic respiratory acidosis (high PaCO2) that may worsen during exacerbation.", "educational_objective": "An acute ventilation/perfusion mismatch (eg, due to pulmonary embolism or pneumonia) causes hypoxemia and triggers hyperventilation. Because the removal of CO2 is directly dependent on ventilation but the absorption of O2 is capped by the high baseline saturation of hemoglobin, the hyperventilation response typically leads to respiratory alkalosis (low arterial partial pressure of carbon dioxide) with persistent hypoxemia.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Pulmonary embolism / hyperventilation and V/Q mismatch", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:29.55258+00:00", "updated_at": "2026-07-20T23:51:29.64753+00:00", "uworld_qid": "528", "review_due_at": null, "review_interval_days": null }, { "id": "859244dc-5f84-4991-bb3a-b0186d6c05b4", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 65-year-old man comes to the office due to worsening exertional dyspnea over the past 3 months. This past year, he has had 4 respiratory infections that improved with medical therapy. He does not use alcohol or illicit drugs and has smoked 1 1/2 packs of cigarettes daily for 30 years. Temperature is 36.7 C (98.1 F), pulse is 76/min, and respirations are 18/min. On physical examination, breath sounds are diffusely decreased. Chest radiography reveals flattened hemidiaphragms, increased radiolucency of the lungs, and a long, narrow heart shadow. This patient's pulmonary function testing will most likely show which of the following patterns (total lung capacity; FEV1/FVC ratio; forced vital capacity; residual volume)?", "explanation": "This clinical picture is consistent with chronic obstructive pulmonary disease (COPD), a combination of chronic bronchitis and emphysema most commonly due to heavy smoking; patients typically have progressive dyspnea and recurrent upper respiratory infections (characteristic of chronic bronchitis). Air trapping and airway obstruction in COPD reduce both forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC); because the decrease in FEV1 is more profound, the FEV1/FVC ratio is also reduced, the hallmark of obstructive lung disease. Air trapping raises functional residual capacity so respiration occurs at a higher baseline lung volume; residual volume (RV) is increased, and total lung capacity (TLC) is also increased. (Choices A and B) RV and TLC values are rarely discordant, so these PFT patterns are unlikely to represent true clinical findings. (Choice D) Normal RV with increased TLC can be seen in highly trained athletes due to increased vital capacity. (Choice E) Decreased RV and TLC with decreased FVC and increased or normal FEV1/FVC ratio are seen in restrictive lung disease (eg, pulmonary fibrosis); FEV1 decreases but less than FVC.", "educational_objective": "Chronic obstructive pulmonary disease is a combination of emphysema and chronic bronchitis and commonly presents with progressive dyspnea and recurrent upper respiratory infections. Bronchial obstruction and alveolar destruction cause air trapping that manifests on pulmonary function testing as decreased FEV1, FVC, and FEV1/FVC ratio. Residual volume and total lung capacity are increased.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: COPD pulmonary function testing pattern", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:29.672116+00:00", "updated_at": "2026-07-20T23:51:29.764188+00:00", "uworld_qid": "521", "review_due_at": null, "review_interval_days": null }, { "id": "e7db8887-e200-4261-b1ef-f581a2e8d924", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 28-year-old previously healthy man comes to the urgent care clinic due to shortness of breath. He is on a ski vacation in Breckenridge, Colorado, situated at an altitude of 2926 m (9600 ft). On arrival 4 days ago, he experienced mild headache and nausea that resolved spontaneously, but since yesterday he has had worsening dyspnea and cough. He now feels short of breath even with minimal exertion. Temperature is 37.3 C (99.1 F), blood pressure is 134/82 mm Hg, pulse is 98/min, and respirations are 22/min. Oxygen saturation is 86% on ambient air, which rapidly improves to 95% with supplemental oxygen. Physical examination shows pink mucous membranes, flat neck veins, bilateral inspiratory crackles, and no heart murmurs or pedal edema. Chest x-ray reveals patchy alveolar infiltrates. Which of the following is the most likely cause of this patient's current condition?", "explanation": "PARAPHRASED (explanation text was not captured in the source OCR beyond the stem, options, and the correct answer). Faithful short paraphrase based on the correct answer: This young traveler who ascended to high altitude and developed cough, exertional dyspnea, hypoxemia, and bilateral crackles with patchy alveolar infiltrates but no signs of left heart failure (flat neck veins, no edema, no murmur) has high-altitude pulmonary edema (HAPE), a form of noncardiogenic pulmonary edema. At high altitude, hypoxia causes uneven hypoxic pulmonary vasoconstriction, leading to regional over-perfusion and elevated capillary pressures that cause stress failure and disruption of the alveolar-capillary membrane, with leakage of fluid and protein into the alveoli. This distinguishes it from cardiogenic edema (Choice D, impaired left ventricular function), pulmonary embolism (Choice B), respiratory alkalosis from hyperventilation (Choice C), and the increased red cell mass of chronic altitude acclimatization/polycythemia (Choice E).", "educational_objective": null, "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: High-altitude pulmonary edema (HAPE)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:29.789776+00:00", "updated_at": "2026-07-20T23:51:29.921383+00:00", "uworld_qid": "18938", "review_due_at": null, "review_interval_days": null }, { "id": "bbe21490-9145-4813-b560-a8f139a00b70", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 24-year-old man comes to the office due to paroxysmal episodes of breathlessness and wheezing for the past 6 months. He does not recognize any triggers for these episodes and reports they are not associated with exercise or stress. He has no history of recent illness. He had eczema as a child. He has no other medical conditions and takes no medications. Vital signs are within normal limits. Lung examination shows good air movement and no wheezing. Sputum microscopy reveals many granule-containing cells and crystalloid masses. The sputum findings in this patient are a direct result of which of the following cytokines?", "explanation": "This young patient with paroxysmal dyspnea and wheezing likely has asthma, a disease characterized by airway inflammation, bronchial hyperreactivity, and variable airflow obstruction. Symptoms that cannot be related to pulmonary infection, inhalation of irritants, stress, exercise, or aspirin ingestion should raise suspicion for atopic (extrinsic) asthma. Atopic asthma occurs in genetically predisposed individuals; patients often have a family history of asthma, allergies, or eczema. Sputum microscopy classically demonstrates elevated levels of eosinophils (granule-containing cells) with Charcot-Leyden crystals (bipyramidal-shaped accumulations of eosinophil membrane protein). Atopic asthma occurs due to an excessive TH2-mediated reaction to environmental aero-antigens (eg, pollen, pet dander). In response to allergic stimuli, these cells secrete IL-5, a critical cytokine for eosinophil activation, recruitment, and prolonged survival in the bronchial mucosa. TH2 cells also synthesize IL-4, which stimulates IgE formation by plasma cells. As with other type I hypersensitivity reactions, these antigen-specific antibodies bind to receptors on mast cells, and repeated exposure induces mast cell degranulation, leading to bronchoconstriction, increased vascular permeability, and increased mucus production associated with acute asthma exacerbations. Eosinophils also release inflammatory mediators (ie, major basic protein, eosinophil cationic protein) that damage the bronchial epithelium later in the immune response. (Choice A) Although IL-1 release from macrophages is involved in asthma pathogenesis, it is not a specific cytokine; IL-1 release is a component of almost all inflammatory processes and does not necessarily cause eosinophil infiltration. (Choice C) IL-12 functions to promote the differentiation of TH1 cells; it is not directly involved in eosinophil recruitment. (Choice D) Interferon-gamma is secreted by helper T cells and functions to activate macrophages, thereby promoting adaptive immunity against intracellular pathogens; it is not directly chemotactic for eosinophils. (Choice E) Transforming growth factor beta (TGF-beta) is a growth factor involved in tissue regeneration and repair; high levels are associated with subepithelial fibrosis and airway remodeling seen in chronic asthma, but it is not chemotactic for eosinophils.", "educational_objective": "Paroxysmal breathlessness and wheezing in a young patient that are unrelated to ingestion of aspirin, pulmonary infection, inhalation of irritants, and/or exercise should raise a strong suspicion for atopic (extrinsic) asthma. Classic sputum findings include eosinophils and Charcot-Leyden crystals. Eosinophils are recruited and activated by IL-5 secreted by TH2-type T cells.", "source": "UWorld", "difficulty": "easy", "personal_notes": "Tema: Asthma", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:29.947051+00:00", "updated_at": "2026-07-20T23:51:30.045231+00:00", "uworld_qid": "527", "review_due_at": null, "review_interval_days": null }, { "id": "7c26ca63-738c-4397-9323-a778c8973321", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 60-year-old woman is brought to the hospital due to progressive shortness of breath and cough for 2 weeks. The patient was diagnosed with right breast cancer and completed radiation therapy 6 weeks ago. Temperature is 37.3 C (99.1 F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 22/min. Oxygen saturation is 93% on room air. Examination reveals inspiratory crackles over the right lung anteriorly; the lungs are otherwise clear to auscultation. Chest radiograph shows ground-glass opacities in the right lung where radiation was delivered. Laboratory studies reveal no significant changes. Acute radiation-induced lung injury is suspected. Histopathologic examination would most likely reveal formation of which of the following?", "explanation": "Radiation-induced lung injury usually occurs following thoracic irradiation for the treatment of malignancy (eg, breast or lung cancers, lymphoma). Ionizing radiation causes DNA damage directly (eg, double-strand breaks) and indirectly through generation of reactive oxygen and nitrogen species that damage both DNA and other cellular components. In the lung, this damage primarily affects the alveolar-capillary barrier, formed from alveolar epithelial cells (pneumocytes) and vascular endothelial cells, and initiates an inflammatory response with a cascade of cytokines (eg, IL-1, TNF-alpha) and growth factors (eg, PDGF, TGF-beta). Manifestations vary based on chronicity: Acutely, immune-mediated damage results in impaired gas exchange due to exudative alveolitis, with sloughing of pneumocytes and vascular endothelial cells, alveolar/interstitial edema, and hyaline membrane formation; this usually manifests as dyspnea and cough 3-12 weeks after initial radiation exposure. Radiation fibrosis is a delayed manifestation that can develop 6-12 months after exposure; TGF-beta released by immune cells and surrounding tissue initiates fibroblast proliferation, collagen deposition, and formation of dense fibrous bands, resulting in decreased lung volume, dilated bronchi and bronchioles (traction bronchiectasis), impaired mucociliary clearance, and predisposition to chronic infections. (Choices B and C) Hemosiderin-laden macrophages (due to diffuse alveolar hemorrhage) and necrotizing vasculitis are both associated with autoimmune vasculitis (eg, anti-GBM disease); these patients typically have hemoptysis and/or other systemic effects of vasculitis (eg, glomerulonephritis, arthralgias). (Choice D) Although significant neutrophilic infiltrate occurs in radiation-induced lung injury, frank abscess formation usually follows introduction of anaerobic bacteria to the lung parenchyma due to aspiration (eg, alcoholism) or septic embolism.", "educational_objective": "Radiation-induced lung injury typically occurs following thoracic irradiation (eg, breast cancer), which damages pneumocytes and vascular endothelial cells and initiates an inflammatory response (eg, IL-1, TNF-alpha, TGF-beta). This immune response can have both acute (eg, exudative alveolitis, hyaline membrane formation) and delayed (eg, dense fibrosis) effects that typically manifest with cough and dyspnea.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Radiation-induced lung injury", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:30.074945+00:00", "updated_at": "2026-07-20T23:51:30.172191+00:00", "uworld_qid": "18928", "review_due_at": null, "review_interval_days": null }, { "id": "013e6f3e-3193-4065-ab32-b21b3fcfad72", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 62-year-old man comes to the office for evaluation of progressive exertional dyspnea. His medical history is significant for pneumonia and hypertension. He has a 45-pack-year smoking history. On physical examination, breath sounds are decreased bilaterally and wheezes are heard. A CT scan of the chest is shown below. Which of the following cells are most responsible for the development of this patient's lung condition?", "explanation": "This patient's heavy smoking history, exertional dyspnea, and dilated airspaces (red arrows) on CT scan (compared with normal) are indicative of centriacinar emphysema. The pathogenesis of smoking-induced emphysema involves oxidative injury to the respiratory bronchioles and activation of resident alveolar macrophages by components of cigarette smoke, followed by inflammatory recruitment of neutrophils into the affected airspaces. Activated macrophages and neutrophils release proteases, including elastase and others (eg, cathepsins, matrix metalloproteinases), that degrade the extracellular matrix and generate oxygen free radicals that impair the function of protease inhibitors (eg, alpha-1 antitrypsin). The resultant protease-antiprotease imbalance leads to acinar wall destruction and irreversible airspace dilation distal to the terminal bronchioles. Excess protease activity is also implicated in panacinar emphysema, such as occurs with alpha-1 antitrypsin deficiency. (Choice A) Club (formerly Clara) cells are nonciliated secretory constituents of the terminal respiratory epithelium; they secrete club cell secretory protein and surfactant components and help detoxify inhaled substances (eg, tobacco smoke) via a cytochrome P450 mechanism. (Choice B) Eosinophils play an important role in the late-phase component of type I immediate hypersensitivity reactions; in the lung they are recruited to sustain the localized inflammatory response following allergen exposure. (Choice C) Interstitial pulmonary mast cells play a central role in the pathogenesis of allergic asthma by releasing histamine and leukotrienes that induce bronchospasm. (Choice E) Type I pneumocytes constitute >95% of the inner epithelial lining of the alveoli; in emphysema they are destroyed by the acinar wall damage inflicted by neutrophils and other inflammatory cells. (Choice F) Type II pneumocytes are the source of pulmonary surfactant and the main cell type responsible for repair of alveolar epithelium after destruction of type I pneumocytes.", "educational_objective": "The pathogenesis of centriacinar emphysema associated with chronic, heavy smoking predominantly involves the release of proteases, especially elastase, from infiltrating neutrophils and alveolar macrophages.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: Centriacinar emphysema (COPD)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:30.199922+00:00", "updated_at": "2026-07-21T10:31:33.157147+00:00", "uworld_qid": "488", "review_due_at": "2026-07-22T10:31:33.143+00:00", "review_interval_days": 1 }, { "id": "51c9c19b-1aff-409b-8d35-484b303003db", "user_id": "6a5cf4a7-a19f-4f1c-8e75-11f086e900d1", "stem": "A 48-year-old man comes to the office for an initial visit. He says that he feels well and has no medical problems. The patient has a 20-pack-year smoking history and does not use alcohol or illicit drugs. He is counseled on smoking cessation. To explain how smoking affects lung function, the patient is shown a graph of the expected change in forced expiratory volume in 1 second (FEV1) over time if he continues to smoke at the same rate (curve D in the image). Which of the following curves most likely demonstrates the expected FEV1 over time if this patient were to stop smoking now?", "explanation": "Smoking is the strongest risk factor for chronic obstructive pulmonary disease (COPD). Cigarette smoke contains numerous toxins (eg, formaldehyde, cadmium) that impair ciliary function (contributing to chronic bronchitis) and cause oxidative cellular damage (contributing to centrilobular emphysema). These changes are responsible for the airway obstruction and air-trapping that cause the reduction in FEV1 that characterizes COPD. Beginning at approximately age 30, there is a gradual decline in FEV1 with age. Smoking-induced lung damage in COPD rapidly accelerates this normal age-related decline in FEV1, and once the decline occurs it is not recoverable. However, smoking cessation can markedly slow the decline in FEV1 in patients with COPD, an improvement typically apparent within the first year of cessation. Following smoking cessation, the trajectory of this patient's FEV1 decline will improve compared with if he had continued to smoke, but his FEV1 will not return to the level it would have been had he never smoked. This trajectory is best represented by curve C. (Choice A) It is not physiologically possible for FEV1 to increase with age in either smokers or nonsmokers. (Choice B) FEV1 does not remain constant after age 30, even in nonsmokers. (Choice D) With smoking cessation, the trajectory of this patient's FEV1 decline will improve rather than stay the same. (Choice E) This patient would experience a more rapid decline in FEV1 if he were to increase his rate of smoking.", "educational_objective": "Smoking is the strongest risk factor for chronic obstructive pulmonary disease (COPD) and is responsible for accelerated decline in FEV1 in patients with COPD. Smoking cessation will slow the accelerated decline in FEV1, but FEV1 will not return to the level it would have been had the patient never smoked.", "source": "UWorld", "difficulty": "medium", "personal_notes": "Tema: COPD (FEV1 decline and smoking cessation)", "image_path": null, "status": "active", "is_bookmarked": false, "created_at": "2026-07-20T23:51:30.33273+00:00", "updated_at": "2026-07-20T23:51:30.432505+00:00", "uworld_qid": "7558", "review_due_at": null, "review_interval_days": null } ], "question_options": [ { "id": "40b2c941-1348-4b1d-8ac0-7e94f8e56a0b", "question_id": "0fafe00f-3831-469c-892b-69c3871617cb", "option_key": "A", "option_text": "Branching papillae with cells containing empty-appearing nuclei", "is_correct": false, "position": 0, "created_at": "2026-07-19T23:03:13.808651+00:00", "updated_at": "2026-07-19T23:03:13.808651+00:00", "answer_pct": null }, { "id": "ce950b08-e8df-499e-ac87-480696bf707e", "question_id": "0fafe00f-3831-469c-892b-69c3871617cb", "option_key": "B", "option_text": "Dense fibrous tissue extending beyond the thyroid capsule", "is_correct": false, "position": 1, "created_at": "2026-07-19T23:03:13.808651+00:00", "updated_at": "2026-07-19T23:03:13.808651+00:00", "answer_pct": null }, { "id": "65275c66-7ade-4983-8cac-8b944e330cd0", "question_id": "0fafe00f-3831-469c-892b-69c3871617cb", "option_key": "C", "option_text": "Follicular hyperplasia with tall cells projecting into the follicular lumen", "is_correct": true, "position": 2, "created_at": "2026-07-19T23:03:13.808651+00:00", "updated_at": "2026-07-19T23:03:13.808651+00:00", "answer_pct": null }, { "id": "fd280e6a-0718-4655-8ca9-5d929814ec4d", "question_id": "0fafe00f-3831-469c-892b-69c3871617cb", "option_key": "D", "option_text": "Intense lymphoplasmacytic infiltrate with active germinal centers", "is_correct": false, "position": 3, "created_at": "2026-07-19T23:03:13.808651+00:00", "updated_at": "2026-07-19T23:03:13.808651+00:00", "answer_pct": null }, { "id": "dfd44bb3-7c77-4de6-af0b-f5f5c5ec3e48", "question_id": "0fafe00f-3831-469c-892b-69c3871617cb", "option_key": "E", "option_text": "Widespread inflammatory infiltrates, giant cells, and disrupted follicles", "is_correct": false, "position": 4, "created_at": "2026-07-19T23:03:13.808651+00:00", "updated_at": "2026-07-19T23:03:13.808651+00:00", "answer_pct": null }, { "id": "b0f94b8f-949d-444e-979d-bae6bbe4c287", "question_id": "6db60284-8382-4d7b-ba54-600a3b0ec86e", "option_key": "A", "option_text": "Pancreatic islet infiltration with leukocytes", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:36:17.7142+00:00", "updated_at": "2026-07-20T01:36:17.7142+00:00", "answer_pct": 4 }, { "id": "389bc807-1df3-4266-ae91-41041455f123", "question_id": "6db60284-8382-4d7b-ba54-600a3b0ec86e", "option_key": "B", "option_text": "Pancreatic islet amyloid deposition", "is_correct": true, "position": 1, "created_at": "2026-07-20T01:36:17.7142+00:00", "updated_at": "2026-07-20T01:36:17.7142+00:00", "answer_pct": 67 }, { "id": "8a08d47b-66db-4bc5-80bf-76b3a865f2e8", "question_id": "6db60284-8382-4d7b-ba54-600a3b0ec86e", "option_key": "C", "option_text": "Circulating anti-islet antibodies", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:36:17.7142+00:00", "updated_at": "2026-07-20T01:36:17.7142+00:00", "answer_pct": 3 }, { "id": "62b9c82b-ed04-46d0-9299-6cfd427abceb", "question_id": "6db60284-8382-4d7b-ba54-600a3b0ec86e", "option_key": "D", "option_text": "Strong linkage with HLA class II gene makeup", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:36:17.7142+00:00", "updated_at": "2026-07-20T01:36:17.7142+00:00", "answer_pct": 16 }, { "id": "9232ac79-8ac0-4fb9-bd1c-bb868b05cc6d", "question_id": "6db60284-8382-4d7b-ba54-600a3b0ec86e", "option_key": "E", "option_text": "Episodic ketoacidosis that requires insulin therapy", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:36:17.7142+00:00", "updated_at": "2026-07-20T01:36:17.7142+00:00", "answer_pct": 7 }, { "id": "6e6270bc-ece9-4ab1-b2e7-38aef578be82", "question_id": "cdc8acc1-6feb-4cd0-8d4e-a8c208945bd4", "option_key": "A", "option_text": "Beta-thalassemia minor", "is_correct": true, "position": 0, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 76 }, { "id": "c476cf1f-625b-47b9-8079-a03da9e9e35f", "question_id": "cdc8acc1-6feb-4cd0-8d4e-a8c208945bd4", "option_key": "B", "option_text": "Folate deficiency", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 1 }, { "id": "0a037dc0-3b06-4b76-8a66-f89bb86e0b88", "question_id": "cdc8acc1-6feb-4cd0-8d4e-a8c208945bd4", "option_key": "C", "option_text": "Iron deficiency", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 2 }, { "id": "42bfa940-8165-4ce1-a347-a90031a47a2b", "question_id": "cdc8acc1-6feb-4cd0-8d4e-a8c208945bd4", "option_key": "D", "option_text": "Low erythropoietin", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 4 }, { "id": "db17606e-f748-4804-a6dd-d7b70edf1632", "question_id": "cdc8acc1-6feb-4cd0-8d4e-a8c208945bd4", "option_key": "E", "option_text": "Poor glycemic control", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 1 }, { "id": "760c8235-0482-4f51-bd8d-4230e8150bb4", "question_id": "cdc8acc1-6feb-4cd0-8d4e-a8c208945bd4", "option_key": "F", "option_text": "Sickle cell trait", "is_correct": false, "position": 5, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 12 }, { "id": "c83e7ee8-45e3-4625-b4bf-01ccbccbcf8e", "question_id": "2ed54b03-f801-4b82-83a3-1012f85b5291", "option_key": "A", "option_text": "ACTH production from an ectopic site", "is_correct": true, "position": 0, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 85 }, { "id": "80cc2308-62bf-421a-b619-63a7c9484f0e", "question_id": "2ed54b03-f801-4b82-83a3-1012f85b5291", "option_key": "B", "option_text": "Excess cortisol release from the lung mass", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 3 }, { "id": "04efc084-d3f4-4d7a-9c06-0ed66389f81b", "question_id": "2ed54b03-f801-4b82-83a3-1012f85b5291", "option_key": "C", "option_text": "Excessive ACTH secretion from the pituitary", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 3 }, { "id": "b881a5e3-3736-46c0-8cc9-f5c1161b6b16", "question_id": "2ed54b03-f801-4b82-83a3-1012f85b5291", "option_key": "D", "option_text": "Hypothalamic dysfunction from metastatic process", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 2 }, { "id": "825e86a4-b7d1-4da7-a98e-8ec6590ee78b", "question_id": "2ed54b03-f801-4b82-83a3-1012f85b5291", "option_key": "E", "option_text": "Malignant invasion of the adrenal cortex", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 4 }, { "id": "2e19e7d4-3e25-4c19-80d8-77332fcc9a9e", "question_id": "b20f6c18-9a6b-4d84-81f7-3fe7cadf50fa", "option_key": "A", "option_text": "Prolactin secreting cells of the anterior pituitary", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 6 }, { "id": "fa7170a8-63ec-45ae-8ff3-1b37d5751b4a", "question_id": "b20f6c18-9a6b-4d84-81f7-3fe7cadf50fa", "option_key": "B", "option_text": "Remnants of the Rathke pouch", "is_correct": true, "position": 1, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 80 }, { "id": "b6589c9b-0cdb-4d06-b685-8b49387e3fbe", "question_id": "b20f6c18-9a6b-4d84-81f7-3fe7cadf50fa", "option_key": "C", "option_text": "Astrocytes", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 7 }, { "id": "c6f3f334-da76-452d-b18a-0b948820dcc6", "question_id": "b20f6c18-9a6b-4d84-81f7-3fe7cadf50fa", "option_key": "D", "option_text": "Arachnoid cap cells", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 2 }, { "id": "9c80265c-5f51-4924-83ff-d9b571cbae40", "question_id": "b20f6c18-9a6b-4d84-81f7-3fe7cadf50fa", "option_key": "E", "option_text": "Posterior pituitary cells", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 3 }, { "id": "025ee6f1-9070-4f58-8c9d-6841108b94eb", "question_id": "f4554808-aae2-40de-8adc-0023c7a6895a", "option_key": "A", "option_text": "Activation of ALK", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 0 }, { "id": "80dfcdd5-cd21-4bdf-b1c1-4d0e61eafa04", "question_id": "f4554808-aae2-40de-8adc-0023c7a6895a", "option_key": "B", "option_text": "Activation of RET", "is_correct": true, "position": 1, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 76 }, { "id": "023aeefc-a153-4195-acd0-05a930b42a0e", "question_id": "f4554808-aae2-40de-8adc-0023c7a6895a", "option_key": "C", "option_text": "Inactivation of MEN1", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 16 }, { "id": "7ea2f4f6-d9ea-463d-ba4a-130df3240945", "question_id": "f4554808-aae2-40de-8adc-0023c7a6895a", "option_key": "D", "option_text": "Inactivation of p53", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 3 }, { "id": "7f5b265a-3b51-403a-b452-7dea2df7f459", "question_id": "f4554808-aae2-40de-8adc-0023c7a6895a", "option_key": "E", "option_text": "Overexpression of BCL2", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 1 }, { "id": "7bb3f86c-ce0f-459e-b56b-2160f6c9ce31", "question_id": "f4554808-aae2-40de-8adc-0023c7a6895a", "option_key": "F", "option_text": "Overexpression of JAK2", "is_correct": false, "position": 5, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 0 }, { "id": "f30192cb-6059-4297-842f-c805d391191b", "question_id": "29e8373c-b2ce-4fcd-ba46-d368ee9136dd", "option_key": "A", "option_text": "Hypothalamic neurons", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 3 }, { "id": "41a78321-5a33-47b7-89d1-93578189d234", "question_id": "29e8373c-b2ce-4fcd-ba46-d368ee9136dd", "option_key": "B", "option_text": "Ovarian granulosa cells", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 0 }, { "id": "e6c51114-5ac3-425d-a29e-c0e903cc15b2", "question_id": "29e8373c-b2ce-4fcd-ba46-d368ee9136dd", "option_key": "C", "option_text": "Ovarian theca cells", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 1 }, { "id": "c85e291c-4eb8-45c5-8ceb-0dfe963f4ba9", "question_id": "29e8373c-b2ce-4fcd-ba46-d368ee9136dd", "option_key": "D", "option_text": "Pituitary lactotrophs", "is_correct": true, "position": 3, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 85 }, { "id": "ee338e9d-6ac8-4495-b8ff-acbc3835dc2a", "question_id": "29e8373c-b2ce-4fcd-ba46-d368ee9136dd", "option_key": "E", "option_text": "Pituitary somatotrophs", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 8 }, { "id": "ac7c3dc4-ada6-42a4-9502-077ea8f51841", "question_id": "413b3b1e-c7f9-4235-b8b8-18df1d125308", "option_key": "A", "option_text": "Atrophy of both adrenal glands", "is_correct": true, "position": 0, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 52 }, { "id": "7492032b-e3cd-48b7-819b-5a498514aa09", "question_id": "413b3b1e-c7f9-4235-b8b8-18df1d125308", "option_key": "B", "option_text": "Bilateral adrenal hemorrhage", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 18 }, { "id": "a9acdd8d-e7fe-4e60-a819-04c06339bf6a", "question_id": "413b3b1e-c7f9-4235-b8b8-18df1d125308", "option_key": "C", "option_text": "Ischemic anterior pituitary necrosis", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 4 }, { "id": "95a696e5-08ee-4cdc-920c-5759a1db3985", "question_id": "413b3b1e-c7f9-4235-b8b8-18df1d125308", "option_key": "D", "option_text": "Large pituitary tumor with hemorrhage", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 12 }, { "id": "dc744dcf-5584-4677-b801-f09c521d3945", "question_id": "413b3b1e-c7f9-4235-b8b8-18df1d125308", "option_key": "E", "option_text": "Unilateral adrenal mass with contralateral adrenal atrophy", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 12 }, { "id": "bdf5ffd1-b9c7-46cc-a9a2-5763c05826df", "question_id": "9732b557-cc57-415e-a5d9-5dacd433ba78", "option_key": "A", "option_text": "Breast cancer", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 6 }, { "id": "cf0dcf6f-97e0-4acd-8503-588814711c3d", "question_id": "9732b557-cc57-415e-a5d9-5dacd433ba78", "option_key": "B", "option_text": "Hyperosmolar nonketotic coma", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 3 }, { "id": "f240f96b-c6fa-4de7-885f-3d5fb0daf016", "question_id": "9732b557-cc57-415e-a5d9-5dacd433ba78", "option_key": "C", "option_text": "Myocardial infarction", "is_correct": true, "position": 2, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 61 }, { "id": "95fd2a07-8aac-4e5d-a3b0-b3030d439aea", "question_id": "9732b557-cc57-415e-a5d9-5dacd433ba78", "option_key": "D", "option_text": "Renal failure", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 23 }, { "id": "3f9ed2a6-d27c-49ca-999a-6ec2fa711c8c", "question_id": "9732b557-cc57-415e-a5d9-5dacd433ba78", "option_key": "E", "option_text": "Stroke", "is_correct": false, "position": 4, "created_at": 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"2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 3 }, { "id": "6f777e52-c7dd-4a12-b30e-bb443e561650", "question_id": "65f8ebc1-b7ab-42d8-a6e5-b15c7e675c62", "option_key": "D", "option_text": "Renal artery stenosis", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 1 }, { "id": "fadc46b8-6447-40ea-a193-fda6eb8580b1", "question_id": "65f8ebc1-b7ab-42d8-a6e5-b15c7e675c62", "option_key": "E", "option_text": "Steroid drug abuse", "is_correct": true, "position": 4, "created_at": "2026-07-20T01:39:18.379319+00:00", "updated_at": "2026-07-20T01:39:18.379319+00:00", "answer_pct": 86 }, { "id": "da95cfe0-e3c1-43fb-93c4-f10a1a18b475", "question_id": "65f8ebc1-b7ab-42d8-a6e5-b15c7e675c62", "option_key": "F", "option_text": "Volume depletion due to excessive sweating", "is_correct": false, "position": 5, "created_at": 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"5f2ec6c8-6f5a-4cd8-9728-c8acc67d296f", "question_id": "210ed155-4942-45d6-a02c-74674ed742f0", "option_key": "D", "option_text": "Pituitary adenoma", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 8 }, { "id": "21157b47-8f99-4d30-89a7-692536f4c64b", "question_id": "210ed155-4942-45d6-a02c-74674ed742f0", "option_key": "E", "option_text": "Seminoma", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 1 }, { "id": "c91c1ff1-683e-475a-918f-e6f0ef6d3c1c", "question_id": "ac776f04-21e2-4c12-9b3e-c8e9b7a57603", "option_key": "A", "option_text": "Cortisol", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 3 }, { "id": "dd27125f-7751-4ba5-8f96-d8adb4c2e016", "question_id": 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effect", "is_correct": true, "position": 2, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 63 }, { "id": "7174fc83-6579-4e9b-bcf4-3aeb11454ef4", "question_id": "ee50d0b5-f25f-4d8e-bc10-939a159fef4f", "option_key": "D", "option_text": "Primary hyperparathyroidism", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 4 }, { "id": "5b2a5ba6-b46e-4516-8940-39729c116fe3", "question_id": "ee50d0b5-f25f-4d8e-bc10-939a159fef4f", "option_key": "E", "option_text": "Secondary hyperparathyroidism", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 9 }, { "id": "6d3b1308-98b5-4b34-96b0-09632185a111", "question_id": "85d141db-255b-4f8d-8d9b-86b7341c5055", "option_key": "A", "option_text": "Ehlers-Danlos syndrome", "is_correct": false, 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"2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 3 }, { "id": "dcf86c9d-dcef-40fe-8b3d-1bb38b3daa93", "question_id": "45d2d6c6-d013-441d-80df-6d05417bcff1", "option_key": "B", "option_text": "Elevated gastrin", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 2 }, { "id": "38df8b57-c5cd-465c-9d2c-a8fa16b148e7", "question_id": "45d2d6c6-d013-441d-80df-6d05417bcff1", "option_key": "C", "option_text": "Elevated glucagon", "is_correct": true, "position": 2, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 30 }, { "id": "b1e29811-d535-4b3e-b2b4-d0cc1939cdb9", "question_id": "45d2d6c6-d013-441d-80df-6d05417bcff1", "option_key": "D", "option_text": "Elevated somatostatin", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 4 }, { "id": "c37bab2f-5cd1-42e0-beda-ac0443ed2c3b", "question_id": "45d2d6c6-d013-441d-80df-6d05417bcff1", "option_key": "E", "option_text": "Elevated vasoactive intestinal polypeptide", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 9 }, { "id": "fd4ae9a5-0eca-4924-8b0c-805b004c54c3", "question_id": "45d2d6c6-d013-441d-80df-6d05417bcff1", "option_key": "F", "option_text": "Low insulin", "is_correct": false, "position": 5, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 10 }, { "id": "06cbe342-36c4-4378-8b0f-6d9e989b20e8", "question_id": "1df86dff-d94b-4e58-bf07-8ab1df1ee6c8", "option_key": "A", "option_text": "Cortisol baja, Aldosterona baja, ADH alta, Norepinefrina alta", "is_correct": true, "position": 0, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 66 }, { "id": "4640e433-fdbc-4c94-bf54-2e3eddbda515", "question_id": "1df86dff-d94b-4e58-bf07-8ab1df1ee6c8", "option_key": "B", "option_text": "Cortisol normal, Aldosterona normal, ADH alta, Norepinefrina normal", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": null }, { "id": "26ff8811-1452-4a69-b311-cc48d4594768", "question_id": "1df86dff-d94b-4e58-bf07-8ab1df1ee6c8", "option_key": "C", "option_text": "Cortisol normal, Aldosterona alta, ADH alta, Norepinefrina alta", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 5 }, { "id": "c1e8a942-d063-41cb-8e73-9e47da14fc30", "question_id": "bd48df0c-70d9-42ab-b977-39741a4adf5e", "option_key": "A", "option_text": "Cerebellar hemangioblastomas", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 5 }, { "id": "ba2314c2-08fa-47f4-8bc9-c18468be0dad", "question_id": "bd48df0c-70d9-42ab-b977-39741a4adf5e", "option_key": "B", "option_text": "Mucosal neuromas", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 16 }, { "id": "fb1cf462-3645-45e2-8ba7-a3a0da97e932", "question_id": "bd48df0c-70d9-42ab-b977-39741a4adf5e", "option_key": "C", "option_text": "Plexiform neurofibromas", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 7 }, { "id": "e0d45355-ca0b-4a3f-8956-4ede282e07c3", "question_id": "bd48df0c-70d9-42ab-b977-39741a4adf5e", "option_key": "D", "option_text": "Recurrent nephrolithiasis", "is_correct": true, "position": 3, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 37 }, { "id": "5d88e752-62b9-4d1c-be5e-3527a70bae3d", "question_id": "bd48df0c-70d9-42ab-b977-39741a4adf5e", "option_key": "E", "option_text": "Thyroid malignancy", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 33 }, { "id": "cdb27bc0-aeb8-4532-b82a-84c16152f992", "question_id": "cd056d63-d305-4acb-9fed-596cd9425be8", "option_key": "A", "option_text": "Alpha cell tumor", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 5 }, { "id": "3be40354-8f6f-495a-8a66-f5f4e47856b0", "question_id": "cd056d63-d305-4acb-9fed-596cd9425be8", "option_key": "B", "option_text": "Insulin administration", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 7 }, { "id": "4d454693-a15e-46b5-9c62-8a3f7cc3d1d3", "question_id": "cd056d63-d305-4acb-9fed-596cd9425be8", "option_key": "C", "option_text": "Somatostatinoma", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 5 }, { "id": "3ca6101e-093d-4bcc-a968-ed3f0306899d", "question_id": "cd056d63-d305-4acb-9fed-596cd9425be8", "option_key": "D", "option_text": "Sulfonylurea use", "is_correct": true, "position": 3, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 72 }, { "id": "4ead87d5-9177-4ae8-bb6c-4167195bb422", "question_id": "cd056d63-d305-4acb-9fed-596cd9425be8", "option_key": "E", "option_text": "VIP-secreting tumor", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:41:38.340998+00:00", "updated_at": "2026-07-20T01:41:38.340998+00:00", "answer_pct": 8 }, { "id": "dc2dee91-ecbb-4ae7-b354-602d604d7881", "question_id": "dec70849-dfde-48d6-8089-6b4e3e99b09d", "option_key": "A", "option_text": "ECG and serum cardiac enzymes", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 0 }, { "id": "fcca19c4-1281-4941-b3b1-a85ff5016d7c", "question_id": "4d59e664-e724-416d-87b2-46181fd2607e", "option_key": "A", "option_text": "Branching papillary structures with interspersed calcified bodies", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 4 }, { "id": "460191a2-f858-4aa9-8f0c-39d79a2d0415", "question_id": "4d59e664-e724-416d-87b2-46181fd2607e", "option_key": "B", "option_text": "Extensive stromal fibrosis extending beyond the thyroid capsule", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 9 }, { "id": "abedd41c-2f5e-4a32-8c2b-c52098e65204", "question_id": "4d59e664-e724-416d-87b2-46181fd2607e", "option_key": "C", "option_text": "Follicular hyperplasia with tall cells forming intrafollicular papillary projections", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 10 }, { "id": "48dcb83e-a547-4313-be1c-baa80292a2c8", "question_id": "4d59e664-e724-416d-87b2-46181fd2607e", "option_key": "D", "option_text": "Mixed, cellular infiltration with occasional multinucleated giant cells", "is_correct": true, "position": 3, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 58 }, { "id": "39bc2e07-5150-45b1-a62b-df23f0e8dc63", "question_id": "4d59e664-e724-416d-87b2-46181fd2607e", "option_key": "E", "option_text": "Mononuclear, parenchymal infiltration with well-developed germinal centers", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 17 }, { "id": "fed7dd1a-4ea1-4648-bb73-6979fe119bb5", "question_id": "760e1294-e23b-4892-8979-70bb75e48fa8", "option_key": "A", "option_text": "Punto A del diagrama (GnRH hipotalámica)", "is_correct": true, "position": 0, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 57 }, { "id": "2c0df4c5-678a-4621-a5ce-455f1ab7b087", "question_id": "760e1294-e23b-4892-8979-70bb75e48fa8", "option_key": "B", "option_text": "Punto B del diagrama", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 4 }, { "id": "3a179dd2-34c1-48a9-b11f-85813b049d96", "question_id": "760e1294-e23b-4892-8979-70bb75e48fa8", "option_key": "C", "option_text": "Punto C del diagrama", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 8 }, { "id": "4d931db1-8af5-4701-8e73-8a2b6666cc77", "question_id": "760e1294-e23b-4892-8979-70bb75e48fa8", "option_key": "D", "option_text": "Punto D del diagrama", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 20 }, { "id": "3ec3f8cc-5b6f-4ac7-b72c-a77728d58bf5", "question_id": "760e1294-e23b-4892-8979-70bb75e48fa8", "option_key": "E", "option_text": "Punto E del diagrama", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 8 }, { "id": "3c8b9889-5df4-4126-b3b3-ef0f01fc8386", "question_id": "9f5aa740-a6fe-4281-ad28-7cd802e5b375", "option_key": "A", "option_text": "Aortic root dilation", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 18 }, { "id": "592c9904-a7a6-4a2f-a6ca-865d9614a2fc", "question_id": "9f5aa740-a6fe-4281-ad28-7cd802e5b375", "option_key": "B", "option_text": "Bicuspid aortic valve", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 3 }, { "id": "c3a37c11-c3e9-4e00-8ad9-560e905d348e", "question_id": "9f5aa740-a6fe-4281-ad28-7cd802e5b375", "option_key": "C", "option_text": "Left ventricular hypertrophy", "is_correct": true, "position": 2, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 66 }, { "id": "7d7e3be2-a91a-40db-a64a-c503a9aafd62", "question_id": "9f5aa740-a6fe-4281-ad28-7cd802e5b375", "option_key": "D", "option_text": "Mitral valve prolapse", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 10 }, { "id": "5d3ff505-46d8-4ec1-8f95-f74243a5c921", "question_id": "9f5aa740-a6fe-4281-ad28-7cd802e5b375", "option_key": "E", "option_text": "Pericardial effusion", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 2 }, { "id": "ffd297e5-b17d-492c-b173-d97c794e4a36", "question_id": "f5343518-293a-4656-aab6-4f0a3153f772", "option_key": "A", "option_text": "Anaplastic carcinoma", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 12 }, { "id": "d6cb5952-aa75-4248-bca3-c7f37ad2942b", "question_id": "f5343518-293a-4656-aab6-4f0a3153f772", "option_key": "B", "option_text": "Colloid nodule", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 1 }, { "id": "fe3b368c-e2fb-42d8-8eeb-1f0fac3673c0", "question_id": "f5343518-293a-4656-aab6-4f0a3153f772", "option_key": "C", "option_text": "Follicular adenoma", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 10 }, { "id": "e9fb50eb-c2f2-4e1f-bca1-9b45c470e0dc", "question_id": "f5343518-293a-4656-aab6-4f0a3153f772", "option_key": "D", "option_text": "Follicular carcinoma", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 9 }, { "id": "e28bb16f-216c-41cc-bb2f-84d672aadca5", "question_id": "f5343518-293a-4656-aab6-4f0a3153f772", "option_key": "E", "option_text": "Medullary carcinoma", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 9 }, { "id": "88829e7a-b581-4fd8-8d98-acd8982d2033", "question_id": "f5343518-293a-4656-aab6-4f0a3153f772", "option_key": "F", "option_text": "Papillary carcinoma", "is_correct": true, "position": 5, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 55 }, { "id": "1702a623-2569-40b9-8aca-0ae440353f39", "question_id": "5d38d52c-6d11-4b71-9b08-ad85a3a0eb74", "option_key": "A", "option_text": "Acute pancreatitis", "is_correct": true, "position": 0, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 38 }, { "id": "e95f87fa-e9ad-40d9-8e8c-4d38547e61a6", "question_id": "5d38d52c-6d11-4b71-9b08-ad85a3a0eb74", "option_key": "B", "option_text": "Intellectual disability", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 1 }, { "id": "0f818cd5-9216-4aa1-8ee7-0d8274237275", "question_id": "5d38d52c-6d11-4b71-9b08-ad85a3a0eb74", "option_key": "C", "option_text": "Myocardial infarction", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 20 }, { "id": "75b68960-bc5a-478b-b521-6b060710677b", "question_id": "5d38d52c-6d11-4b71-9b08-ad85a3a0eb74", "option_key": "D", "option_text": "Tendon xanthomas", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 24 }, { "id": "bae6c8b9-e0c1-4093-806b-1460aebd7f42", "question_id": "5d38d52c-6d11-4b71-9b08-ad85a3a0eb74", "option_key": "E", "option_text": "Xanthelasmas", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 14 }, { "id": "819cd063-a7a5-4c14-b9aa-7da598248bce", "question_id": "c2f4f6e4-d59e-4f4e-9fca-73f4cf228e48", "option_key": "A", "option_text": "C-cell hyperplasia", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 5 }, { "id": "15ef39d1-1606-4693-9135-e1dee33c868e", "question_id": "c2f4f6e4-d59e-4f4e-9fca-73f4cf228e48", "option_key": "B", "option_text": "Cells with empty appearing nuclei", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 10 }, { "id": "885b470a-e50e-4c71-bd19-65958b330d16", "question_id": "c2f4f6e4-d59e-4f4e-9fca-73f4cf228e48", "option_key": "C", "option_text": "Hurthle cells", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 9 }, { "id": "033aea3f-1b59-4bb9-be27-4e424caac649", "question_id": "c2f4f6e4-d59e-4f4e-9fca-73f4cf228e48", "option_key": "D", "option_text": "Lymphocytic germinal centers", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 8 }, { "id": "a2ce9270-6a05-4ea9-aa41-67a15df69b4f", "question_id": "c2f4f6e4-d59e-4f4e-9fca-73f4cf228e48", "option_key": "E", "option_text": "Multinucleated giant cells", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 3 }, { "id": "efce3176-8bbe-460e-80de-21a0f9dfd680", "question_id": "c2f4f6e4-d59e-4f4e-9fca-73f4cf228e48", "option_key": "F", "option_text": "Tumor capsular invasion", "is_correct": true, "position": 5, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 63 }, { "id": "310a2009-7dc8-429e-86fd-f88005bb8268", "question_id": "dec70849-dfde-48d6-8089-6b4e3e99b09d", "option_key": "B", "option_text": "Serum lipids and blood glucose level", "is_correct": true, "position": 1, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 93 }, { "id": "4f503c26-e7df-43ee-9596-83ac7e073161", "question_id": "dec70849-dfde-48d6-8089-6b4e3e99b09d", "option_key": "C", "option_text": "Liver function tests and abdominal ultrasonography", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 3 }, { "id": "3a0dcde0-4585-45c2-bfe1-24bbf6e5aea6", "question_id": "dec70849-dfde-48d6-8089-6b4e3e99b09d", "option_key": "D", "option_text": "Complete blood count and stool guaiac test", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 0 }, { "id": "f6c72168-c5b1-4f55-a07f-6698a20e52ad", "question_id": "dec70849-dfde-48d6-8089-6b4e3e99b09d", "option_key": "E", "option_text": "Slit lamp exam and ophthalmoscopy", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 0 }, { "id": "8211d3e9-204d-448f-975c-24fefec07178", "question_id": "dec70849-dfde-48d6-8089-6b4e3e99b09d", "option_key": "F", "option_text": "Lesion biopsy and surgeon referral", "is_correct": false, "position": 5, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 0 }, { "id": "e6790d48-10d2-47be-a2c8-49f84cc776fa", "question_id": "7d4e0ce9-7b09-43a2-8808-40b5698f19bb", "option_key": "A", "option_text": "ACTH baja y cortisol bajo (supresión) — patrón de fuente pituitaria", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": null }, { "id": "b50c1f53-2ad2-47f3-8cd6-1a0859eb957f", "question_id": "7d4e0ce9-7b09-43a2-8808-40b5698f19bb", "option_key": "B", "option_text": "ACTH alta y cortisol bajo", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": null }, { "id": "57921816-8a0d-4614-8785-7a36e7defad4", "question_id": "7d4e0ce9-7b09-43a2-8808-40b5698f19bb", "option_key": "C", "option_text": "ACTH alta y cortisol alto", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": null }, { "id": "22236af0-d0b8-4803-b317-5b2a00faddfb", "question_id": "7d4e0ce9-7b09-43a2-8808-40b5698f19bb", "option_key": "D", "option_text": "ACTH sin cambio y cortisol bajo", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": null }, { "id": "149c007a-4c86-4649-b3e5-9e10cd359adb", "question_id": "7d4e0ce9-7b09-43a2-8808-40b5698f19bb", "option_key": "E", "option_text": "ACTH sin cambio y cortisol sin cambio", "is_correct": true, "position": 4, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": null }, { "id": "730fed88-5a00-4405-9055-eee3aded99d2", "question_id": "a248b6d1-5267-4e3b-abca-a812af0093e5", "option_key": "A", "option_text": "Branching structures with interspersed calcified bodies", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 14 }, { "id": "2c85e3f8-c061-4d90-99aa-c163211cd8c6", "question_id": "a248b6d1-5267-4e3b-abca-a812af0093e5", "option_key": "B", "option_text": "Follicular hyperplasia with tall cells forming intrafollicular projections", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 12 }, { "id": "45449725-13c6-4870-9159-d95fc0a6208c", "question_id": "a248b6d1-5267-4e3b-abca-a812af0093e5", "option_key": "C", "option_text": "Nests of polygonal cells with Congo red-positive deposits", "is_correct": true, "position": 2, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 54 }, { "id": "f2520d4e-5dc7-432b-849e-324039e29c5c", "question_id": "a248b6d1-5267-4e3b-abca-a812af0093e5", "option_key": "D", "option_text": "Pleomorphic giant cell nests with occasional multinucleated cells", "is_correct": false, "position": 3, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 6 }, { "id": "231323ca-5d61-42dc-9cf5-44e503de273e", "question_id": "a248b6d1-5267-4e3b-abca-a812af0093e5", "option_key": "E", "option_text": "Sheets of uniform cells forming small follicles", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 10 }, { "id": "b07c8c87-ec66-437a-86da-f847b2c912ab", "question_id": "a3519669-3e62-4230-b67d-da5c62ab2a7a", "option_key": "A", "option_text": "LH aumentada, FSH aumentada, Estradiol disminuido", "is_correct": false, "position": 0, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 16 }, { "id": "acfb4514-fe87-4e4c-aee3-22d828d89451", "question_id": "a3519669-3e62-4230-b67d-da5c62ab2a7a", "option_key": "B", "option_text": "LH aumentada, FSH disminuida, Estradiol disminuido", "is_correct": false, "position": 1, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 4 }, { "id": "a46ffbe8-e1f2-4c26-a726-e4f83833be63", "question_id": "a3519669-3e62-4230-b67d-da5c62ab2a7a", "option_key": "C", "option_text": "LH disminuida, FSH normal, Estradiol normal", "is_correct": false, "position": 2, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 2 }, { "id": "d24d87aa-ec73-49ac-a25d-cf3bf20127a8", "question_id": "a3519669-3e62-4230-b67d-da5c62ab2a7a", "option_key": "D", "option_text": "LH disminuida, FSH disminuida, Estradiol disminuido", "is_correct": true, "position": 3, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 74 }, { "id": "d1937ca7-25d1-4206-89ec-0e6693bf962a", "question_id": "a3519669-3e62-4230-b67d-da5c62ab2a7a", "option_key": "E", "option_text": "LH normal, FSH normal, Estradiol disminuido", "is_correct": false, "position": 4, "created_at": "2026-07-20T01:47:12.877053+00:00", "updated_at": "2026-07-20T01:47:12.877053+00:00", "answer_pct": 2 }, { "id": "37579210-c598-4308-934b-be820a6d0818", "question_id": "b1a1f140-4109-416c-a70b-c13526e97931", "option_key": "A", "option_text": "Aspiration of oropharyngeal secretion", "is_correct": false, "position": 0, "created_at": "2026-07-20T18:51:48.444737+00:00", "updated_at": "2026-07-20T18:51:48.444737+00:00", "answer_pct": 16 }, { "id": "c277d097-7603-459a-bf49-2d1a20917734", "question_id": "b1a1f140-4109-416c-a70b-c13526e97931", "option_key": "B", "option_text": "Decreased mucociliary clearance", "is_correct": false, "position": 1, "created_at": "2026-07-20T18:51:48.444737+00:00", "updated_at": "2026-07-20T18:51:48.444737+00:00", "answer_pct": 2 }, { "id": "98d87dbd-091e-4474-8cb1-803b6e727e68", "question_id": "b1a1f140-4109-416c-a70b-c13526e97931", "option_key": "C", "option_text": "Defective antibody-specific response", "is_correct": false, "position": 2, "created_at": "2026-07-20T18:51:48.444737+00:00", "updated_at": "2026-07-20T18:51:48.444737+00:00", "answer_pct": 3 }, { "id": "941e102d-fabd-427a-9e7b-33befe42ea31", "question_id": "b1a1f140-4109-416c-a70b-c13526e97931", "option_key": "D", "option_text": "Impaired cell-mediated immunity", "is_correct": true, "position": 3, "created_at": "2026-07-20T18:51:48.444737+00:00", "updated_at": "2026-07-20T18:51:48.444737+00:00", "answer_pct": 71 }, { "id": "88bfa871-8fe4-4cd5-8938-6dbd645dae21", "question_id": "b1a1f140-4109-416c-a70b-c13526e97931", "option_key": "E", "option_text": "Postsplenectomy state", "is_correct": false, "position": 4, "created_at": "2026-07-20T18:51:48.444737+00:00", "updated_at": "2026-07-20T18:51:48.444737+00:00", "answer_pct": 6 }, { "id": "52d9c2b0-dc6c-4e6e-b8fe-ada9164350fb", "question_id": "d5d8a5bf-9053-420f-a2ef-0396b926dc79", "option_key": "A", "option_text": "Exposure to inhaled allergens", "is_correct": true, "position": 0, "created_at": "2026-07-20T23:51:26.853295+00:00", "updated_at": "2026-07-20T23:51:26.853295+00:00", "answer_pct": 67 }, { "id": "89ef170c-cccb-4122-8b62-eee77ac2aac1", "question_id": "d5d8a5bf-9053-420f-a2ef-0396b926dc79", "option_key": "B", "option_text": "Inhalation of fungal spores", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:26.853295+00:00", "updated_at": "2026-07-20T23:51:26.853295+00:00", "answer_pct": 23 }, { "id": "b30a64ac-db9f-4775-a78c-9327c1867289", "question_id": "d5d8a5bf-9053-420f-a2ef-0396b926dc79", "option_key": "C", "option_text": "Inherited protease inhibitor deficiency", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:26.853295+00:00", "updated_at": "2026-07-20T23:51:26.853295+00:00", "answer_pct": 5 }, { "id": "252ee9ad-384c-412d-946a-7e4ff58d9389", "question_id": "d5d8a5bf-9053-420f-a2ef-0396b926dc79", "option_key": "D", "option_text": "Mutation in BMPR2 gene", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:26.853295+00:00", "updated_at": "2026-07-20T23:51:26.853295+00:00", "answer_pct": 2 }, { "id": "8fb6c797-dd14-44c8-b507-3e8e05e0e837", "question_id": "d5d8a5bf-9053-420f-a2ef-0396b926dc79", "option_key": "E", "option_text": "Necrotizing vasculitis of small vessels", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:26.853295+00:00", "updated_at": "2026-07-20T23:51:26.853295+00:00", "answer_pct": 1 }, { "id": "beb1061e-b2ea-48d2-962d-ac7439f4a3ae", "question_id": "bed51e3a-8a2f-4d75-99d3-a535d0a78274", "option_key": "A", "option_text": "No perfusion abnormalities (normal perfusion)", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:27.014566+00:00", "updated_at": "2026-07-20T23:51:27.014566+00:00", "answer_pct": null }, { "id": "56907bd4-a3c5-4620-844d-4886c8602d72", "question_id": "bed51e3a-8a2f-4d75-99d3-a535d0a78274", "option_key": "B", "option_text": "Matched ventilation-perfusion defect", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:27.014566+00:00", "updated_at": "2026-07-20T23:51:27.014566+00:00", "answer_pct": null }, { "id": "d5bc50b0-ccd2-4618-acbb-28f28becaff7", "question_id": "bed51e3a-8a2f-4d75-99d3-a535d0a78274", "option_key": "C", "option_text": "Perfusion defect without ventilation defect (mismatched perfusion defect)", "is_correct": true, "position": 2, "created_at": "2026-07-20T23:51:27.014566+00:00", "updated_at": "2026-07-20T23:51:27.014566+00:00", "answer_pct": null }, { "id": "0c8e2ed5-2ab9-42ff-a25b-b869342da970", "question_id": "bed51e3a-8a2f-4d75-99d3-a535d0a78274", "option_key": "D", "option_text": "Ventilation defect without perfusion defect", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:27.014566+00:00", "updated_at": "2026-07-20T23:51:27.014566+00:00", "answer_pct": null }, { "id": "459c2b6c-d5d4-431e-9829-1a517eae466e", "question_id": "bed51e3a-8a2f-4d75-99d3-a535d0a78274", "option_key": "E", "option_text": "Matched ventilation-perfusion defect", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:27.014566+00:00", "updated_at": "2026-07-20T23:51:27.014566+00:00", "answer_pct": null }, { "id": "0494d2d2-45f1-4a58-9177-f5659de5b388", "question_id": "8f78d983-0cd3-4de4-9a7d-8a5d70a077d7", "option_key": "A", "option_text": "Decreased alveolar surface tension", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:27.146706+00:00", "updated_at": "2026-07-20T23:51:27.146706+00:00", "answer_pct": 12 }, { "id": "af331cc4-28da-460a-b77e-21a46bc1a339", "question_id": "8f78d983-0cd3-4de4-9a7d-8a5d70a077d7", "option_key": "B", "option_text": "Decreased lung compliance", "is_correct": true, "position": 1, "created_at": "2026-07-20T23:51:27.146706+00:00", "updated_at": "2026-07-20T23:51:27.146706+00:00", "answer_pct": 38 }, { "id": "369e15e2-b245-44d4-8000-9107f286d7e7", "question_id": "8f78d983-0cd3-4de4-9a7d-8a5d70a077d7", "option_key": "C", "option_text": "Increased dead space ventilation", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:27.146706+00:00", "updated_at": "2026-07-20T23:51:27.146706+00:00", "answer_pct": 31 }, { "id": "fcc6cb24-4ff0-448e-954e-847d40d6a91e", "question_id": "8f78d983-0cd3-4de4-9a7d-8a5d70a077d7", "option_key": "D", "option_text": "Increased functional residual capacity", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:27.146706+00:00", "updated_at": "2026-07-20T23:51:27.146706+00:00", "answer_pct": 6 }, { "id": "c27298e6-c28c-4471-a71b-14694e09c471", "question_id": "8f78d983-0cd3-4de4-9a7d-8a5d70a077d7", "option_key": "E", "option_text": "Left-to-right cardiac shunting", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:27.146706+00:00", "updated_at": "2026-07-20T23:51:27.146706+00:00", "answer_pct": 11 }, { "id": "78d85532-6818-4b6d-84f3-b5f389eae9f1", "question_id": "a1925a25-3b99-4716-a97c-72a4b9b35c23", "option_key": "A", "option_text": "Avoidance of competitive sports participation", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:27.292218+00:00", "updated_at": "2026-07-20T23:51:27.292218+00:00", "answer_pct": 4 }, { "id": "0f38b1c9-87c5-48ba-941f-2306a4a66c9c", "question_id": "a1925a25-3b99-4716-a97c-72a4b9b35c23", "option_key": "B", "option_text": "Avoidance of immunosuppressive agents", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:27.292218+00:00", "updated_at": "2026-07-20T23:51:27.292218+00:00", "answer_pct": 4 }, { "id": "8aba6062-e588-4dbb-bf14-59fc198fdd16", "question_id": "a1925a25-3b99-4716-a97c-72a4b9b35c23", "option_key": "C", "option_text": "Avoidance of second-hand smoke", "is_correct": true, "position": 2, "created_at": "2026-07-20T23:51:27.292218+00:00", "updated_at": "2026-07-20T23:51:27.292218+00:00", "answer_pct": 76 }, { "id": "01abb399-9f55-4128-b56f-6ca541ce10a7", "question_id": "a1925a25-3b99-4716-a97c-72a4b9b35c23", "option_key": "D", "option_text": "Periodic aortic diameter monitoring", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:27.292218+00:00", "updated_at": "2026-07-20T23:51:27.292218+00:00", "answer_pct": 11 }, { "id": "36179df3-3478-4e9f-8cef-1b06ff51bc57", "question_id": "a1925a25-3b99-4716-a97c-72a4b9b35c23", "option_key": "E", "option_text": "Regular bone density measurement", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:27.292218+00:00", "updated_at": "2026-07-20T23:51:27.292218+00:00", "answer_pct": 1 }, { "id": "02d3898e-fc00-42c2-ac2c-32aeddd09f49", "question_id": "a1925a25-3b99-4716-a97c-72a4b9b35c23", "option_key": "F", "option_text": "Regular ophthalmologic examinations", "is_correct": false, "position": 5, "created_at": "2026-07-20T23:51:27.292218+00:00", "updated_at": "2026-07-20T23:51:27.292218+00:00", "answer_pct": 2 }, { "id": "1ba0067d-604e-487b-a78c-bd4e4ccc50c2", "question_id": "f3bdaa59-d163-40dd-9651-cf259fd4ac80", "option_key": "A", "option_text": "Decreased bicarbonate secretion", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:27.424412+00:00", "updated_at": "2026-07-20T23:51:27.424412+00:00", "answer_pct": 6 }, { "id": "86e6d955-29ba-4914-b385-a55dc862251d", "question_id": "f3bdaa59-d163-40dd-9651-cf259fd4ac80", "option_key": "B", "option_text": "Increased chloride secretion", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:27.424412+00:00", "updated_at": "2026-07-20T23:51:27.424412+00:00", "answer_pct": 38 }, { "id": "870bb20b-930c-4b24-b6fd-83cdfdb4d234", "question_id": "f3bdaa59-d163-40dd-9651-cf259fd4ac80", "option_key": "C", "option_text": "Increased mucus water content", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:27.424412+00:00", "updated_at": "2026-07-20T23:51:27.424412+00:00", "answer_pct": 7 }, { "id": "8efad2ca-4e70-4e50-a457-bf19868a3318", "question_id": "f3bdaa59-d163-40dd-9651-cf259fd4ac80", "option_key": "D", "option_text": "Increased sodium absorption", "is_correct": true, "position": 3, "created_at": "2026-07-20T23:51:27.424412+00:00", "updated_at": "2026-07-20T23:51:27.424412+00:00", "answer_pct": 40 }, { "id": "10c036a5-3fb9-4ea5-9434-6786ffa9ec8b", "question_id": "f3bdaa59-d163-40dd-9651-cf259fd4ac80", "option_key": "E", "option_text": "Intracellular potassium depletion", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:27.424412+00:00", "updated_at": "2026-07-20T23:51:27.424412+00:00", "answer_pct": 7 }, { "id": "693866ba-6caf-4fec-91fa-fc58059c032a", "question_id": "ede07339-1741-4aa6-9683-af4b7b392b9e", "option_key": "A", "option_text": "Histamine", "is_correct": true, "position": 0, "created_at": "2026-07-20T23:51:27.603976+00:00", "updated_at": "2026-07-20T23:51:27.603976+00:00", "answer_pct": 86 }, { "id": "c11e8a71-7ff5-4eff-ae6c-3c51fa054e9a", "question_id": "ede07339-1741-4aa6-9683-af4b7b392b9e", "option_key": "B", "option_text": "Leukotriene D4", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:27.603976+00:00", "updated_at": "2026-07-20T23:51:27.603976+00:00", "answer_pct": 5 }, { "id": "bd05923a-6678-40b8-82cd-981be97fe148", "question_id": "ede07339-1741-4aa6-9683-af4b7b392b9e", "option_key": "C", "option_text": "Major basic proteins", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:27.603976+00:00", "updated_at": "2026-07-20T23:51:27.603976+00:00", "answer_pct": 4 }, { "id": "afb4ff60-c6d9-46e0-8f7f-62bf1181885d", "question_id": "ede07339-1741-4aa6-9683-af4b7b392b9e", "option_key": "D", "option_text": "Platelet-activating factor", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:27.603976+00:00", "updated_at": "2026-07-20T23:51:27.603976+00:00", "answer_pct": 0 }, { "id": "1f27037c-9f7f-42b4-92b1-473e16c48bc4", "question_id": "ede07339-1741-4aa6-9683-af4b7b392b9e", "option_key": "E", "option_text": "Prostaglandin D2", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:27.603976+00:00", "updated_at": "2026-07-20T23:51:27.603976+00:00", "answer_pct": 1 }, { "id": "ca6c648e-68f6-43d3-89ea-8707b563922f", "question_id": "0df48947-e3c3-4b64-8481-19c884bcdd84", "option_key": "A", "option_text": "Alveolar hyaline membranes", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:27.747946+00:00", "updated_at": "2026-07-20T23:51:27.747946+00:00", "answer_pct": 10 }, { "id": "2f7dd2b1-6441-4c38-8834-917013757366", "question_id": "0df48947-e3c3-4b64-8481-19c884bcdd84", "option_key": "B", "option_text": "Birefringent silicate particles", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:27.747946+00:00", "updated_at": "2026-07-20T23:51:27.747946+00:00", "answer_pct": 12 }, { "id": "b35457d8-d909-497c-b940-ba267bc26fc7", "question_id": "0df48947-e3c3-4b64-8481-19c884bcdd84", "option_key": "C", "option_text": "Carbon-laden macrophages", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:27.747946+00:00", "updated_at": "2026-07-20T23:51:27.747946+00:00", "answer_pct": 5 }, { "id": "bf4b73e6-c2ce-4350-909c-98e96195c86e", "question_id": "0df48947-e3c3-4b64-8481-19c884bcdd84", "option_key": "D", "option_text": "Cells with dense-core granules", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:27.747946+00:00", "updated_at": "2026-07-20T23:51:27.747946+00:00", "answer_pct": 8 }, { "id": "7681f015-6e5b-4a19-9628-1335406a652d", "question_id": "0df48947-e3c3-4b64-8481-19c884bcdd84", "option_key": "E", "option_text": "Coalescence of granulomas", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:27.747946+00:00", "updated_at": "2026-07-20T23:51:27.747946+00:00", "answer_pct": 7 }, { "id": "9da78b0d-fcec-4cb0-9910-51dace815397", "question_id": "0df48947-e3c3-4b64-8481-19c884bcdd84", "option_key": "F", "option_text": "Ferruginous bodies", "is_correct": true, "position": 5, "created_at": "2026-07-20T23:51:27.747946+00:00", "updated_at": "2026-07-20T23:51:27.747946+00:00", "answer_pct": 56 }, { "id": "b5b0e3ad-044b-4a8c-965b-d78299c4670f", "question_id": "53c6cde7-43e9-4246-9b78-9d49c0e62ab2", "option_key": "A", "option_text": "Decreased functional residual capacity", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:27.867414+00:00", "updated_at": "2026-07-20T23:51:27.867414+00:00", "answer_pct": 15 }, { "id": "f718f8c6-760c-4270-9b1f-bc961f892505", "question_id": "53c6cde7-43e9-4246-9b78-9d49c0e62ab2", "option_key": "B", "option_text": "Decreased right ventricular afterload", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:27.867414+00:00", "updated_at": "2026-07-20T23:51:27.867414+00:00", "answer_pct": 3 }, { "id": "6e679c1d-37b2-43b6-860d-7152e9b09db5", "question_id": "53c6cde7-43e9-4246-9b78-9d49c0e62ab2", "option_key": "C", "option_text": "Increased erythropoietin production", "is_correct": true, "position": 2, "created_at": "2026-07-20T23:51:27.867414+00:00", "updated_at": "2026-07-20T23:51:27.867414+00:00", "answer_pct": 70 }, { "id": "9eeacc37-4ed7-43fe-b247-b154565e2af9", "question_id": "53c6cde7-43e9-4246-9b78-9d49c0e62ab2", "option_key": "D", "option_text": "Increased expiratory flow rates", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:27.867414+00:00", "updated_at": "2026-07-20T23:51:27.867414+00:00", "answer_pct": 7 }, { "id": "c0a7f65d-eae8-43c4-8115-5147dbd5d1b2", "question_id": "53c6cde7-43e9-4246-9b78-9d49c0e62ab2", "option_key": "E", "option_text": "Increased left ventricular compliance", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:27.867414+00:00", "updated_at": "2026-07-20T23:51:27.867414+00:00", "answer_pct": 3 }, { "id": "20d0ed63-c586-4633-8fa5-cf16024a6215", "question_id": "42e7eb5a-8265-4b43-b653-3cb26666aa4a", "option_key": "A", "option_text": "Tuberculosis", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:27.973787+00:00", "updated_at": "2026-07-20T23:51:27.973787+00:00", "answer_pct": null }, { "id": "996fbd06-55a9-4381-b3d9-76e18989dd59", "question_id": "42e7eb5a-8265-4b43-b653-3cb26666aa4a", "option_key": "B", "option_text": "Silicosis", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:27.973787+00:00", "updated_at": "2026-07-20T23:51:27.973787+00:00", "answer_pct": null }, { "id": "78e095ec-9682-4656-a565-e170ab35fed3", "question_id": "42e7eb5a-8265-4b43-b653-3cb26666aa4a", "option_key": "C", "option_text": "Small cell lung cancer", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:27.973787+00:00", "updated_at": "2026-07-20T23:51:27.973787+00:00", "answer_pct": null }, { "id": "5bdef4ab-e307-4c2f-b4d3-8846e94c3004", "question_id": "42e7eb5a-8265-4b43-b653-3cb26666aa4a", "option_key": "D", "option_text": "Malignant mesothelioma", "is_correct": true, "position": 3, "created_at": "2026-07-20T23:51:27.973787+00:00", "updated_at": "2026-07-20T23:51:27.973787+00:00", "answer_pct": null }, { "id": "82a25497-ece4-4079-890f-ab1e9faa4e24", "question_id": "42e7eb5a-8265-4b43-b653-3cb26666aa4a", "option_key": "E", "option_text": "Empyema", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:27.973787+00:00", "updated_at": "2026-07-20T23:51:27.973787+00:00", "answer_pct": null }, { "id": "1a7c8add-01bd-4cb0-87dd-e2d7591d9773", "question_id": "cb2fc84d-b20f-4a26-8c14-6a771ac5f139", "option_key": "A", "option_text": "Increased total lung capacity, decreased FEV1/FVC, increased DLCO (obstructive pattern with high DLCO, eg asthma)", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:28.088964+00:00", "updated_at": "2026-07-20T23:51:28.088964+00:00", "answer_pct": 9 }, { "id": "08abaa43-86b1-462a-92eb-1c4dbda544d1", "question_id": "cb2fc84d-b20f-4a26-8c14-6a771ac5f139", "option_key": "B", "option_text": "Increased total lung capacity, decreased FEV1/FVC, decreased DLCO (emphysema)", "is_correct": true, "position": 1, "created_at": "2026-07-20T23:51:28.088964+00:00", "updated_at": "2026-07-20T23:51:28.088964+00:00", "answer_pct": 58 }, { "id": "b7ab8335-a061-4537-b15e-d00c7fea280b", "question_id": "cb2fc84d-b20f-4a26-8c14-6a771ac5f139", "option_key": "C", "option_text": "Decreased total lung capacity, decreased FEV1/FVC, decreased DLCO (combined restrictive-obstructive)", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:28.088964+00:00", "updated_at": "2026-07-20T23:51:28.088964+00:00", "answer_pct": 5 }, { "id": "4a821a45-5098-45ab-aa3f-4789507268cf", "question_id": "cb2fc84d-b20f-4a26-8c14-6a771ac5f139", "option_key": "D", "option_text": "Increased total lung capacity, decreased FEV1/FVC, normal DLCO (eg chronic bronchitis-predominant COPD or asthma)", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:28.088964+00:00", "updated_at": "2026-07-20T23:51:28.088964+00:00", "answer_pct": 21 }, { "id": "69831888-426a-4091-88c5-c88318c496d5", "question_id": "cb2fc84d-b20f-4a26-8c14-6a771ac5f139", "option_key": "E", "option_text": "Decreased total lung capacity, normal/increased FEV1/FVC, decreased DLCO (intrinsic restrictive lung disease)", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:28.088964+00:00", "updated_at": "2026-07-20T23:51:28.088964+00:00", "answer_pct": 1 }, { "id": "046b3b26-5d29-4d38-a435-055ac1db3273", "question_id": "cb2fc84d-b20f-4a26-8c14-6a771ac5f139", "option_key": "F", "option_text": "Decreased total lung capacity, normal/increased FEV1/FVC, normal DLCO (extrinsic restrictive lung disease)", "is_correct": false, "position": 5, "created_at": "2026-07-20T23:51:28.088964+00:00", "updated_at": "2026-07-20T23:51:28.088964+00:00", "answer_pct": 3 }, { "id": "223b8363-1e87-49d3-9e60-af6f6962d7b7", "question_id": "7eb75cde-edad-417b-8364-9c37392a7c6a", "option_key": "A", "option_text": "Central sleep apnea", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:28.233449+00:00", "updated_at": "2026-07-20T23:51:28.233449+00:00", "answer_pct": 3 }, { "id": "81872cb1-4406-4e80-b2ac-1b93173529b3", "question_id": "7eb75cde-edad-417b-8364-9c37392a7c6a", "option_key": "B", "option_text": "Narcolepsy", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:28.233449+00:00", "updated_at": "2026-07-20T23:51:28.233449+00:00", "answer_pct": 14 }, { "id": "e101527a-61be-4b56-af26-054f2dae9caf", "question_id": "7eb75cde-edad-417b-8364-9c37392a7c6a", "option_key": "C", "option_text": "Obesity hypoventilation syndrome", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:28.233449+00:00", "updated_at": "2026-07-20T23:51:28.233449+00:00", "answer_pct": 8 }, { "id": "f692461b-379c-47de-abbf-5b1ec49009f8", "question_id": "7eb75cde-edad-417b-8364-9c37392a7c6a", "option_key": "D", "option_text": "Obstructive sleep apnea", "is_correct": true, "position": 3, "created_at": "2026-07-20T23:51:28.233449+00:00", "updated_at": "2026-07-20T23:51:28.233449+00:00", "answer_pct": 71 }, { "id": "0b5209db-452e-4711-abe5-076e8ec33d95", "question_id": "7eb75cde-edad-417b-8364-9c37392a7c6a", "option_key": "E", "option_text": "Primary insomnia", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:28.233449+00:00", "updated_at": "2026-07-20T23:51:28.233449+00:00", "answer_pct": 2 }, { "id": "749b4617-9ef6-49a5-a95c-f0e50e2a0236", "question_id": "7eb75cde-edad-417b-8364-9c37392a7c6a", "option_key": "F", "option_text": "Restless leg syndrome", "is_correct": false, "position": 5, "created_at": "2026-07-20T23:51:28.233449+00:00", "updated_at": "2026-07-20T23:51:28.233449+00:00", "answer_pct": 0 }, { "id": "4a85984d-74bf-499e-8230-2e586eda5ad4", "question_id": "48a48d43-bd2f-4317-981c-55217b9036db", "option_key": "A", "option_text": "Aldosterone", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:28.374516+00:00", "updated_at": "2026-07-20T23:51:28.374516+00:00", "answer_pct": 5 }, { "id": "c3057899-707c-4000-8d69-88e08ce6dad7", "question_id": "48a48d43-bd2f-4317-981c-55217b9036db", "option_key": "B", "option_text": "Angiotensin II", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:28.374516+00:00", "updated_at": "2026-07-20T23:51:28.374516+00:00", "answer_pct": 18 }, { "id": "62215e77-cb37-4391-b54f-e439c149e0fe", "question_id": "48a48d43-bd2f-4317-981c-55217b9036db", "option_key": "C", "option_text": "Endothelin", "is_correct": true, "position": 2, "created_at": "2026-07-20T23:51:28.374516+00:00", "updated_at": "2026-07-20T23:51:28.374516+00:00", "answer_pct": 69 }, { "id": "c87d5d99-d6b6-45bd-849e-c3da5ba01e32", "question_id": "48a48d43-bd2f-4317-981c-55217b9036db", "option_key": "D", "option_text": "Norepinephrine", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:28.374516+00:00", "updated_at": "2026-07-20T23:51:28.374516+00:00", "answer_pct": 4 }, { "id": "0206b344-3d9a-4d70-a044-034130d2f8c5", "question_id": "48a48d43-bd2f-4317-981c-55217b9036db", "option_key": "E", "option_text": "Serotonin", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:28.374516+00:00", "updated_at": "2026-07-20T23:51:28.374516+00:00", "answer_pct": 1 }, { "id": "d827a31b-69a5-4b71-af06-99781d732e76", "question_id": "d5d8ba84-9683-4124-b440-2f3d59c06031", "option_key": "A", "option_text": "Accumulation of interstitial fluid within the pleural space", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:28.493332+00:00", "updated_at": "2026-07-20T23:51:28.493332+00:00", "answer_pct": 12 }, { "id": "3a5d133d-9ed0-4e7d-ab29-ead169e86a72", "question_id": "d5d8ba84-9683-4124-b440-2f3d59c06031", "option_key": "B", "option_text": "Embolic occlusion of a pulmonary segmental artery", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:28.493332+00:00", "updated_at": "2026-07-20T23:51:28.493332+00:00", "answer_pct": 2 }, { "id": "5ed4bf31-ceea-4896-abe4-5e97fe951f9a", "question_id": "d5d8ba84-9683-4124-b440-2f3d59c06031", "option_key": "C", "option_text": "Exudation of neutrophil-rich fluid in the lung parenchyma", "is_correct": true, "position": 2, "created_at": "2026-07-20T23:51:28.493332+00:00", "updated_at": "2026-07-20T23:51:28.493332+00:00", "answer_pct": 58 }, { "id": "e65e769e-71ca-4e94-8b64-b107523c7101", "question_id": "d5d8ba84-9683-4124-b440-2f3d59c06031", "option_key": "D", "option_text": "Leakage of air from spontaneous rupture of visceral pleura", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:28.493332+00:00", "updated_at": "2026-07-20T23:51:28.493332+00:00", "answer_pct": 7 }, { "id": "cf2889b6-b6a0-44e6-8715-9fde5266179e", "question_id": "d5d8ba84-9683-4124-b440-2f3d59c06031", "option_key": "E", "option_text": "Lung collapse due to a mass causing bronchial obstruction", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:28.493332+00:00", "updated_at": "2026-07-20T23:51:28.493332+00:00", "answer_pct": 5 }, { "id": "7158a72a-00e6-4120-a2c7-52e98c876d74", "question_id": "d5d8ba84-9683-4124-b440-2f3d59c06031", "option_key": "F", "option_text": "Transudation of interstitial fluid within the alveolar spaces", "is_correct": false, "position": 5, "created_at": "2026-07-20T23:51:28.493332+00:00", "updated_at": "2026-07-20T23:51:28.493332+00:00", "answer_pct": 14 }, { "id": "aa451065-41b1-4851-a4f0-ec555ee4e926", "question_id": "88ac1c09-8407-4a03-9ef2-79ca74ddc8ff", "option_key": "A", "option_text": "Extensive pulmonary fibrosis", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:28.615218+00:00", "updated_at": "2026-07-20T23:51:28.615218+00:00", "answer_pct": 15 }, { "id": "f2f93341-6f3c-4e38-b4ea-cf289da10a97", "question_id": "88ac1c09-8407-4a03-9ef2-79ca74ddc8ff", "option_key": "B", "option_text": "Impaired immunoglobulin G response", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:28.615218+00:00", "updated_at": "2026-07-20T23:51:28.615218+00:00", "answer_pct": 0 }, { "id": "db1068d6-2be0-4aba-a47f-3f265ed90a30", "question_id": "88ac1c09-8407-4a03-9ef2-79ca74ddc8ff", "option_key": "C", "option_text": "Impaired macrophage function", "is_correct": true, "position": 2, "created_at": "2026-07-20T23:51:28.615218+00:00", "updated_at": "2026-07-20T23:51:28.615218+00:00", "answer_pct": 68 }, { "id": "1925c938-49c6-4e54-82b5-5a2793df630f", "question_id": "88ac1c09-8407-4a03-9ef2-79ca74ddc8ff", "option_key": "D", "option_text": "Impaired type 2 helper T cell function", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:28.615218+00:00", "updated_at": "2026-07-20T23:51:28.615218+00:00", "answer_pct": 7 }, { "id": "82d974de-9cc6-4d08-ad5d-57c7dce4c075", "question_id": "88ac1c09-8407-4a03-9ef2-79ca74ddc8ff", "option_key": "E", "option_text": "Ineffective mucociliary clearance", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:28.615218+00:00", "updated_at": "2026-07-20T23:51:28.615218+00:00", "answer_pct": 7 }, { "id": "46e8dd58-f327-491d-b06f-5ebc45eef51d", "question_id": "7ff91228-6021-4e52-9cf7-7d5b86a1f129", "option_key": "A", "option_text": "Bronchiectasis", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:28.746307+00:00", "updated_at": "2026-07-20T23:51:28.746307+00:00", "answer_pct": 6 }, { "id": "f7094892-23fe-4b21-9772-f99256052ea7", "question_id": "7ff91228-6021-4e52-9cf7-7d5b86a1f129", "option_key": "B", "option_text": "Hypertrophic cardiomyopathy", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:28.746307+00:00", "updated_at": "2026-07-20T23:51:28.746307+00:00", "answer_pct": 9 }, { "id": "acb9dc7d-a582-4952-8ec9-89baf2d8b925", "question_id": "7ff91228-6021-4e52-9cf7-7d5b86a1f129", "option_key": "C", "option_text": "Laryngeal carcinoma", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:28.746307+00:00", "updated_at": "2026-07-20T23:51:28.746307+00:00", "answer_pct": 3 }, { "id": "961aae6c-c026-4982-ada9-3c8d1c476d11", "question_id": "7ff91228-6021-4e52-9cf7-7d5b86a1f129", "option_key": "D", "option_text": "Narcolepsy", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:28.746307+00:00", "updated_at": "2026-07-20T23:51:28.746307+00:00", "answer_pct": 7 }, { "id": "9870b170-14e9-4209-8564-18a0e2c34390", "question_id": "7ff91228-6021-4e52-9cf7-7d5b86a1f129", "option_key": "E", "option_text": "Pulmonary hypertension", "is_correct": true, "position": 4, "created_at": "2026-07-20T23:51:28.746307+00:00", "updated_at": "2026-07-20T23:51:28.746307+00:00", "answer_pct": 73 }, { "id": "bbffd40c-c895-4394-9af2-4afa12827ecb", "question_id": "9a87b31f-3754-417d-b1ba-e98b31774138", "option_key": "A", "option_text": "Interferon-gamma production by CD4 lymphocytes", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:28.920177+00:00", "updated_at": "2026-07-20T23:51:28.920177+00:00", "answer_pct": 30 }, { "id": "530f1be3-3d75-469e-afeb-0c9ee4ebf4e8", "question_id": "9a87b31f-3754-417d-b1ba-e98b31774138", "option_key": "B", "option_text": "Interleukin-12 secretion by dendritic cells", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:28.920177+00:00", "updated_at": "2026-07-20T23:51:28.920177+00:00", "answer_pct": 3 }, { "id": "281c3831-1d4f-4250-a41f-57128cf6b87c", "question_id": "9a87b31f-3754-417d-b1ba-e98b31774138", "option_key": "C", "option_text": "Lysosomal content release by neutrophils", "is_correct": true, "position": 2, "created_at": "2026-07-20T23:51:28.920177+00:00", "updated_at": "2026-07-20T23:51:28.920177+00:00", "answer_pct": 47 }, { "id": "9c503c5a-96f2-4765-9ad1-75a501e3db16", "question_id": "9a87b31f-3754-417d-b1ba-e98b31774138", "option_key": "D", "option_text": "Major basic protein release by eosinophils", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:28.920177+00:00", "updated_at": "2026-07-20T23:51:28.920177+00:00", "answer_pct": 2 }, { "id": "971d0b63-2aa4-4820-a628-271aacc1d878", "question_id": "9a87b31f-3754-417d-b1ba-e98b31774138", "option_key": "E", "option_text": "Transforming growth factor-beta secretion by macrophages", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:28.920177+00:00", "updated_at": "2026-07-20T23:51:28.920177+00:00", "answer_pct": 16 }, { "id": "fb3322fe-28b3-4362-8f60-f32d6698479d", "question_id": "54e20c19-b41e-4677-ad31-9b69f6bec927", "option_key": "A", "option_text": "pH 7.22; PaCO2 60; HCO3 24; PaO2 70", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:29.043171+00:00", "updated_at": "2026-07-20T23:51:29.043171+00:00", "answer_pct": 14 }, { "id": "a0483fd2-7508-4856-96fb-f8747814fee8", "question_id": "54e20c19-b41e-4677-ad31-9b69f6bec927", "option_key": "B", "option_text": "pH 7.36; PaCO2 63; HCO3 34; PaO2 60", "is_correct": true, "position": 1, "created_at": "2026-07-20T23:51:29.043171+00:00", "updated_at": "2026-07-20T23:51:29.043171+00:00", "answer_pct": 67 }, { "id": "0d40add0-0422-4108-94cb-0b36dcc49b5e", "question_id": "54e20c19-b41e-4677-ad31-9b69f6bec927", "option_key": "C", "option_text": "pH 7.40; PaCO2 40; HCO3 24; PaO2 80", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:29.043171+00:00", "updated_at": "2026-07-20T23:51:29.043171+00:00", "answer_pct": 4 }, { "id": "b2a873e8-5052-4627-8b9e-7118ad3b1976", "question_id": "54e20c19-b41e-4677-ad31-9b69f6bec927", "option_key": "D", "option_text": "pH 7.44; PaCO2 47; HCO3 31; PaO2 75", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:29.043171+00:00", "updated_at": "2026-07-20T23:51:29.043171+00:00", "answer_pct": 7 }, { "id": "5d1bd9b0-9cc0-4779-9cae-85ed86e01547", "question_id": "54e20c19-b41e-4677-ad31-9b69f6bec927", "option_key": "E", "option_text": "pH 7.59; PaCO2 25; HCO3 23; PaO2 65", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:29.043171+00:00", "updated_at": "2026-07-20T23:51:29.043171+00:00", "answer_pct": 5 }, { "id": "88eeb56d-89a1-423e-9bba-7be2590b3a96", "question_id": "83b4976e-6bb1-4d2b-b89c-4882c6aebc34", "option_key": "A", "option_text": "Pulmonary vascular resistance", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:29.199456+00:00", "updated_at": "2026-07-20T23:51:29.199456+00:00", "answer_pct": 11 }, { "id": "bb68930f-fd75-48e7-9424-5787c31ef17b", "question_id": "83b4976e-6bb1-4d2b-b89c-4882c6aebc34", "option_key": "B", "option_text": "Reactive oxygen species production", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:29.199456+00:00", "updated_at": "2026-07-20T23:51:29.199456+00:00", "answer_pct": 22 }, { "id": "09c737a4-56db-4384-bcce-4efc8454e61b", "question_id": "83b4976e-6bb1-4d2b-b89c-4882c6aebc34", "option_key": "C", "option_text": "Renal bicarbonate reabsorption", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:29.199456+00:00", "updated_at": "2026-07-20T23:51:29.199456+00:00", "answer_pct": 5 }, { "id": "232ef58f-509e-4b31-8b67-890213d8cde3", "question_id": "83b4976e-6bb1-4d2b-b89c-4882c6aebc34", "option_key": "D", "option_text": "Respiratory minute ventilation", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:29.199456+00:00", "updated_at": "2026-07-20T23:51:29.199456+00:00", "answer_pct": 23 }, { "id": "92188d68-4934-46c8-84f1-ea735ab5a03b", "question_id": "83b4976e-6bb1-4d2b-b89c-4882c6aebc34", "option_key": "E", "option_text": "Ventilation-perfusion mismatch", "is_correct": true, "position": 4, "created_at": "2026-07-20T23:51:29.199456+00:00", "updated_at": "2026-07-20T23:51:29.199456+00:00", "answer_pct": 36 }, { "id": "cb78a31f-df4e-468a-812a-1ecb6f504b34", "question_id": "d208f9f2-f304-433a-b871-eab746e01b4a", "option_key": "A", "option_text": "Epithelial necrosis", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:29.320305+00:00", "updated_at": "2026-07-20T23:51:29.320305+00:00", "answer_pct": 5 }, { "id": "f0ffe41e-d6de-41b9-94c1-55cb2fae1c3e", "question_id": "d208f9f2-f304-433a-b871-eab746e01b4a", "option_key": "B", "option_text": "Hemolysis", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:29.320305+00:00", "updated_at": "2026-07-20T23:51:29.320305+00:00", "answer_pct": 6 }, { "id": "f1451076-fd32-4f14-af46-e55b4a8eb28c", "question_id": "d208f9f2-f304-433a-b871-eab746e01b4a", "option_key": "C", "option_text": "High bacterial load", "is_correct": false, "position": 2, "created_at": "2026-07-20T23:51:29.320305+00:00", "updated_at": "2026-07-20T23:51:29.320305+00:00", "answer_pct": 17 }, { "id": "3e6117ce-f8de-4165-822a-eb6a2f344088", "question_id": "d208f9f2-f304-433a-b871-eab746e01b4a", "option_key": "D", "option_text": "Mucopolysaccharides", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:29.320305+00:00", "updated_at": "2026-07-20T23:51:29.320305+00:00", "answer_pct": 20 }, { "id": "4a55bf7c-66fd-4f64-9dda-ac056eab511f", "question_id": "d208f9f2-f304-433a-b871-eab746e01b4a", "option_key": "E", "option_text": "Myeloperoxidase", "is_correct": true, "position": 4, "created_at": "2026-07-20T23:51:29.320305+00:00", "updated_at": "2026-07-20T23:51:29.320305+00:00", "answer_pct": 50 }, { "id": "6d69ec6b-a6c7-4315-b890-d71716c7fc78", "question_id": "fa97954e-3446-481a-b8f2-f1adf8c9e8ae", "option_key": "A", "option_text": "Alveolar hyaline membranes", "is_correct": false, "position": 0, "created_at": "2026-07-20T23:51:29.443094+00:00", "updated_at": "2026-07-20T23:51:29.443094+00:00", "answer_pct": 3 }, { "id": "3e471a74-8734-4940-b6ee-9b9ea770e856", "question_id": "fa97954e-3446-481a-b8f2-f1adf8c9e8ae", "option_key": "B", "option_text": "Compression atelectasis", "is_correct": false, "position": 1, "created_at": "2026-07-20T23:51:29.443094+00:00", "updated_at": "2026-07-20T23:51:29.443094+00:00", "answer_pct": 4 }, { "id": "2ebca973-26f4-48ab-9321-38679a2e8814", "question_id": "fa97954e-3446-481a-b8f2-f1adf8c9e8ae", "option_key": "C", "option_text": "Interalveolar wall destruction", "is_correct": true, "position": 2, "created_at": "2026-07-20T23:51:29.443094+00:00", "updated_at": "2026-07-20T23:51:29.443094+00:00", "answer_pct": 63 }, { "id": "537abff9-ea35-472b-9b3b-88626dc7c931", "question_id": "fa97954e-3446-481a-b8f2-f1adf8c9e8ae", "option_key": "D", "option_text": "Intraalveolar hemorrhage", "is_correct": false, "position": 3, "created_at": "2026-07-20T23:51:29.443094+00:00", "updated_at": "2026-07-20T23:51:29.443094+00:00", "answer_pct": 0 }, { "id": "d0af3008-9c9d-40f7-b34d-ec01a021a564", "question_id": "fa97954e-3446-481a-b8f2-f1adf8c9e8ae", "option_key": "E", "option_text": "Pulmonary fibrosis", "is_correct": false, "position": 4, "created_at": "2026-07-20T23:51:29.443094+00:00", "updated_at": "2026-07-20T23:51:29.443094+00:00", "answer_pct": 26 }, { "id": "da7abc36-121e-48cf-84b0-a075409d335b", "question_id": "fa97954e-3446-481a-b8f2-f1adf8c9e8ae", "option_key": "F", "option_text": "Thromboembolic disease", "is_correct": false, "position": 5, "created_at": "2026-07-20T23:51:29.443094+00:00", "updated_at": "2026-07-20T23:51:29.443094+00:00", "answer_pct": 1 }, { "id": "51081791-9baa-4ec3-bc94-c0fb0448e311", "question_id": "9b068f7c-00a1-4d16-9659-cb9c3d9f6bf9", "option_key": "A", "option_text": "Alveolar hyperventilation", "is_correct": true, "position": 0, "created_at": 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