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38-year-old woman presents with acute onset pain over the lateral aspect of the right breast. On examination, a tender, cord-like structure is palpable extending along the anterior chest wall. There is no overlying skin erythema or systemic symptoms. Ultrasound shows a superficial, non-compressible tubular structure without internal flow. Which of the following is the MOST appropriate next step in management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"a3ef16f4e3c352477f6853d74b11de783d516c242bf77b05ae53538e4e2080f6","minhash":[73,71,117,1,163,70,9,12,129,219,165,2,113,231,166,5,14,247,67,9,125,37,248,2,133,48,70,1,154,255,233,2,186,121,76,2,13,92,242,2,8,213,189,3,89,194,140,1,251,169,176,2,98,157,151,11,149,220,86,4,56,186,244,9,142,221,125,2,5,105,5,0,173,2,151,2,115,117,19,3,142,169,54,0,247,245,91,3,66,61,79,0,107,236,87,1,211,174,163,8,141,232,231,0,241,142,220,0,236,2,99,0,56,128,81,2,55,191,98,0,108,239,71,7,71,25,54,0,125,33,230,2,148,218,87,1,15,67,208,3,201,128,38,5,200,229,50,2,225,221,174,2,7,49,74,3,17,189,201,2,63,250,196,0,157,221,156,4,205,69,10,3,75,201,222,5,104,175,199,0,98,201,151,5,213,239,186,2,81,138,27,1,79,101,66,5,12,84,207,5,43,154,224,0,227,198,172,12,115,81,34,1,89,116,249,2,92,202,164,2,169,171,140,5,136,10,192,1,141,9,63,7,241,82,137,10,213,150,99,3,133,8,170,3,228,249,243,8,171,86,59,5,70,195,118,0,40,173,106,5,92,38,34,0,172,183,26,2,70,64,83,1,235,61,26,6,168,202,204,11,40,59,120,2,231,69,76,7,93,107,211,0,27,33,6,2,44,36,108,1,181,180,113,0,197,24,114,2,45,59,132,1,142,135,161,2,113,111,71,1,129,191,236,2,152,105,136,10,96,133,20,1,145,175,121,7,38,246,113,2,23,52,104,7,40,214,233,4,142,174,16,1,9,99,195,1,32,158,1,4,255,156,109,13,81,53,52,0,192,51,42,3,67,223,156,9,122,149,30,2,24,31,113,3,180,230,77,7,12,207,122,1,194,65,3,1,145,34,212,5,197,245,187,0,240,186,206,14,42,205,113,0,172,157,163,1,129,149,203,1,105,145,224,7,132,97,171,1,137,104,128,0,56,127,66,1,211,228,209,1,142,231,171,2,119,249,5,5,37,10,53,4,142,124,241,5,239,85,4,3,33,91,57,3,184,104,147,0,71,182,11,7,45,165,211,4,135,202,99,4,106,79,27,1,249,165,142,0,235,166,66,6,191,46,25,10,201,56,73,0,198,192,50,6,109,231,254,1,109,63,134,2],"created_at":1778400600926,"updated_at":1778436184423,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":5,"stem":"A 42-year-old woman presents with a rapidly enlarging, painless breast mass measuring 8 cm. On examination, the mass is mobile, bosselated, and there is stretching of the overlying skin without nipple retraction. Core biopsy suggests a fibroepithelial lesion. Which of the following features MOST strongly favors a diagnosis of malignant phyllodes tumor over fibroadenoma?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"6cc3bd026f768a803bdc41d3b98a3c089152d4b2cf33f9d44fa3f34add2f78af","minhash":[124,191,226,1,83,164,87,3,152,203,0,1,8,210,186,2,72,116,55,6,185,75,29,3,190,114,68,1,66,175,194,0,211,86,47,8,10,143,234,2,114,99,181,2,61,120,113,0,71,191,235,0,104,149,45,16,122,245,119,2,144,34,32,5,32,188,115,2,145,28,240,2,166,128,231,0,251,55,83,0,187,49,227,4,95,157,49,1,245,129,18,0,253,245,149,0,186,5,101,5,133,87,75,6,139,192,46,1,233,230,185,3,149,51,255,0,176,134,77,2,74,191,113,1,139,191,19,5,201,183,9,2,62,109,249,3,152,17,117,2,129,236,107,3,173,29,70,2,90,196,130,9,7,49,74,3,62,238,113,0,211,201,143,2,145,199,182,3,9,173,12,3,140,220,102,0,9,49,0,0,145,56,96,10,147,176,158,1,49,73,164,1,152,77,60,2,122,190,113,3,94,130,187,0,169,188,70,0,2,195,47,8,44,239,75,1,61,141,204,10,245,181,63,0,160,57,179,2,108,9,98,2,241,56,204,1,144,68,114,4,247,115,81,1,92,165,83,3,99,144,6,3,204,27,175,0,15,191,125,1,112,181,102,1,157,58,196,5,33,83,214,0,49,229,8,0,196,34,65,4,11,235,67,3,16,88,134,1,232,241,176,2,10,23,92,6,69,73,115,1,222,48,155,0,217,200,172,4,197,204,168,4,203,54,45,2,228,143,110,1,169,233,31,14,2,85,64,0,74,87,221,10,74,254,204,6,52,209,184,2,247,106,229,5,85,99,96,0,156,166,64,8,233,108,23,2,2,4,252,5,137,48,109,0,136,230,79,0,2,130,254,0,17,40,87,2,145,248,75,11,33,239,52,6,184,196,176,1,10,74,100,6,73,215,122,0,5,209,75,0,138,23,237,1,152,90,11,5,121,191,66,0,154,141,203,0,155,204,124,2,132,120,37,2,76,185,19,1,109,75,78,2,96,122,166,1,219,191,121,8,253,114,155,8,73,19,113,0,184,247,159,0,216,68,207,0,170,148,73,4,34,96,253,4,38,197,26,7,48,40,190,1,94,164,252,3,36,197,224,4,247,71,58,8,243,25,146,0,205,148,211,3,163,20,166,4,137,86,127,3,2,237,250,6,216,150,218,1,204,191,51,2],"created_at":1778400600926,"updated_at":1778436184423,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":6,"stem":"A 62-year-old man presents with a firm retroareolar breast mass associated with nipple retraction and ipsilateral axillary lymphadenopathy. Histopathology reveals invasive carcinoma. Which of the following statements is MOST accurate regarding the biology of this tumor?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"9479d7ae4a38d397975a55278f01e8888112c48d4fbcd8e85817f9aea1f2642d","minhash":[1,6,193,0,54,159,247,13,161,212,117,20,92,65,232,1,172,120,19,7,217,103,120,0,105,211,148,5,165,98,211,6,132,80,126,7,139,31,172,0,127,172,6,1,44,169,199,2,133,206,37,1,172,14,36,0,244,90,100,18,132,81,185,2,238,54,156,6,36,16,88,1,231,105,226,8,140,151,173,6,176,105,121,4,138,205,67,9,228,10,119,12,70,181,212,2,95,202,86,3,67,42,225,2,246,19,85,1,38,30,121,10,138,82,23,3,158,78,38,2,173,126,68,12,198,52,223,8,209,176,20,4,183,146,95,1,137,18,56,8,198,1,204,1,118,137,66,5,84,183,253,8,239,146,202,4,149,147,82,12,127,121,138,6,167,101,113,8,206,209,216,0,23,248,170,6,191,244,132,1,70,174,67,4,134,90,33,8,199,131,110,1,38,41,113,20,193,245,187,2,173,31,42,8,40,230,149,1,17,140,215,2,84,156,47,3,193,200,206,1,223,148,170,5,38,107,191,2,207,57,155,3,241,131,21,3,17,78,205,3,153,241,242,2,119,150,150,0,47,236,203,10,104,50,114,1,106,143,148,0,32,25,157,2,6,66,230,5,0,162,78,13,221,121,21,14,224,48,194,1,124,37,249,20,167,195,202,18,28,128,152,8,139,181,94,0,114,119,231,1,183,161,101,0,26,66,199,0,133,28,200,0,155,152,132,11,64,245,177,6,81,24,106,0,238,214,127,0,56,135,247,3,196,84,7,1,238,182,160,3,71,16,165,6,238,246,124,6,112,23,245,6,28,113,56,3,233,91,193,2,6,224,204,0,209,214,244,11,134,118,157,1,76,98,91,9,145,227,235,6,158,19,103,6,241,132,178,0,3,29,10,1,92,86,219,14,251,229,166,1,38,6,151,0,238,86,66,4,35,196,254,1,95,231,67,18,253,183,133,1,148,120,50,4,59,248,244,1,128,255,81,0,111,151,20,0,135,203,150,0,227,60,241,1,117,52,35,2,206,7,31,4,166,15,220,6,166,45,144,9,198,44,122,7,224,84,179,1,65,9,120,0,163,37,237,3,254,78,242,3,38,123,59,8,181,30,79,3,77,140,53,4,57,35,109,13,206,211,6,0,198,244,39,6,127,171,170,4,245,188,161,14],"created_at":1778400600926,"updated_at":1778436184423,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":7,"stem":"Ductal carcinoma in situ (DCIS) most commonly presents as:","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"c724cc7e5eaeeb7bf4402490cacd64acd14c6e3587d4b827c98d591e04324323","minhash":[221,208,120,23,135,211,79,8,65,59,167,4,13,206,79,0,221,18,14,4,243,154,208,15,244,22,28,4,245,33,195,6,29,191,74,9,156,120,129,17,45,231,142,11,245,69,113,8,181,235,20,9,39,203,121,3,230,149,255,0,139,207,160,24,207,104,141,0,193,215,198,10,38,65,199,2,60,10,58,12,55,63,235,26,229,83,18,30,58,118,2,1,35,198,110,12,143,166,237,7,123,208,95,10,52,1,204,8,205,0,40,7,12,163,28,21,230,184,25,19,103,243,225,12,181,102,128,0,20,168,215,10,28,39,166,47,63,27,72,2,18,209,6,12,84,129,20,1,143,117,53,12,58,96,180,0,105,182,77,35,3,198,211,2,210,68,11,0,31,243,40,1,9,120,210,6,250,121,170,13,100,81,12,0,185,253,5,2,18,182,221,5,76,94,69,0,145,186,163,2,223,68,173,23,60,41,230,0,175,8,203,1,217,189,95,27,38,250,102,41,124,217,238,8,204,218,88,10,166,91,200,9,135,228,239,23,201,102,125,0,209,75,131,1,37,61,162,1,103,18,144,1,38,161,207,8,166,80,68,11,164,73,201,0,178,38,45,2,201,117,126,19,102,99,222,6,89,180,162,8,172,58,7,1,105,179,223,4,114,4,88,17,36,216,58,17,37,40,92,1,43,14,135,0,15,102,2,7,133,175,130,8,185,250,166,0,252,130,33,22,61,112,98,17,47,49,91,14,50,39,11,3,18,139,15,0,89,102,202,1,231,180,118,5,141,98,29,12,124,251,146,12,73,42,120,13,154,18,235,14,159,45,7,46,18,74,30,0,250,87,14,0,230,72,105,7,233,101,138,13,11,91,194,8,20,252,232,7,154,159,24,11,1,160,161,50,67,137,20,0,117,102,21,1,177,90,136,2,38,6,210,15,146,208,88,6,29,74,144,10,191,103,222,0,186,170,62,11,33,51,77,3,15,253,16,8,210,85,181,3,58,93,233,0,38,109,159,0,102,38,102,1,156,183,178,19,11,81,82,3,31,186,118,2,207,218,250,8,115,21,222,17,58,242,188,44,85,89,92,6,49,95,109,0,154,198,134,20,203,111,71,0,218,179,107,5,189,251,243,7,217,78,87,5,44,101,71,8,90,186,161,20],"created_at":1778400600926,"updated_at":1778436184423,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":8,"stem":"Characteristic histologic feature of invasive lobular carcinoma:","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"ab5a8513d600e0aa62e99e6a28980b248f59fe9110ddb19345085095bea62ba0","minhash":[239,30,174,46,136,83,185,20,123,162,171,22,155,132,255,0,88,76,212,16,72,246,36,15,3,99,10,25,188,72,216,2,175,84,166,4,18,106,145,1,120,240,186,30,115,135,215,39,76,143,73,13,167,8,45,6,46,37,236,17,252,75,64,25,178,6,26,27,28,131,135,25,205,48,65,3,232,240,71,25,46,185,26,26,75,111,111,2,91,91,35,67,168,207,16,18,46,49,204,47,67,232,240,6,233,100,174,45,104,166,14,20,147,98,123,45,91,109,222,27,56,44,89,8,252,92,132,7,195,140,135,4,225,155,204,2,77,85,73,0,119,20,119,12,121,25,22,12,129,162,239,1,191,45,203,22,251,72,96,3,131,133,175,7,195,241,169,45,159,228,198,23,55,164,248,31,107,94,146,55,146,61,97,31,108,9,25,31,149,195,52,73,189,195,200,19,18,69,21,5,114,154,254,7,60,150,118,6,221,244,12,19,46,79,79,6,172,134,212,12,46,139,136,1,153,245,54,5,251,30,48,9,120,73,52,23,219,219,24,14,235,171,207,20,133,231,164,4,67,24,177,6,252,254,207,9,46,225,127,47,3,200,181,12,115,163,27,20,60,71,103,14,93,1,158,0,72,226,46,12,3,169,150,11,124,247,228,8,204,13,189,1,229,37,53,1,44,53,64,4,252,60,102,44,12,168,83,4,193,0,160,2,147,124,199,18,211,83,87,1,140,13,177,33,37,190,63,7,114,118,209,16,210,118,196,16,163,207,169,74,227,81,42,39,237,45,116,13,46,75,50,0,139,57,51,17,46,71,130,8,46,141,191,4,188,128,244,56,57,68,37,11,163,102,144,33,27,108,74,16,83,5,166,10,152,225,248,17,92,185,72,28,41,10,229,45,235,57,81,2,121,211,66,3,92,4,84,15,109,162,14,30,168,166,139,10,46,145,95,16,199,17,220,21,105,37,219,5,252,94,214,10,46,9,80,19,28,14,75,43,46,101,127,21,40,12,222,32,115,46,155,72,131,68,123,0,243,239,21,5,107,95,76,2,211,150,24,38,227,68,237,17,184,196,202,17,209,203,63,5,24,22,3,21,161,137,161,37,233,11,242,0,46,195,58,26,147,59,10,34,146,115,153,6,137,63,73,1,21,158,234,6],"created_at":1778400600926,"updated_at":1778575558070,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":9,"stem":"A tumor is negative for ER, PR, and HER2 but expresses CK5/6 and EGFR. Which subtype does this represent?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"f6233715ce7aebeb9eaed75b885bc46407cfd80d2cf7694e6e1de99f3121cd96","minhash":[177,135,81,2,255,209,129,4,185,168,28,3,156,95,226,12,108,202,127,3,44,23,151,19,12,11,38,11,32,241,154,4,194,132,140,4,100,117,19,3,18,211,9,1,156,201,110,4,122,29,187,3,196,19,28,2,104,213,243,11,77,244,46,2,37,83,30,13,183,156,161,8,153,16,175,7,39,230,137,19,136,130,107,8,248,80,23,1,126,172,129,0,125,217,74,1,250,236,149,13,145,11,190,5,245,218,242,0,24,37,132,4,77,107,235,4,172,12,99,7,121,213,0,0,248,224,248,1,159,9,158,2,56,119,3,19,125,141,210,7,33,228,180,7,120,240,206,8,34,79,140,1,111,240,153,7,242,226,149,5,172,146,5,10,191,30,50,12,89,94,243,3,68,89,81,0,84,2,103,4,49,142,46,2,146,78,169,7,217,140,34,8,80,254,251,0,127,164,115,4,151,198,205,0,161,102,77,5,120,131,179,4,44,172,125,0,161,26,59,3,76,68,191,13,104,13,243,1,17,166,0,8,60,79,173,13,67,228,29,6,210,102,233,9,152,29,120,21,146,44,138,2,160,85,178,0,165,76,152,2,254,252,186,1,18,92,120,23,184,99,242,5,210,69,241,0,179,23,19,10,240,34,201,1,207,79,105,4,215,61,90,2,178,142,16,1,176,36,197,5,29,242,71,0,169,215,26,0,209,134,240,11,104,193,80,3,220,49,124,19,194,95,194,3,128,1,11,2,164,136,161,5,161,153,170,9,251,131,136,4,44,212,90,6,15,40,152,0,133,199,100,6,28,190,204,11,177,116,72,11,133,102,66,1,90,163,154,6,55,21,101,1,50,32,208,5,124,197,173,1,216,249,217,6,172,68,23,0,162,17,105,0,253,206,203,7,156,229,218,4,108,0,242,22,60,60,25,4,81,35,147,0,135,72,101,5,117,100,111,0,252,82,117,21,58,218,92,5,90,93,104,61,5,206,59,3,172,19,159,7,124,166,248,12,68,95,163,11,204,185,71,16,228,129,83,5,15,85,44,7,161,94,75,4,136,196,57,0,151,95,178,3,126,124,17,3,32,26,138,7,231,58,206,11,252,195,252,3,217,70,198,0,231,119,251,1,55,68,214,1,188,69,85,1,121,140,16,0,254,77,94,11],"created_at":1778400600926,"updated_at":1778436184423,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":10,"stem":"Which of the following BEST explains the increased risk of endometrial carcinoma with Tamoxifen?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"71334d06629647ea42e86144454a60bfd6ce18bd2f6ca8c8e9d5eda5a3226bf7","minhash":[237,252,190,7,65,82,112,12,246,123,125,29,229,238,247,0,38,194,238,10,159,147,181,6,157,241,98,4,177,155,16,6,250,198,88,11,145,234,161,10,110,65,117,6,219,47,190,3,254,16,170,2,115,120,215,4,230,149,255,0,79,108,51,8,156,95,206,13,239,42,111,8,110,161,102,5,47,51,138,18,83,38,181,7,31,191,70,11,128,48,150,3,75,216,34,11,173,203,198,6,82,70,177,9,178,169,50,0,171,99,88,5,32,128,136,12,139,14,13,13,85,237,6,1,218,21,36,0,254,214,130,5,82,149,150,39,35,96,240,9,112,65,180,3,71,54,46,7,166,134,135,21,139,250,164,10,177,144,232,20,28,89,132,3,16,42,63,1,75,108,158,12,81,225,186,6,25,247,98,3,166,200,141,30,167,124,140,10,59,28,243,5,77,113,131,4,82,115,79,11,9,67,165,9,112,232,207,0,160,126,189,2,110,21,229,6,125,167,18,0,122,246,173,0,45,41,79,7,82,2,3,6,134,15,184,2,198,229,170,6,193,50,97,5,126,10,27,10,50,209,145,8,197,86,142,7,109,131,81,2,147,18,200,3,230,154,34,11,126,15,30,6,102,99,222,6,79,76,227,1,157,227,23,10,48,4,142,18,38,195,123,2,70,207,195,5,235,158,18,3,198,89,233,6,27,210,63,8,3,15,130,5,213,206,135,12,35,112,201,13,73,227,224,3,179,196,176,11,253,170,65,1,131,248,183,9,118,175,62,3,195,251,197,6,59,56,249,6,126,165,16,3,242,189,112,31,233,237,225,18,155,123,155,11,225,134,51,0,135,228,208,4,154,192,146,4,251,186,160,11,129,121,254,6,115,29,170,16,227,48,130,4,91,118,210,4,67,137,20,0,122,24,114,5,241,188,169,6,185,216,171,14,150,148,118,45,9,37,214,20,251,89,125,25,166,223,98,4,219,128,127,1,205,73,220,24,22,205,183,22,171,219,234,22,38,109,159,0,102,38,102,1,54,197,225,9,192,66,28,0,112,179,156,11,102,15,72,10,27,42,190,0,169,220,41,3,133,0,173,7,102,152,168,3,70,107,114,12,203,111,71,0,67,208,51,1,32,99,110,2,53,95,231,38,93,31,94,10,129,158,67,13],"created_at":1778400600926,"updated_at":1778436184423,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":11,"stem":"Which of the following statements BEST differentiates Oncotype DX from 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most common cause of benign bile duct stricture 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a new born baby undergoes pyloromyotomy. During the procedure, a deep mucosal injury is noted at the distal aspect of the incision. How should this patient’s mucosal injury be managed?","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"d78556f80dfe4561906d0e695545ad8f7dd1882f1494190f37785b940501b6ba","minhash":[235,231,102,13,22,225,58,9,194,175,194,4,114,21,13,33,151,32,29,1,149,116,58,6,11,9,141,0,133,159,183,6,236,114,131,8,93,180,210,0,69,110,235,2,11,173,97,10,1,210,66,7,65,138,217,1,156,242,117,21,25,12,97,6,251,160,80,14,5,212,41,11,201,170,224,6,82,116,228,3,65,223,151,0,73,69,208,12,36,108,110,2,153,237,46,8,210,62,166,17,207,110,169,3,197,182,246,5,171,46,209,0,210,132,47,4,220,134,111,0,115,180,135,16,186,222,44,8,67,86,50,14,197,37,190,3,104,161,119,1,57,110,251,2,82,51,27,9,111,131,211,6,37,207,248,25,77,183,73,0,171,225,131,7,188,72,43,8,75,102,15,0,220,111,175,1,3,46,56,2,229,42,115,3,86,150,235,11,25,89,198,7,8,156,38,4,46,229,242,22,125,104,125,0,58,83,120,4,86,102,60,0,178,172,146,10,135,221,103,1,51,171,244,1,210,56,178,3,22,11,133,4,236,107,153,6,21,175,57,5,131,79,231,3,178,241,139,39,145,3,170,0,53,23,39,12,50,218,13,2,22,17,89,0,242,153,29,9,107,132,127,0,233,93,172,0,3,188,118,6,73,128,37,19,197,20,177,6,119,222,153,8,155,229,31,2,18,5,89,2,109,97,38,3,217,44,209,11,22,236,84,10,157,181,242,1,25,166,228,2,245,129,16,0,12,85,218,1,194,205,21,4,150,204,9,11,172,81,59,11,18,22,17,10,214,225,68,1,35,22,240,1,43,202,152,0,150,91,171,23,146,74,69,19,22,1,173,3,82,110,115,10,51,141,187,6,114,162,84,13,22,244,31,22,235,56,162,17,53,118,129,2,45,124,104,4,91,79,140,4,67,75,154,3,50,1,93,3,172,224,19,11,209,252,152,0,163,209,186,3,140,130,113,16,86,171,195,18,164,228,6,2,155,158,242,3,22,194,160,0,82,116,91,7,178,153,4,16,76,171,159,15,203,138,23,2,146,89,85,2,251,138,189,2,189,157,96,0,187,20,210,3,201,131,118,10,34,127,172,0,99,19,139,2,226,11,180,8,203,105,31,1,150,74,236,3,109,248,252,3,18,177,52,15,81,125,129,11,22,12,95,5],"created_at":1778400600926,"updated_at":1778509790493,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":24,"stem":"The true statement about Ladd bands is:","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"dc8757ac7bcca2c31f73e534c68f0da1b9beba9b0c1ddb563f260924e9faca27","minhash":[199,169,18,17,12,46,23,13,192,191,164,1,159,162,139,1,244,229,13,7,215,86,83,1,66,129,88,7,61,164,14,6,242,155,67,8,135,111,173,4,143,174,69,4,45,227,156,3,44,243,215,3,4,157,192,0,37,132,86,12,115,203,158,5,229,17,64,3,141,137,163,6,117,205,85,11,228,210,136,5,5,134,18,0,144,110,243,18,62,166,166,7,48,54,68,1,23,236,6,15,160,207,123,12,255,174,26,4,242,103,191,4,62,39,36,25,98,77,182,8,78,0,9,2,236,231,13,8,32,75,216,3,12,0,251,5,197,204,201,2,159,25,45,1,169,132,20,4,144,165,138,13,148,133,140,19,190,157,70,3,112,126,44,23,220,104,74,5,44,206,229,8,18,170,247,2,79,233,52,8,28,141,158,10,37,53,248,0,64,179,179,0,223,94,14,15,47,35,68,2,208,115,15,2,18,41,96,8,9,34,178,7,71,120,135,7,236,88,46,1,97,116,248,13,2,106,69,21,161,86,66,1,249,136,156,8,173,40,133,18,187,14,132,2,98,121,234,7,76,232,59,8,34,186,156,23,240,0,189,24,57,8,161,7,178,80,82,1,190,247,5,28,78,94,247,9,76,64,102,9,159,94,159,8,81,115,252,17,165,231,145,5,196,113,135,0,53,239,32,4,207,186,187,2,111,207,157,9,208,120,127,4,239,66,53,0,28,136,142,19,78,58,51,2,93,48,216,2,169,130,178,19,143,132,15,14,251,142,70,14,215,214,62,5,144,183,67,8,103,28,5,0,245,63,174,19,16,38,225,7,12,240,225,3,172,249,7,6,247,193,56,9,63,64,123,6,108,79,76,7,114,43,177,7,229,170,53,19,151,56,66,2,197,110,46,17,18,227,98,12,78,254,16,23,199,158,42,0,171,120,58,19,190,253,201,12,191,102,250,11,223,242,220,10,92,30,188,22,242,237,224,16,124,217,201,3,176,103,204,17,50,191,88,2,34,28,140,1,62,165,135,6,226,184,165,1,63,90,152,0,31,227,234,2,191,35,139,10,132,129,107,7,50,102,199,20,189,131,14,0,64,205,55,1,205,114,9,5,91,94,44,2,162,12,167,12,187,36,148,7,204,175,181,1,85,253,171,2,253,253,49,1],"created_at":1778400600926,"updated_at":1778436184423,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":25,"stem":"Regarding gastric duplications, which of the following is true?","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"8d6e67c6aa86c13b58762c0bfc3828cf0a407ba529e67dc4785cdf56cbc01bfb","minhash":[147,248,27,33,36,6,103,4,52,150,104,19,43,57,166,15,225,235,73,20,100,153,45,2,53,205,172,2,221,230,200,27,20,93,37,11,35,204,120,0,175,36,58,0,124,95,156,25,190,239,231,9,13,29,187,1,117,61,110,15,101,89,194,4,79,88,104,2,177,74,136,9,145,139,129,9,217,203,138,16,76,142,228,6,22,225,146,7,100,235,228,3,150,14,16,7,21,96,115,3,40,160,208,18,185,185,168,53,136,152,12,22,202,208,87,4,22,231,80,7,31,113,88,0,39,245,138,18,74,129,81,0,39,86,75,20,44,89,119,27,43,4,153,18,212,53,156,8,195,94,66,10,129,202,165,1,73,207,102,2,153,68,159,14,153,5,48,11,197,172,224,14,251,223,50,6,97,148,184,3,57,205,113,5,211,123,65,9,51,156,8,8,12,14,196,0,235,172,14,7,29,151,60,2,129,85,5,2,202,35,6,2,129,70,31,0,79,242,162,5,27,188,37,0,86,234,135,13,103,185,41,5,137,248,90,1,75,119,189,23,163,19,8,13,232,196,199,11,190,122,28,7,249,247,167,2,121,5,136,17,11,56,192,8,255,210,225,3,52,26,165,2,225,85,123,11,203,253,210,1,223,185,238,3,251,225,53,2,129,78,66,1,167,133,51,0,214,231,190,5,217,82,82,17,3,141,124,9,43,234,25,6,99,240,59,24,91,208,169,6,217,8,204,18,177,244,121,4,4,100,150,0,135,95,128,10,153,9,204,1,41,39,44,9,216,137,193,0,103,15,183,15,67,232,218,1,22,164,164,0,213,205,8,1,124,52,229,0,86,221,21,2,185,160,179,18,123,174,186,4,9,234,31,3,133,164,76,3,116,57,117,0,249,234,61,22,189,70,202,10,249,176,213,13,212,239,98,12,241,184,45,9,155,68,71,24,129,163,6,17,40,215,52,3,9,188,194,4,69,202,208,4,35,72,88,6,156,140,49,2,253,43,58,0,17,168,88,6,117,40,158,29,225,41,94,21,4,94,88,4,177,28,250,34,195,232,142,3,219,131,171,6,100,57,24,7,201,247,137,6,74,60,58,0,163,62,236,2,161,255,3,10,105,13,242,5,202,156,240,0,141,84,23,13,123,153,100,12,72,37,178,2],"created_at":1778400600926,"updated_at":1778575864294,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":26,"stem":"A 35-year-old patient is intubated in the ICU after being exposed to smoke. He has thick yellow secretions that require frequent suctioning along with the administration of bronchodilators. On hospital day 5, he has a percutaneous central venous catheter placed through the right internal jugular vein. Several hours later, he undergoes respiratory arrest. His peak inspiratory pressure has risen from 24 to 41 cm H₂O. Choose the most likely reason for the respiratory arrest:","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"4bed79666986f801771113faf33c6c2b2d85f879f42d95e44aa4d390e3b39cb1","minhash":[173,241,242,0,21,35,134,0,97,50,92,11,165,170,234,4,199,211,157,8,243,240,156,4,106,146,94,10,196,175,55,2,50,156,30,9,214,46,19,17,49,232,82,3,5,186,84,1,151,203,111,6,251,241,93,1,37,24,156,0,208,91,184,2,45,52,168,7,229,60,109,0,133,241,132,8,139,250,154,1,176,6,110,0,187,208,0,2,32,136,136,1,205,201,7,0,37,61,123,8,49,207,140,9,209,21,44,3,182,223,115,4,161,196,212,5,114,127,41,8,103,230,60,4,33,19,80,1,227,207,58,3,162,42,102,0,93,107,215,2,248,141,155,2,192,158,48,1,88,29,98,3,156,76,126,0,189,129,204,3,8,51,35,1,62,86,235,1,81,36,141,4,83,121,80,0,11,219,193,2,53,184,178,2,189,66,49,0,25,32,144,0,81,102,193,1,84,129,132,4,221,135,188,1,80,74,81,0,213,52,205,0,246,184,141,6,10,63,94,1,69,98,23,2,54,169,123,10,160,102,106,6,234,20,162,4,131,7,149,2,31,46,160,8,246,134,48,7,197,13,97,0,112,37,245,0,65,198,38,0,163,143,119,2,189,184,174,7,83,34,211,0,132,13,132,0,253,106,155,1,182,57,174,2,119,115,50,1,74,147,231,3,58,161,196,2,253,168,1,10,178,245,252,1,136,8,75,5,46,66,244,0,153,199,7,0,10,107,132,9,112,157,213,0,207,249,152,2,90,171,118,11,233,105,249,1,9,7,48,0,212,171,255,7,32,132,192,2,89,40,46,1,169,221,29,0,27,208,242,3,167,213,239,0,118,199,211,0,73,226,104,1,117,202,41,12,224,60,152,2,244,163,252,4,85,102,186,0,147,171,233,2,189,243,102,6,151,180,224,11,67,32,175,4,235,43,138,1,223,206,160,5,189,19,119,2,168,205,217,14,49,139,113,2,176,248,160,4,105,172,3,2,190,240,126,1,239,193,160,1,7,95,139,1,170,76,168,6,245,249,179,4,85,170,208,6,67,87,5,6,83,205,124,1,232,244,145,2,131,136,81,0,218,221,81,4,202,43,69,1,109,9,72,0,133,6,12,4,80,100,218,0,46,22,152,0,49,68,40,0,84,56,130,0,76,94,152,6,171,193,94,0],"created_at":1778400600926,"updated_at":1778436184423,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":27,"stem":"A 35-year-old woman is rescued from a house fire during which she was trapped in a smoke-filled bedroom for 30 minutes. On arrival in the Emergency Room, she has marked facial burns and hoarseness of voice but no stridor. She is expectorating carbonaceous sputum, appears confused and has a cherry-red visage. Which statement is FALSE about this case?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"e87f70685f85cf86b48c5b06f921e86c399d810ffc9d9583a87be42296d7f7a8","minhash":[35,67,148,2,216,66,79,13,69,201,221,7,75,13,184,14,46,228,63,6,152,43,188,0,129,50,127,4,251,213,162,13,46,163,206,7,174,110,209,1,162,90,156,7,252,245,61,3,75,50,140,4,249,61,97,1,91,166,177,0,190,143,219,9,113,169,169,4,99,67,116,0,36,15,161,18,130,2,16,10,89,33,95,4,79,198,69,2,95,150,158,0,201,53,217,11,46,131,17,2,3,28,224,13,137,22,213,14,160,228,16,4,244,54,120,2,64,95,172,2,62,88,70,0,36,154,143,5,171,2,223,6,99,38,93,6,53,235,47,8,224,173,84,0,200,69,192,0,28,205,228,1,140,148,181,2,107,177,7,6,230,219,210,1,241,144,41,3,162,134,17,0,96,58,69,7,100,253,188,16,64,211,219,1,233,130,29,0,49,73,164,1,69,44,185,1,167,12,47,14,73,48,74,2,224,220,252,1,63,54,109,4,67,148,41,5,205,163,153,1,125,130,226,2,136,7,134,4,207,220,120,3,237,134,175,0,45,26,58,0,55,240,200,2,159,25,231,3,169,88,120,6,77,39,174,2,57,111,128,1,124,244,164,3,151,108,195,1,216,246,46,3,12,21,63,0,125,48,94,6,34,197,191,2,90,24,195,0,108,123,73,2,176,28,85,5,48,159,38,0,235,91,119,3,72,1,123,2,139,114,212,0,105,68,19,10,38,12,20,2,99,202,102,1,154,126,71,6,46,79,59,0,155,3,210,4,23,197,27,0,166,105,91,0,12,52,6,0,49,48,144,7,0,254,177,3,129,143,171,4,137,48,109,0,17,60,39,6,137,46,79,8,184,19,111,1,102,217,58,12,177,88,197,0,122,179,173,8,196,226,183,8,22,4,215,1,81,185,155,18,108,82,28,2,147,96,26,0,3,212,29,8,7,33,7,2,17,56,249,1,128,195,81,1,1,18,29,2,235,230,237,5,3,79,54,0,38,84,138,4,230,172,219,0,60,148,41,3,143,49,239,3,91,202,79,5,186,176,20,1,99,25,182,5,254,105,76,9,190,200,8,3,62,220,60,0,241,49,74,0,136,51,75,6,35,193,213,8,204,230,86,0,180,158,178,2,168,128,186,1,161,223,33,12,148,234,19,3,90,131,204,3],"created_at":1778400600926,"updated_at":1778436184423,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":28,"stem":"Five days following percutaneous drainage of a pelvic collection after right hemicolectomy for Crohn’s disease, the catheter output remains > 100 mL/day. What should be done next?","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"fa5fc98a2425ece2488a9b7ee05439b9a9e1a4d74efb24cab4d29b3392741e98","minhash":[98,188,146,3,1,9,174,5,145,106,140,34,125,78,142,6,143,161,81,3,207,90,74,0,131,140,101,0,27,197,172,14,208,11,240,3,182,10,210,3,97,99,58,20,217,225,172,1,218,5,243,12,171,21,175,0,49,164,47,3,212,155,145,31,41,66,112,12,71,216,87,4,48,51,52,0,53,73,157,19,93,254,214,42,185,194,106,18,21,83,150,3,29,70,147,10,208,210,238,15,40,170,72,7,252,196,253,4,169,1,202,9,226,130,136,20,63,138,241,2,99,17,41,15,118,183,103,16,115,240,92,1,75,176,53,5,118,211,152,26,197,218,2,25,226,189,13,1,161,48,135,13,149,19,22,2,16,254,99,10,224,227,161,10,171,65,12,0,118,161,98,0,76,145,5,2,29,233,175,14,187,124,187,14,224,168,227,9,125,176,94,1,1,206,84,23,159,58,255,0,245,101,185,24,95,252,51,0,161,10,6,9,202,50,183,2,26,52,57,6,32,69,55,5,7,0,91,3,182,190,122,4,99,147,74,1,138,93,15,3,231,105,116,4,15,135,13,8,173,113,134,22,165,125,86,8,246,179,188,0,109,62,31,1,159,195,104,11,240,242,118,22,109,78,7,12,246,61,131,23,130,22,181,17,43,234,48,6,193,117,177,2,240,193,180,2,131,139,156,18,226,189,209,7,183,207,129,2,246,203,144,40,118,208,172,9,215,56,228,9,147,165,207,8,9,107,150,9,160,250,249,25,56,111,223,5,201,27,53,7,185,92,180,7,51,176,19,1,58,32,43,3,56,67,231,6,47,191,138,9,9,252,139,3,61,223,68,3,160,124,194,17,139,21,253,6,196,194,225,12,47,117,59,1,115,150,50,7,37,13,40,0,249,69,54,3,54,168,87,5,226,149,254,5,194,108,247,7,103,131,0,3,137,188,240,3,54,142,102,11,173,221,241,4,162,122,215,22,184,83,99,0,98,11,226,10,17,100,175,0,63,167,144,0,59,115,83,16,100,20,186,1,181,15,27,16,209,93,10,8,143,67,110,5,25,21,142,15,127,169,53,1,162,48,110,4,249,99,106,1,83,253,161,0,9,71,154,12,141,224,86,14,54,226,118,44,226,198,62,5,169,80,114,5,169,24,187,0,72,79,40,1],"created_at":1778400600926,"updated_at":1778575902513,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":29,"stem":"Which of the following statements regarding interleukins (ILs) is true?","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"3938d1f417b4f26bf61652c092f14faccfb4d5b13ea1ba88fa56b93e33c38e5f","minhash":[113,175,35,34,153,50,78,34,25,158,65,6,104,75,164,18,13,140,117,21,73,47,55,3,88,255,173,8,31,70,10,3,70,94,112,10,26,226,101,15,58,164,17,5,157,184,245,14,233,153,212,28,248,31,87,8,37,103,161,1,1,183,201,16,137,105,96,12,184,116,162,18,193,152,193,13,161,221,187,3,145,112,0,0,237,155,154,3,21,84,63,3,141,177,57,8,245,176,239,0,168,200,69,26,1,30,67,10,33,47,75,5,177,105,121,7,76,174,173,3,149,117,35,16,88,182,119,9,237,57,106,16,46,95,139,4,58,163,4,4,93,127,155,16,46,1,5,22,17,18,32,5,185,40,123,34,137,208,194,10,55,241,35,6,46,207,248,8,220,138,215,9,114,61,209,0,122,23,37,11,61,187,34,5,184,112,170,17,125,9,144,0,137,246,12,2,134,112,101,3,152,3,162,14,159,237,188,1,113,157,135,11,143,114,203,10,156,163,180,37,216,34,220,32,229,100,42,1,56,76,38,0,32,43,184,1,90,5,130,5,73,153,91,8,79,148,128,21,108,76,242,9,60,110,244,23,72,49,34,13,113,226,98,2,160,186,75,0,101,172,14,6,210,60,199,4,241,193,19,29,88,11,74,3,188,22,160,15,177,122,15,1,46,143,230,13,241,79,189,8,152,214,5,7,252,127,211,11,81,28,229,28,25,53,194,20,60,95,165,9,137,131,178,3,40,95,181,16,120,135,124,12,121,16,112,11,122,208,217,6,46,55,61,0,101,189,16,36,127,249,148,1,201,206,144,0,26,228,215,39,39,168,241,8,201,78,93,17,70,111,25,5,111,107,164,31,85,14,27,19,129,51,231,2,237,75,119,10,213,17,105,10,172,76,204,4,124,48,23,12,129,84,159,12,241,150,81,26,199,153,76,10,1,197,31,6,82,16,177,8,46,79,148,1,129,194,65,7,57,122,93,6,49,70,153,12,121,236,68,2,249,105,104,16,189,130,35,9,46,233,54,24,85,26,176,12,58,53,36,18,6,119,214,4,41,36,208,0,120,83,155,14,57,65,14,3,189,197,212,10,184,11,79,10,136,171,218,12,53,217,186,27,46,107,179,1,5,75,183,17,176,59,126,2,46,45,187,6,108,106,254,29],"created_at":1778400600926,"updated_at":1778575932833,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":30,"stem":"In patients receiving massive blood transfusion for acute blood loss, which of the following is 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25-year-old man is seen in the office with complaints of contracture of his left index finger after a burn injury. Which of the following statements is true about growth 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most common fluid disorder in surgical patients is:","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"e1b20ac0e58f2472a6c5d665164e3eedccc05525721ba1958915aa89eeafe8e8","minhash":[91,186,109,6,101,177,235,62,13,140,142,1,67,170,212,28,64,86,103,0,245,102,48,21,107,196,248,46,191,178,229,50,0,22,18,38,165,9,58,43,228,22,65,21,165,14,100,39,123,232,39,1,197,163,24,7,39,66,186,0,85,36,52,7,128,93,18,19,85,219,185,32,96,94,72,39,16,183,55,3,141,148,86,13,5,52,195,25,173,3,150,0,196,139,154,5,189,108,24,41,100,22,66,14,203,232,176,11,244,196,176,0,221,109,254,10,179,1,63,4,237,37,12,0,227,76,239,8,167,247,45,16,228,52,69,5,13,213,87,2,16,14,216,29,4,61,119,8,243,215,167,24,103,65,37,27,133,189,12,1,212,73,200,5,165,138,61,5,77,239,82,11,165,239,136,84,20,139,241,19,112,111,168,3,109,90,243,60,99,54,25,37,84,212,217,34,19,139,87,7,139,123,191,13,116,68,190,7,141,189,166,7,5,149,147,45,235,220,227,13,180,117,179,2,0,99,231,3,47,84,120,23,75,250,211,21,4,13,108,70,221,70,92,96,69,53,5,54,55,32,71,10,99,226,112,0,237,150,179,57,239,29,241,16,100,212,12,15,245,85,93,6,4,247,237,8,115,69,246,12,29,79,178,19,21,50,245,15,215,235,121,91,83,37,84,13,224,58,100,20,159,25,101,7,192,169,169,2,179,107,16,48,171,106,126,16,143,43,230,6,128,25,138,46,19,142,192,27,7,226,149,47,116,174,12,12,7,140,219,48,240,48,193,0,231,79,164,18,196,191,10,6,189,222,7,7,100,138,186,11,224,217,177,56,181,138,171,6,132,210,254,10,31,112,255,45,237,119,160,36,99,245,118,7,237,159,72,109,255,56,132,25,96,57,185,31,132,13,212,5,148,100,200,38,20,219,63,35,52,144,59,4,191,119,151,30,0,48,50,12,165,140,27,51,116,173,184,0,144,165,212,25,192,199,117,3,179,142,235,5,93,174,75,42,99,92,226,45,39,213,201,86,127,148,149,33,151,86,66,0,195,92,16,4,148,121,167,16,95,249,14,0,119,130,217,1,5,192,141,41,189,23,47,94,47,226,1,90,116,114,188,23,181,219,77,4,199,186,39,4,31,135,31,4,180,55,162,13,227,5,253,8],"created_at":1778400600926,"updated_at":1778575955953,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":1},{"id":33,"stem":"In a 40-year-old woman receiving TPN for small-bowel fistula, what finding can be attributed to 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cirrhotic patient presents with massive hematemesis. 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25-year-old man presents with right lower quadrant pain, fever, and leukocytosis. CT scan shows a perforated appendix with an abdominal abscesses. Which of the following is the most appropriate initial management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"efe02581feab9a1e501d91d83f6abdd7b48327c60fc6a2720bd647aff6f7dcec","minhash":[29,114,204,1,183,80,0,13,178,75,231,3,224,252,138,10,13,172,121,0,245,210,60,12,29,233,0,9,234,23,31,11,208,35,39,10,0,69,43,7,61,82,83,14,224,159,0,8,216,140,168,19,230,72,152,10,93,15,109,7,200,221,164,8,159,229,46,7,202,159,73,1,73,75,122,7,111,185,95,8,48,9,206,12,73,214,17,18,234,30,39,18,113,129,75,3,2,70,72,26,202,64,105,4,130,129,70,2,88,84,2,8,67,62,160,12,137,77,59,5,100,197,175,18,54,220,6,10,152,148,7,7,243,125,163,0,201,129,69,6,98,86,243,0,3,71,142,0,84,11,94,6,174,47,69,1,183,2,26,1,223,178,19,5,191,109,2,3,19,215,164,1,165,27,73,4,148,214,217,7,7,210,179,5,169,68,117,5,199,16,51,6,80,101,192,7,193,245,187,2,191,45,42,3,4,254,28,3,225,255,217,3,170,65,190,0,40,82,244,7,85,172,76,7,208,248,79,2,182,1,35,11,147,32,28,1,11,147,44,6,153,241,242,2,228,220,187,1,145,108,130,3,51,76,235,0,166,100,91,1,162,245,156,19,118,86,64,2,136,161,26,0,25,174,26,6,12,242,197,1,220,239,53,1,72,12,113,2,45,45,238,16,230,47,8,6,28,64,27,8,185,93,6,0,22,135,4,8,36,216,18,1,56,212,69,0,143,136,72,1,56,57,149,10,169,10,27,5,174,231,239,12,86,199,34,2,7,129,218,0,107,43,102,0,203,226,173,0,4,29,93,12,138,251,75,5,63,96,228,3,38,39,159,11,96,79,195,8,114,120,31,18,43,46,95,3,52,193,206,5,107,217,40,6,237,107,127,2,42,91,43,9,116,222,58,17,121,183,153,4,114,175,2,4,56,235,10,17,75,80,200,2,68,84,102,15,80,14,120,7,228,182,125,0,48,130,46,0,165,221,113,17,29,137,203,6,87,227,151,0,223,120,133,11,40,163,142,0,2,247,22,0,100,53,211,0,194,57,17,3,75,230,8,1,243,145,244,4,37,142,49,3,111,33,197,1,113,32,76,5,2,42,103,3,32,145,38,18,174,119,104,2,106,138,108,0,170,195,245,11,230,132,48,9,55,35,20,8,174,209,69,10],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":75,"stem":"A 65-year-old woman with a history of multiple abdominal surgeries presents with small bowel obstruction. She has been on conservative management for 48 hours without improvement. A water-soluble contrast study is performed, and a follow-up radiograph after 24 hours shows contrast in the colon. Which of the following is the most appropriate next step?","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"80d369c6a1e3039dba970e8da3655a6083f8692f3036caf6410525dad4063394","minhash":[113,178,20,3,211,114,212,1,255,135,78,3,124,149,217,3,61,131,27,6,33,227,171,20,120,109,61,5,213,158,220,0,178,16,158,0,80,110,64,15,180,213,243,2,73,33,131,4,55,140,67,3,196,52,135,7,240,75,120,1,246,190,109,10,221,124,123,2,67,250,121,0,255,33,117,13,246,213,175,1,253,105,43,10,161,213,224,1,207,52,70,1,239,60,134,7,32,146,150,5,60,249,244,9,128,255,55,1,96,109,235,8,225,43,43,2,79,15,225,0,179,49,3,4,164,24,63,1,129,180,79,0,111,65,140,0,176,68,60,2,23,86,181,6,39,174,52,1,237,21,132,8,117,64,46,2,246,243,73,1,203,141,106,7,137,23,107,0,63,31,44,0,149,226,222,2,162,9,0,5,117,8,125,2,54,243,189,4,203,31,241,5,3,18,46,11,80,13,1,8,255,40,101,16,124,72,200,5,143,43,183,0,11,168,179,3,64,207,224,2,178,159,38,1,119,16,156,8,255,249,182,6,21,183,49,1,59,225,62,0,182,179,98,1,101,48,175,11,98,104,20,4,31,178,30,1,87,189,58,3,92,156,200,1,51,107,120,2,139,211,98,19,204,195,112,0,219,148,62,3,167,145,197,2,223,241,152,2,7,139,166,7,128,7,9,2,148,42,23,9,108,1,51,8,141,250,31,17,128,52,12,0,247,137,210,4,117,127,64,1,1,84,177,7,199,97,124,4,215,1,4,3,55,250,60,8,123,23,245,9,7,202,212,2,245,49,77,0,107,148,211,2,167,81,8,1,9,147,155,2,112,28,163,0,96,41,180,1,171,59,84,2,38,120,118,6,199,107,15,5,180,166,140,9,116,148,5,4,23,161,120,2,45,222,167,4,255,37,114,0,71,183,86,2,252,221,174,1,223,131,37,6,4,177,148,1,203,3,169,2,27,206,23,0,9,110,222,7,107,230,64,2,231,51,28,13,128,178,192,2,191,22,74,2,172,77,101,30,182,54,203,1,204,233,165,3,172,24,100,8,244,84,164,0,123,98,248,2,144,229,73,0,127,144,229,8,224,68,3,10,144,58,23,14,141,133,19,2,245,187,163,0,87,27,250,6,162,55,79,9,99,0,140,8,82,113,252,3,75,11,192,5],"created_at":1778400840859,"updated_at":1778576970764,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":76,"stem":"A 45-year-old woman with a BRCA1 mutation is diagnosed with a 2 cm invasive ductal carcinoma of the breast. The tumor is estrogen receptor-positive, progesterone receptor-positive, and HER2-negative. There is no evidence of metastatic disease. Which of the following is the most appropriate treatment?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"4e7b41b6f5757912a1845365b9d90f373705a64a6af32f44cb653f945422e529","minhash":[24,125,196,11,140,45,239,0,123,14,130,3,104,255,168,7,85,115,180,4,204,171,78,8,222,2,123,5,176,165,104,0,123,238,146,2,195,234,215,5,176,67,126,0,219,59,180,1,128,41,48,0,175,241,31,10,241,138,215,1,220,168,41,0,172,123,235,7,128,248,11,0,235,61,36,3,30,97,234,1,3,36,154,1,208,135,56,3,140,88,148,0,163,115,130,1,11,49,97,7,201,156,238,2,227,211,112,3,32,160,66,5,189,67,4,1,188,6,116,2,22,72,83,3,92,197,7,25,44,209,73,3,140,127,79,9,166,157,118,6,121,96,78,1,98,86,224,11,204,61,252,1,143,173,247,6,144,105,190,9,123,121,58,10,51,217,70,1,247,20,231,1,138,90,5,2,84,38,205,0,87,150,67,2,241,143,200,0,75,228,38,5,126,54,166,7,128,246,22,1,84,6,31,9,182,235,196,15,97,109,17,2,41,76,244,0,147,14,16,5,63,110,208,0,172,26,37,0,124,216,2,0,45,17,153,13,254,214,54,0,87,122,230,8,35,181,135,0,167,209,39,1,203,185,203,6,53,187,200,3,235,84,248,4,64,47,195,0,30,89,30,11,253,194,27,17,202,227,25,9,48,69,136,1,220,139,89,8,188,70,33,1,12,246,19,3,163,104,204,7,179,118,148,7,61,153,89,1,233,185,200,0,211,20,35,0,175,250,35,1,172,31,232,10,243,172,227,0,234,131,1,9,139,218,67,12,97,34,169,7,208,227,71,15,156,200,26,3,163,25,178,1,143,170,24,2,196,27,5,9,133,102,66,1,139,224,47,0,19,125,183,4,72,172,93,12,112,240,56,0,67,63,104,3,172,68,23,0,102,254,103,2,187,78,9,4,96,22,156,1,27,232,154,3,101,177,196,3,156,25,152,0,183,239,110,4,150,99,24,0,64,196,104,1,192,107,78,16,207,82,217,7,83,251,154,7,48,161,97,4,155,29,198,5,160,37,79,1,118,99,176,1,115,139,116,3,237,64,243,1,91,126,52,3,42,124,81,19,229,185,202,1,15,215,180,0,3,142,0,0,95,157,223,3,252,195,252,3,192,26,4,6,103,243,106,9,211,52,208,3,60,72,12,1,205,192,239,4,31,136,154,5],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":77,"stem":"A 50-year-old man presents with a right inguinal hernia. On physical exam, the hernia is indirect and reducible. He has no comorbidities. Which of the following is the most appropriate surgical approach?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"df06b64fdb3b2e3f0f21ff36c9c0202a4b3b1613987a4c5d3d27e9f577bdf48c","minhash":[224,96,200,27,58,58,136,9,177,176,124,1,31,135,227,1,170,197,50,9,156,11,225,3,236,86,127,19,77,233,198,13,189,59,194,7,59,83,40,9,110,112,184,0,181,71,248,0,199,189,83,8,186,233,65,5,93,168,12,7,157,36,17,4,250,163,209,0,58,68,35,0,189,221,44,2,89,164,31,11,33,219,141,13,110,252,158,0,19,26,6,10,25,2,129,9,21,115,55,2,202,209,129,3,36,66,54,6,90,151,176,6,5,209,249,1,245,198,99,2,100,193,196,0,29,185,179,17,102,247,60,7,111,119,117,2,151,232,111,4,45,133,122,9,110,120,100,1,208,139,167,3,234,57,27,16,79,214,5,5,101,213,104,13,109,0,39,13,69,130,218,7,232,153,210,1,122,173,8,9,154,74,168,2,83,0,134,10,199,55,115,10,3,89,70,1,193,245,187,2,81,177,180,12,91,127,45,11,225,255,217,3,117,93,166,9,187,196,54,15,21,209,182,0,250,124,42,11,148,25,75,8,215,163,236,6,122,128,10,1,153,241,242,2,45,60,145,1,198,244,184,1,143,179,193,1,39,22,101,14,8,80,117,3,7,207,4,8,90,200,62,7,255,77,113,7,41,105,164,3,81,141,58,0,59,110,237,3,42,194,12,12,47,88,130,4,223,73,231,2,31,210,171,5,55,80,204,0,6,40,108,6,81,115,185,0,110,68,6,16,198,240,209,14,125,40,76,5,172,109,50,18,158,6,173,7,204,83,195,1,207,232,105,0,30,84,29,0,207,192,219,14,42,180,78,1,189,234,11,5,30,94,89,0,205,47,144,15,198,199,118,4,186,219,54,11,63,40,119,6,179,36,28,0,87,230,195,26,183,4,129,1,31,63,134,2,219,199,101,6,117,155,106,0,186,32,161,3,213,56,208,8,40,31,167,3,87,143,75,2,233,227,42,8,87,42,154,7,122,126,214,11,191,214,90,2,15,174,143,0,237,143,144,0,191,126,148,6,110,232,222,7,202,124,155,11,53,211,86,9,21,60,154,2,135,218,249,13,223,92,100,3,221,133,168,1,110,100,225,3,198,114,11,8,144,64,85,1,113,235,64,4,121,227,74,3,63,170,216,0,158,207,242,5,221,15,55,2,117,160,161,9],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":78,"stem":"A 35-year-old man undergoes emergency appendectomy for acute appendicitis. Postoperatively, he develops fever, abdominal pain, and leukocytosis. CT scan shows a 5 cm fluid collection in the right lower quadrant with air pockets. Which of the following is the most appropriate management?","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"e425e26082302a7b372bdb0151271a69811ca3491a358fdc5b7387ef0aeb781b","minhash":[197,176,162,1,54,141,8,17,85,46,30,1,203,24,56,1,153,70,181,4,13,4,105,5,93,118,169,7,187,109,255,14,203,190,3,0,204,219,198,4,251,81,189,4,183,101,80,3,44,76,32,9,194,203,152,7,161,204,14,5,200,72,232,2,237,85,234,0,66,221,31,5,101,146,131,29,40,73,43,3,118,75,73,0,89,144,210,7,88,146,190,11,248,198,63,16,221,60,27,8,238,42,79,5,117,208,205,3,97,7,95,9,101,132,210,0,24,71,174,7,219,42,60,3,79,250,23,9,5,68,136,1,195,207,76,5,138,219,79,8,238,94,182,0,184,108,197,16,48,173,237,5,233,243,253,3,45,16,2,2,8,44,69,3,65,134,120,2,216,62,252,1,157,130,178,8,56,182,207,1,161,251,219,0,162,29,103,8,79,141,40,0,234,87,8,3,238,158,218,17,53,113,131,2,219,100,177,4,184,223,106,3,67,35,207,10,238,170,143,0,85,172,76,7,120,72,46,3,54,63,142,8,42,13,137,0,184,230,109,1,122,89,63,3,104,45,166,5,219,181,134,0,48,54,184,4,179,59,106,2,191,254,191,6,246,183,120,2,11,94,154,0,19,220,10,6,152,198,65,3,24,192,190,3,218,48,253,9,250,40,59,10,204,255,158,2,12,192,72,5,45,33,28,6,3,113,103,1,247,38,219,2,221,169,205,1,117,179,248,12,201,25,36,0,20,158,11,9,149,243,191,2,56,235,38,1,37,234,77,5,184,14,13,8,168,10,157,0,83,171,103,4,124,151,75,5,157,134,52,6,23,202,173,5,238,94,143,0,168,166,221,0,223,68,194,0,76,35,98,11,221,160,135,5,250,119,183,10,133,191,39,1,229,108,189,4,229,145,138,3,121,232,66,3,251,203,178,1,174,250,111,1,211,220,4,2,238,170,40,26,238,158,99,27,31,167,178,13,17,101,81,24,29,137,203,6,173,241,163,6,152,71,88,3,123,245,215,0,173,185,134,1,40,69,36,6,200,182,136,6,139,94,109,3,131,111,138,4,241,9,84,4,225,232,9,6,241,70,127,14,35,195,253,6,21,131,93,0,216,141,120,0,55,178,31,0,160,147,25,1,194,21,0,4,10,15,79,11,171,196,193,17],"created_at":1778400840859,"updated_at":1778577298962,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":79,"stem":"A 25-year-old man is brought to the emergency department after a motor vehicle accident. He has a blood pressure of 80/40 mm Hg, heart rate of 120 beats per minute, and respiratory rate of 20 per minute. On physical exam, he has a distended abdomen and tenderness in the left upper quadrant. Which of the following is the most likely cause of his shock?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"47e8cee564189d3d48ad8b9b7465d3f3033c293ec49d70d514e1429e278bcb5c","minhash":[59,24,230,0,150,252,227,0,130,108,199,0,69,84,155,4,22,242,66,6,61,103,99,2,163,33,84,1,195,200,166,0,245,116,199,7,137,21,140,4,116,31,249,0,105,248,221,0,213,149,5,19,25,240,170,1,180,4,192,1,53,110,224,1,53,205,239,0,4,196,170,1,250,98,11,7,246,243,156,2,122,49,213,4,193,55,159,2,188,203,165,0,72,141,61,7,212,56,186,1,94,173,28,0,122,46,21,3,149,222,80,2,85,220,186,11,172,162,187,1,212,236,162,0,189,178,56,5,175,225,32,2,94,113,191,3,69,44,130,11,98,186,15,6,199,188,101,2,237,166,133,4,155,125,126,0,13,5,143,3,245,181,51,0,137,210,16,4,24,17,150,3,29,248,230,3,13,126,124,6,245,96,77,4,37,167,189,0,100,29,162,5,77,241,95,1,169,202,14,13,86,220,134,2,170,198,129,0,96,130,170,1,244,35,99,0,141,9,165,29,226,157,182,2,53,179,240,1,221,192,157,7,101,155,165,2,36,79,211,8,226,63,99,0,19,97,48,7,174,250,137,3,131,39,75,5,116,234,193,2,93,23,140,8,159,217,35,7,55,61,249,0,186,210,229,1,36,186,215,0,163,39,49,5,153,245,85,3,194,48,86,4,51,88,81,4,107,148,62,10,191,204,13,13,179,239,178,5,88,186,152,2,77,56,111,2,3,65,181,0,53,207,99,3,40,230,143,1,24,101,195,0,148,83,191,1,77,57,234,3,249,13,112,2,200,138,17,0,3,119,191,14,245,17,200,0,64,17,203,7,116,204,99,0,116,151,139,2,87,161,181,0,174,185,192,1,212,64,203,6,79,56,198,9,123,24,135,5,41,86,75,1,174,35,224,1,174,252,29,13,85,196,121,3,214,188,115,2,85,154,93,7,86,39,174,2,111,85,112,4,40,199,103,0,148,180,193,3,154,121,34,6,213,78,23,0,45,15,218,4,174,90,97,1,86,93,75,3,202,161,172,6,95,243,13,0,195,185,211,20,48,45,35,14,228,32,171,1,34,209,95,0,87,26,242,0,117,114,253,8,138,232,116,8,97,169,218,8,197,195,127,5,216,178,177,1,27,16,217,1,1,80,37,1,60,34,39,6,187,247,244,1],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":80,"stem":"A 40-year-old woman sustains a burn injury to her right arm and chest. On exam, part of the burn has blistering and pain, while another part has charred skin with no pain. Which of the following best describes this burn?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"32367846daaf3568e773ef5c7111a4bb86e0b5a196d6151aef8fbb4e0cfcf539","minhash":[195,131,212,7,38,202,30,1,10,12,87,10,127,226,189,1,93,10,244,8,111,12,168,4,152,126,244,6,82,22,229,23,255,156,83,7,31,61,132,7,87,122,230,2,255,91,157,15,38,16,66,6,70,57,114,1,134,56,42,8,149,229,226,16,191,78,136,5,12,244,18,16,102,181,200,3,181,53,155,2,50,216,57,1,74,47,106,7,220,194,251,7,136,99,218,4,191,67,112,0,232,1,211,5,175,27,27,0,108,9,23,8,230,231,172,21,18,73,19,5,143,140,119,5,241,146,237,7,178,202,237,10,101,214,199,2,114,130,22,0,94,20,125,16,59,127,36,11,146,68,240,4,134,118,164,8,95,50,127,14,125,184,66,19,15,199,38,33,92,45,255,20,230,116,252,4,38,24,125,2,160,147,130,20,102,150,239,11,230,221,209,9,135,57,222,12,204,200,246,2,167,19,21,5,239,83,201,6,187,228,153,8,46,62,71,24,220,164,0,1,198,120,21,10,222,88,156,8,102,32,79,0,144,170,78,9,199,59,175,2,230,47,250,7,175,32,92,32,134,105,216,4,213,81,37,12,124,112,114,1,143,113,133,5,231,25,171,30,82,154,135,3,222,238,10,11,18,164,157,8,107,50,34,19,82,142,95,7,176,243,41,7,229,8,28,2,175,168,146,1,244,159,132,17,46,80,62,20,70,9,199,0,199,89,216,0,128,170,64,7,124,49,227,5,255,213,249,0,10,86,59,1,236,48,16,7,187,239,19,0,193,161,171,1,235,207,39,5,223,196,162,6,248,80,156,21,251,99,223,3,144,56,58,20,192,29,140,20,215,166,136,2,55,5,58,43,102,66,55,6,241,252,56,2,6,240,162,9,151,1,179,5,222,29,11,4,63,179,227,7,29,34,96,10,38,3,188,5,78,101,175,12,0,105,127,17,42,76,117,11,78,136,52,0,231,246,203,15,209,210,150,6,157,147,102,0,255,2,58,19,134,48,78,0,223,185,155,7,196,246,90,2,212,78,33,1,137,176,253,22,7,206,75,3,217,163,179,5,38,21,201,9,102,118,65,5,44,237,192,0,222,120,65,13,101,74,222,1,78,201,165,3,94,192,87,2,31,38,155,4,18,61,117,23,92,177,114,8,230,81,133,0],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":81,"stem":"A 30-year-old male smoker presents with pain and discoloration of his left foot. On physical exam, his foot is cold, and there are no palpable pulses below the popliteal artery,Which of the following is the most likely diagnosis?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"8501d291df1398518c9205596afbf66760c7d350bf34f0825146b01e79aec3dc","minhash":[243,250,36,9,164,113,203,0,149,180,214,10,248,159,76,0,43,142,81,5,33,48,90,5,43,253,49,13,31,34,135,9,91,40,15,1,236,239,104,2,200,21,30,0,24,85,54,23,57,87,234,19,199,245,162,5,92,25,99,3,91,204,53,7,122,132,173,9,90,235,63,0,68,211,67,11,209,208,63,8,21,63,39,4,161,162,92,12,95,186,185,6,81,196,170,35,104,86,24,3,33,90,241,20,179,74,183,2,175,238,219,0,91,199,103,5,115,168,202,3,26,172,112,0,251,142,194,3,28,5,15,3,90,229,8,2,231,101,100,23,51,87,68,4,251,139,150,16,203,75,224,20,119,17,93,0,44,247,108,2,83,50,197,2,24,222,232,11,192,236,55,36,125,180,174,7,12,31,214,13,116,246,231,13,245,127,251,13,123,76,103,3,27,86,242,3,225,173,32,15,133,200,29,2,55,63,62,2,218,133,93,6,244,16,3,2,67,2,104,0,44,176,27,0,233,172,246,0,194,87,244,10,227,248,213,19,249,230,250,9,151,200,15,4,91,127,247,8,138,68,73,4,90,22,19,16,76,26,107,9,194,170,252,13,154,102,183,1,155,1,55,4,168,236,57,14,152,122,19,6,195,83,163,0,88,144,10,17,72,237,163,3,106,76,91,4,186,186,118,0,120,61,99,2,101,9,110,5,218,252,159,2,55,28,90,2,141,139,31,1,247,15,133,13,243,65,129,2,243,155,60,11,152,234,231,9,165,21,25,10,166,217,18,6,26,183,19,14,44,162,200,3,57,202,23,7,75,2,194,25,63,107,1,0,127,232,122,21,107,112,178,3,66,149,104,3,44,166,209,0,35,48,48,12,102,129,105,0,43,64,238,2,67,250,168,4,91,26,51,27,32,58,212,3,1,220,145,7,136,201,13,4,227,156,188,13,181,119,142,6,76,239,94,0,192,168,165,16,87,97,164,1,219,50,20,8,80,10,75,3,34,213,118,0,87,191,188,29,75,7,232,4,139,162,249,3,103,51,73,2,23,25,14,1,153,173,124,4,250,67,223,6,71,21,207,8,58,171,38,16,57,167,61,2,143,139,177,7,105,63,148,2,155,6,55,4,98,206,125,4,203,131,73,2,183,242,218,3,143,150,32,4],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":82,"stem":"A 45-year-old woman with Graves' disease has her hyperthyroidism well-controlled with antithyroid medications. She is scheduled for total thyroidectomy. Which of the following is the most important pre-operative management step to prevent complications?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"a709e72a1db9abd17cfc1c267803f24d16a9e421ac4c02ebc31fe8b2f6822ec2","minhash":[58,190,21,0,45,251,16,12,122,37,99,12,173,103,51,11,252,177,140,14,96,197,94,0,60,213,167,0,86,126,174,5,47,63,122,1,244,193,159,27,41,233,195,19,235,5,81,9,210,232,45,2,39,159,54,12,229,76,18,0,12,199,210,11,82,0,178,0,147,111,3,6,163,82,148,25,44,112,130,8,46,107,209,10,76,252,58,3,246,139,85,16,242,112,127,23,68,13,20,2,90,124,2,14,167,14,10,1,172,92,106,15,249,40,132,17,46,225,225,5,14,9,103,3,51,210,24,4,119,177,108,13,116,49,200,10,80,157,135,6,154,186,97,7,76,50,98,12,180,10,184,7,107,164,131,23,14,116,158,5,241,175,83,25,57,234,114,4,180,226,179,9,23,57,217,5,176,96,75,0,46,193,7,0,14,121,81,1,145,152,49,7,82,124,1,3,103,210,33,14,121,239,252,5,189,62,232,4,14,19,141,1,228,83,185,3,161,12,58,8,46,205,3,2,46,99,108,2,3,145,167,27,174,211,143,0,244,112,175,5,17,17,48,14,100,50,89,3,219,168,255,5,26,208,175,5,153,195,107,8,79,183,165,7,35,23,76,15,196,42,155,3,174,215,110,2,54,21,0,1,246,31,115,20,64,110,203,2,183,12,142,0,92,201,172,11,23,17,35,12,177,21,15,1,31,121,222,16,27,148,200,21,196,84,235,10,14,76,12,4,112,16,168,0,107,178,13,0,220,163,123,2,171,214,110,0,83,192,93,1,81,17,210,5,174,107,54,2,87,227,97,8,58,197,108,3,241,81,89,2,122,92,166,1,55,49,189,5,132,196,235,41,100,236,147,0,246,41,0,2,182,26,154,0,100,166,230,0,54,126,203,4,233,228,213,8,191,250,23,0,37,110,229,13,75,83,38,6,14,1,91,5,15,124,133,15,46,3,69,20,178,6,48,4,57,18,87,6,124,8,105,2,84,212,54,3,223,66,91,0,123,167,77,1,86,124,194,0,139,57,157,10,29,168,190,1,174,3,94,10,19,32,9,18,151,161,123,14,203,88,170,3,161,182,221,6,108,40,158,1,55,83,213,10,84,87,83,12,52,3,96,3,127,71,93,7,124,201,68,8,14,14,203,5,7,133,168,1,73,58,88,4],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":83,"stem":"A 60-year-old man is admitted with acute pancreatitis. He has a history of alcohol abuse and is currently confused and disoriented. His vital signs are stable, but he has a GCS of 13. Which of the following is the most appropriate initial management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"f11b73b4a5f1accdb3845591d10398de62b9bfdd2a2343ee9923f28ee0a5be2e","minhash":[20,119,9,4,189,71,3,1,163,35,190,4,131,171,68,0,167,241,183,14,203,216,108,1,46,61,144,2,132,118,55,7,211,95,195,1,221,22,10,3,95,85,108,3,169,222,47,3,79,45,158,9,240,235,56,8,1,128,197,4,161,194,8,12,20,140,51,0,11,206,225,10,75,93,138,2,173,77,246,4,123,210,147,0,57,102,16,12,123,47,107,4,137,95,66,4,181,126,48,1,33,200,211,12,52,42,44,19,88,140,33,8,47,226,160,0,184,165,221,7,233,34,105,1,127,228,247,0,143,110,9,10,31,141,192,3,97,83,31,3,213,103,194,6,21,41,155,14,129,20,93,1,37,143,69,0,43,47,172,4,87,145,38,19,249,53,175,0,249,138,121,0,232,80,15,1,232,101,61,0,28,88,42,7,204,131,164,2,46,227,47,4,27,98,117,7,157,103,255,9,193,201,45,4,83,174,0,7,21,35,218,4,1,215,29,15,73,4,67,0,77,62,27,7,153,247,150,0,60,140,117,1,222,11,25,0,159,86,140,1,64,73,249,2,229,98,73,20,191,10,150,2,55,127,235,2,57,129,139,6,69,196,25,0,97,4,157,4,177,133,92,0,204,52,75,3,57,86,51,4,3,192,147,6,132,42,18,7,197,179,72,8,60,93,140,3,95,163,61,3,105,91,191,3,119,71,93,14,28,26,121,9,72,54,187,0,161,204,181,0,20,224,0,3,167,194,139,2,252,246,153,5,173,127,44,4,21,132,247,6,207,136,102,7,56,218,34,2,73,80,92,3,215,103,148,3,153,138,105,0,52,190,236,0,194,209,142,11,67,253,147,7,28,59,254,9,67,210,5,1,17,230,173,1,21,49,98,4,25,159,64,5,173,87,199,2,41,13,218,7,216,81,94,2,89,24,182,12,35,133,151,7,66,230,178,3,197,164,131,8,248,175,211,2,199,85,126,1,207,119,58,3,79,50,43,12,67,49,123,20,32,195,193,7,245,26,234,1,34,215,137,1,159,6,237,12,45,12,86,4,100,19,113,2,104,47,23,18,7,229,237,1,40,182,156,9,40,161,194,11,239,40,163,4,87,102,4,2,44,46,140,1,195,2,93,10,64,133,140,0,157,48,16,3,129,249,90,0,137,220,203,19],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":84,"stem":"A 22-year-old man is involved in a motorcycle accident and presents with left upper quadrant pain and tenderness. His initial blood pressure is 90/50 mm Hg, and heart rate is 120 beats per minute. After fluid resuscitation, his blood pressure is 110/70 mm Hg, and heart rate is 90 beats per minute. CT scan shows a grade III splenic laceration with moderate hemoperitoneum. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"496c544875e1d3eb5f5a5c1ae413d039b7b6fbe4c20c3ede52c7f3f965f5f8f7","minhash":[50,142,10,7,116,230,63,10,45,89,146,0,20,146,151,1,227,52,48,5,145,1,173,6,114,245,158,2,11,203,125,3,93,199,125,5,59,141,132,1,116,243,68,4,105,248,221,0,158,113,58,4,238,64,137,1,13,214,1,8,29,1,218,7,53,205,239,0,227,16,44,2,33,207,103,0,127,131,184,2,178,135,44,3,109,133,2,3,141,109,230,0,27,1,82,10,119,150,31,1,244,181,134,0,26,207,113,15,149,99,186,5,49,178,18,2,211,103,118,16,238,208,209,7,16,137,159,16,100,41,66,0,228,56,216,15,67,138,111,2,216,248,24,3,98,127,79,10,123,195,13,7,21,250,65,4,52,61,59,3,245,181,51,0,158,7,112,2,138,106,35,1,50,229,55,11,27,13,174,1,165,161,20,6,34,119,30,0,132,169,44,0,124,135,248,3,89,129,161,15,149,204,51,1,236,150,228,3,125,211,208,2,253,93,154,1,89,102,238,4,2,211,122,0,238,240,69,0,244,223,222,3,158,116,151,20,216,28,185,2,35,170,203,5,56,110,74,0,19,118,100,7,179,13,213,2,157,6,53,1,27,169,59,8,30,140,18,11,88,246,11,9,238,176,51,0,176,154,239,4,51,32,117,5,152,207,56,0,252,88,171,9,31,226,31,1,251,36,108,4,82,9,229,21,177,233,247,2,140,68,65,2,114,196,42,6,205,165,195,2,100,176,166,1,89,110,214,13,33,249,122,12,127,177,84,5,163,162,111,0,198,0,201,0,34,238,86,2,178,59,186,13,136,5,152,4,244,9,249,3,116,204,99,0,157,224,234,0,65,75,195,3,238,64,178,14,168,232,9,10,80,31,126,0,34,140,64,3,255,159,220,2,210,12,112,7,30,81,75,3,178,113,175,8,30,238,143,12,30,102,119,6,141,56,78,8,29,23,148,15,212,228,255,8,242,216,52,8,30,37,28,11,255,193,114,3,237,102,113,9,161,118,167,2,70,225,19,0,93,8,141,1,114,212,130,4,162,188,198,13,93,231,9,4,125,114,9,5,130,32,86,5,119,177,100,11,117,114,253,8,93,138,146,6,75,138,71,0,28,177,230,0,238,160,138,4,90,252,65,3,153,205,246,5,171,139,108,3,210,230,94,11],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":85,"stem":"A 40-year-old woman presents with right upper quadrant pain, fever, and jaundice. Ultrasound shows gallstones and a dilated common bile duct. Her WBC count is 15,000/mm³, and she has a positive Murphy's sign. Which of the following is the most appropriate initial management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"74249ce7576cc9f3f46b295baf04a59b09b899b921b7c09107fe86580d009971","minhash":[147,245,70,15,143,61,117,3,167,156,206,1,160,53,182,3,214,183,237,16,150,141,170,2,126,154,241,1,126,211,224,0,218,20,64,3,51,201,94,2,234,207,13,5,55,249,43,1,53,248,15,3,175,233,103,2,86,114,97,4,10,12,46,4,66,126,114,2,135,204,92,10,64,248,53,3,196,218,207,3,32,1,149,0,175,81,211,2,160,137,32,4,95,37,72,2,128,196,115,6,75,90,183,0,180,236,165,6,181,238,222,0,228,227,190,0,212,52,77,0,254,237,4,0,195,204,59,17,56,135,85,1,250,105,133,1,224,36,160,2,59,129,61,11,68,247,164,10,128,136,131,0,7,49,74,3,215,124,116,1,173,169,236,27,15,156,220,0,103,59,182,13,251,231,124,8,84,63,229,6,39,6,29,1,136,61,246,10,108,72,128,1,148,64,2,2,150,78,142,1,216,125,248,12,86,16,238,13,23,43,189,23,128,135,246,1,86,48,149,4,24,246,72,6,175,9,186,0,12,157,245,13,24,137,137,0,58,16,16,23,214,236,41,5,128,201,127,11,138,22,99,4,11,3,63,5,183,222,235,0,150,141,193,1,86,113,76,1,196,129,43,4,245,145,252,2,208,146,114,6,126,122,69,4,173,49,116,7,251,231,48,5,150,243,198,11,234,23,79,9,63,69,80,1,215,89,71,8,108,152,143,2,199,40,30,7,31,189,37,2,126,109,54,0,229,153,249,3,86,114,154,7,191,44,12,9,42,37,122,14,239,33,19,4,88,146,147,14,4,230,50,0,248,243,39,7,44,7,191,1,103,22,56,0,191,16,166,3,143,29,138,8,150,239,179,7,217,139,131,8,225,188,95,7,214,244,203,8,59,24,65,7,167,249,243,8,136,246,36,1,74,197,39,1,162,105,83,0,0,155,164,9,120,64,36,0,214,106,232,16,199,197,163,10,36,179,249,12,22,161,115,6,126,159,175,7,244,227,154,3,244,130,216,4,243,200,2,7,92,30,39,1,150,97,162,4,249,7,199,9,175,10,21,1,115,191,181,3,207,86,171,0,71,55,114,2,236,168,233,0,247,71,58,8,113,233,36,1,86,155,105,9,138,153,3,4,28,255,7,5,76,111,20,1,93,244,209,9,115,106,214,8],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":86,"stem":"A 50-year-old man presents with severe abdominal pain, nausea, and vomiting. His serum amylase is elevated, and CT scan shows pancreatic edema and peripancreatic fluid collections. He has been taking hydrochlorothiazide for hypertension. Which of the following is the most likely cause of his pancreatitis?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"7a5354dbf7de160889c1f7485c1c698c8413a6430a7b81b149ea8ab9bae93bf5","minhash":[22,17,54,3,78,118,132,8,193,129,9,7,209,115,177,43,161,149,11,9,42,205,249,2,173,174,62,3,216,35,246,10,10,127,133,11,201,45,13,12,180,16,227,0,48,250,49,16,161,30,10,8,244,82,69,1,161,143,129,1,177,125,170,1,253,13,105,4,73,143,3,4,73,197,78,3,175,132,123,4,117,178,112,0,169,14,229,15,225,172,214,5,37,61,134,19,129,92,115,2,137,214,235,25,47,20,198,3,164,117,223,10,78,77,78,9,68,154,177,9,136,162,180,3,121,162,52,0,148,4,107,2,170,132,83,9,87,51,191,1,111,19,1,0,149,221,192,1,100,43,125,8,78,171,88,4,41,177,37,8,12,48,27,0,93,48,18,0,78,235,102,0,205,111,36,12,20,111,138,21,248,255,53,0,232,113,177,8,27,222,175,1,59,58,221,1,193,245,187,2,168,44,158,18,135,148,83,19,153,201,51,17,120,97,162,8,5,114,28,2,78,228,29,3,164,219,246,4,73,73,226,0,200,41,126,21,17,217,87,1,91,52,146,0,197,64,217,7,202,95,169,2,85,129,1,4,213,77,47,0,184,87,10,2,150,102,191,2,78,76,217,9,223,63,219,14,240,58,69,4,202,48,183,6,78,64,76,4,185,17,236,2,112,172,46,7,1,109,116,7,80,48,184,6,161,8,121,2,78,30,67,1,84,144,147,34,68,205,113,9,148,131,46,24,48,92,217,9,215,57,94,10,81,8,111,13,138,208,59,7,171,225,9,3,32,119,22,11,169,236,76,0,147,199,158,9,78,146,164,1,197,19,85,37,73,70,1,4,33,99,61,4,153,56,233,0,136,78,97,10,80,81,139,15,121,191,245,1,63,101,189,0,239,239,100,13,212,212,81,8,157,149,76,9,95,153,241,0,233,224,252,7,106,237,100,6,123,21,65,14,78,10,131,30,17,175,48,6,205,97,137,10,40,19,214,36,48,120,68,28,108,30,22,20,106,134,182,13,65,110,46,20,255,111,79,9,32,255,137,5,78,188,85,4,95,10,127,12,247,40,29,2,227,210,134,6,196,221,94,24,78,25,84,6,112,65,177,2,78,143,74,4,152,41,72,1,237,240,43,8,164,179,28,5,41,63,110,10,240,56,186,15],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":87,"stem":"A 60-year-old man presents with sudden onset of severe abdominal pain, rigidity, and hypotension. He has a history of peptic ulcer disease. Upright chest X-ray shows free air under the diaphragm. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"0a6888d6bdee1cd79778518b7a42d195155c21af338c4aa5ae84a66809f38242","minhash":[26,182,125,8,58,26,117,11,58,81,5,7,30,188,70,4,38,185,164,0,102,238,89,2,136,52,220,10,104,54,42,0,43,64,11,1,18,176,185,17,17,51,168,6,210,85,148,9,152,145,186,4,208,37,21,4,177,201,83,9,181,125,181,6,12,123,52,3,73,58,15,1,66,152,77,5,213,41,189,0,116,196,208,5,42,18,117,0,219,59,52,3,248,95,103,1,10,140,219,23,19,170,153,2,56,227,157,0,21,158,209,12,107,153,8,2,146,133,93,5,94,226,65,2,250,222,117,8,130,163,149,0,213,69,21,0,184,60,250,6,233,219,134,4,129,154,169,4,105,154,62,3,240,232,75,6,185,160,226,6,45,138,128,15,26,104,196,3,158,223,176,1,70,139,50,9,138,118,220,10,34,40,162,0,248,102,221,0,176,137,41,15,27,102,100,8,193,245,187,2,48,182,44,1,112,23,244,4,40,127,32,3,28,144,58,1,194,173,58,5,30,30,161,27,194,136,79,12,162,172,244,3,113,253,186,3,195,64,9,5,154,55,41,2,9,50,38,1,129,250,2,4,30,178,251,15,225,206,2,8,57,207,22,4,252,155,85,3,101,34,167,2,161,2,204,10,227,108,125,1,82,201,243,0,119,44,206,2,134,250,77,5,114,42,10,2,111,16,192,2,145,171,125,6,235,193,237,0,154,106,119,4,79,137,176,2,222,92,91,19,75,143,32,1,73,52,67,0,210,31,58,16,209,200,94,6,50,144,157,3,222,175,79,15,2,6,188,0,32,80,189,2,180,53,78,2,162,152,194,1,166,194,93,1,142,231,148,33,252,106,175,1,236,126,87,6,242,118,94,0,218,65,221,7,18,92,67,1,44,193,149,12,74,191,29,0,230,117,253,3,16,101,136,5,229,13,89,16,141,71,157,2,226,41,183,4,83,15,172,6,0,4,44,2,139,83,126,0,135,122,18,13,134,39,221,20,236,119,144,3,94,138,65,15,232,237,170,3,250,43,177,1,102,113,133,7,210,155,64,0,122,147,25,1,76,163,104,9,99,121,198,2,13,183,234,5,245,252,114,1,219,46,144,3,170,26,82,3,84,241,254,1,234,166,181,2,107,238,86,2,156,20,186,0,236,255,94,15,160,229,243,14],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":88,"stem":"A 55-year-old woman presents with left lower quadrant pain, fever, and leukocytosis. CT scan shows sigmoid colon diverticulitis with a 5 cm pericolonic abscesses. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"a274665a312d58f344ebacf5551454aff5f3cef0c970ab677c04a3f110a75da5","minhash":[136,176,15,14,83,229,169,0,91,187,93,14,181,30,116,18,136,228,63,7,211,213,95,12,91,116,34,1,255,27,124,4,75,248,32,13,208,207,248,14,151,57,33,5,79,253,33,19,91,180,23,13,207,117,56,4,119,117,177,1,90,17,47,6,63,86,121,1,154,250,68,5,87,125,26,32,36,148,118,3,140,117,131,7,167,188,43,11,199,51,49,1,134,201,13,8,156,217,139,18,156,192,65,10,104,209,213,9,216,242,24,5,107,23,239,13,216,21,79,15,148,61,134,4,115,165,26,1,183,126,144,4,108,202,112,1,6,167,69,5,243,165,85,1,183,154,254,41,227,71,16,10,7,49,74,3,183,2,26,1,204,64,36,15,3,122,73,9,236,248,108,5,216,133,46,7,10,139,65,22,132,68,234,2,104,104,74,1,35,129,248,3,56,235,103,2,42,90,208,7,191,45,42,3,248,190,113,13,198,70,198,9,51,48,131,25,230,25,117,1,127,190,35,7,123,117,130,8,223,136,195,0,239,194,9,3,7,210,231,15,8,187,44,0,132,209,197,0,40,130,47,5,51,76,235,0,73,34,100,8,71,47,175,4,156,159,152,5,100,143,9,5,221,145,77,7,163,8,91,5,203,217,33,4,184,110,87,6,138,182,75,17,4,87,29,8,111,16,192,2,53,144,173,10,151,195,66,1,177,126,96,6,244,7,74,2,55,252,39,1,40,246,208,8,199,134,18,0,123,124,35,1,134,68,151,6,171,142,190,4,241,11,20,19,235,226,100,6,4,29,93,12,32,154,74,3,68,85,122,17,8,154,16,3,207,142,116,4,123,205,181,8,120,227,102,7,135,249,8,19,36,174,198,9,27,8,25,7,40,215,100,5,232,42,57,5,60,118,139,5,71,179,189,6,92,129,206,15,107,192,0,3,167,244,42,6,151,180,0,0,3,160,98,2,188,57,110,6,127,211,14,4,29,137,203,6,177,19,107,3,231,4,43,7,36,203,201,13,207,44,205,17,199,117,199,1,152,52,17,0,63,81,36,7,232,102,132,15,143,28,135,2,155,82,125,3,24,204,139,11,168,229,207,0,103,142,56,6,103,84,125,11,239,16,182,0,220,47,117,6,69,229,43,1,104,207,7,1,228,59,170,10],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":89,"stem":"A 65-year-old man is diagnosed with a 3 cm adenocarcinoma in the sigmoid colon. The tumor is invading through the muscularis propria into the serosa, and there are no positive lymph nodes or distant metastases. Which of the following is the most appropriate stage and treatment?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"74723b6b71002d3daa512825caf8ca4ecfa67420ff4033f41fd14ec7f0be6c4d","minhash":[116,144,239,1,203,218,234,0,123,46,88,6,41,86,175,14,147,148,84,3,68,184,88,9,139,220,68,15,80,161,48,13,203,198,47,0,36,114,218,16,170,110,250,5,36,66,244,28,135,57,55,2,106,98,155,1,236,21,31,4,78,139,216,7,206,202,129,10,246,42,184,6,182,207,155,4,175,217,106,11,21,239,183,11,9,54,153,2,10,141,5,3,83,173,137,1,39,35,194,13,92,247,51,6,23,37,43,4,168,96,50,1,152,0,143,0,99,123,105,19,226,139,144,7,46,211,104,1,2,208,43,1,191,40,71,23,206,188,4,0,57,153,23,2,192,231,108,10,46,220,28,2,51,165,57,3,107,68,166,19,106,158,145,5,175,253,133,26,184,74,47,3,187,156,250,12,1,90,149,19,106,198,116,0,182,56,151,8,3,204,146,2,191,42,78,27,242,116,78,0,113,122,151,20,68,195,136,8,159,5,238,9,251,168,94,8,120,90,84,0,104,113,15,1,194,51,12,11,36,105,44,3,123,58,190,2,154,251,243,6,82,174,28,19,107,221,50,0,32,27,76,6,246,203,79,2,74,52,81,9,233,211,89,30,241,252,150,9,45,72,53,9,34,146,97,3,114,30,230,5,250,177,195,10,15,7,91,1,206,194,240,6,41,115,156,11,251,47,18,4,196,38,156,4,14,18,74,1,118,48,215,10,39,69,229,1,206,117,25,9,139,131,46,11,87,31,236,2,134,197,195,0,40,103,115,0,234,103,204,2,118,30,254,2,165,149,17,2,43,181,127,6,216,247,111,1,90,190,55,4,177,56,158,5,135,154,162,0,67,54,182,4,75,54,195,0,79,136,83,2,188,64,24,1,11,225,243,0,72,167,128,3,203,146,0,0,57,115,16,7,46,241,74,7,159,104,217,0,38,231,153,4,198,108,179,5,14,182,155,1,200,162,127,4,49,91,92,0,115,252,95,1,34,41,204,6,143,138,1,12,243,31,80,1,27,8,185,2,106,175,111,1,111,53,234,0,134,109,91,14,168,104,74,3,78,248,64,13,8,237,119,0,54,223,188,13,205,58,234,3,127,218,236,15,11,220,226,4,78,246,60,4,162,3,127,0,171,202,171,3,8,87,37,1,248,209,15,9,226,209,106,15],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":90,"stem":"A 40-year-old woman has a pigmented lesion on her arm that has been growing and changing shape over the past few months. Biopsy shows melanoma with a Breslow thickness of 2.5 mm. There are no palpable lymph nodes. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"1b7dc61faa5c21b0fb7adb700cafa0aad6d27cd2ffe1522394343816f364bdc0","minhash":[116,31,3,4,109,207,216,3,40,25,242,7,211,54,201,4,207,21,3,3,113,154,54,0,13,100,133,2,186,15,153,2,156,213,172,7,136,177,2,3,230,99,212,5,225,222,50,11,17,41,59,2,68,26,52,0,104,169,35,18,74,163,100,0,1,54,54,8,249,184,176,3,243,146,122,6,49,165,117,1,136,150,171,5,68,124,141,3,54,252,182,2,148,175,95,13,241,225,75,4,79,170,106,2,165,233,79,10,241,253,241,15,99,22,250,3,28,32,159,2,54,154,49,1,86,132,94,1,85,169,11,6,199,123,163,3,1,214,78,12,214,113,14,8,204,19,83,9,86,3,234,3,154,87,58,23,91,96,238,3,133,222,100,11,113,217,189,5,183,205,126,1,187,57,218,4,8,215,121,6,68,244,179,4,137,55,115,3,215,133,134,6,111,131,132,1,125,154,182,3,95,136,30,3,114,180,90,3,242,25,127,1,82,50,221,7,140,108,83,5,193,199,86,2,21,103,251,1,5,199,13,5,230,207,68,7,137,201,33,0,102,136,51,19,14,224,11,5,197,210,68,1,197,127,138,6,73,61,34,5,8,205,218,6,172,95,33,4,55,163,201,0,101,19,154,4,11,203,114,3,130,4,168,1,40,214,125,0,17,0,4,5,4,87,88,14,159,253,67,2,5,29,118,0,206,78,144,0,72,13,166,6,154,136,122,3,20,161,71,2,172,86,191,10,213,110,88,6,24,208,35,6,83,206,64,1,90,240,79,14,13,151,200,6,150,222,98,0,206,229,104,3,56,116,116,22,31,127,61,5,230,23,151,8,112,112,141,7,22,255,26,2,65,52,93,7,59,157,253,0,9,177,15,0,63,64,206,1,180,155,13,13,26,185,146,1,105,230,9,15,103,110,9,3,183,179,225,3,125,15,239,1,186,75,81,3,71,100,139,4,40,42,19,5,159,228,40,0,189,86,197,3,241,61,80,2,165,246,118,2,63,147,97,1,86,160,37,7,191,115,77,4,56,58,20,0,42,214,44,7,8,112,245,0,194,239,73,5,241,163,69,2,193,227,176,1,173,185,119,5,60,132,64,8,136,187,31,4,248,65,131,2,137,3,32,3,90,81,63,4,60,7,115,0,131,231,217,1,155,178,148,8],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":91,"stem":"A 55-year-old man has persistent heartburn and regurgitation despite maximal medical therapy with proton pump inhibitors. He has a hiatal hernia with reflux on barium swallow. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"6cf20b2cfdf155531a6a8dc7c4488d90443abbe30b4039cdf97c28900968a61c","minhash":[33,163,156,3,45,199,189,1,49,50,116,6,248,86,153,4,28,68,26,11,108,248,180,0,26,224,233,11,38,200,11,1,12,247,70,1,33,50,77,7,193,196,67,1,58,108,157,10,76,169,159,8,220,200,39,7,9,28,80,7,207,157,14,3,40,239,171,3,28,29,87,7,124,23,166,0,124,59,199,14,204,5,82,21,145,237,113,6,142,102,207,0,93,93,132,4,142,140,44,3,48,113,72,9,194,23,165,3,249,34,84,2,73,82,220,13,98,140,239,1,52,88,147,0,34,29,6,4,220,29,87,4,142,11,9,2,116,149,212,2,61,38,122,26,137,189,25,3,129,12,197,12,118,106,194,2,38,80,57,11,236,193,190,1,41,67,96,2,113,128,183,10,188,39,243,13,201,184,34,9,100,167,39,36,9,73,144,1,28,209,171,4,225,113,80,7,105,89,113,0,200,218,242,1,56,117,47,6,40,51,178,22,73,108,124,23,61,35,13,3,89,51,176,2,12,162,74,20,166,96,2,8,149,61,203,32,125,133,237,2,142,216,105,0,122,245,181,7,129,157,193,1,38,182,111,15,81,29,180,3,152,145,52,0,153,92,134,2,233,35,92,10,128,91,130,9,137,94,26,0,55,102,145,4,156,66,250,3,2,135,207,1,33,252,191,4,72,187,210,11,186,154,47,8,142,136,20,1,100,97,151,2,76,164,117,13,140,92,204,4,201,25,36,0,25,19,227,5,149,247,233,0,4,171,47,2,113,146,105,10,236,68,181,27,109,187,148,0,184,210,44,21,39,164,20,17,237,75,250,4,177,44,232,4,253,29,140,12,7,106,255,13,137,96,43,3,81,160,107,29,153,11,6,4,33,66,133,5,245,173,164,0,180,29,253,0,4,152,66,4,246,210,76,2,122,30,213,1,33,183,221,12,184,181,23,7,241,20,17,2,53,2,149,0,113,10,212,13,253,146,172,4,64,122,163,12,252,169,88,1,45,194,98,4,144,170,243,8,5,207,28,1,226,151,182,3,77,9,242,5,249,86,204,8,71,137,224,8,156,216,43,0,189,75,4,0,132,198,28,7,125,33,213,11,45,74,122,9,221,160,220,3,186,56,77,12,109,116,103,4,65,210,171,6,81,52,119,0,60,146,169,6],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":92,"stem":"A 70-year-old man is found to have a 5 cm abdominal aorticaneurysm on routine screening ultrasound. He has hypertension and hyperlipidemia but no symptoms related to the AAA. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"1b2937ec1c57ef4ec03240ff9ecfbc09a8a463cf61f367b5e05a1e81c8f3ad87","minhash":[254,111,21,14,66,124,190,5,84,62,90,4,128,123,142,11,97,55,71,1,4,199,141,0,6,87,248,0,240,131,187,2,241,31,245,7,79,10,9,0,163,217,223,1,100,16,107,0,158,210,142,3,100,141,111,4,20,114,68,19,112,167,51,7,141,237,236,1,77,150,48,3,103,209,236,0,215,103,127,4,104,102,82,7,139,69,101,9,241,133,166,2,17,204,126,3,115,106,163,7,141,4,167,4,175,7,240,0,46,245,90,3,105,213,13,17,4,246,29,19,136,72,96,2,130,65,221,7,165,51,178,32,245,186,212,3,209,217,111,2,226,81,30,15,158,110,52,2,194,105,37,3,199,50,121,4,84,53,219,7,46,115,204,25,186,64,21,2,158,125,233,1,197,76,5,11,158,189,221,1,203,69,13,3,148,252,136,6,4,236,136,2,129,110,249,1,30,232,149,20,91,48,17,1,48,75,134,1,30,135,236,3,132,89,127,5,198,186,150,4,55,147,48,10,240,194,185,2,247,130,170,3,221,197,206,1,191,4,104,11,211,213,59,11,29,216,239,9,49,20,30,5,30,96,98,0,13,107,127,0,198,129,235,0,218,248,72,8,87,134,253,1,147,218,123,2,96,46,21,2,159,190,171,1,164,245,178,4,40,26,138,6,30,161,62,1,93,226,172,5,210,176,253,6,221,37,127,0,100,1,253,1,177,86,149,7,164,39,168,3,158,108,224,7,103,103,22,2,114,103,47,3,70,88,130,24,69,185,226,0,180,228,66,9,200,148,209,1,57,207,34,14,178,102,240,0,216,34,117,1,39,95,233,23,100,65,85,9,176,154,250,6,175,198,51,1,20,251,82,4,195,152,191,2,127,73,130,0,171,237,220,15,83,31,92,2,35,13,155,0,185,232,185,1,211,9,52,1,33,145,222,12,64,201,129,3,104,198,226,3,208,165,59,9,167,142,71,18,89,77,237,1,5,70,237,3,158,215,57,1,223,161,87,6,184,23,201,11,254,247,119,19,43,35,68,3,157,33,104,12,113,138,139,2,19,39,41,7,158,139,199,1,20,123,217,1,98,93,192,10,113,97,215,5,152,92,113,9,175,182,132,9,199,255,254,8,116,183,50,18,41,205,153,4,192,106,120,3,195,75,168,14],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":93,"stem":"A 65-year-old man with diabetes and smoking history presents with rest pain and a non-healing ulcer on his left foot. His ABI is 0.4. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"eae15015d89ca76963717fd487b60aa1e45d1c9624a99a7ddef7d9e74c51d7a7","minhash":[189,36,152,7,37,142,128,2,44,156,135,1,214,174,211,9,114,78,211,6,126,186,223,2,116,2,198,6,156,41,143,8,140,20,52,0,192,1,241,10,128,99,169,0,245,128,203,2,204,150,132,34,119,71,184,13,68,241,154,14,245,151,206,23,32,228,42,0,59,68,195,2,77,31,121,18,236,95,3,8,36,61,27,0,232,73,83,5,9,238,3,12,214,85,217,1,242,127,10,13,197,187,220,15,160,76,114,2,214,176,95,12,147,17,164,10,16,18,150,1,92,246,187,7,28,251,248,8,160,119,43,18,138,93,76,14,233,224,225,1,112,79,143,17,212,164,237,0,27,51,197,1,88,141,47,28,32,67,140,1,192,238,26,1,144,172,82,4,51,172,46,1,112,174,60,0,96,166,255,3,192,99,11,3,195,133,117,9,169,237,54,2,25,27,65,4,86,41,163,3,128,229,160,2,228,74,34,0,159,177,171,7,64,163,197,1,26,187,230,6,58,187,216,18,124,135,79,7,188,9,194,3,193,197,190,24,42,115,122,2,52,141,142,2,106,143,13,0,97,214,67,2,28,125,99,1,155,248,11,3,208,121,76,8,32,250,37,0,108,187,18,7,16,247,240,2,37,155,186,1,50,18,33,0,144,246,92,6,217,160,220,10,232,229,163,1,180,43,154,1,236,215,90,5,128,204,36,31,12,184,36,5,64,111,47,5,164,153,212,4,120,114,87,3,59,122,160,0,243,131,17,1,92,2,28,0,81,1,53,2,64,97,18,7,196,131,104,0,48,138,221,10,125,169,62,6,19,101,112,0,141,251,203,1,195,24,37,0,44,70,83,10,210,119,114,16,0,66,66,11,112,136,46,9,150,93,170,8,80,72,98,0,163,84,219,3,48,62,227,16,198,208,23,29,10,214,97,2,211,73,8,6,112,67,167,2,90,106,66,7,116,52,170,0,13,128,172,12,141,145,204,11,120,249,108,1,250,6,115,6,48,122,141,3,240,134,205,23,252,26,202,0,68,48,21,9,243,118,48,2,164,76,36,16,160,65,214,0,210,68,12,2,109,117,255,4,156,112,241,0,127,6,25,1,0,99,105,0,4,249,18,9,224,61,166,5,60,163,233,7,10,137,110,22,5,254,6,8,117,83,151,2],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":94,"stem":"A 45-year-old woman has a 2 cm thyroid nodule. Fine needle aspiration (FNA) shows follicular neoplasm. Which of the following is the most appropriate next step?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"ae1b071d32494232c393dd2e97f10e542173e9e95e65ab309c9524a790b701b5","minhash":[118,133,135,4,61,107,143,5,63,55,151,6,197,50,190,3,47,41,95,3,82,27,182,14,3,78,191,4,199,64,51,8,42,30,151,4,194,212,181,1,119,50,17,2,131,193,221,1,245,3,178,3,84,62,189,4,43,235,193,5,37,165,106,12,94,53,166,8,213,234,109,15,69,163,101,4,151,177,229,10,82,120,77,11,117,65,120,1,58,1,86,4,71,72,164,13,85,30,242,1,231,10,19,4,106,168,18,8,133,171,121,13,38,13,159,11,191,122,170,9,94,132,248,9,164,24,63,1,149,30,43,7,68,197,241,1,37,175,253,24,54,60,25,14,244,227,148,10,181,250,192,11,234,157,177,1,116,243,63,13,226,1,185,8,117,197,16,3,162,214,133,23,91,129,210,1,149,47,169,41,178,206,155,12,20,164,115,5,47,220,75,0,109,4,116,6,21,7,251,3,118,19,14,14,229,81,250,16,196,70,194,3,27,139,156,19,159,48,236,1,197,212,30,8,71,5,112,9,149,42,103,1,15,85,222,3,54,118,201,1,205,225,114,11,222,53,206,1,18,113,25,20,18,246,198,1,223,156,43,36,54,130,38,23,118,47,155,8,195,146,80,0,13,132,28,1,102,220,59,2,151,91,181,10,13,195,2,5,4,71,184,17,103,161,206,0,157,206,180,7,101,111,151,1,99,132,202,1,63,77,190,12,166,173,121,0,183,93,193,3,122,163,199,10,231,88,78,0,36,90,26,8,130,234,198,1,187,71,18,1,213,34,85,14,29,63,144,2,230,88,57,12,173,119,187,1,21,41,30,22,247,182,123,2,207,46,14,6,118,54,197,2,66,228,48,8,215,198,118,14,99,197,127,1,77,153,65,20,50,92,97,53,186,224,203,5,101,227,19,9,111,196,150,16,253,182,40,0,94,104,192,1,54,155,79,17,94,97,92,2,222,155,175,27,106,130,191,2,100,6,185,44,82,173,250,4,63,45,131,8,31,79,135,13,18,176,16,6,210,180,127,0,54,246,183,3,55,171,178,5,242,45,37,9,167,85,158,6,215,233,231,11,235,34,31,2,239,43,29,5,210,83,22,2,223,86,34,11,227,106,78,26,37,36,22,2,77,141,47,12,117,73,179,18,151,66,202,3,247,115,51,8],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":95,"stem":"A 55-year-old woman has elevated serum calcium and parathyroid hormone levels. Ultrasound shows a single enlarged parathyroid gland. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"2a83ac59dfdb2b8733ca5761a0ed337647504c3abacaeaaa1c652f8a87cda91a","minhash":[88,84,248,26,211,148,79,2,125,171,17,21,7,6,37,2,156,196,13,3,217,57,97,0,140,70,184,3,91,33,99,22,57,197,181,11,163,36,221,7,167,149,105,14,218,7,34,8,68,186,128,1,116,139,145,11,29,173,105,7,105,192,135,23,113,138,185,5,72,197,171,6,75,78,33,4,135,205,23,4,117,223,154,8,29,112,7,7,148,19,51,8,148,113,233,6,138,197,98,1,143,13,68,15,154,229,17,2,238,53,175,2,90,44,229,4,136,237,167,1,114,101,136,11,192,13,10,13,164,244,67,9,203,238,214,3,84,31,163,3,220,195,184,2,218,155,32,5,170,113,153,5,154,158,217,3,252,27,229,0,218,135,158,11,121,78,18,1,196,181,155,5,218,251,41,10,205,134,192,6,122,184,65,8,41,100,60,4,124,148,4,1,45,0,216,6,205,160,211,1,61,223,255,5,204,253,209,6,12,21,124,0,238,69,209,13,93,108,129,1,103,108,160,6,172,49,173,8,253,75,159,2,67,152,140,8,60,213,169,1,123,204,58,5,179,225,91,1,251,215,55,9,140,96,177,4,109,50,191,3,79,102,53,1,165,121,49,12,141,167,5,11,53,207,49,3,67,90,13,4,197,65,37,4,5,198,231,5,55,171,143,3,60,103,152,3,204,84,178,0,88,112,138,10,236,120,152,2,181,236,170,6,135,221,223,6,173,122,68,2,136,234,137,13,21,149,186,8,232,2,176,4,135,107,66,11,215,74,156,1,175,4,27,3,16,45,171,5,103,155,251,0,31,38,109,9,11,218,119,4,154,205,160,4,141,242,164,18,72,76,146,4,179,4,208,25,228,43,73,0,155,51,211,2,255,251,147,2,248,199,137,2,202,128,66,4,195,2,144,0,228,191,235,5,119,17,114,0,140,92,173,7,125,241,74,2,90,226,91,2,32,92,109,5,208,49,25,0,180,4,210,8,236,10,117,4,245,77,205,0,135,220,213,8,164,160,38,19,50,143,167,7,180,50,209,4,124,210,74,9,81,207,70,17,181,144,165,0,179,117,156,4,238,205,207,11,115,11,229,26,183,49,107,1,11,37,72,9,232,107,139,27,92,201,92,1,5,252,210,4,97,10,187,2,144,206,138,3,58,224,217,1],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":96,"stem":"A 35-year-old man presents with hypertension, palpitations, and sweating. Biochemical testing confirms elevated catecholamine levels, and CT scan shows a left adrenal mass. Which of the following is the most appropriate management before surgical resection?","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"e215bab629623e8d65e4a2fc8d1094d703a3891f1155d8ed35a63976b4930196","minhash":[17,155,239,6,3,192,163,6,178,6,153,2,183,121,108,9,221,227,10,5,87,163,203,0,173,218,85,12,172,89,104,3,222,8,11,2,237,216,102,5,178,13,245,6,107,186,0,0,11,199,196,4,7,28,152,2,224,201,228,2,87,171,142,24,19,215,122,19,175,236,215,3,148,68,167,13,201,255,163,7,43,128,101,10,25,98,237,12,45,111,79,14,93,240,250,3,143,166,111,5,204,142,147,17,7,179,46,8,235,223,100,0,235,94,201,22,68,193,113,0,231,80,196,12,121,135,212,3,17,96,127,4,71,216,40,4,123,187,189,4,214,138,224,2,54,183,29,26,88,210,105,1,57,81,193,14,9,91,215,0,15,227,100,9,89,213,250,0,255,37,43,2,208,166,212,3,163,148,39,10,210,181,162,7,239,238,40,4,99,212,229,3,49,223,144,5,193,245,187,2,207,255,102,4,108,170,17,0,222,46,138,10,135,69,171,5,185,207,20,2,23,178,169,7,124,143,88,3,135,99,201,12,203,209,187,0,125,184,239,9,51,155,33,1,244,90,186,1,173,195,39,5,94,138,134,15,95,149,184,1,103,63,69,5,207,160,157,11,212,99,145,12,114,94,107,8,3,187,49,2,255,90,200,4,255,61,13,4,137,130,76,0,203,231,46,3,13,229,15,0,3,35,24,8,150,162,153,6,231,22,149,10,45,24,176,6,129,213,203,3,215,162,6,0,22,114,125,2,13,126,77,2,214,14,18,9,109,203,27,19,22,165,87,0,125,98,79,2,21,170,41,5,139,135,123,6,109,103,228,2,157,223,76,8,164,128,180,15,54,137,95,0,94,33,241,3,220,246,121,7,157,212,81,17,1,53,251,7,238,186,117,4,177,238,42,3,25,129,24,7,171,99,2,7,86,60,186,10,8,184,12,12,16,97,204,1,113,239,160,4,81,230,177,0,15,56,159,7,181,226,61,1,179,183,87,22,95,81,128,1,193,208,187,0,146,199,117,19,232,193,141,2,4,241,27,14,89,184,48,0,55,6,109,0,99,203,51,5,97,138,22,8,212,3,81,7,127,224,7,2,168,4,186,4,137,226,80,1,153,167,98,3,23,235,40,1,79,156,205,1,216,26,18,10,50,123,200,32,214,247,6,1],"created_at":1778400840859,"updated_at":1778577608272,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":97,"stem":"A 25-year-old man sustains a stab wound to the chest. He has decreased breath sounds on the left side and subcutaneous emphysema. Chest X-ray shows a large left pneumothora x. Which of the following is the most appropriate initial management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"c38d215d5f41eacde580af87150fa62c19d1a69491c8c8d82f54235bc9d7f686","minhash":[168,133,210,12,52,34,141,7,167,145,138,6,101,65,4,1,23,181,177,4,106,129,55,0,249,97,239,3,1,66,85,2,27,238,207,4,155,199,135,0,50,75,224,1,61,204,24,1,242,194,102,7,133,230,216,6,96,91,124,8,25,100,92,17,183,8,160,2,214,14,201,5,196,248,21,0,49,10,33,1,69,8,88,1,218,54,197,19,183,89,193,0,21,35,206,3,19,188,188,11,79,31,119,5,177,163,99,3,67,180,93,22,205,145,88,12,125,57,129,2,108,188,244,0,169,28,240,1,217,149,212,3,249,196,24,3,165,87,149,5,42,73,6,2,146,106,153,0,13,58,159,2,183,49,60,7,237,54,36,4,147,245,176,5,57,64,229,2,45,159,145,1,52,183,159,1,85,116,230,0,82,159,24,7,130,250,149,9,93,208,145,17,140,55,55,17,203,205,205,0,1,90,221,5,195,79,211,0,195,30,167,0,53,166,250,10,141,72,41,0,87,26,3,8,153,75,240,4,79,70,58,6,44,8,77,16,239,147,114,8,19,149,49,1,5,88,178,1,150,81,182,12,60,224,102,3,66,195,224,2,114,226,221,5,50,220,16,9,42,109,115,13,92,30,127,8,189,180,98,3,101,71,16,21,204,56,201,8,237,164,85,13,148,151,108,17,117,197,0,4,252,184,24,14,220,214,129,6,245,178,228,2,119,108,146,1,170,130,76,7,37,222,98,4,210,234,25,9,37,33,235,12,185,137,41,5,207,61,93,5,176,215,196,0,213,235,155,9,13,194,14,5,91,22,164,0,220,68,172,5,151,71,235,15,113,137,118,0,87,38,6,0,73,84,21,3,221,236,110,1,163,86,74,1,112,226,190,6,145,102,15,7,164,205,205,15,73,160,230,13,13,6,53,9,214,197,71,4,55,255,88,0,114,195,54,0,73,33,227,3,114,133,123,1,117,198,5,7,52,11,71,1,221,242,7,15,217,109,130,22,237,74,46,3,197,218,31,0,61,106,69,4,214,22,35,4,164,58,230,0,50,140,235,3,249,183,245,1,61,50,111,0,245,24,189,12,227,12,253,2,61,174,163,3,81,38,174,12,2,135,97,8,52,32,154,9,93,63,209,9,44,16,128,11,195,165,134,12,141,105,17,7],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":98,"stem":"A 30-year-old man sustains a crush injury to his right leg. He has severe pain, pallor, and paresthesias in the leg. His compartment pressure is 30 mm Hg. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"d16456ac20833e5c5ff93a1b89cb979234dbd0eb02d835101bc6255c6ced99b5","minhash":[91,64,246,0,70,141,206,2,41,65,92,0,220,116,50,0,3,57,40,0,120,242,25,11,160,199,81,0,28,81,159,7,83,227,72,0,118,173,117,8,21,6,57,9,131,131,91,17,245,105,118,4,248,115,73,1,34,208,141,4,155,73,212,9,249,45,145,7,126,62,123,0,245,164,7,8,65,65,99,4,229,120,152,2,251,139,254,8,193,169,10,24,28,210,177,7,19,164,29,0,133,98,220,5,131,231,26,10,138,222,51,3,117,202,86,3,240,240,111,3,35,157,245,1,126,63,3,6,217,61,189,0,19,54,218,6,254,211,43,26,107,65,90,2,78,90,198,9,70,18,220,6,149,115,101,10,9,83,213,5,155,40,108,4,78,95,50,0,134,227,218,5,92,215,225,1,230,149,56,11,109,74,134,2,99,147,243,4,235,229,157,0,58,66,230,0,176,207,37,21,57,126,17,5,155,56,207,10,182,167,36,0,202,103,163,2,124,46,166,1,28,84,162,3,58,119,135,8,75,147,205,5,131,34,124,13,3,48,126,6,19,149,49,1,165,161,109,8,85,172,202,0,2,179,50,2,35,184,101,1,184,81,250,5,11,75,111,9,198,71,38,1,92,152,162,7,243,144,146,7,250,13,114,7,219,176,160,6,36,139,236,16,236,220,252,3,196,21,51,2,126,201,177,5,42,181,226,1,66,198,111,26,4,1,229,4,145,23,173,0,35,254,45,0,70,145,98,0,83,79,125,5,154,190,117,4,186,168,185,3,101,90,29,2,211,226,166,2,75,33,133,10,223,76,195,6,60,155,7,1,230,134,63,4,171,12,249,2,102,207,30,15,77,12,77,1,78,28,34,5,198,34,234,3,102,216,38,15,11,161,116,3,12,86,97,2,77,33,201,2,243,91,218,1,120,196,249,24,111,189,33,5,81,239,6,3,27,164,85,3,219,64,190,7,22,37,24,2,16,16,166,12,185,48,86,5,187,158,116,7,32,17,157,2,125,34,67,1,0,206,197,9,38,110,74,4,85,241,18,26,126,53,143,1,192,123,4,2,118,170,3,10,73,154,222,10,91,153,101,1,102,46,138,3,48,175,113,4,147,203,116,7,61,242,101,27,115,129,157,4,179,220,66,26,35,166,149,11,198,10,114,1],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":99,"stem":"A 60-year-old woman undergoes colorectal surgery and develops a wound infection on postoperative day 5. The wound is erythematous, tender, and has purulent drainage. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"82b546ecbf274c4a0f51e62c87008294e25a71886fa73487680fc600944592fd","minhash":[72,68,141,4,104,147,102,0,180,250,131,8,76,250,102,3,208,166,169,3,136,25,35,1,112,153,109,0,225,42,109,3,92,96,112,5,188,175,34,0,167,241,170,3,100,203,51,25,146,47,214,2,98,51,125,8,96,161,125,2,40,150,237,6,2,71,96,2,54,201,180,0,240,79,163,6,173,134,189,1,173,41,143,13,98,30,228,0,82,72,97,0,205,147,227,3,15,195,237,14,73,246,109,9,42,8,171,3,228,45,134,2,116,156,110,15,208,145,88,2,11,91,207,8,40,1,43,9,180,217,40,13,228,122,78,8,252,208,198,1,50,8,44,2,106,1,38,0,36,54,95,12,46,177,29,2,69,215,80,2,46,13,167,3,128,154,23,2,38,166,118,6,28,165,89,2,166,58,44,37,205,157,9,10,240,130,217,0,221,237,83,14,178,209,22,3,230,220,196,0,185,159,241,6,200,56,224,9,186,138,159,7,169,0,231,6,52,183,222,24,34,91,232,3,166,189,228,3,221,170,183,7,42,108,123,4,104,72,224,0,20,214,65,8,218,18,243,10,48,59,210,3,119,219,57,1,208,207,130,2,79,34,142,7,107,95,62,15,217,253,80,10,155,66,197,2,54,108,33,7,12,154,31,10,36,68,124,8,212,233,183,8,252,243,118,0,114,30,212,2,220,42,18,7,212,70,246,10,253,114,85,4,113,21,208,11,96,178,183,7,108,28,1,3,164,143,213,8,38,112,147,0,215,244,165,7,144,4,9,8,83,224,129,0,184,138,59,7,102,174,186,0,181,71,205,2,36,30,209,3,255,67,94,5,69,75,215,6,136,39,66,0,248,213,91,9,242,127,65,0,28,168,179,0,118,160,20,1,137,215,141,7,191,93,172,30,224,177,88,3,146,116,142,12,230,145,48,9,38,197,231,0,82,235,45,13,58,235,142,7,173,94,115,4,48,21,242,6,189,52,225,17,212,176,147,27,125,163,12,9,135,184,243,2,104,107,253,4,18,99,137,26,44,105,187,7,122,231,49,11,24,93,230,3,215,245,208,3,40,103,72,14,128,190,75,1,182,91,46,0,178,176,169,4,100,138,174,0,39,190,243,7,61,217,66,0,16,54,5,3,209,205,210,3,0,22,42,7,28,42,145,5],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":100,"stem":"A 35-year-old man presents with pain and swelling in his perianal region. On exam, there is a fluctuant mass at the 3 o'clock position near the anal verge. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"07355ad35e5cb5587203eb73d80d57585b392cc435fb40c57e1c1b5d3533dd55","minhash":[143,173,51,2,54,73,38,17,228,111,22,16,81,42,87,14,25,92,12,0,135,166,142,4,2,250,135,5,163,47,127,0,218,187,68,0,217,127,146,0,250,133,189,13,166,231,76,16,38,222,197,0,221,247,80,0,2,205,60,7,12,101,20,2,230,197,231,2,218,102,80,2,130,222,238,0,22,121,47,0,91,255,21,0,9,61,142,6,107,60,150,13,91,19,210,5,17,89,66,8,135,61,190,2,137,198,168,0,116,232,65,1,58,179,224,0,230,101,14,1,159,92,175,0,108,153,109,18,191,110,134,5,238,206,200,5,111,166,165,1,166,45,123,1,234,61,82,0,171,42,87,9,145,168,124,2,104,78,162,11,214,95,206,1,200,222,13,3,10,119,57,2,26,215,133,4,58,93,113,0,201,49,56,2,1,93,173,10,18,126,239,3,90,127,19,1,193,245,187,2,71,245,95,1,237,134,248,9,23,96,229,7,90,209,176,15,139,32,10,0,186,68,10,11,114,222,94,0,139,107,156,3,50,250,189,27,225,21,181,11,79,191,93,2,238,78,251,11,154,189,157,10,3,53,203,6,213,44,167,14,72,135,118,9,130,208,25,2,102,231,181,4,124,236,92,0,57,254,239,0,138,82,57,10,64,124,62,12,230,67,45,5,145,168,63,7,26,49,247,4,238,142,94,4,87,179,43,14,33,20,179,13,79,92,252,19,103,166,80,5,60,177,175,17,1,238,253,4,250,210,49,6,151,198,87,5,31,84,124,1,230,131,86,1,38,167,37,7,91,201,87,2,17,227,211,2,122,74,11,0,250,55,114,0,199,255,187,12,252,157,235,14,20,116,161,1,43,201,102,19,186,189,242,0,218,10,240,5,143,191,16,41,92,179,201,12,186,158,45,10,55,21,171,0,247,81,126,7,130,243,57,4,52,136,150,21,166,15,183,0,32,173,190,3,89,222,235,1,59,160,87,11,58,5,126,7,207,209,86,1,164,11,59,3,102,90,254,1,85,222,33,15,160,180,103,1,71,243,165,6,227,61,191,13,183,140,8,0,138,31,245,5,36,210,174,5,23,201,57,6,188,211,49,3,29,136,175,1,154,89,170,7,163,10,229,1,66,120,236,4,250,192,123,9,138,121,97,7,159,165,0,0],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":101,"stem":"A 70-year-old woman undergoes emergency surgery for perforated diverticulitis. Postoperatively, she develops fever, hypotension, and leukocytosis. Blood cultures are positive for gram-negative rods. Which of the following is the most appropriate initial management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"f05ff8241597745435b5160c42735a8bf8b88aa92ec6f23e91b67805f1e91fac","minhash":[51,36,1,14,45,20,78,4,58,237,106,1,252,220,144,5,37,220,198,4,37,91,0,3,30,191,96,3,221,33,243,10,69,0,213,7,188,175,34,0,23,80,103,3,83,62,49,2,44,90,251,11,114,102,220,8,168,101,41,4,156,12,196,2,103,38,230,0,196,202,24,7,158,248,83,2,252,45,12,0,123,115,81,15,159,80,107,8,87,117,217,23,137,2,110,1,2,206,4,2,60,50,183,3,250,21,233,10,26,147,231,4,212,208,99,3,153,208,205,3,33,252,4,5,158,175,85,20,250,149,201,2,78,97,214,4,158,96,139,4,61,163,190,10,38,133,202,1,191,186,193,0,205,54,223,11,19,50,83,3,43,52,151,0,107,122,81,0,82,9,142,1,245,139,130,5,227,227,24,4,138,255,156,2,210,64,155,2,207,204,224,3,27,35,61,4,224,30,24,2,119,212,233,2,83,103,241,7,37,206,238,7,4,4,228,12,91,40,236,9,175,42,194,11,48,28,31,9,36,133,17,1,50,174,73,9,228,121,183,2,208,194,157,0,141,205,244,0,107,217,39,9,28,38,144,1,252,148,88,0,107,231,85,7,44,49,182,1,47,215,159,0,103,202,158,5,252,212,168,1,186,183,69,5,243,213,36,7,197,234,120,13,109,252,59,2,13,193,107,3,228,246,137,2,72,109,91,3,41,206,21,0,45,41,198,1,121,176,183,9,108,28,1,3,76,43,20,16,158,152,137,9,5,44,237,0,165,70,92,9,89,215,49,3,78,142,248,8,230,190,206,4,146,121,179,11,248,19,97,1,82,3,113,2,158,21,33,7,49,48,19,4,5,37,143,16,78,246,30,3,28,168,179,0,5,255,135,1,10,246,57,4,119,70,74,3,79,246,121,2,84,207,71,1,69,98,41,19,97,227,253,2,96,184,96,6,179,178,203,4,123,223,22,0,212,144,156,10,15,192,88,7,253,76,75,1,203,83,37,9,66,88,12,1,163,206,10,10,81,161,27,5,93,39,74,2,144,186,111,5,25,29,105,2,30,154,180,8,102,14,39,1,18,135,83,3,185,128,124,6,125,241,202,2,217,91,2,0,141,35,34,1,125,240,59,3,45,194,108,9,5,3,22,3,20,223,16,15,220,124,26,3],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":102,"stem":"A 45-year-old woman with symptomatic gallstones requests cholecystectomy. She has no history of previous abdominal surgery or comorbidities. Which of the following is the most appropriate surgical approach?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"c8dfba24e6985bd8458458b8adccac490b951829c172430c4853d51d0eb3eb54","minhash":[90,75,211,2,64,78,73,1,107,190,84,14,232,191,33,13,110,223,120,1,224,62,122,5,215,195,181,0,184,97,242,13,90,248,49,12,122,66,30,1,8,198,21,7,64,3,143,0,137,155,224,7,186,233,65,5,16,166,247,8,101,170,176,1,62,172,28,10,58,68,35,0,116,31,81,5,4,174,205,7,208,147,122,6,186,174,1,10,81,93,43,2,192,82,220,1,166,78,235,11,151,62,123,8,113,213,129,0,235,231,239,2,219,233,217,2,9,58,156,4,100,193,196,0,195,23,64,13,97,77,21,0,87,126,209,11,247,146,227,1,102,10,84,3,88,28,93,4,248,44,98,18,147,241,85,2,153,121,136,6,112,188,155,21,192,203,197,17,212,104,205,0,24,33,43,1,218,90,187,3,200,147,240,20,195,220,74,0,10,38,166,10,33,56,161,8,41,138,234,1,38,49,192,23,186,106,179,4,155,166,79,4,183,175,190,10,14,96,104,8,190,100,114,5,168,96,102,1,148,25,75,8,47,232,59,28,122,128,10,1,148,229,40,9,19,51,28,11,52,209,16,9,89,219,134,1,100,253,104,0,152,175,19,0,235,16,30,5,152,29,227,1,166,153,6,6,0,158,128,16,68,55,96,9,153,198,154,7,228,67,17,46,196,83,203,6,62,187,111,4,190,242,54,0,154,81,214,3,200,9,226,16,83,129,115,11,212,159,129,0,59,58,216,0,14,33,2,7,208,159,202,18,186,126,145,1,99,112,216,1,201,92,251,8,144,213,5,4,58,9,169,2,161,59,31,8,74,137,109,22,110,199,50,9,15,227,176,18,48,123,190,10,186,219,54,11,38,44,144,11,102,129,223,50,200,179,200,2,169,213,113,1,247,48,133,5,185,88,76,16,173,163,106,0,186,32,161,3,62,229,149,1,190,108,204,7,90,148,153,9,196,45,182,9,221,187,121,12,132,53,36,7,237,237,1,4,32,104,230,7,26,80,46,23,212,41,60,5,225,145,109,10,177,233,135,0,144,231,253,4,27,9,212,6,1,252,22,0,250,85,97,12,209,125,198,16,224,205,188,6,24,224,213,0,228,253,85,11,234,147,229,0,71,83,124,13,91,223,157,8,183,37,142,1,106,80,229,2,89,245,73,24],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":103,"stem":"A 50-year-old man has a primary unilateral inguinal hernia. He has no history of previous surgery or comorbidities. Which of the following is the most appropriate surgical approach?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"afd42d79737d44ac9faa395c140ffdbd408004eeb052c085c23c4501652f3c2c","minhash":[169,3,35,0,199,197,135,3,177,176,124,1,38,45,38,2,119,30,71,10,156,11,225,3,153,248,11,7,77,233,198,13,101,132,159,11,122,66,30,1,110,112,184,0,112,145,120,12,199,189,83,8,186,233,65,5,100,116,31,18,60,181,109,4,255,28,91,0,58,68,35,0,234,30,158,7,221,43,28,22,33,219,141,13,110,252,158,0,228,138,62,16,25,2,129,9,97,65,163,12,177,179,46,10,36,66,54,6,90,151,176,6,5,209,249,1,175,181,34,5,100,193,196,0,167,103,158,18,102,213,240,6,111,119,117,2,248,86,195,3,45,133,122,9,110,120,100,1,208,139,167,3,153,149,181,7,79,214,5,5,101,213,104,13,49,254,207,12,69,130,218,7,100,114,210,4,218,90,187,3,154,74,168,2,20,4,120,2,199,55,115,10,233,149,113,6,239,90,53,23,81,177,180,12,186,106,179,4,193,185,103,4,81,123,13,5,187,196,54,15,168,255,105,9,52,246,241,1,148,25,75,8,223,30,121,1,129,166,250,0,125,42,48,4,45,60,145,1,17,44,51,4,167,214,16,1,170,100,149,10,68,127,179,6,249,244,56,6,90,200,62,7,255,77,113,7,105,159,226,4,81,141,58,0,59,110,237,3,63,201,20,8,47,88,130,4,36,201,121,22,31,210,171,5,55,80,204,0,6,40,108,6,81,115,185,0,233,238,243,4,47,171,170,11,0,176,39,10,230,49,121,3,186,126,145,1,204,83,195,1,207,232,105,0,247,106,49,7,58,9,169,2,198,10,158,4,87,182,84,1,215,146,187,0,112,84,88,18,9,31,169,2,186,219,54,11,89,16,148,3,179,36,28,0,140,10,142,36,183,4,129,1,219,221,86,5,219,199,101,6,69,215,140,1,186,32,161,3,213,56,208,8,59,233,19,8,87,143,75,2,233,227,42,8,87,42,154,7,65,61,168,7,191,214,90,2,15,174,143,0,26,80,46,23,161,236,124,3,85,81,191,0,55,100,162,36,234,10,75,8,21,60,154,2,201,148,81,7,192,137,63,1,85,153,57,8,110,100,225,3,24,224,213,0,144,64,85,1,234,147,229,0,121,227,74,3,63,170,216,0,81,223,175,38,106,80,229,2,87,204,198,6],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":104,"stem":"A 65-year-old man with coronary artery disease is scheduled for elective colon resection. He has stable angina and is on beta-blockers and statins. Which of the following is the most appropriate preoperative cardiac evaluation?","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"f640811ef423ddb55fe53cd315c7e1395b533cc5b09644f2a082dab73e220c7e","minhash":[105,224,27,2,224,152,1,11,76,101,197,3,245,19,62,1,247,135,104,5,222,119,62,3,249,237,107,5,90,226,249,3,94,223,40,15,209,184,231,12,249,14,99,3,113,191,92,8,194,36,253,1,3,4,24,10,9,22,50,0,206,137,25,0,15,27,189,0,138,44,214,0,219,29,28,3,134,154,52,14,119,159,58,17,172,119,20,10,192,69,13,0,206,145,57,14,189,76,204,0,251,25,112,3,179,81,251,9,43,111,128,0,0,143,216,8,6,139,57,17,55,249,194,15,68,242,7,1,122,109,9,2,225,15,209,3,182,92,42,32,97,224,32,2,169,171,113,2,145,227,228,0,103,175,113,2,162,250,11,5,25,43,231,0,124,111,69,4,206,120,156,3,1,242,13,22,85,192,5,24,219,128,59,2,94,26,105,6,240,221,242,6,15,242,203,0,87,8,209,1,244,59,205,1,198,252,228,2,134,111,177,3,14,157,183,8,14,160,32,3,198,137,235,7,25,82,92,20,93,195,113,1,121,106,183,11,241,14,107,2,105,245,140,5,206,199,72,4,76,46,254,1,206,185,255,4,143,125,69,31,145,221,167,2,7,122,242,4,173,60,193,29,94,157,213,0,223,254,78,5,201,76,211,4,74,185,141,19,64,76,18,1,209,34,152,7,38,67,119,10,220,193,183,1,236,201,51,19,15,202,48,9,147,162,240,0,183,70,155,6,23,7,190,4,59,177,148,11,206,96,112,0,19,41,27,9,119,125,50,0,230,170,129,10,80,249,61,12,90,132,219,3,122,240,162,2,206,227,135,10,14,252,94,5,109,55,197,4,134,129,132,1,162,190,187,5,180,189,71,21,90,65,219,5,84,131,45,0,108,114,234,1,229,136,42,2,95,86,148,5,166,237,172,1,226,249,26,9,94,246,155,10,243,140,43,4,212,237,99,13,14,137,179,3,63,177,160,4,218,20,92,6,57,127,184,1,143,27,112,1,64,56,41,22,76,9,70,18,14,118,252,6,111,166,53,8,206,128,39,10,34,19,147,1,148,73,53,25,246,34,195,1,217,214,10,7,98,12,124,3,122,4,239,22,81,18,191,13,188,94,180,3,218,14,157,18,44,120,179,9,198,7,189,5,170,234,16,4,220,147,41,0],"created_at":1778400840859,"updated_at":1778577701345,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":105,"stem":"A 25-year-old man with a family history of malignant hyperthermia is scheduled for appendectomy. Which of the following anesthetic agents should be avoided?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"ca96cca7f0932224197429a637bfd057629752086ee461fcbc0c2394f6362354","minhash":[52,249,91,5,239,140,191,28,42,51,73,53,209,110,223,35,150,226,168,4,4,91,108,1,103,183,175,23,164,213,225,17,160,132,170,2,80,153,204,26,203,233,4,2,99,139,3,0,244,16,166,8,143,37,105,31,41,40,102,1,227,253,63,3,234,248,243,12,226,215,110,13,201,43,25,24,214,196,78,3,108,94,20,17,102,79,173,3,20,49,26,30,117,234,87,24,160,163,199,56,47,202,13,17,9,223,214,13,214,26,65,71,89,194,11,22,37,60,162,5,205,58,151,16,49,115,200,17,52,131,13,11,243,51,70,0,216,143,45,0,195,231,143,16,38,6,19,6,144,93,141,7,233,25,180,2,112,167,164,25,172,125,161,8,138,179,156,13,171,17,112,2,162,49,147,26,130,192,66,15,225,230,30,12,166,44,247,23,53,15,146,31,38,57,81,12,102,190,83,4,37,201,143,9,214,28,213,6,125,211,147,14,229,148,32,5,203,77,77,19,112,142,16,4,248,178,80,0,68,169,58,22,22,119,251,19,162,103,178,26,89,63,226,0,10,134,170,25,169,27,82,30,99,250,139,22,21,25,51,8,102,226,250,10,194,234,34,11,205,183,66,3,59,106,37,10,98,39,253,7,170,207,88,79,3,181,184,0,248,69,129,21,133,191,90,53,45,249,241,11,162,157,160,50,61,166,91,21,102,205,216,10,12,108,95,0,230,149,173,61,151,252,134,1,104,176,81,19,107,99,184,2,28,129,203,1,224,179,38,2,33,237,74,33,231,228,129,3,34,30,50,4,185,206,9,27,193,227,243,6,88,74,217,20,202,247,77,10,106,182,148,19,97,30,224,17,66,45,176,11,240,95,108,29,2,196,54,2,102,42,103,22,0,102,83,29,162,14,114,1,150,42,128,2,98,83,225,0,107,141,9,4,214,91,168,0,150,189,47,0,138,59,189,3,71,158,114,2,202,57,136,15,217,218,128,41,16,229,148,16,170,76,161,21,220,86,57,28,32,158,66,33,147,67,222,7,7,214,224,22,28,131,55,0,108,148,172,1,229,150,134,5,22,164,71,72,164,96,20,52,180,14,205,11,124,8,71,23,173,214,240,6,72,200,170,12,245,112,2,10,168,98,168,23,12,247,76,0,67,246,31,54],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":106,"stem":"A 50-year-old woman undergoes total abdominal hysterectomy and develops shortness of breath and chest pain on postoperative day 3. Her oxygen saturation is 88% on room air. Which of the following is the most appropriate initial management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"e29ba15efc23f71dadec44afd3f6d013c85e981ccb6a11396a78aad82a9dde70","minhash":[193,140,34,2,139,214,187,3,34,250,121,1,199,0,229,0,102,8,64,0,241,65,98,0,104,103,70,2,130,220,62,0,75,166,168,7,188,175,34,0,12,74,159,4,34,45,43,13,51,94,187,6,161,10,167,8,65,90,223,7,248,67,236,6,17,254,23,2,11,28,67,0,60,96,230,7,193,28,1,17,63,156,173,1,128,206,110,3,194,21,72,2,97,3,249,2,79,79,141,0,236,25,30,4,225,194,55,2,52,229,61,0,40,192,125,7,213,197,179,15,239,213,187,1,60,78,164,5,15,141,233,0,160,204,139,3,185,193,176,2,89,60,199,1,165,63,239,7,205,12,119,0,232,15,164,4,137,239,192,5,1,111,12,2,55,33,178,0,97,13,107,6,132,95,174,2,220,214,19,2,247,41,109,0,222,117,14,7,201,142,205,0,122,193,158,14,146,22,242,2,76,77,223,5,105,39,167,8,107,53,169,6,84,56,17,2,189,255,251,0,77,186,230,14,255,215,39,3,103,149,23,5,44,88,153,2,125,104,158,10,121,121,62,3,43,101,140,6,99,87,248,3,28,38,144,1,223,95,150,4,87,207,78,0,16,225,245,2,125,20,238,0,233,72,46,8,156,55,50,4,89,152,143,1,210,177,228,9,16,59,39,33,193,167,167,11,40,190,95,7,135,58,183,3,250,122,71,6,171,186,23,4,52,68,223,9,192,94,188,4,72,111,157,2,88,215,176,3,244,247,246,3,94,158,74,1,8,166,36,0,194,191,208,0,47,166,161,5,39,158,106,1,132,93,235,3,216,64,194,1,208,62,235,1,152,116,135,3,136,251,49,5,43,208,202,1,129,36,21,12,28,168,179,0,245,68,202,5,9,166,91,2,255,85,77,0,180,179,221,9,112,105,129,5,98,11,207,0,48,87,169,0,90,152,103,0,211,42,1,9,228,158,224,15,97,66,234,0,97,45,66,10,250,14,72,5,105,158,158,9,169,225,226,3,201,251,102,0,102,123,111,0,247,182,240,2,40,116,139,0,59,237,105,13,153,92,216,7,120,78,234,0,181,173,81,2,196,203,241,4,72,117,85,8,64,36,17,5,16,0,148,8,156,164,76,10,121,51,32,8,166,73,29,4,241,247,57,10,28,42,145,5],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":107,"stem":"A 40-year-old man undergoes laparotomy for small bowel obstruction. He has severe pain postoperatively despite receiving intravenous morphine via PCA pump. Which of the following is the most appropriate next step?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"edac22fcd5386126c28c670ba360e543f444de74fcbcc8aef02eb47dbc0e9603","minhash":[33,194,238,0,199,185,123,3,135,245,5,3,223,148,199,3,210,114,7,4,63,32,31,3,80,142,37,4,191,193,228,4,52,7,3,7,81,189,229,3,101,244,140,3,64,45,178,5,212,34,59,1,194,203,152,7,54,133,248,0,104,12,99,14,135,242,38,8,69,34,140,4,7,43,74,17,246,122,93,16,119,146,142,2,13,132,247,34,146,246,95,5,74,188,17,0,192,105,208,1,41,152,82,5,211,48,3,18,75,25,254,0,125,40,182,4,165,192,114,4,128,208,242,1,164,24,63,1,216,205,125,0,210,175,91,0,37,193,96,5,206,80,239,15,226,72,125,7,149,131,11,4,243,53,18,0,132,56,70,4,234,128,246,6,69,200,98,2,83,26,158,10,121,231,173,0,210,205,123,3,61,178,109,7,20,164,115,5,245,36,185,3,20,94,31,1,237,99,1,2,0,112,147,12,139,17,127,0,92,77,156,0,176,209,209,10,54,91,6,13,63,91,48,13,139,73,220,0,96,181,187,10,34,81,17,4,8,18,238,5,207,220,135,15,44,108,207,10,170,83,30,11,130,107,175,1,23,113,170,3,54,248,79,9,173,186,148,7,79,164,90,3,152,200,68,9,177,82,160,0,17,84,32,8,13,142,106,6,205,73,208,3,173,166,43,0,71,187,9,14,112,207,96,0,164,250,57,6,251,19,206,1,64,134,192,2,127,141,193,3,249,233,235,3,108,63,31,3,89,161,153,1,161,41,55,4,229,50,11,5,172,97,29,9,246,221,252,0,52,202,148,0,57,57,120,5,159,142,106,2,65,176,33,2,2,126,45,3,128,5,48,3,163,25,150,5,81,158,159,7,200,130,37,1,175,244,97,1,208,118,189,7,159,149,14,6,176,132,130,0,0,141,27,0,37,88,80,6,141,215,235,22,176,111,73,0,48,120,79,13,169,192,218,5,9,210,22,6,176,251,202,8,182,209,79,22,213,129,108,8,96,29,46,16,101,97,239,22,118,175,239,4,1,70,171,0,18,43,206,3,95,245,105,5,169,132,130,3,25,77,37,11,36,1,45,11,240,124,8,11,137,39,154,0,144,2,161,3,192,186,32,3,31,85,10,4,212,213,116,7,104,60,134,1,41,40,16,0,167,102,168,2],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":108,"stem":"A 75-year-old man with dementia is admitted with acute appendicitis. He is confused and disoriented. His wife is present and wants to give consent for surgery. Which of the following is the most appropriate action?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"5102666ba97aa440db1a2a58b865fd3b633b2f0293417f19482ee659aa725522","minhash":[18,2,177,7,118,220,249,22,118,209,16,15,24,114,68,1,36,142,63,5,27,12,72,14,36,143,138,2,3,153,29,0,196,58,38,6,172,239,191,6,25,5,169,10,125,154,252,10,3,86,64,2,141,57,60,0,179,209,241,10,54,179,27,2,189,5,194,5,89,163,6,1,193,202,30,4,137,7,88,7,151,84,72,12,171,243,243,5,53,102,239,1,154,19,3,3,35,165,88,1,82,70,229,27,178,169,70,1,7,45,127,6,50,206,69,2,94,182,230,2,161,24,188,8,231,124,184,6,91,1,182,0,114,17,52,7,246,38,64,9,182,95,61,0,37,83,32,9,43,161,74,6,1,166,64,6,163,133,104,9,92,227,112,5,79,122,80,15,75,210,41,0,121,211,53,2,87,147,142,0,247,226,224,16,23,131,158,4,157,86,84,3,242,10,66,5,75,191,10,7,21,29,99,10,18,133,123,3,28,196,146,0,155,228,110,1,118,28,200,1,35,79,93,10,200,20,114,7,212,52,94,19,118,115,156,2,20,79,1,5,246,98,51,25,119,2,188,16,68,134,141,11,12,145,93,1,113,203,106,4,165,96,80,5,39,203,70,2,182,215,51,3,231,196,61,9,114,198,152,6,99,142,245,4,47,173,153,1,69,200,84,3,179,161,175,12,54,115,191,1,91,190,218,5,222,151,253,3,20,231,125,13,79,161,46,4,180,117,198,1,146,177,46,10,173,184,14,11,131,53,9,5,178,48,202,4,132,128,124,0,187,172,78,0,53,168,121,6,50,164,239,0,109,10,45,2,194,9,251,4,179,76,142,2,229,203,225,9,156,110,215,4,132,246,249,3,81,234,208,9,29,212,141,0,187,158,130,9,182,58,200,10,217,140,78,8,53,128,66,1,98,211,48,8,120,81,15,13,122,52,73,1,82,177,50,2,19,1,23,9,43,231,28,2,49,138,121,13,191,72,181,7,157,243,47,1,5,60,73,11,65,117,254,4,88,166,243,6,246,93,206,10,173,241,140,5,212,121,66,9,54,234,167,0,155,187,57,0,211,199,209,15,50,162,113,13,164,164,187,0,146,220,35,29,212,200,248,3,85,103,157,1,18,188,226,13,4,252,161,7,119,0,96,7,43,191,165,6,21,209,19,3],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":109,"stem":"A 60-year-old woman with stage IV ovarian cancer has a small bowel obstruction due to tumor progression. She has significant pain and nausea but is alert and oriented. Her performance status is Karnofsky score of 50. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"961384423fe2a6b087612aee6a148f7f3c95476302ccf5aed4c7075338032f09","minhash":[138,110,46,9,202,120,217,4,96,230,114,0,241,189,46,10,82,183,129,22,223,192,126,1,183,2,251,7,13,254,189,3,198,44,94,0,176,74,94,9,120,33,178,2,242,23,71,8,10,40,74,1,15,134,24,1,167,195,34,1,80,172,226,0,231,48,209,3,50,139,156,17,143,3,117,11,109,101,131,7,209,137,135,6,74,3,245,2,155,65,39,12,10,138,248,1,131,97,16,7,113,252,24,16,220,230,40,6,104,239,232,5,97,237,70,25,227,176,130,2,92,246,187,7,49,66,98,2,53,10,13,3,221,214,165,1,129,105,30,0,73,32,113,4,193,208,143,2,6,76,211,4,184,182,57,0,234,105,91,6,32,202,71,2,205,78,231,7,250,58,158,1,121,80,7,3,243,115,205,5,235,98,244,2,37,233,76,0,121,242,204,10,229,15,130,2,128,115,239,1,227,161,196,7,16,116,163,4,64,250,252,3,202,67,10,5,118,121,217,6,126,121,35,5,186,199,154,3,192,66,73,0,108,64,168,0,138,62,30,4,43,166,196,0,223,123,173,1,57,21,87,7,27,100,254,7,76,5,150,7,177,40,195,0,128,183,163,3,242,72,96,7,85,133,105,8,200,63,93,13,83,84,16,3,168,185,3,1,201,204,247,0,251,141,35,5,146,236,197,5,134,167,244,4,252,252,187,2,235,13,186,1,192,14,10,2,41,177,26,3,254,34,74,16,140,65,4,3,69,154,226,2,134,177,50,1,42,74,42,6,6,200,26,7,211,206,41,11,236,128,219,5,76,82,28,2,218,148,226,5,233,100,63,21,44,184,72,3,58,108,7,3,74,140,22,3,81,207,23,0,205,50,244,4,129,181,253,4,233,4,228,3,187,241,165,0,153,69,114,12,81,111,96,12,90,168,143,11,21,11,204,3,113,145,193,8,204,115,214,1,50,136,231,3,5,223,232,0,27,215,223,6,243,153,153,2,74,78,249,3,184,204,210,1,139,117,218,7,121,51,73,11,218,203,255,0,118,146,135,2,26,5,203,0,57,60,13,3,240,93,164,4,149,75,199,0,61,230,215,2,198,24,197,12,175,207,82,1,41,186,195,0,65,109,164,6,224,120,98,2,235,95,97,3,137,101,137,4,207,236,180,7],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":110,"stem":"Which of the following suture materials is most appropriate for closing the skin in a clean wound on the face?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"a811e944ce197a98224848dcb7524b8cc3aebd1b2c364114c627c2ec9d0cec5e","minhash":[224,172,93,10,97,132,93,24,140,106,230,55,89,41,251,9,248,229,254,21,225,102,152,39,41,249,213,0,54,115,40,38,144,232,159,6,16,11,134,12,112,56,18,23,129,2,30,9,72,255,238,20,21,104,123,1,105,68,137,4,54,113,88,2,77,141,229,16,144,246,102,9,107,157,221,11,174,224,112,10,13,22,172,11,145,230,52,21,125,99,196,19,152,200,234,16,96,123,22,0,201,62,122,35,232,115,138,2,220,252,113,11,32,71,55,1,161,26,80,16,153,32,236,1,54,237,124,18,57,12,47,35,68,131,10,42,118,183,224,50,229,188,168,22,237,160,165,15,83,230,4,24,128,253,200,16,3,242,202,10,144,54,96,24,196,233,236,0,212,88,218,19,160,136,167,11,25,129,18,20,33,141,24,10,241,33,3,6,176,136,15,22,16,186,5,44,68,112,186,6,253,6,32,35,35,27,65,5,172,61,156,15,85,149,152,9,174,14,211,14,54,231,62,13,169,96,109,10,196,22,27,1,232,233,248,45,160,215,75,0,153,191,33,32,208,89,55,45,153,61,48,10,176,79,18,9,57,105,202,1,174,220,248,16,235,85,132,34,65,27,162,3,248,49,251,7,225,48,202,22,118,166,177,1,225,81,174,4,13,125,2,13,192,119,210,4,171,188,165,15,220,159,141,33,120,171,92,3,19,66,78,5,216,220,123,13,241,196,210,0,237,172,246,18,120,128,145,10,152,169,73,9,32,30,142,27,9,242,128,12,97,67,205,27,128,42,217,0,133,76,27,7,52,14,63,20,16,30,11,28,249,248,191,31,241,24,239,19,174,26,73,3,182,185,127,26,48,45,166,7,28,253,160,26,224,38,189,40,85,91,18,19,174,38,212,33,92,97,46,39,172,56,249,6,182,215,242,23,73,199,58,13,3,216,173,13,52,147,255,3,16,213,247,29,118,245,245,13,133,124,56,10,32,226,76,6,104,190,100,38,221,119,247,10,164,7,135,26,77,136,212,12,120,70,108,10,140,217,107,22,35,65,149,7,109,119,64,5,132,19,155,6,128,200,152,6,224,155,224,10,251,196,114,15,49,190,249,4,174,214,224,2,165,159,242,1,73,26,85,13,147,134,230,1,153,119,147,5,174,56,188,3],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":111,"stem":"A 30-year-old man has a 5 cm laceration on his arm with full-thickness skin loss but intact underlying muscle and fascia. The wound bed is clean and granulating. Which of the following is the most appropriate wound closure method?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"ad721ec905816316fe8c8a458a5d80e0b2677fc14b959bbf5a4d33a3d34f13d4","minhash":[143,137,121,30,114,88,44,10,43,203,246,1,251,227,222,11,111,186,233,0,150,157,165,8,86,225,131,4,229,140,196,6,228,23,142,1,194,139,67,8,156,173,46,4,137,147,148,1,188,244,71,4,71,182,204,15,217,78,130,12,171,75,91,0,55,195,76,2,104,172,247,28,131,36,61,0,199,51,166,25,234,114,12,8,218,105,64,0,92,126,247,4,223,112,145,7,228,4,122,6,194,241,53,11,162,159,42,7,18,10,37,0,172,235,64,2,211,114,123,1,82,179,190,10,54,106,149,10,3,8,160,0,53,166,51,12,93,12,46,2,248,65,2,2,73,183,22,6,224,121,96,1,92,239,210,6,179,186,188,0,188,109,77,2,60,22,52,4,195,230,169,13,154,75,246,9,214,85,189,16,76,211,120,0,16,73,86,4,22,97,247,5,106,131,17,19,10,38,211,0,4,127,52,2,130,229,130,17,210,4,100,1,204,39,240,9,72,119,84,21,193,198,37,7,168,79,59,17,185,225,255,16,144,159,132,4,22,154,80,3,98,140,84,2,210,51,149,4,34,9,87,0,242,92,163,0,1,63,239,3,150,42,185,2,216,253,15,0,22,32,213,16,181,148,236,13,244,125,148,1,118,107,68,15,242,35,85,10,175,128,89,11,114,23,40,8,162,97,139,15,100,141,90,27,112,42,213,7,182,202,225,1,211,75,207,4,20,108,76,3,48,116,165,5,123,4,61,0,255,77,67,1,153,177,150,1,146,98,118,16,213,231,127,10,223,116,72,6,146,138,196,5,13,95,121,6,114,101,173,1,83,63,60,19,130,116,209,16,95,33,121,7,39,80,200,11,255,111,220,12,165,127,141,0,120,154,117,2,152,236,4,4,208,123,70,24,71,185,188,0,232,109,157,3,183,115,149,36,42,233,11,7,229,47,85,5,106,89,172,13,103,179,184,7,220,202,172,10,55,164,120,8,173,10,24,0,157,206,37,1,207,14,219,7,129,159,136,4,60,114,12,3,82,77,233,15,92,115,133,7,50,90,55,37,203,240,222,1,81,144,216,2,253,211,195,11,184,93,124,0,85,104,46,7,160,116,50,4,170,232,172,13,74,197,91,1,210,219,27,1,66,135,248,10,179,114,84,20,131,71,91,3],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":112,"stem":"A 70-year-old woman presents with severe abdominal pain disproportionate to physical findings. She has a history of atrial fibrillation and is not anticoagulated. CT scan shows pneumatosis intestinalis and portal venous gas. Which of the following is the most likely diagnosis?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"e3026e11e40e35d743c5f7def6f8d8357de2dc4bf85003ebad986b57126b4124","minhash":[35,25,174,3,97,228,111,18,229,44,229,37,13,241,78,4,72,152,87,11,245,187,37,8,141,12,130,5,136,60,61,0,1,55,246,0,162,99,112,2,47,73,23,6,220,251,56,12,235,188,164,15,35,103,12,12,205,118,23,15,157,106,11,25,165,101,141,1,103,93,202,3,235,158,230,30,52,225,252,8,209,16,122,2,25,210,106,5,53,43,243,0,173,190,95,5,173,208,175,4,126,228,50,4,65,178,115,9,9,207,199,2,229,187,246,16,27,156,254,5,76,234,45,9,35,179,249,7,120,82,208,3,77,153,169,6,140,124,189,23,61,150,35,6,227,231,120,0,111,110,56,18,51,74,56,2,123,161,239,2,241,141,93,3,188,246,231,1,253,123,185,17,107,185,237,5,184,252,199,3,31,156,176,12,21,148,37,5,247,208,7,3,49,207,37,7,9,15,246,1,10,16,90,9,43,148,122,13,141,218,113,1,223,89,139,5,152,155,49,0,126,189,123,3,254,178,192,15,67,219,13,2,10,17,137,0,126,27,1,30,61,82,45,0,126,146,228,9,223,192,73,21,226,63,253,17,36,248,23,11,253,25,62,0,203,234,212,3,51,234,29,6,72,68,226,3,41,119,155,17,147,208,133,18,125,157,156,0,45,94,36,0,59,83,7,20,61,165,186,11,101,31,154,7,68,110,45,1,173,245,196,8,205,8,14,8,157,60,129,0,108,73,97,7,52,86,70,0,1,39,29,19,203,222,59,5,86,22,169,2,169,133,74,10,152,97,216,14,253,129,221,3,197,213,112,1,162,49,72,8,11,7,79,18,216,191,23,2,35,157,32,1,233,228,184,2,157,86,104,16,150,235,197,12,36,18,219,15,45,98,123,5,254,13,199,11,101,230,160,4,125,49,121,8,6,66,167,1,147,99,72,2,93,147,171,0,164,168,181,1,154,60,98,1,61,190,224,3,107,207,114,0,66,37,4,6,26,123,109,0,62,63,63,10,67,130,185,21,165,24,3,8,85,195,114,1,10,24,125,8,89,249,219,1,197,180,188,6,25,153,57,1,214,159,152,1,134,84,238,7,173,43,52,3,106,79,214,6,59,45,216,0,191,46,25,10,254,224,69,13,234,99,61,0,254,15,112,11,61,53,127,1],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":113,"stem":"A 45-year-old man presents with colicky abdominal pain and bloody diarrhea. CT scan shows a segment of small bowel invaginated into another segment with a lead point mass. Which of the following is the most likely diagnosis?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"8f1dc7495d1b8933049030a45dcba61ac688bb0488f3b12a19aceae2f2ad0ef0","minhash":[127,235,80,5,143,119,214,0,88,10,186,13,101,51,73,5,164,176,57,8,96,205,205,14,27,154,39,10,103,211,110,8,119,190,66,12,38,120,205,0,218,104,26,4,163,98,23,12,15,64,46,11,75,203,50,3,15,11,184,5,135,205,107,16,174,61,111,12,65,28,222,11,102,67,38,7,72,245,159,3,63,210,13,14,38,123,31,5,204,144,51,3,129,143,28,15,154,81,58,12,104,190,244,3,107,205,63,3,169,150,68,0,176,17,67,6,174,247,179,5,129,151,141,5,73,168,147,25,108,145,197,0,143,222,79,3,80,101,220,9,166,58,169,21,69,253,164,3,168,250,234,0,195,46,37,1,125,15,10,12,154,203,70,0,21,37,236,11,175,239,182,10,72,175,200,15,174,21,58,17,23,237,157,1,93,121,99,11,28,53,52,9,209,57,25,1,193,245,187,2,79,120,117,26,72,171,180,24,110,215,154,14,247,122,175,0,102,180,33,7,5,243,228,2,203,190,49,6,131,193,80,2,102,253,188,1,33,91,68,6,153,241,242,2,38,37,65,12,174,201,26,0,7,196,22,2,127,185,39,6,119,254,108,23,178,98,167,3,128,130,233,0,151,188,111,16,103,21,22,5,195,17,32,12,110,216,209,2,63,171,40,6,244,6,235,6,61,85,255,21,71,77,113,15,31,230,174,1,174,215,1,1,110,148,83,2,136,230,47,11,165,74,201,7,110,160,107,31,65,32,143,2,7,105,229,1,230,19,145,15,231,124,253,1,41,27,177,4,110,24,17,1,177,194,227,2,149,94,167,2,216,106,253,7,55,101,154,20,143,89,218,33,227,36,143,2,143,180,170,2,251,18,106,22,183,23,185,5,213,106,224,4,181,74,45,8,91,104,9,2,164,254,37,8,38,79,197,14,195,244,209,2,156,168,225,5,73,4,99,14,82,98,116,18,153,85,64,3,161,226,107,1,31,237,232,25,110,80,90,2,1,220,43,6,136,220,152,14,127,87,223,14,195,218,17,5,137,216,90,4,99,216,163,5,184,30,200,16,11,151,245,6,225,69,101,10,87,86,13,3,191,82,144,25,104,192,198,1,208,203,165,13,220,221,253,9,25,83,202,0,55,105,133,1,102,118,214,14,146,73,62,8],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":114,"stem":"A 3-week-old infant presents with projectile vomiting after feeding and failure to thrive. Physical exam shows an olive-shaped mass in the epigastrium. Which of the following is the most likely diagnosis?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"1919e5c038ce3455ba6bc9bae1ee5b365c60192ecf18e55bb8eb0ec057416280","minhash":[165,48,165,3,134,123,175,5,103,143,17,2,121,111,13,5,21,75,2,39,232,215,4,29,91,193,94,12,253,42,25,5,53,193,172,14,104,176,157,11,187,96,226,1,127,3,41,21,31,177,210,1,199,102,87,31,225,201,89,2,213,203,85,4,119,2,30,11,10,78,98,3,122,101,113,3,23,29,168,0,176,204,225,14,10,48,115,3,206,198,99,9,227,209,197,0,11,105,74,3,87,219,86,7,59,182,180,6,205,226,150,2,187,209,126,9,229,109,248,2,235,25,134,1,141,22,51,14,192,139,238,10,40,31,158,13,103,238,116,30,51,161,63,11,215,37,20,8,233,120,0,10,209,191,184,12,176,46,171,23,193,96,111,27,104,6,103,0,122,116,214,6,29,127,85,0,235,147,252,17,45,52,5,20,7,56,36,7,202,79,138,0,248,38,68,5,184,178,193,0,208,106,30,1,188,249,115,10,128,186,199,9,47,179,197,2,37,9,35,2,206,99,241,13,91,57,24,0,134,1,250,15,24,254,107,2,154,71,254,15,147,159,144,5,173,144,214,3,42,24,152,2,189,34,92,22,125,151,145,5,121,55,62,9,81,230,138,7,51,70,228,2,70,128,150,1,48,239,1,13,24,184,198,3,100,27,51,8,224,85,134,32,90,80,27,0,24,161,252,5,6,188,182,0,140,255,222,0,93,186,250,4,170,143,163,3,74,29,255,1,253,243,186,39,235,19,48,2,148,155,11,1,36,237,77,1,106,68,133,4,157,148,179,33,113,135,172,0,153,103,119,3,112,138,195,4,57,249,129,5,192,15,52,17,85,94,151,11,160,240,11,5,55,91,225,7,128,87,49,7,223,85,82,2,74,50,124,4,16,139,125,4,198,173,182,40,72,201,134,10,157,9,92,13,233,178,6,9,173,29,195,19,205,206,159,5,219,217,200,0,28,132,40,1,187,19,8,4,217,72,125,11,140,241,55,21,80,208,17,4,237,127,24,5,89,9,117,6,248,114,129,3,101,36,80,7,181,3,45,9,136,158,200,3,12,190,2,5,165,120,120,11,33,86,17,3,206,163,149,10,11,72,42,2,15,200,199,0,17,255,212,8,112,191,220,3,234,19,89,3,68,170,205,23,206,110,134,2,124,214,87,17],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":115,"stem":"A 2-year-old boy has an undescended left testis. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"2a97b3a3c4d084f275dea13bb0635bf06a01c37bbc43106f5f9c0e6edcfb1d6e","minhash":[169,56,192,22,32,31,214,27,106,45,53,6,145,171,32,31,176,164,26,16,51,152,195,2,144,106,251,4,12,131,99,13,0,9,112,7,251,216,113,6,125,109,107,29,154,157,181,16,192,0,50,11,74,124,160,9,60,106,106,4,106,146,201,19,108,21,111,17,221,158,137,2,121,170,203,1,129,72,230,2,253,67,231,13,82,76,36,3,204,173,76,4,99,207,102,16,0,191,168,8,213,224,151,9,183,175,217,10,111,175,188,8,170,84,229,8,145,36,234,17,85,103,137,1,79,42,52,14,92,112,106,2,77,127,49,3,109,47,28,2,107,254,196,2,205,185,138,3,209,185,213,13,87,187,112,17,15,36,140,7,114,69,142,11,255,69,8,12,139,223,159,6,128,165,114,9,69,190,6,29,91,253,150,21,165,145,87,1,189,228,148,11,114,252,171,16,205,171,80,0,208,201,174,0,17,11,111,0,123,195,146,8,191,40,193,22,25,239,201,5,189,214,64,1,121,72,205,26,160,243,209,0,224,94,93,14,81,168,150,4,9,167,154,7,108,206,238,16,202,215,205,7,28,203,60,1,169,152,126,3,202,250,187,26,106,117,215,3,234,108,39,1,69,225,152,0,209,4,15,1,169,73,3,6,208,24,88,2,220,234,46,42,210,213,144,24,181,226,94,4,157,126,205,4,192,60,194,1,91,184,105,3,233,116,96,11,225,93,72,8,27,51,210,4,177,98,97,2,75,25,136,0,10,71,222,23,35,38,75,47,101,35,74,2,93,48,115,22,69,92,139,22,112,25,69,27,29,27,197,7,53,51,153,4,241,105,10,4,242,18,51,10,33,255,245,3,157,198,176,17,11,81,134,31,89,172,149,31,202,254,70,7,109,1,187,2,173,48,79,10,138,138,251,0,155,156,84,10,32,176,103,12,26,187,180,18,233,72,206,15,221,187,175,6,224,187,237,13,154,57,234,2,44,13,122,10,65,68,102,2,202,125,237,6,17,213,31,14,117,131,194,8,172,43,95,0,189,182,63,10,10,139,12,7,205,114,134,2,191,22,180,5,215,80,54,4,245,18,34,4,109,39,253,7,129,33,220,11,122,170,131,23,29,220,58,6,5,159,105,11,42,12,223,15,234,64,91,1,140,150,86,9],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":116,"stem":"A 30-year-old woman undergoes breast augmentation with silicone implants. Postoperatively, she develops fever, chest pain, and dyspnea. Chest X-ray shows a pneumothora x on the left side. Which of the following is the most likely cause?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"799373c938f346521347376fa54c0da44c3c56d00346d6cc32cce705d81373f8","minhash":[77,156,234,6,187,187,92,1,134,1,209,0,11,71,1,20,4,217,43,5,246,151,61,5,35,78,247,8,91,213,123,7,168,86,49,6,188,175,34,0,12,74,159,4,125,205,66,2,253,171,62,1,197,203,10,0,155,204,173,1,211,131,6,4,40,228,101,7,133,167,60,1,43,17,241,0,123,117,203,0,63,77,123,5,20,168,46,13,74,185,108,0,197,60,160,34,93,155,202,0,70,139,119,17,109,111,187,9,133,25,90,12,111,55,179,4,83,127,253,0,141,150,43,6,145,159,26,1,196,63,212,1,35,254,159,13,37,26,157,0,19,68,50,4,250,80,139,5,116,74,81,11,181,161,59,23,90,151,6,0,69,50,48,6,34,77,213,7,94,201,12,8,101,23,242,3,51,113,74,2,118,77,224,3,179,128,229,5,243,27,206,5,207,143,87,0,75,136,232,0,251,168,173,0,124,84,47,0,175,24,176,0,215,31,191,6,77,165,67,12,234,161,71,28,94,120,48,9,27,23,127,1,27,239,132,11,198,189,61,3,235,241,177,0,43,37,201,5,87,233,139,23,222,173,213,0,171,124,198,0,70,205,28,0,141,200,112,0,124,229,21,6,115,71,227,8,43,221,10,2,35,84,19,8,180,144,231,15,61,138,237,0,213,244,126,0,8,233,57,3,220,42,18,7,13,230,35,2,245,248,86,5,67,105,10,25,148,90,110,6,108,28,1,3,107,32,56,3,243,96,124,2,59,114,41,1,182,136,128,4,133,116,219,4,54,116,216,11,243,106,43,17,139,117,228,7,37,84,20,4,125,226,190,4,118,234,88,2,75,218,64,4,69,254,167,6,105,91,229,5,28,168,179,0,36,84,61,0,203,120,224,4,136,217,183,11,145,138,140,6,109,70,209,1,116,158,167,0,204,93,131,3,234,55,49,6,138,145,186,16,171,189,208,1,182,59,102,2,213,182,187,5,250,61,1,1,65,211,33,16,58,57,27,3,133,7,57,3,43,37,169,1,133,10,18,1,100,49,168,3,103,149,100,15,182,128,158,11,70,6,202,0,130,248,185,10,101,134,0,3,35,138,255,6,245,234,251,2,94,241,104,4,253,236,35,1,76,247,172,1,193,245,25,22,27,157,77,23,234,226,4,1],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":117,"stem":"A 18-year-old boy has a left varicocele noted on physical exam during a routine checkup. He has no symptoms or fertility concerns. Which of the following is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"cc21d395c386e204899249a7be72007b096e0c3a8d2cd914d6fe06cc1181ceb2","minhash":[114,128,96,20,143,228,235,8,131,93,153,21,74,130,23,0,212,11,156,2,107,214,209,12,114,168,92,2,210,128,242,17,50,60,116,19,210,150,120,2,18,20,192,8,146,80,99,5,221,210,103,4,82,150,166,1,71,16,228,5,210,143,247,9,183,165,176,1,87,234,151,1,33,207,103,0,233,148,127,22,210,6,246,4,30,233,212,3,178,101,9,17,66,50,31,8,75,33,86,6,197,178,161,2,231,45,112,22,135,181,38,3,49,178,18,2,18,184,47,2,114,237,216,8,144,155,85,2,40,246,150,11,2,16,84,3,158,67,62,3,196,176,102,3,51,154,31,4,88,250,249,3,135,183,215,9,64,125,144,25,95,135,113,13,30,155,158,0,50,223,51,1,213,95,65,0,104,78,173,0,216,177,192,6,11,108,13,6,56,9,93,6,82,27,255,12,2,86,208,0,175,171,221,25,6,204,25,8,232,109,186,3,18,213,144,20,203,186,72,7,137,139,93,10,85,179,217,6,37,3,58,0,186,69,215,1,85,88,108,9,250,76,4,18,138,35,198,0,175,189,220,15,242,48,250,25,158,94,233,20,25,17,201,8,52,106,148,7,80,59,126,2,113,184,28,1,66,60,24,16,123,163,221,2,2,47,177,7,34,58,38,0,210,14,167,14,186,239,78,6,179,50,199,6,177,233,247,2,18,178,176,10,144,89,106,3,147,167,209,21,107,104,125,36,35,142,56,4,33,249,122,12,248,17,219,4,250,219,131,3,78,33,187,14,135,127,180,8,7,180,171,15,34,80,161,10,79,130,220,23,8,125,25,0,41,230,66,1,98,162,63,12,138,103,195,8,34,63,139,9,18,94,138,18,34,123,70,11,210,64,234,1,143,77,226,15,80,41,160,0,162,248,47,16,239,70,170,12,155,48,88,11,242,147,29,1,34,102,27,5,165,100,231,4,239,219,224,13,74,239,248,2,11,158,56,5,66,123,162,0,99,112,215,0,91,32,139,1,122,5,207,8,115,64,174,6,186,120,42,22,187,9,72,5,167,198,69,3,30,217,194,12,251,99,74,1,97,20,181,4,135,148,91,0,139,179,43,1,249,72,222,16,208,11,15,3,178,9,64,6,175,57,244,5,224,4,5,0,210,33,65,7],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":118,"stem":"A 40-year-old woman with a body mass index (BMI) of 45 kg/m² has tried multiple weight loss programs without success. She has type 2 diabetes and hypertension. Which of the following bariatric procedures has the highest risk of nutritional deficiencies?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"783a359d37e88137c8ae1810d6157cafc4d2c9f2e34b3e808d772fbb7b28d1eb","minhash":[147,90,44,0,15,0,76,2,240,60,221,2,154,8,46,2,119,122,99,12,12,235,74,7,75,0,40,9,252,31,67,0,61,172,2,10,134,19,227,9,253,221,186,0,180,109,19,4,253,84,161,8,242,6,76,10,71,249,71,3,167,133,159,12,224,155,71,5,72,11,27,5,218,38,38,9,119,56,65,2,103,118,244,2,94,99,195,11,191,217,28,0,92,167,26,9,144,15,31,6,193,87,85,0,164,71,64,1,181,196,26,0,79,193,232,7,116,210,68,2,228,150,95,6,220,135,114,1,7,156,5,17,154,140,134,4,7,44,71,7,236,28,42,6,196,180,156,5,170,174,44,1,193,67,16,9,234,138,20,6,36,109,235,1,213,237,240,1,103,6,89,8,156,36,178,5,49,226,246,9,58,183,128,1,29,220,108,7,85,241,196,0,19,71,118,6,156,201,11,1,132,211,215,0,223,236,106,1,250,251,121,4,52,233,139,2,210,38,166,9,131,222,138,0,154,38,14,1,85,182,218,6,131,230,165,2,172,206,11,4,32,117,123,4,92,134,121,0,250,20,35,8,220,73,126,0,111,4,168,13,111,122,80,11,167,101,242,1,50,108,10,5,38,97,67,2,63,120,38,3,50,187,127,11,155,227,0,1,57,46,154,7,153,152,16,9,198,125,163,10,106,99,188,0,58,249,166,1,19,5,162,4,50,226,178,2,20,53,97,7,138,49,195,1,94,65,219,1,221,42,191,7,55,161,82,7,201,129,15,7,92,216,103,8,82,136,210,2,22,242,37,2,111,138,180,0,75,2,215,1,71,178,223,20,227,221,182,7,114,100,243,0,188,236,114,1,117,247,243,1,252,229,33,0,77,154,40,3,28,93,121,15,210,190,221,3,149,3,45,1,29,154,69,2,242,115,111,4,255,171,77,11,187,22,187,4,96,166,236,8,117,125,14,2,218,85,134,13,230,255,77,1,18,142,88,6,204,253,25,6,90,253,134,5,6,247,185,2,41,47,19,3,177,146,10,2,107,249,112,9,129,216,65,13,26,129,208,2,165,217,29,4,222,181,190,3,6,161,178,2,17,196,153,6,28,142,186,10,4,182,226,1,181,183,6,4,229,104,125,17,136,21,182,2,104,247,87,1,165,33,114,14],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":119,"stem":"A 25-year-old man sustains a severe head injury in a motor vehicle accident and is declared brain dead. He has no history of significant medical conditions and is a potential organ donor. Which of the following conditions would exclude him from donating his liver?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"404889a86139cacb55911b04714a4f76d4cae0e288a416eb816559b64526c552","minhash":[176,113,233,3,62,2,37,0,51,144,126,13,230,6,19,1,51,22,86,3,131,233,122,0,106,50,2,0,200,35,165,2,190,50,25,0,84,75,67,3,67,34,1,1,9,136,245,3,42,195,186,0,232,108,28,0,225,76,54,4,230,225,103,2,38,173,45,14,101,140,153,0,7,82,29,2,146,211,19,18,29,110,59,8,213,150,116,15,33,57,87,14,230,147,29,0,206,255,96,0,204,206,139,26,234,75,117,7,146,114,221,5,115,113,96,2,32,78,178,0,36,252,33,1,10,8,154,6,190,246,51,0,61,90,165,4,131,127,40,25,27,235,212,11,128,143,154,1,58,241,185,7,178,58,16,12,64,55,41,33,38,243,68,0,54,231,242,3,71,153,173,5,147,139,27,12,36,181,230,0,58,86,181,1,163,87,168,5,155,85,59,0,41,226,32,9,181,239,25,2,24,208,40,5,80,66,40,7,237,75,95,9,171,14,0,12,202,186,191,2,18,7,41,0,41,68,205,20,102,44,99,1,195,193,69,2,62,193,191,13,19,149,49,1,206,240,142,16,167,158,124,2,27,246,18,10,190,166,41,4,76,245,191,5,206,49,170,6,251,4,94,0,242,18,23,2,202,162,36,1,147,138,10,1,84,105,234,11,43,44,237,16,185,4,21,8,205,46,255,3,62,217,68,19,188,68,195,6,232,24,133,0,206,69,229,3,10,34,5,11,170,250,191,8,102,34,172,0,4,109,226,15,120,130,55,5,206,251,153,3,121,251,105,3,106,140,196,5,21,141,216,6,119,252,247,2,170,47,153,5,229,82,10,24,244,225,241,2,243,83,180,3,235,102,156,2,88,28,225,2,18,173,204,7,17,25,104,7,74,91,165,10,246,115,47,6,108,117,34,11,48,144,1,11,252,35,85,3,200,75,118,1,115,110,59,31,15,154,101,2,244,36,41,3,33,11,237,5,206,222,247,23,183,200,77,1,57,205,133,7,83,90,77,0,122,225,193,6,168,233,247,15,210,88,224,5,3,12,103,1,20,251,171,2,242,175,39,5,67,163,235,0,96,211,146,5,122,22,149,5,68,138,116,3,60,229,168,1,185,78,219,0,208,73,158,21,232,49,149,0,135,170,156,2,97,54,88,9,27,44,44,4],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":120,"stem":"A 50-year-old man has a soft tissue sarcomas of his leg. After wide local excision, pathology shows positive margins. Which of the following is most appropriate?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"7da883bd16d7d714951a44e152dd44f7e8d5b6d1c4cc7855d040c06a165efe53","minhash":[199,163,225,0,43,186,177,9,101,118,120,6,6,87,86,1,19,174,106,13,224,123,98,26,214,179,206,12,48,31,120,15,21,186,66,25,44,86,146,10,118,248,22,2,171,153,123,6,211,66,130,5,224,168,218,27,185,197,27,5,176,242,27,4,240,254,118,2,51,142,18,9,14,161,69,1,128,169,155,0,39,37,211,26,147,104,240,10,14,253,109,20,174,226,229,16,96,51,161,4,243,158,162,29,103,220,113,2,163,180,241,24,0,212,255,7,96,66,239,1,71,174,126,5,192,108,138,0,195,130,140,28,174,246,160,2,118,34,126,2,150,230,108,13,167,100,76,2,134,189,118,1,23,114,72,5,14,192,235,28,240,98,21,3,113,86,182,11,86,28,86,9,207,189,194,15,86,48,87,18,108,80,33,19,197,115,215,5,193,176,59,18,112,14,152,1,32,145,52,19,124,211,81,8,204,188,72,1,91,85,75,15,80,214,83,8,174,152,40,4,223,40,177,8,240,25,194,22,16,40,14,6,204,154,162,0,0,39,27,2,86,220,174,14,83,52,166,21,75,251,237,7,174,178,253,44,183,90,111,45,14,86,61,10,192,235,138,17,174,250,153,8,73,206,61,0,14,210,127,5,118,177,81,7,161,42,30,9,59,119,110,8,235,146,250,5,252,180,64,14,14,92,238,17,28,166,233,9,208,104,223,1,214,217,209,22,140,6,37,4,9,52,162,12,22,125,211,14,229,208,152,8,107,122,64,7,160,251,176,9,150,161,18,24,188,51,43,4,67,166,38,3,14,251,118,10,207,44,26,12,235,255,69,2,246,238,137,30,14,151,185,4,108,123,72,7,174,232,117,2,246,197,55,10,224,222,121,33,195,114,103,3,118,146,152,33,1,143,222,7,73,137,232,1,111,137,76,2,14,45,248,16,6,84,103,4,201,101,80,3,131,63,216,3,64,177,109,7,63,128,137,13,0,191,51,22,219,166,102,21,185,188,215,4,140,152,27,8,9,65,12,4,253,92,71,0,76,210,135,10,14,52,108,6,48,4,9,11,29,228,227,0,83,66,111,32,45,7,220,4,112,52,233,5,240,201,215,7,185,66,189,6,43,0,117,6,236,34,5,0,93,174,29,11,69,126,109,1,3,30,216,17],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":121,"stem":"A 60-year-old man with albumin 2.5 g/dL is scheduled for elective colectomy. Which of the following is most appropriate?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"556b0969d6ca04c03bc02fd28c020c10212999da0ff01f27d1346b282487a143","minhash":[79,153,42,1,113,148,218,11,88,90,196,4,159,211,60,2,147,52,172,0,117,38,151,8,220,141,181,14,103,172,210,1,38,26,9,28,175,175,138,2,50,199,152,1,227,197,136,6,28,105,57,5,251,108,189,4,178,34,10,4,19,88,131,0,176,84,194,2,213,74,16,5,88,93,50,0,31,175,73,4,12,195,12,20,187,139,47,3,96,103,215,5,16,220,175,1,87,43,213,9,28,162,40,7,211,7,83,5,191,153,151,3,73,72,184,0,175,100,80,8,233,196,31,3,167,7,54,13,176,171,55,6,65,219,236,5,44,133,162,0,80,233,59,17,183,128,213,8,213,253,142,12,170,63,66,0,149,197,173,2,251,223,11,6,245,73,219,28,231,54,24,3,76,53,188,8,204,111,255,7,92,159,198,4,221,79,47,2,188,179,233,6,220,216,65,20,31,20,214,3,35,71,96,5,72,123,174,0,184,162,194,0,145,168,222,0,167,236,128,1,8,174,62,20,114,197,174,4,41,203,78,4,103,6,212,1,208,203,140,9,215,53,104,0,100,181,159,0,236,198,18,0,113,180,13,2,243,7,255,7,220,175,58,8,50,88,104,2,35,47,187,16,141,93,14,1,108,182,208,3,144,253,71,17,99,38,82,4,225,216,120,0,169,57,138,5,216,247,33,3,133,156,95,14,106,248,54,0,47,241,213,0,221,136,34,5,135,19,1,10,151,141,197,0,232,148,39,6,203,167,32,1,87,16,53,3,242,205,58,7,119,64,233,1,47,228,113,6,223,20,34,7,31,155,185,0,167,37,57,7,61,40,118,4,200,142,182,3,103,46,56,9,10,190,244,9,93,5,152,21,140,206,74,2,38,176,249,1,103,65,146,7,144,245,83,7,35,194,62,3,237,43,244,4,12,246,104,2,39,155,255,7,191,125,122,18,38,50,82,2,242,205,88,8,71,95,142,22,155,46,60,0,45,230,26,0,115,132,90,0,116,182,19,7,18,181,249,1,179,198,105,0,213,61,187,2,55,27,34,9,103,138,85,4,106,165,28,14,48,198,58,0,75,242,108,1,192,163,217,6,252,63,29,11,87,181,150,0,227,181,250,16,207,94,29,11,242,0,100,8,96,38,99,6,215,38,135,1,167,84,102,7],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":122,"stem":"In a surgical department, what is the purpose of morbidity and mortality conferences?","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"1466dd0c0c24a9990ad87f5ce750fa665da9e1ce5dffd0700c481ea7f9ee2103","minhash":[189,46,156,21,178,56,130,6,83,168,43,55,189,56,234,1,184,79,142,5,69,34,204,63,245,101,51,20,37,187,198,5,82,198,229,5,108,20,190,21,19,165,187,14,114,155,26,28,46,170,151,21,188,207,98,32,46,246,173,11,136,128,6,11,35,20,224,1,54,52,12,20,211,17,242,22,53,103,7,1,45,38,43,15,50,74,235,5,13,206,39,5,85,187,28,0,28,21,68,0,104,100,21,1,141,83,240,20,114,41,7,31,201,10,8,17,85,116,227,3,246,75,225,2,182,108,175,9,44,23,119,14,109,101,72,40,205,109,19,23,12,190,17,40,210,170,225,57,229,13,218,36,46,6,142,0,37,92,224,50,118,97,187,20,181,116,205,3,173,29,107,14,253,75,11,3,189,162,71,7,187,100,68,7,252,55,8,3,161,89,111,25,61,36,236,26,178,66,153,17,77,146,38,3,213,252,215,33,45,175,100,0,172,243,64,47,46,102,15,0,245,60,181,16,28,119,251,9,53,77,67,9,213,97,192,1,197,26,97,7,56,114,66,6,188,194,132,12,46,22,74,49,46,228,21,8,189,160,150,1,37,138,29,1,46,238,21,10,125,128,43,18,108,151,153,4,50,148,139,2,189,118,170,2,92,194,55,17,28,232,0,6,173,196,8,7,18,124,72,5,46,172,82,20,46,42,101,22,40,76,152,6,53,104,120,27,21,41,133,2,82,125,37,12,27,89,220,32,18,235,130,0,182,191,78,19,253,33,84,22,197,84,189,23,13,224,70,13,172,69,106,20,5,237,88,35,53,190,232,26,216,160,164,62,197,219,79,1,37,77,252,16,53,129,16,3,220,29,123,2,136,39,96,2,163,11,192,37,37,11,251,10,18,9,94,3,12,226,80,6,141,66,25,24,251,91,95,20,46,134,51,14,242,3,218,24,46,146,102,18,236,168,53,32,249,38,70,7,156,160,107,24,56,139,187,35,187,26,240,13,152,192,114,1,235,55,74,24,252,89,113,9,46,112,1,4,246,126,252,45,114,214,176,2,45,193,102,1,123,201,245,9,109,159,198,13,182,182,57,2,124,10,199,11,108,227,249,43,45,228,221,24,236,153,157,2,101,206,153,39,85,167,230,0,93,186,80,4,46,100,7,44],"created_at":1778400840859,"updated_at":1778596993626,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":123,"stem":"A surgeon wants to know the best treatment for a particular condition. Which of the following provides the highest level of evidence?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"a3b7508f04d0008d6c2e5c834cb894e56fe899019c84f643649b19bec6af30ed","minhash":[220,178,221,22,77,254,188,35,46,224,248,10,76,29,171,24,195,61,26,9,3,22,20,9,135,180,186,41,117,66,47,9,46,100,105,15,207,156,131,29,221,189,254,9,86,184,137,10,237,175,95,14,175,151,108,8,13,6,60,4,77,253,1,11,181,186,56,0,69,166,116,25,53,115,38,42,127,122,202,17,70,108,7,2,45,101,87,17,61,245,23,8,51,104,28,13,163,165,7,8,157,101,191,18,1,236,103,24,183,19,225,21,109,52,37,12,229,65,157,4,198,136,104,3,205,249,113,0,37,60,205,4,7,223,134,0,181,67,233,7,139,122,50,21,78,160,110,13,134,64,48,6,150,157,55,5,37,160,4,10,22,43,49,10,141,133,160,23,245,99,176,0,149,87,161,3,46,60,3,6,173,58,194,17,127,30,249,36,151,150,1,13,70,39,247,23,46,50,238,7,155,177,205,3,11,208,3,16,78,112,14,21,111,88,114,8,78,122,32,9,95,106,185,19,163,200,179,6,172,20,48,1,231,136,194,20,46,238,243,16,125,245,212,0,214,165,66,39,187,51,156,15,151,28,69,16,235,29,164,0,141,181,76,1,181,164,76,7,252,63,156,12,46,204,228,6,229,29,25,11,189,90,145,22,13,233,11,1,177,40,156,7,172,109,54,6,5,143,210,16,78,175,196,13,133,173,61,19,237,128,110,22,21,99,47,52,78,67,138,18,13,5,201,11,168,135,191,9,46,192,174,0,109,176,36,6,61,104,73,1,78,145,84,26,7,146,7,23,165,113,151,0,49,91,6,0,155,66,42,5,124,47,12,24,204,206,88,0,78,248,56,30,165,70,207,11,149,99,172,0,229,65,167,12,239,234,6,38,91,233,240,32,198,245,129,44,85,229,234,28,70,48,139,12,103,250,93,0,189,51,103,9,181,142,250,49,22,91,94,7,5,57,123,0,245,165,2,17,204,247,133,23,46,188,140,24,237,185,141,18,51,83,237,39,78,227,136,6,227,93,233,10,7,246,134,0,45,236,65,0,252,50,117,14,61,97,48,15,101,191,25,15,251,182,109,1,41,160,18,21,47,28,156,1,214,122,74,2,1,11,237,9,147,23,111,30,143,182,15,0,232,129,61,22,255,111,254,0,46,198,126,8],"created_at":1778400840859,"updated_at":1778400840859,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":3},{"id":124,"stem":"A 70 years old male with atrial fibrillation, presents with sudden onset of severe abdominal Pain, CT angiography reveals occlusion of the S M A. what is the most appropriate initial Management?.","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"bd4c54db5255776822a449a436e8a705794808d1ce772200e73760166d85ae03","minhash":[192,123,227,4,138,11,199,3,83,87,132,0,224,45,115,2,144,231,22,8,237,244,208,16,97,255,218,0,220,196,229,2,61,56,120,6,175,203,156,4,41,19,134,3,83,246,242,2,183,255,33,11,45,107,49,1,125,96,84,9,94,231,64,10,141,212,115,5,204,245,215,8,8,76,61,2,18,27,67,5,157,199,143,0,248,172,80,23,189,78,91,6,16,24,117,6,84,162,215,13,249,231,119,40,178,11,144,9,211,71,88,10,67,242,218,27,210,199,27,20,1,146,138,21,216,73,80,12,242,158,145,1,94,104,105,21,91,71,114,13,90,2,119,0,188,57,54,12,120,164,87,14,121,35,74,2,156,155,34,13,229,221,36,1,163,41,61,2,19,231,219,8,202,46,193,5,75,149,243,3,34,40,162,0,129,172,93,6,193,232,96,3,35,86,58,2,33,81,33,7,89,188,246,17,24,154,63,6,104,70,7,2,79,106,160,5,170,2,227,0,44,120,193,1,189,45,172,22,188,121,39,6,205,27,44,8,101,184,235,7,44,228,226,0,1,153,94,13,224,160,101,4,28,237,147,7,23,145,14,0,94,120,247,7,135,147,43,29,105,193,237,7,77,192,203,7,251,103,164,13,45,137,8,23,129,124,114,8,99,44,42,13,85,109,202,9,32,164,183,10,29,216,44,4,44,77,82,0,248,107,228,2,140,212,94,1,175,39,96,7,254,58,44,22,27,96,91,5,157,95,4,1,209,200,94,6,104,124,156,11,57,96,124,0,2,6,188,0,63,53,186,0,101,119,116,3,228,219,95,1,153,8,78,12,181,82,194,6,67,120,123,4,121,187,113,0,224,222,120,0,146,121,82,16,121,71,1,7,227,10,223,7,217,199,18,0,15,198,104,11,3,1,48,4,177,95,37,8,45,114,78,5,226,41,183,4,99,107,65,25,85,190,27,11,93,18,243,6,96,47,5,4,141,203,250,0,176,222,210,3,157,200,52,1,229,111,9,14,212,149,66,11,0,124,86,11,73,212,40,11,156,167,211,2,131,98,253,4,34,59,134,7,151,155,16,8,68,67,142,35,87,67,5,5,82,44,192,1,76,157,219,18,69,238,20,14,67,59,238,2,59,211,120,20,33,150,226,17,255,66,41,0],"created_at":1778401326076,"updated_at":1778401326076,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":4},{"id":125,"stem":"During laparoscopic sigmoidectomy for diverticular disease, whish is essential to minimize The risk of ureteral injury?","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"3732a4183a64ec29a1722c35dcaea80993819ec55859d3bd6b177b35d5cbab2f","minhash":[107,254,19,15,47,200,100,0,176,232,46,0,89,52,179,9,114,210,67,7,179,240,240,1,44,137,169,20,31,34,161,13,48,48,68,26,28,140,230,10,16,38,168,26,126,220,220,12,139,214,199,4,239,245,145,2,240,157,177,6,190,181,63,7,247,177,58,2,128,78,34,0,71,98,188,4,221,25,211,1,75,61,140,39,126,191,82,16,16,1,105,0,127,234,220,7,240,148,34,11,13,204,21,1,62,72,141,18,224,104,124,22,87,101,252,19,167,42,33,2,45,147,134,10,18,85,247,5,62,41,197,10,163,154,69,11,199,65,1,8,102,51,208,42,55,227,174,11,3,23,107,12,254,140,150,10,179,247,55,3,108,21,212,0,28,206,119,19,208,133,157,7,224,151,200,7,242,128,41,1,175,98,220,8,59,124,63,1,151,240,62,3,6,51,203,1,156,46,91,1,48,99,11,20,181,144,183,22,242,151,110,6,192,86,227,14,50,200,128,8,252,199,159,15,171,37,195,0,13,37,73,5,50,247,252,10,63,179,16,4,161,71,110,31,224,182,63,8,254,160,194,11,31,228,80,1,37,88,158,3,9,254,199,7,254,238,62,10,220,37,184,5,23,112,7,14,160,190,120,2,16,22,209,1,255,76,216,5,242,77,10,21,15,209,209,8,178,49,175,3,190,191,80,7,23,208,67,9,230,229,101,5,255,164,201,5,204,93,76,13,183,35,60,0,190,40,66,16,50,108,190,0,190,43,25,1,114,184,167,3,70,106,169,6,62,66,17,0,159,203,196,48,229,172,231,8,99,192,91,29,182,114,154,1,146,149,246,5,140,118,23,13,70,4,101,2,254,16,226,7,32,67,73,6,61,142,141,13,165,43,11,16,77,236,240,14,255,23,50,0,87,195,98,24,197,21,62,4,62,90,37,30,179,125,174,7,254,251,205,20,71,188,121,3,176,115,3,9,60,163,92,33,6,46,50,20,5,70,151,13,241,206,51,4,32,146,106,4,204,129,18,3,126,113,109,0,12,36,193,16,126,104,146,7,62,231,35,15,3,59,155,18,80,65,139,4,64,200,30,25,183,98,82,3,230,136,218,15,50,47,141,28,102,185,19,6,140,104,55,24,92,15,241,3,38,229,127,10,243,167,152,16],"created_at":1778401326076,"updated_at":1778576926944,"created_by":"anonymous@dev","notes":"","dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":4},{"id":126,"stem":"A 65 years old patient, has iron deficiency anemia, during colonoscopy 3 cm ulcerated Mass, 2 cm below hepatic flexure, that proved to be adenocarcinoma and –ve for metastasis what is the most appropriate surgical management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"6921548fe5e88a272f54cbb862e6031b9ef02338dc9f9a21908bb46caa01b7bf","minhash":[47,79,172,4,78,153,176,18,212,246,252,7,183,7,152,5,171,205,228,8,131,179,104,6,14,89,162,9,85,43,84,0,221,84,30,2,33,37,209,6,177,221,5,4,30,205,110,6,188,227,244,8,50,60,142,2,9,247,55,10,38,7,119,30,130,11,93,14,138,118,222,1,13,184,31,28,55,183,253,2,176,228,144,10,196,112,163,0,14,201,172,2,162,7,222,0,57,94,251,1,223,25,18,2,154,133,144,7,28,115,68,0,218,46,134,3,226,73,49,23,112,148,23,5,117,242,8,2,32,231,15,3,124,200,228,1,123,166,172,0,34,232,91,7,52,223,81,2,127,152,201,3,78,54,96,9,220,7,173,5,112,189,174,21,14,26,15,6,28,33,233,0,145,70,31,0,221,73,181,1,67,115,236,0,220,22,101,5,240,174,254,2,130,215,71,2,131,223,79,2,73,106,15,9,0,182,48,27,188,176,5,5,30,142,149,3,146,79,143,4,162,115,88,33,78,112,71,51,80,226,39,4,80,6,216,17,5,32,246,3,249,24,120,3,163,20,41,14,148,89,68,13,21,89,213,0,125,155,33,6,181,186,2,1,48,180,25,0,156,197,97,7,115,229,195,4,250,85,83,13,35,18,104,8,162,41,44,0,7,12,109,33,227,225,8,3,80,45,2,5,202,43,105,8,185,218,164,2,132,249,186,3,112,153,27,17,162,164,227,10,244,208,49,4,128,244,94,19,156,91,20,2,181,225,217,10,16,213,7,1,161,74,110,5,45,141,172,2,14,124,197,6,89,156,100,6,160,50,161,8,21,44,59,0,183,150,206,1,79,163,26,12,133,53,2,25,59,224,70,7,21,10,217,0,102,164,172,31,166,247,214,4,113,51,24,6,177,181,124,5,93,143,90,10,226,236,77,4,109,7,147,14,112,7,117,2,175,253,60,1,195,152,97,16,14,85,55,28,186,11,242,2,144,63,29,5,60,213,145,5,170,114,157,0,211,71,47,1,189,10,25,2,31,17,75,23,18,104,231,2,190,25,134,9,79,216,254,12,69,198,17,11,77,61,230,3,112,238,164,1,171,110,96,1,97,93,12,6,233,224,89,16,189,73,61,1,106,224,145,6,65,229,215,4,14,161,113,16,36,83,134,7],"created_at":1778401326076,"updated_at":1778401326076,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":4},{"id":127,"stem":"55 years old man underwent low anterior resection for low rectal cancer,developed frequent Bowel motions, urgency and incontinence, which is the most appropriate to manage his Symptoms?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"7d59871773120eec92eb680115611c66f3e474b669308127de51a3d2b8acfad8","minhash":[239,176,163,0,91,158,11,5,95,245,198,9,115,150,145,7,160,133,229,1,194,8,207,5,28,102,47,9,30,87,109,14,96,57,66,17,27,117,16,2,59,90,249,9,151,109,170,3,107,72,244,10,227,226,34,5,44,20,84,8,119,59,71,8,233,225,56,14,22,220,49,13,160,219,140,9,44,175,133,8,140,100,58,25,61,118,58,33,128,59,181,0,164,24,91,0,75,205,101,0,106,20,69,5,64,251,120,0,150,223,228,4,209,29,104,17,251,167,165,13,124,191,182,6,236,237,182,14,156,192,79,17,66,147,7,23,65,247,60,4,235,86,245,16,207,44,106,11,76,20,81,2,214,162,191,13,16,115,222,12,180,43,249,9,68,194,152,1,51,208,51,10,75,243,98,0,246,122,251,11,176,198,202,3,223,114,191,14,119,90,237,4,188,47,33,10,196,40,13,24,188,92,89,0,87,148,70,0,161,189,254,3,196,165,126,6,158,70,30,2,80,229,172,3,171,48,45,1,68,175,236,15,83,220,14,2,43,55,95,25,74,140,95,34,22,109,188,22,44,239,53,18,42,5,135,8,76,197,96,7,3,101,105,24,118,117,95,30,2,18,216,14,128,27,251,11,27,242,20,20,10,129,201,6,164,175,173,3,74,147,175,10,123,79,84,12,84,231,171,4,51,165,82,9,43,43,52,3,240,243,148,37,127,64,196,12,147,51,77,2,40,180,251,6,196,2,158,2,147,194,172,4,25,66,4,7,232,174,146,8,231,87,89,5,243,74,215,4,170,113,78,1,65,51,37,14,182,176,243,15,118,223,3,5,54,196,201,6,244,191,83,8,195,231,247,1,101,157,205,3,249,248,185,1,129,64,0,3,30,176,144,2,65,225,3,3,9,114,26,1,52,134,130,1,35,183,114,2,20,16,222,29,215,193,33,5,204,51,177,2,24,2,211,19,32,134,21,12,188,5,40,10,0,65,24,2,153,51,157,25,84,210,254,10,144,106,162,1,117,43,204,5,28,29,144,11,223,93,249,37,243,224,222,1,202,72,138,3,30,130,71,29,113,15,59,5,203,49,141,2,75,126,116,15,4,9,242,20,214,169,48,1,201,79,42,0,0,240,2,4,216,21,218,8,255,202,76,16,141,184,93,4],"created_at":1778401326076,"updated_at":1778401326076,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":4},{"id":128,"stem":"A patient with FAP, undergoes prophylactic proctocolectomy with IPAA. Post operatively he developed pelvic absecc, which is the most likely cause?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"73c1b07a1f9e58258110ccf005b1d5e9a6d576072132ef8e7e14d71f516e04ae","minhash":[55,20,109,1,15,37,208,7,86,58,80,2,234,44,105,38,235,234,2,4,50,107,64,23,32,0,3,5,180,202,58,5,157,84,78,2,153,3,91,2,103,4,20,13,234,37,19,0,215,99,19,2,24,6,250,2,222,43,9,13,94,50,98,3,40,30,127,21,48,36,20,10,100,225,58,15,16,124,125,11,64,162,137,19,35,72,160,4,200,111,120,20,201,123,45,18,0,34,26,19,23,188,45,23,44,62,85,18,94,24,7,1,222,2,133,20,227,76,134,6,108,132,110,18,9,203,207,43,139,72,226,5,67,185,132,6,8,212,209,13,243,81,76,3,204,104,151,23,175,253,250,7,222,215,178,12,184,240,135,15,255,27,7,6,84,16,23,12,72,146,162,34,248,173,239,0,232,181,62,30,42,122,164,13,205,204,187,4,19,25,46,0,40,20,98,1,94,11,20,54,200,135,77,20,16,170,78,1,204,129,185,2,191,124,171,6,32,189,215,2,165,213,85,9,71,75,212,29,79,49,36,7,228,177,13,5,51,156,89,9,39,141,176,11,88,64,70,55,86,143,239,9,94,74,125,14,214,0,232,9,150,94,252,1,136,157,117,12,191,241,106,2,214,203,171,42,150,129,223,0,141,235,249,26,184,54,69,3,68,6,79,18,3,249,24,12,44,217,192,3,184,254,171,0,167,12,158,4,57,229,200,18,71,180,111,12,94,82,110,39,168,30,40,5,24,188,214,7,175,212,38,14,124,217,244,27,104,73,70,5,191,115,243,1,72,95,119,5,106,187,14,57,10,201,86,9,15,79,85,9,72,115,50,49,51,31,234,2,214,237,177,14,127,169,166,13,8,18,165,18,223,163,176,3,7,122,253,68,207,160,224,1,96,70,134,14,255,109,218,19,214,163,205,54,50,255,108,8,72,106,121,14,159,89,83,44,0,205,218,35,31,36,162,8,55,41,220,2,244,225,249,12,215,16,42,15,94,105,114,29,23,209,60,8,19,223,80,18,168,148,14,7,170,158,134,4,97,149,216,8,63,20,106,2,214,143,107,19,20,180,201,5,72,245,186,32,248,10,135,3,0,60,228,33,178,160,14,19,72,137,154,52,105,8,236,38,132,0,160,15,88,12,67,5,86,63,118,17,80,99,187,8],"created_at":1778401326076,"updated_at":1778401326076,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":4},{"id":130,"stem":"A 38-year-old woman presents with acute onset pain over the lateral aspect of the right breast. On examination, a tender, cord-like structure is palpable extending along the anterior chest wall. There is no overlying skin erythema or systemic symptoms. Ultrasound shows a superficial, non-compressible tubular structure without internal flow. Which of the following is the MOST appropriate next step in management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":4,"last_used_year":2026,"norm_hash":"0508b9b40f4667ac446b73d06cadb4d56bd0d75b705b4df8354c12455f4a77f0","minhash":[73,71,117,1,121,186,17,19,129,219,165,2,113,231,166,5,14,247,67,9,125,37,248,2,133,48,70,1,152,251,88,6,106,135,175,3,24,164,209,13,8,213,189,3,89,194,140,1,251,169,176,2,98,157,151,11,149,220,86,4,56,186,244,9,142,221,125,2,5,105,5,0,173,2,151,2,115,117,19,3,142,169,54,0,247,245,91,3,66,61,79,0,107,236,87,1,211,174,163,8,233,72,91,1,241,142,220,0,236,2,99,0,36,1,238,3,55,191,98,0,108,239,71,7,71,25,54,0,125,33,230,2,148,218,87,1,15,67,208,3,201,128,38,5,200,229,50,2,225,221,174,2,7,49,74,3,17,189,201,2,63,250,196,0,157,221,156,4,205,69,10,3,75,201,222,5,104,175,199,0,98,201,151,5,20,164,115,5,81,138,27,1,79,101,66,5,12,84,207,5,43,154,224,0,227,198,172,12,115,81,34,1,89,116,249,2,92,202,164,2,169,171,140,5,136,10,192,1,141,9,63,7,241,82,137,10,213,150,99,3,133,8,170,3,228,249,243,8,171,86,59,5,70,195,118,0,40,173,106,5,92,38,34,0,172,183,26,2,70,64,83,1,235,61,26,6,71,22,223,11,40,59,120,2,231,69,76,7,93,107,211,0,27,33,6,2,44,36,108,1,181,180,113,0,73,69,196,12,45,59,132,1,142,135,161,2,113,111,71,1,129,191,236,2,152,105,136,10,96,133,20,1,145,175,121,7,38,246,113,2,23,52,104,7,40,214,233,4,142,174,16,1,9,99,195,1,32,158,1,4,255,156,109,13,81,53,52,0,192,51,42,3,184,119,175,15,122,149,30,2,24,31,113,3,180,230,77,7,12,207,122,1,194,65,3,1,145,34,212,5,204,79,72,2,240,186,206,14,42,205,113,0,172,157,163,1,129,149,203,1,105,145,224,7,132,97,171,1,137,104,128,0,25,93,181,2,211,228,209,1,142,231,171,2,119,249,5,5,37,10,53,4,142,124,241,5,239,85,4,3,33,91,57,3,14,7,254,2,71,182,11,7,45,165,211,4,135,202,99,4,106,79,27,1,249,165,142,0,235,166,66,6,191,46,25,10,201,56,73,0,198,192,50,6,109,231,254,1,109,63,134,2],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":0.8984,"dup_match_id":4,"parse_warnings":null,"import_id":5},{"id":132,"stem":"A 42-year-old woman presents with a rapidly enlarging, painless breast mass measuring 8 cm. On examination, the mass is mobile, bosselated, and there is stretching of the overlying skin without nipple retraction. Core biopsy suggests a fibroepithelial lesion. Which of the following features MOST strongly favors a diagnosis of malignant phyllodes tumor over fibroadenoma?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"efe2dbd0af006e1a132e85aa8f4bd885e5cb0d3cb613788275a0e4a064c9cd9c","minhash":[124,191,226,1,142,121,51,5,152,203,0,1,8,210,186,2,239,179,29,7,185,75,29,3,190,114,68,1,66,175,194,0,211,86,47,8,141,84,167,5,114,99,181,2,61,120,113,0,71,191,235,0,104,149,45,16,122,245,119,2,144,34,32,5,32,188,115,2,145,28,240,2,166,128,231,0,251,55,83,0,187,49,227,4,95,157,49,1,245,129,18,0,253,245,149,0,186,5,101,5,217,141,13,10,74,128,223,6,230,163,211,8,149,51,255,0,104,64,174,13,224,216,139,2,139,191,19,5,201,183,9,2,62,109,249,3,152,17,117,2,225,70,38,11,173,29,70,2,90,196,130,9,7,49,74,3,62,238,113,0,211,201,143,2,145,199,182,3,20,189,116,6,131,116,144,10,9,49,0,0,211,44,72,13,147,176,158,1,143,189,189,5,13,43,54,10,122,190,113,3,156,191,15,2,213,149,178,0,179,83,217,14,5,188,207,1,61,141,204,10,245,181,63,0,160,57,179,2,252,237,193,12,117,124,96,7,144,68,114,4,247,115,81,1,85,178,105,20,99,144,6,3,24,196,199,5,195,102,44,2,112,181,102,1,157,58,196,5,33,83,214,0,115,28,192,0,196,34,65,4,11,235,67,3,119,86,4,2,205,67,70,5,122,253,227,8,8,42,22,5,123,232,117,5,177,222,120,5,197,204,168,4,42,220,49,5,228,143,110,1,169,233,31,14,2,85,64,0,74,87,221,10,176,54,29,7,52,209,184,2,247,106,229,5,85,99,96,0,163,152,162,9,233,108,23,2,2,4,252,5,47,251,173,6,136,230,79,0,60,121,84,5,102,228,195,3,88,77,51,14,33,239,52,6,184,196,176,1,40,131,52,8,160,232,24,1,5,209,75,0,138,23,237,1,232,17,189,5,121,191,66,0,154,141,203,0,155,204,124,2,81,134,21,7,76,185,19,1,69,167,170,3,96,122,166,1,219,191,121,8,253,114,155,8,73,19,113,0,184,247,159,0,10,188,19,4,170,148,73,4,136,86,170,8,38,197,26,7,48,40,190,1,92,238,176,6,127,37,112,9,247,71,58,8,243,25,146,0,205,148,211,3,163,223,2,6,104,143,32,7,250,61,132,10,216,150,218,1,72,71,214,27],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":5},{"id":133,"stem":"BRCA-1 gene is located on:","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"c2de86cc65c92fe6711880ee079fa7480eec3a1955ec7379435234c77a053a39","minhash":[44,214,68,82,252,159,135,8,236,43,209,42,156,2,124,101,138,140,100,81,42,227,68,11,244,65,81,4,132,8,7,89,44,126,38,1,124,136,253,13,52,103,203,1,60,70,226,7,8,114,35,11,201,118,55,22,140,226,174,12,4,239,146,52,44,255,245,5,252,16,29,106,113,45,246,23,68,142,118,17,108,173,239,36,9,238,245,34,44,163,92,53,132,245,233,7,44,39,57,47,36,228,137,25,52,76,5,49,24,50,152,43,138,15,248,55,120,239,235,47,12,0,128,10,106,2,12,137,44,168,89,92,164,18,127,3,180,110,95,9,234,198,159,95,84,92,9,62,228,21,67,24,202,146,49,15,220,40,158,44,76,226,253,19,28,167,143,37,76,242,30,13,24,37,167,63,140,236,18,24,60,130,194,31,140,148,165,4,25,156,0,16,10,42,154,79,164,207,144,8,204,222,236,37,152,238,135,53,138,210,100,28,220,179,209,13,202,244,241,3,92,90,228,22,225,43,157,124,36,94,253,49,52,150,66,12,196,190,119,6,129,252,207,19,120,53,225,3,12,50,83,56,216,64,4,10,204,247,0,9,124,251,33,23,40,6,144,7,234,42,85,28,12,242,14,7,228,79,89,11,232,200,97,106,220,234,139,39,10,77,107,45,36,219,101,21,52,251,197,62,121,161,81,16,8,158,160,10,188,220,95,30,202,231,42,71,4,163,162,32,204,208,122,39,124,172,83,43,204,208,118,67,188,210,96,21,136,179,163,59,9,232,213,2,140,39,37,46,88,205,194,40,172,39,144,98,184,142,22,12,204,241,201,43,28,248,226,30,140,151,222,0,42,198,32,41,81,19,123,11,106,202,197,11,204,41,159,0,164,6,65,24,40,60,23,10,152,7,87,47,138,24,138,79,60,198,109,24,140,64,230,113,92,125,231,14,76,70,133,26,28,43,254,17,49,83,131,98,60,236,50,39,236,46,75,4,42,24,126,23,116,178,178,7,124,220,227,37,172,120,210,47,124,142,42,6,204,194,106,1,185,129,254,61,84,101,135,78,60,215,37,18,244,36,236,8,89,49,30,70,148,134,48,47,28,12,166,50,108,143,92,1,196,242,88,7,108,107,157,38,73,44,187,19,104,167,79,4,124,173,139,24],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":5},{"id":134,"stem":"A 62-year-old man presents with a firm retroareolar breast mass associated with nipple retraction and ipsilateral axillary lymphadenopathy. Histopathology reveals invasive carcinoma. Which of the following statements is MOST accurate regarding the biology of this tumor?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"2e3692efbc835c702033ace42e4cdc292fcec2ceaaa88b33ae6f4d1ce9498ad4","minhash":[1,6,193,0,54,159,247,13,161,212,117,20,92,65,232,1,172,120,19,7,217,103,120,0,105,211,148,5,165,98,211,6,132,80,126,7,139,31,172,0,127,172,6,1,44,169,199,2,133,206,37,1,172,14,36,0,244,90,100,18,132,81,185,2,238,54,156,6,36,16,88,1,170,125,5,11,140,151,173,6,176,105,121,4,138,205,67,9,228,10,119,12,236,7,158,9,95,202,86,3,67,42,225,2,246,19,85,1,38,30,121,10,138,82,23,3,158,78,38,2,173,126,68,12,198,52,223,8,209,176,20,4,183,146,95,1,137,18,56,8,198,1,204,1,118,137,66,5,84,183,253,8,239,146,202,4,149,147,82,12,127,121,138,6,167,101,113,8,206,209,216,0,23,248,170,6,191,244,132,1,70,174,67,4,134,90,33,8,199,131,110,1,38,41,113,20,193,245,187,2,81,51,240,12,40,230,149,1,17,140,215,2,84,156,47,3,193,200,206,1,223,148,170,5,38,107,191,2,207,57,155,3,241,131,21,3,17,78,205,3,153,241,242,2,119,150,150,0,47,236,203,10,104,50,114,1,106,143,148,0,32,25,157,2,140,228,245,5,0,162,78,13,221,121,21,14,224,48,194,1,124,37,249,20,167,195,202,18,28,128,152,8,139,181,94,0,12,1,27,9,183,161,101,0,26,66,199,0,133,28,200,0,155,152,132,11,64,245,177,6,81,24,106,0,238,214,127,0,56,135,247,3,196,84,7,1,238,182,160,3,71,16,165,6,238,246,124,6,24,126,2,7,28,113,56,3,233,91,193,2,36,198,169,11,209,214,244,11,93,30,235,8,76,98,91,9,145,227,235,6,158,19,103,6,241,132,178,0,3,29,10,1,92,86,219,14,251,229,166,1,38,6,151,0,238,86,66,4,248,234,103,13,95,231,67,18,253,183,133,1,148,120,50,4,59,248,244,1,128,255,81,0,111,151,20,0,135,203,150,0,244,120,112,3,116,203,248,8,206,7,31,4,166,15,220,6,166,45,144,9,198,44,122,7,92,193,128,2,65,9,120,0,189,47,182,5,254,78,242,3,38,123,59,8,181,30,79,3,77,140,53,4,57,35,109,13,206,211,6,0,96,213,165,6,127,171,170,4,113,54,255,19],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":0.8828,"dup_match_id":6,"parse_warnings":null,"import_id":5},{"id":135,"stem":"Ductal carcinoma in situ (DCIS) most commonly presents 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63-y/o female undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The pathology report states that there is a foci of carcinoma which invades, but does not penetrate through, the lamina propria. What is the most appropriate management?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"8c98dd3e1784837ac905cec57221ad351b404060d8d050206128183b706a2e23","minhash":[209,139,104,3,138,74,134,4,239,26,80,2,124,63,47,2,117,141,13,3,67,12,227,2,112,196,50,25,152,218,216,4,75,207,82,2,23,20,115,1,39,85,94,7,188,178,125,2,205,253,85,0,6,224,209,8,48,148,49,11,134,190,232,7,130,43,16,8,28,154,87,0,42,209,235,3,164,13,29,4,172,253,88,1,124,199,94,12,63,172,211,5,39,67,217,7,204,241,14,8,145,103,226,5,68,253,138,1,134,157,120,11,211,180,242,1,184,175,183,4,15,229,155,1,205,150,19,6,62,92,166,34,6,121,46,11,4,173,62,1,191,210,34,0,136,51,193,5,172,179,151,10,68,144,130,1,33,118,226,3,234,223,140,0,248,109,105,9,138,240,36,1,177,109,87,3,111,7,200,10,234,82,64,16,142,255,125,4,149,23,248,0,11,113,198,0,37,81,134,1,98,9,225,16,142,122,62,1,241,149,71,5,248,12,244,4,210,135,59,1,145,179,194,5,202,51,162,2,143,222,120,1,13,216,134,2,205,51,12,5,142,121,143,21,173,247,164,0,170,98,207,0,100,49,213,13,208,10,21,2,87,98,89,0,182,36,27,5,250,77,151,16,113,200,192,3,157,33,147,10,90,226,214,9,156,205,80,0,175,68,236,4,156,157,224,1,236,52,232,2,62,38,186,3,111,62,8,17,239,4,53,3,210,4,237,1,216,60,245,1,169,145,27,13,64,33,184,8,59,243,93,7,66,172,175,20,190,217,37,1,156,91,25,6,226,250,102,16,152,25,169,0,142,13,143,5,156,62,51,12,97,182,239,5,96,125,154,11,142,217,243,6,227,229,46,2,223,82,242,12,252,167,20,0,165,130,71,2,165,114,22,2,240,0,176,1,87,172,100,0,139,58,89,18,124,252,58,3,191,221,192,4,50,27,89,3,137,235,174,8,220,120,147,2,175,189,50,9,62,86,19,0,198,67,227,5,247,154,227,8,62,201,252,9,103,44,220,9,116,216,83,0,79,12,167,6,231,49,131,4,115,60,144,9,213,188,155,4,114,137,85,2,101,5,230,7,159,179,68,5,115,181,143,1,186,165,180,8,62,155,238,1,34,241,156,15,12,34,182,14,131,203,168,1,138,82,142,3,18,240,122,2],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":5},{"id":142,"stem":"Which of the following statements related to liver embryology is true?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"352a691187719bfa7e1ada2d039553647010141a6c84f7b7976055a223ed4ec1","minhash":[228,240,210,11,16,126,200,8,89,244,154,0,172,149,204,0,185,95,181,1,154,189,244,0,17,222,202,6,130,128,234,0,42,131,22,32,187,241,73,11,153,163,165,2,147,110,37,5,127,158,123,10,76,19,232,8,185,202,83,30,232,56,125,9,60,142,226,6,161,98,242,5,106,20,243,3,148,228,103,1,170,160,94,2,194,11,15,4,118,140,90,2,212,241,76,0,216,4,156,15,202,178,95,17,220,138,174,35,20,135,76,29,105,84,249,1,145,159,91,7,172,4,203,3,25,42,82,6,96,109,40,1,33,53,220,2,106,166,170,3,106,180,232,20,12,93,166,2,8,183,161,8,44,121,35,5,54,149,56,1,121,6,215,5,227,138,227,9,177,33,221,1,60,205,127,31,246,174,177,26,182,207,69,6,172,141,124,1,130,143,159,4,95,96,108,12,25,66,107,3,34,192,107,13,54,98,170,16,89,179,127,14,8,146,53,1,22,114,202,22,252,117,33,36,188,83,59,26,116,5,227,3,41,153,132,5,40,227,29,1,255,184,111,6,154,88,194,1,248,238,162,26,203,58,201,3,96,107,28,16,66,156,227,1,106,202,40,0,240,115,207,7,241,27,41,13,194,189,31,3,22,190,60,7,138,2,90,3,89,15,134,3,26,100,8,11,220,170,55,0,65,172,209,8,178,138,152,16,23,10,236,2,118,110,204,2,84,115,192,4,95,103,21,11,16,145,113,5,242,5,25,10,145,16,189,14,10,136,208,22,81,196,96,2,118,252,196,1,236,41,160,0,249,81,190,3,89,226,173,4,192,68,204,6,193,94,85,4,177,63,224,20,74,3,38,0,234,145,128,10,203,37,17,2,25,197,86,7,35,188,250,22,132,221,134,17,43,145,9,3,246,112,254,10,87,233,205,12,118,152,54,6,176,151,233,1,216,179,233,1,202,188,149,14,220,12,40,6,20,192,91,13,25,150,62,5,241,225,181,0,40,76,146,0,152,19,15,2,98,59,204,29,161,17,21,8,161,105,160,6,129,226,123,4,193,185,32,10,182,93,234,16,121,47,4,7,11,110,237,15,73,33,208,30,144,170,42,4,108,124,167,8,82,165,210,16,150,26,93,4,129,41,129,7,185,134,24,1,138,57,188,4],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":0.8672,"dup_match_id":15,"parse_warnings":null,"import_id":5},{"id":143,"stem":"Which of the following is true regarding comparisons of amebic and pyogenic liver abscesses?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"27074c3f403f23b63c2838af56dcb54314e5dfa53b6c86d6def51165dcd74dfc","minhash":[95,188,252,29,197,77,105,6,165,243,19,0,227,194,142,6,236,164,36,19,89,65,224,10,209,132,163,3,169,88,105,2,14,37,69,14,172,129,129,13,124,194,52,7,14,198,65,0,95,17,219,22,42,9,46,19,106,208,49,0,63,135,122,5,221,1,110,7,61,241,169,4,47,248,216,0,21,87,33,12,55,178,73,48,101,52,29,4,202,5,81,4,14,58,13,5,170,165,101,5,141,49,234,10,180,33,35,21,223,117,215,47,155,77,88,12,229,124,110,5,225,41,225,3,135,29,97,0,113,6,186,8,44,183,141,28,52,228,156,8,96,80,201,4,17,133,100,2,188,206,254,5,39,246,87,0,181,55,35,23,229,212,164,36,111,203,92,3,235,191,129,20,213,179,122,9,225,210,64,35,14,244,45,3,186,57,62,23,51,251,155,25,221,154,127,3,14,176,69,30,37,189,246,6,213,243,4,5,122,43,81,0,19,72,90,11,77,60,6,33,195,71,242,7,92,150,37,29,14,168,105,0,109,143,17,9,157,82,39,6,75,155,57,12,137,211,250,1,21,215,36,18,132,31,240,10,157,73,216,5,205,200,199,1,219,133,100,0,9,189,237,1,1,173,253,8,229,149,104,2,87,87,105,16,106,12,77,4,241,249,244,8,170,164,114,46,76,97,24,9,13,178,127,2,81,147,100,9,45,156,83,11,5,74,243,16,160,61,79,3,63,30,150,18,128,74,54,4,47,166,32,1,249,25,44,0,69,142,10,15,19,139,146,0,13,143,111,19,199,207,175,5,49,217,92,1,239,117,216,14,135,134,93,11,68,178,168,3,193,36,84,20,89,30,19,24,161,98,11,0,105,72,84,44,171,147,218,1,185,244,136,13,119,22,134,14,221,237,113,8,1,194,79,29,108,197,4,0,225,217,64,14,115,104,238,2,157,238,84,0,0,121,68,3,237,140,159,1,163,72,75,7,84,120,133,1,236,17,26,25,149,24,207,3,233,102,65,38,225,203,206,5,170,113,89,30,37,159,50,13,153,221,188,8,21,228,89,4,87,107,59,29,13,152,127,20,53,130,21,19,20,52,121,10,185,135,166,9,1,169,99,5,204,152,191,17,155,78,255,16,127,65,110,2,49,219,14,13,189,179,232,8],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":5},{"id":144,"stem":"Which of the following features of IPMN of the pancreas is associated with the lowest risk for cancer?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"2764b9ee92e750257c28c7e7b6d9552050349d9f3036ac9d81f75a13160636e7","minhash":[204,50,97,38,198,232,185,5,6,193,12,41,70,27,247,8,134,7,123,4,5,206,220,6,59,11,42,5,151,59,225,2,76,15,122,4,35,111,198,1,47,2,231,31,126,144,250,4,120,44,239,38,154,77,136,11,237,183,216,22,124,237,84,53,254,219,31,28,218,163,252,3,183,10,5,5,190,32,202,28,139,28,135,5,119,145,229,4,151,18,3,16,70,140,24,6,61,107,197,22,168,77,70,5,24,252,139,2,110,250,11,21,124,131,49,12,92,41,115,27,123,98,190,2,167,166,164,6,62,22,27,1,202,18,107,18,106,13,179,2,19,20,168,11,242,111,90,27,74,27,129,9,46,204,68,8,108,42,63,8,254,47,32,14,137,153,165,19,145,149,223,33,46,130,0,11,134,25,94,3,92,170,108,3,234,98,223,1,46,90,191,19,188,232,231,6,201,112,49,4,6,253,227,5,136,214,25,8,62,84,200,3,133,191,36,11,44,4,35,15,231,113,141,2,186,9,170,7,165,133,115,2,92,97,38,19,53,236,212,7,134,109,204,7,92,171,20,4,63,233,63,36,110,10,91,2,62,70,117,2,202,22,70,2,141,148,86,4,153,11,187,5,122,235,18,0,76,151,120,11,255,2,186,6,190,94,195,13,42,98,58,5,110,50,253,6,39,82,244,3,119,223,201,9,120,120,8,4,46,206,52,11,216,217,207,1,175,203,13,49,1,166,209,7,126,117,215,22,88,95,75,1,10,163,112,4,29,192,99,15,67,158,233,7,187,86,244,4,70,92,29,10,111,72,239,0,198,166,107,0,254,86,178,6,255,73,99,22,120,139,143,36,104,152,190,12,123,57,207,19,18,67,94,24,248,96,149,3,126,109,110,20,254,50,59,20,46,82,21,8,11,144,141,6,154,28,169,5,241,220,0,15,103,24,167,9,60,140,155,7,140,110,236,6,62,157,1,0,200,111,13,5,134,105,163,16,183,134,211,9,7,139,250,7,51,156,167,0,46,40,171,10,126,101,17,8,236,121,216,0,44,37,246,1,46,192,207,1,76,114,125,5,110,214,152,10,23,24,204,9,60,148,18,1,95,128,211,5,108,254,177,2,126,216,107,23,46,240,253,0,90,179,157,4,62,187,91,3,223,25,28,5],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":0.7969,"dup_match_id":17,"parse_warnings":null,"import_id":5},{"id":145,"stem":"Which of the following pancreatic cystic lesions is almost exclusively found in a young female?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"d352e5991e89ab7dbd8e1b78372f1d645fcd310ba731f2e7618ea7e3c1429635","minhash":[199,40,56,0,51,225,117,26,181,65,58,10,41,84,208,13,79,34,129,8,175,107,90,3,73,67,196,6,74,29,115,26,224,149,80,10,25,84,167,14,180,148,224,0,207,99,241,9,84,210,58,27,228,19,195,3,179,6,165,41,9,117,202,40,123,195,49,2,89,167,195,0,251,219,248,12,238,122,93,4,53,244,87,8,46,116,213,4,170,113,241,4,111,52,250,11,85,70,128,17,199,6,138,7,119,35,193,6,29,0,164,1,160,48,125,2,10,122,168,2,91,184,106,10,132,157,123,8,37,139,223,32,61,124,40,2,43,161,87,10,46,168,212,2,79,249,210,54,99,41,182,23,238,122,115,8,176,202,23,5,11,37,142,13,243,148,189,12,161,122,32,2,46,216,11,29,46,118,200,5,254,198,63,21,255,93,69,4,95,54,78,35,165,115,242,40,36,121,19,23,42,193,124,8,205,157,106,11,177,13,194,25,100,236,91,17,11,220,151,0,46,32,147,1,25,18,150,38,254,80,99,9,180,131,105,15,29,41,165,15,231,208,116,27,57,31,58,16,149,225,139,7,223,145,180,32,227,109,37,0,238,122,233,2,48,66,181,17,179,120,129,11,16,28,217,0,64,223,170,24,243,135,211,2,32,46,29,12,224,145,87,16,125,247,145,1,192,92,160,4,163,109,170,30,106,220,232,1,228,135,235,1,219,232,227,5,238,122,117,20,17,232,138,8,254,164,164,2,165,224,11,22,240,137,38,7,87,247,247,5,127,65,236,11,91,245,15,8,211,92,159,25,55,95,247,29,15,36,195,5,119,193,12,9,79,181,221,19,46,150,248,45,227,130,54,1,170,82,207,0,61,113,44,12,111,114,248,10,128,113,214,4,42,87,70,11,77,179,247,1,215,94,117,14,147,132,50,1,1,116,58,3,109,236,204,9,183,246,250,3,46,236,14,41,42,80,162,5,238,122,77,6,106,128,240,12,251,229,134,5,46,130,51,9,238,122,181,3,96,31,238,0,128,176,115,0,41,197,113,49,177,3,121,0,43,135,138,4,64,60,229,5,115,116,4,19,46,160,140,15,46,126,167,5,67,5,90,12,192,105,106,21,35,106,23,3,235,37,120,5,63,126,159,19,27,59,123,19,160,210,197,1],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":0.8047,"dup_match_id":18,"parse_warnings":null,"import_id":5},{"id":146,"stem":"A 60-year-old alcoholic man presents with chronic, vague abdominal pain. He denies a history of pancreatitis and is otherwise in good health. CT reveals a 6-cm multiloculated, septated cyst at the tail of the pancreas. FNA of the cyst is nondiagnostic. Fluid amylase and CEA are in the high normal range. Management consists of:","question_type":"sba","explanation":"","reference_text":"","difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"9ca7923254158ba56b90ff4a841e7408ec9440f1f9aac71e57a62566ba2432e6","minhash":[232,175,97,3,231,79,128,1,225,98,130,0,121,172,154,3,74,10,113,1,72,226,105,0,85,183,16,3,26,24,37,9,115,74,215,4,111,155,6,1,207,4,43,1,247,57,77,8,22,107,103,20,55,70,122,1,100,198,73,2,14,176,33,5,183,184,9,1,206,103,245,4,164,173,170,1,184,179,19,6,155,215,138,1,234,28,69,10,42,43,65,1,14,168,88,2,104,200,131,3,184,48,6,1,232,245,176,4,105,144,29,1,27,203,36,7,234,117,159,0,56,56,161,7,34,76,7,13,205,43,87,0,136,245,113,1,105,205,63,4,74,182,9,7,27,13,178,0,234,14,231,2,205,6,92,0,34,167,228,2,151,180,23,3,113,156,32,9,127,80,173,11,29,152,108,7,79,47,79,2,75,35,211,6,132,244,217,2,63,165,31,17,183,167,13,1,149,218,42,10,97,66,239,5,219,124,22,1,15,253,140,1,77,164,96,0,7,154,71,5,131,170,13,5,23,156,35,4,159,18,2,0,218,217,109,5,163,229,155,0,91,101,207,14,245,106,142,1,250,29,189,3,207,188,118,12,121,108,23,0,49,212,220,4,240,58,246,1,206,9,116,1,74,146,222,17,0,190,216,0,66,71,42,3,195,74,99,1,104,153,138,8,85,207,150,3,85,109,209,0,86,197,148,10,157,49,230,7,184,245,67,3,149,225,199,5,89,89,215,15,77,201,185,4,171,165,248,0,40,95,43,6,130,70,7,5,244,100,49,4,66,205,176,0,25,104,177,2,244,93,103,2,15,152,25,10,213,215,32,5,0,186,58,10,250,103,212,3,116,135,245,0,149,44,4,7,250,49,154,1,39,249,202,6,45,40,193,0,27,103,53,0,201,127,106,3,255,34,56,4,186,215,0,2,0,188,122,5,135,184,91,8,253,254,233,6,197,184,206,0,105,4,64,7,7,5,51,10,247,86,121,0,111,100,35,4,184,251,90,3,90,86,239,4,96,70,85,13,145,47,233,3,161,199,235,8,63,24,226,0,21,193,94,0,88,141,177,10,147,239,98,7,25,133,18,5,141,123,199,8,95,71,183,4,149,221,190,9,53,183,81,10,227,124,80,6,130,209,218,8,128,42,26,0,56,170,93,3,90,198,161,1],"created_at":1778401351232,"updated_at":1778576865097,"created_by":"anonymous@dev","notes":"","dup_score":0.8516,"dup_match_id":19,"parse_warnings":null,"import_id":5},{"id":147,"stem":"A 35-year-old patient is intubated in the ICU after being exposed to smoke. He has thick yellow secretions that require frequent suctioning along with the administration of bronchodilators. On hospital day 5, he has a percutaneous central venous catheter placed through the right internal jugular vein. Several hours later, he undergoes respiratory arrest. His peak inspiratory pressure has risen from 24 to 41 cm H2O. Choose which of the following is the most likely reason for the respiratory arrest:","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"de41b344e30555c3b218fe5fecc3530c5e4a811c701eeb61068235b4167f60a3","minhash":[209,254,37,4,21,35,134,0,97,50,92,11,165,170,234,4,202,218,161,9,243,240,156,4,71,8,188,2,196,175,55,2,238,128,67,20,100,26,150,18,49,232,82,3,5,186,84,1,151,203,111,6,251,241,93,1,37,24,156,0,208,91,184,2,45,52,168,7,229,60,109,0,133,241,132,8,139,250,154,1,124,230,152,0,187,208,0,2,32,136,136,1,205,201,7,0,37,61,123,8,49,207,140,9,209,21,44,3,182,223,115,4,161,196,212,5,114,127,41,8,103,230,60,4,33,19,80,1,227,207,58,3,162,42,102,0,93,107,215,2,248,141,155,2,192,158,48,1,88,29,98,3,156,76,126,0,189,129,204,3,8,51,35,1,117,97,218,3,238,32,127,2,83,121,80,0,18,2,78,6,245,192,109,3,189,66,49,0,25,32,144,0,81,102,193,1,84,129,132,4,221,135,188,1,80,74,81,0,213,52,205,0,246,184,141,6,10,63,94,1,69,98,23,2,54,169,123,10,54,252,216,7,234,20,162,4,131,7,149,2,31,46,160,8,246,134,48,7,197,13,97,0,112,37,245,0,65,198,38,0,53,78,249,4,189,184,174,7,165,108,62,1,132,13,132,0,253,106,155,1,182,57,174,2,119,115,50,1,74,147,231,3,58,161,196,2,173,114,57,11,178,245,252,1,136,8,75,5,46,66,244,0,153,199,7,0,10,107,132,9,112,157,213,0,232,195,254,1,90,171,118,11,233,105,249,1,9,7,48,0,46,242,34,8,32,132,192,2,89,40,46,1,169,221,29,0,27,208,242,3,167,213,239,0,118,199,211,0,73,226,104,1,117,202,41,12,224,60,152,2,39,191,26,5,85,102,186,0,147,171,233,2,161,182,29,8,151,180,224,11,67,32,175,4,235,43,138,1,223,206,160,5,189,19,119,2,168,205,217,14,49,139,113,2,238,32,211,2,105,172,3,2,234,124,56,2,239,193,160,1,7,95,139,1,136,203,26,4,245,249,179,4,228,230,247,6,67,87,5,6,135,154,137,8,232,244,145,2,41,65,137,3,218,221,81,4,202,43,69,1,109,9,72,0,133,6,12,4,246,96,228,2,46,22,152,0,49,68,40,0,216,37,230,4,76,94,152,6,171,193,94,0],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":0.7969,"dup_match_id":26,"parse_warnings":null,"import_id":5},{"id":148,"stem":"A 35-year-old woman rescued from a house fire during which she was trapped in a smoke-filled bedroom for 30 minutes. On arrival in the Emergency Room, she has marked facial burns and hoarseness of voice but no stridor. She is expectorating carbonaceous sputum, appears confused and has a cherry-red visage. Which statement is false about this case?","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":0,"last_used_year":null,"norm_hash":"0850bb71b8953c29fccc647a56cc85e011bdfd95b3dd1548cd0323531a25c907","minhash":[35,67,148,2,120,30,75,15,69,201,221,7,75,13,184,14,46,228,63,6,38,90,34,6,129,50,127,4,53,130,48,18,46,163,206,7,174,110,209,1,172,152,216,13,252,245,61,3,75,50,140,4,249,61,97,1,91,166,177,0,190,143,219,9,113,169,169,4,99,67,116,0,36,15,161,18,218,163,88,10,89,33,95,4,79,198,69,2,95,150,158,0,201,53,217,11,46,131,17,2,3,28,224,13,137,22,213,14,160,228,16,4,244,54,120,2,64,95,172,2,62,88,70,0,36,154,143,5,171,2,223,6,99,38,93,6,53,235,47,8,224,173,84,0,200,69,192,0,28,205,228,1,140,148,181,2,141,196,7,10,230,219,210,1,241,144,41,3,164,194,175,4,96,58,69,7,100,253,188,16,64,211,219,1,233,130,29,0,4,54,199,3,53,28,36,16,167,12,47,14,176,73,79,5,224,220,252,1,63,54,109,4,67,148,41,5,205,163,153,1,125,130,226,2,136,7,134,4,207,220,120,3,237,134,175,0,45,26,58,0,55,240,200,2,159,25,231,3,169,88,120,6,77,39,174,2,57,111,128,1,124,244,164,3,151,108,195,1,216,246,46,3,12,21,63,0,125,48,94,6,119,248,178,5,90,24,195,0,108,123,73,2,176,28,85,5,48,159,38,0,235,91,119,3,72,1,123,2,31,5,8,1,105,68,19,10,38,12,20,2,169,83,151,3,154,126,71,6,46,79,59,0,155,3,210,4,23,197,27,0,166,105,91,0,12,52,6,0,49,48,144,7,0,254,177,3,129,143,171,4,123,30,250,7,156,112,199,6,137,46,79,8,184,19,111,1,102,217,58,12,177,88,197,0,122,179,173,8,196,226,183,8,22,4,215,1,81,185,155,18,108,82,28,2,147,96,26,0,105,155,235,15,7,33,7,2,17,56,249,1,128,195,81,1,1,18,29,2,235,230,237,5,174,76,4,2,38,84,138,4,230,172,219,0,60,148,41,3,143,49,239,3,252,241,88,10,186,176,20,1,99,25,182,5,254,105,76,9,190,200,8,3,62,220,60,0,241,49,74,0,136,51,75,6,35,193,213,8,204,230,86,0,180,158,178,2,16,46,14,6,161,223,33,12,148,234,19,3,90,131,204,3],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":0.8516,"dup_match_id":27,"parse_warnings":null,"import_id":5},{"id":149,"stem":"In a 2-week-old term infant with pyloric stenosis and dehydration the appropriate fluid to be given iv is :","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"5fb30fb8261986205f5c35cead0499bddf4e3aedeb84f7af94f42a875ebe35e1","minhash":[146,13,84,78,19,33,184,25,70,230,225,3,159,251,148,8,205,130,189,15,59,10,110,2,128,102,59,0,178,239,211,12,57,242,154,28,111,11,201,20,203,49,54,12,165,9,58,0,205,82,56,6,47,17,99,11,240,201,229,9,176,105,219,5,237,217,181,5,129,252,159,24,82,117,115,1,165,159,152,29,174,131,113,3,187,87,123,15,70,7,206,1,133,161,163,24,23,125,100,7,151,45,162,8,210,191,64,7,96,123,35,31,192,201,7,23,117,248,233,2,103,133,91,0,50,37,151,57,215,120,172,12,175,72,0,10,82,115,180,2,50,72,111,25,13,204,83,29,6,237,117,12,128,4,221,4,107,18,210,2,45,123,69,1,65,40,200,1,137,97,71,6,135,152,23,4,3,34,246,30,245,208,164,29,179,253,206,12,176,119,217,2,128,40,121,25,147,197,184,3,176,249,149,7,178,86,100,34,23,218,32,7,53,117,19,51,70,239,155,1,208,43,70,17,96,144,136,1,177,144,134,10,239,128,131,5,240,232,204,7,205,18,88,7,81,253,254,19,82,35,197,4,231,143,146,8,198,75,162,3,143,130,245,9,73,59,38,16,178,68,221,1,205,84,204,9,143,254,238,4,89,101,15,4,35,223,238,22,169,231,123,7,222,20,232,16,61,171,161,4,96,200,238,1,192,54,139,6,209,215,159,89,160,187,218,31,197,49,196,0,18,231,191,1,111,253,56,2,19,13,34,26,50,210,188,0,13,199,63,28,187,13,118,12,32,75,17,28,225,24,65,11,255,67,4,12,85,38,103,24,224,182,147,14,240,54,53,0,141,11,196,3,112,137,90,1,167,43,36,1,191,151,202,17,173,26,129,7,239,96,65,4,147,150,229,7,37,114,162,2,198,208,22,1,242,43,92,8,157,224,84,4,95,62,3,3,127,87,233,30,222,164,165,9,70,24,160,0,135,54,27,9,205,141,102,13,247,4,129,15,93,129,139,34,227,190,182,5,233,55,25,4,129,11,2,3,19,224,66,10,101,166,44,4,23,120,93,5,242,185,30,8,112,175,102,7,208,7,240,9,173,145,242,20,222,108,130,18,189,176,41,1,134,84,53,3,174,147,151,13,114,217,36,3,240,234,59,6,178,8,161,11],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":0.7734,"dup_match_id":2,"parse_warnings":null,"import_id":5},{"id":150,"stem":"One of the following drugs may cause pyloric stenosis if administered to a premature infant:","question_type":"sba","explanation":null,"reference_text":null,"difficulty_id":3,"bloom_level":null,"category_id":17,"subcategory_id":null,"contributor_id":1,"status":"approved","first_used_year":2026,"times_used":2,"last_used_year":2026,"norm_hash":"048cf3bfd880913f257ac102616099093052ea14393f83ad76a6b83f0134cf67","minhash":[1,45,123,16,8,70,244,28,87,135,18,15,25,137,121,17,251,204,193,19,89,219,9,55,56,94,40,18,217,53,164,12,97,222,245,28,234,174,75,6,248,62,51,0,67,16,253,82,1,63,163,27,223,5,245,14,247,198,136,10,163,108,241,30,241,215,216,19,8,97,68,6,6,91,225,10,39,195,76,13,255,233,160,4,241,217,117,29,56,49,33,27,7,95,186,1,45,145,214,18,119,97,151,8,207,106,241,11,201,218,214,43,97,41,141,21,87,127,107,27,161,28,237,22,35,246,213,13,159,62,172,15,85,69,148,2,241,209,123,8,9,90,15,16,202,105,223,9,31,255,47,13,57,84,48,29,40,117,154,43,134,58,136,6,255,55,170,9,49,107,146,10,225,40,216,10,183,207,247,0,198,237,54,25,247,213,95,21,168,58,252,59,129,12,37,1,178,155,141,2,75,184,92,25,114,103,163,27,119,243,176,22,179,182,139,15,171,65,0,0,7,238,57,25,74,28,13,7,178,210,164,32,199,237,64,8,114,206,213,21,169,66,219,7,41,65,42,3,119,125,30,11,170,185,8,21,134,56,17,5,178,201,162,24,6,151,237,19,70,1,137,6,127,132,5,5,137,59,15,25,57,81,27,61,40,203,184,4,95,175,60,1,178,128,119,1,79,93,119,5,37,122,2,26,135,61,151,11,106,155,101,16,47,26,30,0,70,216,85,5,201,160,220,2,213,222,53,48,15,67,243,14,101,26,221,25,255,55,7,35,151,141,34,30,17,244,24,4,63,151,154,10,152,134,129,42,136,170,137,12,145,144,128,25,42,145,128,12,97,147,56,59,73,161,162,3,93,231,190,0,168,59,208,10,231,254,143,8,201,91,140,9,241,91,142,9,42,122,154,3,193,128,238,14,200,122,83,6,57,78,175,123,185,211,127,11,177,181,212,29,41,186,164,26,17,67,221,32,121,32,188,11,225,13,20,28,198,189,138,8,247,243,38,8,129,133,49,34,161,66,80,31,83,134,7,32,7,4,58,5,101,187,245,17,13,253,163,14,241,88,11,7,10,98,69,10,70,26,137,8,82,121,32,35,145,197,33,19,18,71,83,19,195,130,149,17,191,128,22,35,95,214,228,65,184,220,225,17,199,103,149,2],"created_at":1778401351232,"updated_at":1778401351232,"created_by":"anonymous@dev","notes":null,"dup_score":null,"dup_match_id":null,"parse_warnings":null,"import_id":5},{"id":151,"stem":"The patient undergoes pyloromyotomy. During the procedure, a deep mucosal injury is noted at the distal aspect of the incision. How should this patient's mucosal injury be 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42-year-old woman presents with a rapidly enlarging, painless breast mass measuring 8 cm. 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fluoroscopy","is_correct":0,"rationale":null,"pick_count":null},{"id":806,"question_id":125,"position":2,"letter":"B","text":"Routine use of ureteral stent","is_correct":0,"rationale":null,"pick_count":null},{"id":807,"question_id":125,"position":3,"letter":"C","text":"Medial to lateral dissection of the colon","is_correct":1,"rationale":null,"pick_count":null},{"id":808,"question_id":125,"position":4,"letter":"D","text":"Division of the inferior colic artery at its Origen","is_correct":0,"rationale":null,"pick_count":null},{"id":809,"question_id":75,"position":1,"letter":"A","text":"Continue conservative management","is_correct":1,"rationale":null,"pick_count":null},{"id":810,"question_id":75,"position":2,"letter":"B","text":"Proceed to laparotomy for surgical exploration","is_correct":0,"rationale":null,"pick_count":null},{"id":811,"question_id":75,"position":3,"letter":"C","text":"Start antibiotics for possible infection","is_correct":0,"rationale":null,"pick_count":null},{"id":812,"question_id":75,"position":4,"letter":"D","text":"Perform a CT scan to look for complications","is_correct":0,"rationale":null,"pick_count":null},{"id":813,"question_id":78,"position":1,"letter":"A","text":"Continue intravenous antibiotics and observe","is_correct":0,"rationale":null,"pick_count":null},{"id":814,"question_id":78,"position":2,"letter":"B","text":"Percutaneous drainage of the fluid collection","is_correct":1,"rationale":null,"pick_count":null},{"id":815,"question_id":78,"position":3,"letter":"C","text":"Exploratory laparotomy and washout","is_correct":0,"rationale":null,"pick_count":null},{"id":816,"question_id":78,"position":4,"letter":"D","text":"Repeat CT scan in 24 hours","is_correct":0,"rationale":null,"pick_count":null},{"id":817,"question_id":96,"position":1,"letter":"A","text":"Alpha-blockade followed by 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history and physical exam","is_correct":1,"rationale":null,"pick_count":null},{"id":825,"question_id":122,"position":1,"letter":"A","text":"To assign blame for adverse outcomes","is_correct":0,"rationale":null,"pick_count":null},{"id":826,"question_id":122,"position":2,"letter":"B","text":"To educate and improve patient care","is_correct":1,"rationale":null,"pick_count":null},{"id":827,"question_id":122,"position":3,"letter":"C","text":"To satisfy regulatory requirements","is_correct":0,"rationale":null,"pick_count":null},{"id":828,"question_id":122,"position":4,"letter":"D","text":"To compare surgeons' 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This is most suggestive of:","options_snapshot":"[{\"id\":189,\"question_id\":48,\"position\":1,\"letter\":\"A\",\"text\":\"Chronic pancreatitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":190,\"question_id\":48,\"position\":2,\"letter\":\"B\",\"text\":\"Periampullary or pancreatic head malignancy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":191,\"question_id\":48,\"position\":3,\"letter\":\"C\",\"text\":\"Choledocholithiasis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":192,\"question_id\":48,\"position\":4,\"letter\":\"D\",\"text\":\"Hepatitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":127,"position":2,"stem_snapshot":"55 years old man underwent low anterior resection for low rectal cancer,developed frequent Bowel motions, urgency and incontinence, which is the most appropriate to manage his Symptoms?","options_snapshot":"[{\"id\":505,\"question_id\":127,\"position\":1,\"letter\":\"A\",\"text\":\"Antidiarrialheal medications\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":506,\"question_id\":127,\"position\":2,\"letter\":\"B\",\"text\":\"Temporary ileostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":507,\"question_id\":127,\"position\":3,\"letter\":\"C\",\"text\":\"Pelvic floor rehabilitation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":508,\"question_id\":127,\"position\":4,\"letter\":\"D\",\"text\":\"High fiber diet\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":30,"position":3,"stem_snapshot":"In patients receiving massive blood transfusion for acute blood loss, which of the following is correct?","options_snapshot":"[{\"id\":117,\"question_id\":30,\"position\":1,\"letter\":\"A\",\"text\":\"Packed red blood cells and crystalloid solution should be infused to restore oxygen-carrying capacity and intravascular volume.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":118,\"question_id\":30,\"position\":2,\"letter\":\"B\",\"text\":\"Two units of FFP should be given with every 5 units of packed red blood cells in most cases.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":119,\"question_id\":30,\"position\":3,\"letter\":\"C\",\"text\":\"A \\\"six pack\\\" of platelets should be administered with every 10 units of packed red blood cells in most cases.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":120,\"question_id\":30,\"position\":4,\"letter\":\"D\",\"text\":\"One ampule of calcium chloride should be administered with every 5 units of packed red blood cells to avoid hypocalcaemia.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":75,"position":4,"stem_snapshot":"A 65-year-old woman with a history of multiple abdominal surgeries presents with small bowel obstruction. She has been on conservative management for 48 hours without improvement. A water-soluble contrast study is performed, and a follow-up radiograph after 24 hours shows contrast in the colon. Which of the following is the most appropriate next step?","options_snapshot":"[{\"id\":297,\"question_id\":75,\"position\":1,\"letter\":\"A\",\"text\":\"Continue conservative management\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":298,\"question_id\":75,\"position\":2,\"letter\":\"B\",\"text\":\"Proceed to laparotomy for surgical exploration\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":299,\"question_id\":75,\"position\":3,\"letter\":\"C\",\"text\":\"Start antibiotics for possible infection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":300,\"question_id\":75,\"position\":4,\"letter\":\"D\",\"text\":\"Perform a CT scan to look for complications\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":23,"position":5,"stem_snapshot":"The patient undergoes pyloromyotomy. During the procedure, a deep mucosal injury is noted at the distal aspect of the incision. How should this patient’s mucosal injury be managed?","options_snapshot":"[{\"id\":89,\"question_id\":23,\"position\":1,\"letter\":\"A\",\"text\":\"Closure of the mucosal defect with the myotomy intact\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":90,\"question_id\":23,\"position\":2,\"letter\":\"B\",\"text\":\"Closure of the mucosal and muscular defects with repeat myotomy at a later date\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":91,\"question_id\":23,\"position\":3,\"letter\":\"C\",\"text\":\"Closure of the mucosal and muscular defects with repeat myotomy on another side of the pylorus\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":92,\"question_id\":23,\"position\":4,\"letter\":\"D\",\"text\":\"Wide local drainage and antibiotics\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":130,"position":6,"stem_snapshot":"A 38-year-old woman presents with acute onset pain over the lateral aspect of the right breast. On examination, a tender, cord-like structure is palpable extending along the anterior chest wall. There is no overlying skin erythema or systemic symptoms. Ultrasound shows a superficial, non-compressible tubular structure without internal flow. Which of the following is the MOST appropriate next step in management?","options_snapshot":"[{\"id\":517,\"question_id\":130,\"position\":1,\"letter\":\"A\",\"text\":\"Immediate excisional biopsy of the lesion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":518,\"question_id\":130,\"position\":2,\"letter\":\"B\",\"text\":\"Start intravenous antibiotics and admit\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":519,\"question_id\":130,\"position\":3,\"letter\":\"C\",\"text\":\"Reassurance with NSAIDs and warm compresses\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":520,\"question_id\":130,\"position\":4,\"letter\":\"D\",\"text\":\"Initiate anticoagulation therapy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":2,"position":7,"stem_snapshot":"In a 2-week-old term infant with pyloric stenosis and dehydration, the appropriate fluid to be given IV is:","options_snapshot":"[{\"id\":5,\"question_id\":2,\"position\":1,\"letter\":\"A\",\"text\":\"5% dextrose with 0.45% saline\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":6,\"question_id\":2,\"position\":2,\"letter\":\"B\",\"text\":\"8.4% sodium bicarbonate\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":7,\"question_id\":2,\"position\":3,\"letter\":\"C\",\"text\":\"potassium chloride\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":8,\"question_id\":2,\"position\":4,\"letter\":\"D\",\"text\":\"calcium gluconate\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":89,"position":8,"stem_snapshot":"A 65-year-old man is diagnosed with a 3 cm adenocarcinoma in the sigmoid colon. The tumor is invading through the muscularis propria into the serosa, and there are no positive lymph nodes or distant metastases. Which of the following is the most appropriate stage and treatment?","options_snapshot":"[{\"id\":353,\"question_id\":89,\"position\":1,\"letter\":\"A\",\"text\":\"Stage II, surgical resection alone\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":354,\"question_id\":89,\"position\":2,\"letter\":\"B\",\"text\":\"Stage III, surgical resection and adjuvant chemotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":355,\"question_id\":89,\"position\":3,\"letter\":\"C\",\"text\":\"Stage I, surgical resection alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":356,\"question_id\":89,\"position\":4,\"letter\":\"D\",\"text\":\"Stage IV, palliative chemotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":119,"position":9,"stem_snapshot":"A 25-year-old man sustains a severe head injury in a motor vehicle accident and is declared brain dead. He has no history of significant medical conditions and is a potential organ donor. Which of the following conditions would exclude him from donating his liver?","options_snapshot":"[{\"id\":473,\"question_id\":119,\"position\":1,\"letter\":\"A\",\"text\":\"Positive hepatitis B surface antigen (HBsAg)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":474,\"question_id\":119,\"position\":2,\"letter\":\"B\",\"text\":\"History of hypertension controlled with medication\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":475,\"question_id\":119,\"position\":3,\"letter\":\"C\",\"text\":\"Family history of colorectal cancer\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":476,\"question_id\":119,\"position\":4,\"letter\":\"D\",\"text\":\"Previous tattooing without hepatitis testing\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":41,"position":10,"stem_snapshot":"The most common complication of massive blood transfusion is:","options_snapshot":"[{\"id\":161,\"question_id\":41,\"position\":1,\"letter\":\"A\",\"text\":\"Transfusion-related acute lung injury\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":162,\"question_id\":41,\"position\":2,\"letter\":\"B\",\"text\":\"Hypothermia and coagulopathy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":163,\"question_id\":41,\"position\":3,\"letter\":\"C\",\"text\":\"Anaphylaxis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":164,\"question_id\":41,\"position\":4,\"letter\":\"D\",\"text\":\"Graft-versus-host disease\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":107,"position":11,"stem_snapshot":"A 40-year-old man undergoes laparotomy for small bowel obstruction. He has severe pain postoperatively despite receiving intravenous morphine via PCA pump. Which of the following is the most appropriate next step?","options_snapshot":"[{\"id\":425,\"question_id\":107,\"position\":1,\"letter\":\"A\",\"text\":\"Increase the PCA morphine bolus dose\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":426,\"question_id\":107,\"position\":2,\"letter\":\"B\",\"text\":\"Add a continuous infusion to the PCA pump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":427,\"question_id\":107,\"position\":3,\"letter\":\"C\",\"text\":\"Switch to hydromorphone via PCA pump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":428,\"question_id\":107,\"position\":4,\"letter\":\"D\",\"text\":\"Add an NSAID for multimodal pain management\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":109,"position":12,"stem_snapshot":"A 60-year-old woman with stage IV ovarian cancer has a small bowel obstruction due to tumor progression. She has significant pain and nausea but is alert and oriented. Her performance status is Karnofsky score of 50. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":433,\"question_id\":109,\"position\":1,\"letter\":\"A\",\"text\":\"Surgical exploration and resection of obstructed bowel segment\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":434,\"question_id\":109,\"position\":2,\"letter\":\"B\",\"text\":\"Placement of a venting gastrostomy tube\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":435,\"question_id\":109,\"position\":3,\"letter\":\"C\",\"text\":\"Palliative care with opioids and antiemetics\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":436,\"question_id\":109,\"position\":4,\"letter\":\"D\",\"text\":\"Total parenteral nutrition (TPN) to bypass the obstruction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":151,"position":13,"stem_snapshot":"The patient undergoes pyloromyotomy. During the procedure, a deep mucosal injury is noted at the distal aspect of the incision. How should this patient's mucosal injury be managed?","options_snapshot":"[{\"id\":601,\"question_id\":151,\"position\":1,\"letter\":\"A\",\"text\":\"Closure of the mucosal defect with the myotomy intact\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":602,\"question_id\":151,\"position\":2,\"letter\":\"B\",\"text\":\"Closure of the mucosal and muscular defects with repeat myotomy at a later date\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":603,\"question_id\":151,\"position\":3,\"letter\":\"C\",\"text\":\"Closure of the mucosal and muscular defects with repeat myotomy on another side of the pylorus\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":604,\"question_id\":151,\"position\":4,\"letter\":\"D\",\"text\":\"Wide local drainage and antibiotics\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":76,"position":14,"stem_snapshot":"A 45-year-old woman with a BRCA1 mutation is diagnosed with a 2 cm invasive ductal carcinoma of the breast. The tumor is estrogen receptor-positive, progesterone receptor-positive, and HER2-negative. There is no evidence of metastatic disease. Which of the following is the most appropriate treatment?","options_snapshot":"[{\"id\":301,\"question_id\":76,\"position\":1,\"letter\":\"A\",\"text\":\"Lumpectomy followed by radiation therapy and tamoxifen\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":302,\"question_id\":76,\"position\":2,\"letter\":\"B\",\"text\":\"Bilateral mastectomy followed by tamoxifen\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":303,\"question_id\":76,\"position\":3,\"letter\":\"C\",\"text\":\"Lumpectomy followed by chemotherapy and tamoxifen\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":304,\"question_id\":76,\"position\":4,\"letter\":\"D\",\"text\":\"Bilateral mastectomy followed by chemotherapy and radiation therapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":50,"position":15,"stem_snapshot":"A Siewert type II gastroesophageal junction tumor is best treated with:","options_snapshot":"[{\"id\":197,\"question_id\":50,\"position\":1,\"letter\":\"A\",\"text\":\"Ivor Lewis esophagectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":198,\"question_id\":50,\"position\":2,\"letter\":\"B\",\"text\":\"Transhiatal esophagectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":199,\"question_id\":50,\"position\":3,\"letter\":\"C\",\"text\":\"Extended total gastrectomy with distal esophagectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":200,\"question_id\":50,\"position\":4,\"letter\":\"D\",\"text\":\"Endoscopic mucosal resection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":55,"position":16,"stem_snapshot":"Damage control surgery in abdominal trauma involves:","options_snapshot":"[{\"id\":217,\"question_id\":55,\"position\":1,\"letter\":\"A\",\"text\":\"Definitive repair of all injuries in one operation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":218,\"question_id\":55,\"position\":2,\"letter\":\"B\",\"text\":\"Abbreviated laparotomy with hemorrhage control, temporary closure, ICU resuscitation, then planned re-exploration\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":219,\"question_id\":55,\"position\":3,\"letter\":\"C\",\"text\":\"Non-operative management with serial imaging\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":220,\"question_id\":55,\"position\":4,\"letter\":\"D\",\"text\":\"Immediate bowel anastomosis and definitive fixation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":95,"position":17,"stem_snapshot":"A 55-year-old woman has elevated serum calcium and parathyroid hormone levels. Ultrasound shows a single enlarged parathyroid gland. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":377,\"question_id\":95,\"position\":1,\"letter\":\"A\",\"text\":\"Medical management with bisphosphonates\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":378,\"question_id\":95,\"position\":2,\"letter\":\"B\",\"text\":\"Surgical resection of the enlarged parathyroid gland\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":379,\"question_id\":95,\"position\":3,\"letter\":\"C\",\"text\":\"Radioactive ablation of the parathyroid gland\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":380,\"question_id\":95,\"position\":4,\"letter\":\"D\",\"text\":\"Observation and repeat testing in 6 months\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":80,"position":18,"stem_snapshot":"A 40-year-old woman sustains a burn injury to her right arm and chest. On exam, part of the burn has blistering and pain, while another part has charred skin with no pain. Which of the following best describes this burn?","options_snapshot":"[{\"id\":317,\"question_id\":80,\"position\":1,\"letter\":\"A\",\"text\":\"Second-degree burn\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":318,\"question_id\":80,\"position\":2,\"letter\":\"B\",\"text\":\"Third-degree burn\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":319,\"question_id\":80,\"position\":3,\"letter\":\"C\",\"text\":\"Mixed second and third-degree burn\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":320,\"question_id\":80,\"position\":4,\"letter\":\"D\",\"text\":\"Fourth-degree burn\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":61,"position":19,"stem_snapshot":"In the LRINEC score for necrotizing fasciitis, which parameter is most specific?","options_snapshot":"[{\"id\":241,\"question_id\":61,\"position\":1,\"letter\":\"A\",\"text\":\"White blood cell count\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":242,\"question_id\":61,\"position\":2,\"letter\":\"B\",\"text\":\"C-reactive protein level\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":243,\"question_id\":61,\"position\":3,\"letter\":\"C\",\"text\":\"Serum sodium\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":244,\"question_id\":61,\"position\":4,\"letter\":\"D\",\"text\":\"Hemoglobin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":134,"position":20,"stem_snapshot":"A 62-year-old man presents with a firm retroareolar breast mass associated with nipple retraction and ipsilateral axillary lymphadenopathy. Histopathology reveals invasive carcinoma. Which of the following statements is MOST accurate regarding the biology of this tumor?","options_snapshot":"[{\"id\":533,\"question_id\":134,\"position\":1,\"letter\":\"A\",\"text\":\"Lobular carcinoma is the most common histological subtype\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":534,\"question_id\":134,\"position\":2,\"letter\":\"B\",\"text\":\"The tumor is likely to be hormone receptor negative\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":535,\"question_id\":134,\"position\":3,\"letter\":\"C\",\"text\":\"Early involvement of pectoralis major\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":536,\"question_id\":134,\"position\":4,\"letter\":\"D\",\"text\":\"Axillary lymph node metastasis is rare\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":146,"position":21,"stem_snapshot":"A 60-year-old alcoholic man presents with chronic, vague abdominal pain. He denies a history of pancreatitis and is otherwise in good health. CT reveals a 6-cm multiloculated, septated cyst at the tail of the pancreas. FNA of the cyst is nondiagnostic. Fluid amylase and CEA are in the high normal range. Management consists of:","options_snapshot":"[{\"id\":581,\"question_id\":146,\"position\":1,\"letter\":\"A\",\"text\":\"Distal pancreatectomy with possible splenectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":582,\"question_id\":146,\"position\":2,\"letter\":\"B\",\"text\":\"CT-guided drainage of the cyst\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":583,\"question_id\":146,\"position\":3,\"letter\":\"C\",\"text\":\"Endoscopic cystogastrostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":584,\"question_id\":146,\"position\":4,\"letter\":\"D\",\"text\":\"Roux-en-Y cystojejunostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":92,"position":22,"stem_snapshot":"A 70-year-old man is found to have a 5 cm abdominal aorticaneurysm on routine screening ultrasound. He has hypertension and hyperlipidemia but no symptoms related to the AAA. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":365,\"question_id\":92,\"position\":1,\"letter\":\"A\",\"text\":\"Elective open surgical repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":366,\"question_id\":92,\"position\":2,\"letter\":\"B\",\"text\":\"Elective endovascular repair\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":367,\"question_id\":92,\"position\":3,\"letter\":\"C\",\"text\":\"Surveillance with ultrasound every 6 months\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":368,\"question_id\":92,\"position\":4,\"letter\":\"D\",\"text\":\"Beta-blocker therapy to reduce aortic wall stress\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":60,"position":23,"stem_snapshot":"The most common postoperative complication specific to pancreaticoduodenectomy is:","options_snapshot":"[{\"id\":237,\"question_id\":60,\"position\":1,\"letter\":\"A\",\"text\":\"Bile leak\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":238,\"question_id\":60,\"position\":2,\"letter\":\"B\",\"text\":\"Delayed gastric emptying\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":239,\"question_id\":60,\"position\":3,\"letter\":\"C\",\"text\":\"Pancreatic fistula (POPF)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":240,\"question_id\":60,\"position\":4,\"letter\":\"D\",\"text\":\"Wound infection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":138,"position":24,"stem_snapshot":"Which of the following BEST explains the increased risk of endometrial carcinoma with Tamoxifen?","options_snapshot":"[{\"id\":549,\"question_id\":138,\"position\":1,\"letter\":\"A\",\"text\":\"Complete estrogen receptor blockade in uterus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":550,\"question_id\":138,\"position\":2,\"letter\":\"B\",\"text\":\"Increased peripheral aromatization\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":551,\"question_id\":138,\"position\":3,\"letter\":\"C\",\"text\":\"Partial agonist effect on uterine estrogen receptors\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":552,\"question_id\":138,\"position\":4,\"letter\":\"D\",\"text\":\"Direct mutagenic effect on endometrium\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":58,"position":25,"stem_snapshot":"An 80-year-old male patient with a T2N0 squamous cell carcinoma of the anal canal should be treated with:","options_snapshot":"[{\"id\":229,\"question_id\":58,\"position\":1,\"letter\":\"A\",\"text\":\"Abdominoperineal resection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":230,\"question_id\":58,\"position\":2,\"letter\":\"B\",\"text\":\"Chemoradiotherapy (Nigro protocol)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":231,\"question_id\":58,\"position\":3,\"letter\":\"C\",\"text\":\"Wide local excision\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":232,\"question_id\":58,\"position\":4,\"letter\":\"D\",\"text\":\"Diverting colostomy alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":99,"position":26,"stem_snapshot":"A 60-year-old woman undergoes colorectal surgery and develops a wound infection on postoperative day 5. The wound is erythematous, tender, and has purulent drainage. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":393,\"question_id\":99,\"position\":1,\"letter\":\"A\",\"text\":\"Oral antibiotics and wound care\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":394,\"question_id\":99,\"position\":2,\"letter\":\"B\",\"text\":\"Intravenous antibiotics and wound debridement\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":395,\"question_id\":99,\"position\":3,\"letter\":\"C\",\"text\":\"Vacuum-assisted closure (VAC) therapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":396,\"question_id\":99,\"position\":4,\"letter\":\"D\",\"text\":\"Secondary closure of the wound\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":87,"position":27,"stem_snapshot":"A 60-year-old man presents with sudden onset of severe abdominal pain, rigidity, and hypotension. He has a history of peptic ulcer disease. Upright chest X-ray shows free air under the diaphragm. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":345,\"question_id\":87,\"position\":1,\"letter\":\"A\",\"text\":\"Intravenous proton pump inhibitors and antibiotics\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":346,\"question_id\":87,\"position\":2,\"letter\":\"B\",\"text\":\"Emergent laparotomy and repair of perforation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":347,\"question_id\":87,\"position\":3,\"letter\":\"C\",\"text\":\"Endoscopic clipping of the perforation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":348,\"question_id\":87,\"position\":4,\"letter\":\"D\",\"text\":\"Percutaneous drainage of any fluid collections\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":152,"position":28,"stem_snapshot":"The true statement about Ladd bands is","options_snapshot":"[{\"id\":605,\"question_id\":152,\"position\":1,\"letter\":\"A\",\"text\":\"Ladd bands obstruct the duodenum\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":606,\"question_id\":152,\"position\":2,\"letter\":\"B\",\"text\":\"Ladd bands can originate from the duodenum\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":607,\"question_id\":152,\"position\":3,\"letter\":\"C\",\"text\":\"Ladd bands are peritoneal bands that can be associated with an annular pancreas\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":608,\"question_id\":152,\"position\":4,\"letter\":\"D\",\"text\":\"Ladd bands can originate in the hepatic flexure\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":46,"position":29,"stem_snapshot":"A Meckel diverticulum is a remnant of the:","options_snapshot":"[{\"id\":181,\"question_id\":46,\"position\":1,\"letter\":\"A\",\"text\":\"Allantois\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":182,\"question_id\":46,\"position\":2,\"letter\":\"B\",\"text\":\"Vitelline (omphalomesenteric) duct\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":183,\"question_id\":46,\"position\":3,\"letter\":\"C\",\"text\":\"Urachus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":184,\"question_id\":46,\"position\":4,\"letter\":\"D\",\"text\":\"Wolffian duct\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":1,"position":30,"stem_snapshot":"Which of the following statements regarding rejection of solid organ transplants is true?","options_snapshot":"[{\"id\":1,\"question_id\":1,\"position\":1,\"letter\":\"A\",\"text\":\"Hyperacute rejection begins in the operating room with the reperfusion of the transplanted organ.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":2,\"question_id\":1,\"position\":2,\"letter\":\"B\",\"text\":\"Liver transplants are especially susceptible to hyperacute rejection.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":3,\"question_id\":1,\"position\":3,\"letter\":\"C\",\"text\":\"Most immunosuppressive medications are used to prevent chronic rejection.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":4,\"question_id\":1,\"position\":4,\"letter\":\"D\",\"text\":\"The major cause of graft failure is acute rejection.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":3,"position":31,"stem_snapshot":"In ductography, intraductal papilloma typically appears as:","options_snapshot":"[{\"id\":9,\"question_id\":3,\"position\":1,\"letter\":\"A\",\"text\":\"Irregular spiculated mass\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":10,\"question_id\":3,\"position\":2,\"letter\":\"B\",\"text\":\"Dilated cystic duct\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":11,\"question_id\":3,\"position\":3,\"letter\":\"C\",\"text\":\"Filling defect surrounded by contrast\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":12,\"question_id\":3,\"position\":4,\"letter\":\"D\",\"text\":\"Homogeneous opacity\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":25,"position":32,"stem_snapshot":"Regarding gastric duplications, which of the following is true?","options_snapshot":"[{\"id\":97,\"question_id\":25,\"position\":1,\"letter\":\"A\",\"text\":\"Gastric duplication cysts account for 20% of all duplications of the gastrointestinal tract.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":98,\"question_id\":25,\"position\":2,\"letter\":\"B\",\"text\":\"Gastric duplication tends to occur along the greater curvature.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":99,\"question_id\":25,\"position\":3,\"letter\":\"C\",\"text\":\"Gastric duplications usually communicate with the gastric lumen.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":100,\"question_id\":25,\"position\":4,\"letter\":\"D\",\"text\":\"Gastric duplications are more common in males.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":128,"position":33,"stem_snapshot":"A patient with FAP, undergoes prophylactic proctocolectomy with IPAA. Post operatively he developed pelvic absecc, which is the most likely cause?","options_snapshot":"[{\"id\":509,\"question_id\":128,\"position\":1,\"letter\":\"A\",\"text\":\"Paucities\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":510,\"question_id\":128,\"position\":2,\"letter\":\"B\",\"text\":\"infected pelvic hematoma\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":511,\"question_id\":128,\"position\":3,\"letter\":\"C\",\"text\":\"leak\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":512,\"question_id\":128,\"position\":4,\"letter\":\"D\",\"text\":\"injury of the urinary bladder\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":32,"position":34,"stem_snapshot":"The most common fluid disorder in surgical patients is:","options_snapshot":"[{\"id\":125,\"question_id\":32,\"position\":1,\"letter\":\"A\",\"text\":\"Extracellular fluid deficit\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":126,\"question_id\":32,\"position\":2,\"letter\":\"B\",\"text\":\"Hyperkalemia\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":127,\"question_id\":32,\"position\":3,\"letter\":\"C\",\"text\":\"Hyponatremia\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":128,\"question_id\":32,\"position\":4,\"letter\":\"D\",\"text\":\"Metabolic acidosis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":62,"position":35,"stem_snapshot":"In adrenocortical carcinoma, the most important prognostic factor after complete resection is:","options_snapshot":"[{\"id\":245,\"question_id\":62,\"position\":1,\"letter\":\"A\",\"text\":\"Tumor grade (Ki-67 index and mitotic rate)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":246,\"question_id\":62,\"position\":2,\"letter\":\"B\",\"text\":\"Patient age\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":247,\"question_id\":62,\"position\":3,\"letter\":\"C\",\"text\":\"Cortisol level\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":248,\"question_id\":62,\"position\":4,\"letter\":\"D\",\"text\":\"Tumor laterality\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":67,"position":36,"stem_snapshot":"In GIST, the molecular target for imatinib therapy is:","options_snapshot":"[{\"id\":265,\"question_id\":67,\"position\":1,\"letter\":\"A\",\"text\":\"EGFR mutation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":266,\"question_id\":67,\"position\":2,\"letter\":\"B\",\"text\":\"BRAF V600E mutation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":267,\"question_id\":67,\"position\":3,\"letter\":\"C\",\"text\":\"HER2 overexpression\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":268,\"question_id\":67,\"position\":4,\"letter\":\"D\",\"text\":\"PDGFRA mutation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":63,"position":37,"stem_snapshot":"Robotic surgery provides the greatest advantage over conventional laparoscopy in:","options_snapshot":"[{\"id\":249,\"question_id\":63,\"position\":1,\"letter\":\"A\",\"text\":\"Appendectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":250,\"question_id\":63,\"position\":2,\"letter\":\"B\",\"text\":\"Low pelvic dissection (e.g., low rectal cancer, prostatectomy)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":251,\"question_id\":63,\"position\":3,\"letter\":\"C\",\"text\":\"Open hernia repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":252,\"question_id\":63,\"position\":4,\"letter\":\"D\",\"text\":\"Diagnostic laparoscopy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":15,"position":38,"stem_snapshot":"Which of the following statements related to liver embryology is true?","options_snapshot":"[{\"id\":57,\"question_id\":15,\"position\":1,\"letter\":\"A\",\"text\":\"The liver is derived from the hindgut.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":58,\"question_id\":15,\"position\":2,\"letter\":\"B\",\"text\":\"Two umbilical veins carry placental blood to the liver.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":59,\"question_id\":15,\"position\":3,\"letter\":\"C\",\"text\":\"The ductus venosus shunts blood from the portal vein to the systemic circulation.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":60,\"question_id\":15,\"position\":4,\"letter\":\"D\",\"text\":\"The falciform ligament is the obliterated ductus arteriosus.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":72,"position":39,"stem_snapshot":"Definitive fixation of a femoral shaft fracture in polytrauma with pulmonary contusion is optimally timed:","options_snapshot":"[{\"id\":285,\"question_id\":72,\"position\":1,\"letter\":\"A\",\"text\":\"Within 6 hours regardless of pulmonary status\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":286,\"question_id\":72,\"position\":2,\"letter\":\"B\",\"text\":\"After 4 weeks of skeletal traction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":287,\"question_id\":72,\"position\":3,\"letter\":\"C\",\"text\":\"After stabilization, typically day 5-10 (damage control orthopedics)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":288,\"question_id\":72,\"position\":4,\"letter\":\"D\",\"text\":\"Only after all other injuries have healed\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":17,"position":40,"stem_snapshot":"Which of the following features of IPMN of the pancreas is associated with the lowest risk for cancer?","options_snapshot":"[{\"id\":65,\"question_id\":17,\"position\":1,\"letter\":\"A\",\"text\":\"Branch duct type with mural nodularity\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":66,\"question_id\":17,\"position\":2,\"letter\":\"B\",\"text\":\"Branch duct type smaller than 3 cm\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":67,\"question_id\":17,\"position\":3,\"letter\":\"C\",\"text\":\"Main duct type with segmental dilation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":68,\"question_id\":17,\"position\":4,\"letter\":\"D\",\"text\":\"Multifocal IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":12,"position":41,"stem_snapshot":"BRCA-1 gene is located on:","options_snapshot":"[{\"id\":45,\"question_id\":12,\"position\":1,\"letter\":\"A\",\"text\":\"Chromosome 13\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":46,\"question_id\":12,\"position\":2,\"letter\":\"B\",\"text\":\"Chromosome 17\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":47,\"question_id\":12,\"position\":3,\"letter\":\"C\",\"text\":\"Chromosome 21\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":48,\"question_id\":12,\"position\":4,\"letter\":\"D\",\"text\":\"Chromosome X\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":37,"position":42,"stem_snapshot":"A patient on warfarin requires emergency surgery. The fastest way to reverse anticoagulation is:","options_snapshot":"[{\"id\":145,\"question_id\":37,\"position\":1,\"letter\":\"A\",\"text\":\"Vitamin K oral administration\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":146,\"question_id\":37,\"position\":2,\"letter\":\"B\",\"text\":\"Fresh frozen plasma or prothrombin complex concentrate\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":147,\"question_id\":37,\"position\":3,\"letter\":\"C\",\"text\":\"Withholding warfarin for 3 days\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":148,\"question_id\":37,\"position\":4,\"letter\":\"D\",\"text\":\"Platelet transfusion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":153,"position":43,"stem_snapshot":"Regarding gastric duplications, which of the following is true?","options_snapshot":"[{\"id\":609,\"question_id\":153,\"position\":1,\"letter\":\"A\",\"text\":\"Gastric duplication cysts account for 20% of all duplications of the gastrointestinal tract\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":610,\"question_id\":153,\"position\":2,\"letter\":\"B\",\"text\":\"Gastric duplication tends to occur along the greater curvature\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":611,\"question_id\":153,\"position\":3,\"letter\":\"C\",\"text\":\"Gastric duplications usually communicate with the gastric lumen\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":612,\"question_id\":153,\"position\":4,\"letter\":\"D\",\"text\":\"Gastric duplications are more common in males\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":106,"position":44,"stem_snapshot":"A 50-year-old woman undergoes total abdominal hysterectomy and develops shortness of breath and chest pain on postoperative day 3. Her oxygen saturation is 88% on room air. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":421,\"question_id\":106,\"position\":1,\"letter\":\"A\",\"text\":\"Chest X-ray to rule out pneumonia\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":422,\"question_id\":106,\"position\":2,\"letter\":\"B\",\"text\":\"CT pulmonary angiogram to confirm PE\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":423,\"question_id\":106,\"position\":3,\"letter\":\"C\",\"text\":\"Administration of oxygen and anticoagulation pending further evaluation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":424,\"question_id\":106,\"position\":4,\"letter\":\"D\",\"text\":\"Ventilation-perfusion scan to evaluate for PE\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":85,"position":45,"stem_snapshot":"A 40-year-old woman presents with right upper quadrant pain, fever, and jaundice. Ultrasound shows gallstones and a dilated common bile duct. Her WBC count is 15,000/mm³, and she has a positive Murphy's sign. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":337,\"question_id\":85,\"position\":1,\"letter\":\"A\",\"text\":\"Laparoscopic cholecystectomy with intraoperative cholangiography\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":338,\"question_id\":85,\"position\":2,\"letter\":\"B\",\"text\":\"ERCP for possible stone extraction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":339,\"question_id\":85,\"position\":3,\"letter\":\"C\",\"text\":\"Percutaneous cholecystostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":340,\"question_id\":85,\"position\":4,\"letter\":\"D\",\"text\":\"Intravenous antibiotics and observation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":47,"position":46,"stem_snapshot":"Informed surgical consent must include discussion of:","options_snapshot":"[{\"id\":185,\"question_id\":47,\"position\":1,\"letter\":\"A\",\"text\":\"Surgical technique details only\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":186,\"question_id\":47,\"position\":2,\"letter\":\"B\",\"text\":\"Risks, benefits, alternatives, and expected outcomes\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":187,\"question_id\":47,\"position\":3,\"letter\":\"C\",\"text\":\"Hospital administrative policies\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":188,\"question_id\":47,\"position\":4,\"letter\":\"D\",\"text\":\"Insurance coverage details\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":144,"position":47,"stem_snapshot":"Which of the following features of IPMN of the pancreas is associated with the lowest risk for cancer?","options_snapshot":"[{\"id\":573,\"question_id\":144,\"position\":1,\"letter\":\"A\",\"text\":\"Branch duct type with mural nodularity\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":574,\"question_id\":144,\"position\":2,\"letter\":\"B\",\"text\":\"Branch duct type smaller than 3 cm\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":575,\"question_id\":144,\"position\":3,\"letter\":\"C\",\"text\":\"Main duct type with segmental dilation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":576,\"question_id\":144,\"position\":4,\"letter\":\"D\",\"text\":\"Multifocal IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":10,"position":48,"stem_snapshot":"Which of the following BEST explains the increased risk of endometrial carcinoma with Tamoxifen?","options_snapshot":"[{\"id\":37,\"question_id\":10,\"position\":1,\"letter\":\"A\",\"text\":\"Complete estrogen receptor blockade in uterus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":38,\"question_id\":10,\"position\":2,\"letter\":\"B\",\"text\":\"Increased peripheral aromatization\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":39,\"question_id\":10,\"position\":3,\"letter\":\"C\",\"text\":\"Partial agonist effect on uterine estrogen receptors\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":40,\"question_id\":10,\"position\":4,\"letter\":\"D\",\"text\":\"Direct mutagenic effect on endometrium\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":100,"position":49,"stem_snapshot":"A 35-year-old man presents with pain and swelling in his perianal region. On exam, there is a fluctuant mass at the 3 o'clock position near the anal verge. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":397,\"question_id\":100,\"position\":1,\"letter\":\"A\",\"text\":\"Incision and drainage under local anesthesia\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":398,\"question_id\":100,\"position\":2,\"letter\":\"B\",\"text\":\"Intravenous antibiotics alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":399,\"question_id\":100,\"position\":3,\"letter\":\"C\",\"text\":\"Surgical exploration and seton placement for fistula-in-ano\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":400,\"question_id\":100,\"position\":4,\"letter\":\"D\",\"text\":\"Sitz baths and stool softeners\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":93,"position":50,"stem_snapshot":"A 65-year-old man with diabetes and smoking history presents with rest pain and a non-healing ulcer on his left foot. His ABI is 0.4. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":369,\"question_id\":93,\"position\":1,\"letter\":\"A\",\"text\":\"Surgical bypass grafting or endovascular intervention\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":370,\"question_id\":93,\"position\":2,\"letter\":\"B\",\"text\":\"Cilostazol and risk factor modification\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":371,\"question_id\":93,\"position\":3,\"letter\":\"C\",\"text\":\"Amputation of the affected limb\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":372,\"question_id\":93,\"position\":4,\"letter\":\"D\",\"text\":\"Hyperbaric oxygen therapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":74,"position":51,"stem_snapshot":"A 25-year-old man presents with right lower quadrant pain, fever, and leukocytosis. CT scan shows a perforated appendix with an abdominal abscesses. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":293,\"question_id\":74,\"position\":1,\"letter\":\"A\",\"text\":\"Immediate appendectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":294,\"question_id\":74,\"position\":2,\"letter\":\"B\",\"text\":\"Percutaneous drainage of the abscesses followed by interval appendectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":295,\"question_id\":74,\"position\":3,\"letter\":\"C\",\"text\":\"Intravenous antibiotics alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":296,\"question_id\":74,\"position\":4,\"letter\":\"D\",\"text\":\"Laparoscopic appendectomy with intraoperative irrigation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":98,"position":52,"stem_snapshot":"A 30-year-old man sustains a crush injury to his right leg. He has severe pain, pallor, and paresthesias in the leg. His compartment pressure is 30 mm Hg. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":389,\"question_id\":98,\"position\":1,\"letter\":\"A\",\"text\":\"Elevation of the leg and ice packs\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":390,\"question_id\":98,\"position\":2,\"letter\":\"B\",\"text\":\"Fasciotomy of the affected compartments\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":391,\"question_id\":98,\"position\":3,\"letter\":\"C\",\"text\":\"Intravenous fluids and pain management\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":392,\"question_id\":98,\"position\":4,\"letter\":\"D\",\"text\":\"Doppler ultrasound to assess blood flow\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":77,"position":53,"stem_snapshot":"A 50-year-old man presents with a right inguinal hernia. On physical exam, the hernia is indirect and reducible. He has no comorbidities. Which of the following is the most appropriate surgical approach?","options_snapshot":"[{\"id\":305,\"question_id\":77,\"position\":1,\"letter\":\"A\",\"text\":\"Open inguinal herniorrhaphy with mesh\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":306,\"question_id\":77,\"position\":2,\"letter\":\"B\",\"text\":\"Laparoscopic transabdominal preperitoneal (TAPP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":307,\"question_id\":77,\"position\":3,\"letter\":\"C\",\"text\":\"Laparoscopic totally extraperitoneal (TEP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":308,\"question_id\":77,\"position\":4,\"letter\":\"D\",\"text\":\"Bassini repair without mesh\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":147,"position":54,"stem_snapshot":"A 35-year-old patient is intubated in the ICU after being exposed to smoke. He has thick yellow secretions that require frequent suctioning along with the administration of bronchodilators. On hospital day 5, he has a percutaneous central venous catheter placed through the right internal jugular vein. Several hours later, he undergoes respiratory arrest. His peak inspiratory pressure has risen from 24 to 41 cm H2O. Choose which of the following is the most likely reason for the respiratory arrest:","options_snapshot":"[{\"id\":585,\"question_id\":147,\"position\":1,\"letter\":\"A\",\"text\":\"Tension pneumothorax\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":586,\"question_id\":147,\"position\":2,\"letter\":\"B\",\"text\":\"Flash pulmonary edema\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":587,\"question_id\":147,\"position\":3,\"letter\":\"C\",\"text\":\"Pulmonary embolism (PE)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":588,\"question_id\":147,\"position\":4,\"letter\":\"D\",\"text\":\"Endotracheal tube obstruction\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":108,"position":55,"stem_snapshot":"A 75-year-old man with dementia is admitted with acute appendicitis. He is confused and disoriented. His wife is present and wants to give consent for surgery. Which of the following is the most appropriate action?","options_snapshot":"[{\"id\":429,\"question_id\":108,\"position\":1,\"letter\":\"A\",\"text\":\"Proceed with surgery based on the wife's consent\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":430,\"question_id\":108,\"position\":2,\"letter\":\"B\",\"text\":\"Obtain consent from the patient's primary care physician\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":431,\"question_id\":108,\"position\":3,\"letter\":\"C\",\"text\":\"Wait until the patient regains capacity to give consent\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":432,\"question_id\":108,\"position\":4,\"letter\":\"D\",\"text\":\"Seek court approval for surgery\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":136,"position":56,"stem_snapshot":"Characteristic histologic feature of invasive lobular carcinoma:","options_snapshot":"[{\"id\":541,\"question_id\":136,\"position\":1,\"letter\":\"A\",\"text\":\"Comedo necrosis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":542,\"question_id\":136,\"position\":2,\"letter\":\"B\",\"text\":\"Indian file pattern\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":543,\"question_id\":136,\"position\":3,\"letter\":\"C\",\"text\":\"Keratin pearls\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":544,\"question_id\":136,\"position\":4,\"letter\":\"D\",\"text\":\"Spindle cells\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":135,"position":57,"stem_snapshot":"Ductal carcinoma in situ (DCIS) most commonly presents as:","options_snapshot":"[{\"id\":537,\"question_id\":135,\"position\":1,\"letter\":\"A\",\"text\":\"Palpable lump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":538,\"question_id\":135,\"position\":2,\"letter\":\"B\",\"text\":\"Skin ulceration\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":539,\"question_id\":135,\"position\":3,\"letter\":\"C\",\"text\":\"Mammographic calcifications\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":540,\"question_id\":135,\"position\":4,\"letter\":\"D\",\"text\":\"Axillary lymphadenopathy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":149,"position":58,"stem_snapshot":"In a 2-week-old term infant with pyloric stenosis and dehydration the appropriate fluid to be given iv is :","options_snapshot":"[{\"id\":593,\"question_id\":149,\"position\":1,\"letter\":\"A\",\"text\":\"5% dextrose with 0.45% saline\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":594,\"question_id\":149,\"position\":2,\"letter\":\"B\",\"text\":\"8.4% sodium bicarbonate\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":595,\"question_id\":149,\"position\":3,\"letter\":\"C\",\"text\":\"potassium chloride\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":596,\"question_id\":149,\"position\":4,\"letter\":\"D\",\"text\":\"calcium gluconate\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":102,"position":59,"stem_snapshot":"A 45-year-old woman with symptomatic gallstones requests cholecystectomy. She has no history of previous abdominal surgery or comorbidities. Which of the following is the most appropriate surgical approach?","options_snapshot":"[{\"id\":405,\"question_id\":102,\"position\":1,\"letter\":\"A\",\"text\":\"Open cholecystectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":406,\"question_id\":102,\"position\":2,\"letter\":\"B\",\"text\":\"Laparoscopic cholecystectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":407,\"question_id\":102,\"position\":3,\"letter\":\"C\",\"text\":\"Robotic-assisted cholecystectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":408,\"question_id\":102,\"position\":4,\"letter\":\"D\",\"text\":\"Natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":20,"position":60,"stem_snapshot":"The most appropriate chemotherapy regimen to accompany radiation therapy in stage 3 epidermoid anal cancer would be:","options_snapshot":"[{\"id\":77,\"question_id\":20,\"position\":1,\"letter\":\"A\",\"text\":\"Carboplatin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":78,\"question_id\":20,\"position\":2,\"letter\":\"B\",\"text\":\"Gemcitabine\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":79,\"question_id\":20,\"position\":3,\"letter\":\"C\",\"text\":\"Leucovarin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":80,\"question_id\":20,\"position\":4,\"letter\":\"D\",\"text\":\"Mytomycin C\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":27,"position":61,"stem_snapshot":"A 35-year-old woman is rescued from a house fire during which she was trapped in a smoke-filled bedroom for 30 minutes. On arrival in the Emergency Room, she has marked facial burns and hoarseness of voice but no stridor. She is expectorating carbonaceous sputum, appears confused and has a cherry-red visage. Which statement is FALSE about this case?","options_snapshot":"[{\"id\":105,\"question_id\":27,\"position\":1,\"letter\":\"A\",\"text\":\"Early intubation is advisable.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":106,\"question_id\":27,\"position\":2,\"letter\":\"B\",\"text\":\"A significant thermal injury to the trachea is likely.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":107,\"question_id\":27,\"position\":3,\"letter\":\"C\",\"text\":\"Lavage with sodium bicarbonate 1.4% has a role in the management of this patient.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":108,\"question_id\":27,\"position\":4,\"letter\":\"D\",\"text\":\"Lung function is likely to worsen over the next 12 hours.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":57,"position":62,"stem_snapshot":"In gastric cancer, the Borrmann type IV (linitis plastica) is characterized by:","options_snapshot":"[{\"id\":225,\"question_id\":57,\"position\":1,\"letter\":\"A\",\"text\":\"Polypoid growth\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":226,\"question_id\":57,\"position\":2,\"letter\":\"B\",\"text\":\"Ulcerative lesion with well-defined margins\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":227,\"question_id\":57,\"position\":3,\"letter\":\"C\",\"text\":\"Diffuse infiltration of the gastric wall with thickening\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":228,\"question_id\":57,\"position\":4,\"letter\":\"D\",\"text\":\"Superficial spreading lesion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":118,"position":63,"stem_snapshot":"A 40-year-old woman with a body mass index (BMI) of 45 kg/m² has tried multiple weight loss programs without success. She has type 2 diabetes and hypertension. Which of the following bariatric procedures has the highest risk of nutritional deficiencies?","options_snapshot":"[{\"id\":469,\"question_id\":118,\"position\":1,\"letter\":\"A\",\"text\":\"Gastric bypass (Roux-en-Y)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":470,\"question_id\":118,\"position\":2,\"letter\":\"B\",\"text\":\"Sleeve gastrectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":471,\"question_id\":118,\"position\":3,\"letter\":\"C\",\"text\":\"Adjustable gastric banding\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":472,\"question_id\":118,\"position\":4,\"letter\":\"D\",\"text\":\"Biliopancreatic diversion with duodenal switch (BPD-DS)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":97,"position":64,"stem_snapshot":"A 25-year-old man sustains a stab wound to the chest. He has decreased breath sounds on the left side and subcutaneous emphysema. Chest X-ray shows a large left pneumothora x. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":385,\"question_id\":97,\"position\":1,\"letter\":\"A\",\"text\":\"Observation and repeat X-ray in 2 hours\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":386,\"question_id\":97,\"position\":2,\"letter\":\"B\",\"text\":\"Placement of a chest tube\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":387,\"question_id\":97,\"position\":3,\"letter\":\"C\",\"text\":\"Immediate thoracotomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":388,\"question_id\":97,\"position\":4,\"letter\":\"D\",\"text\":\"Needle aspiration of the pneumothora x\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":96,"position":65,"stem_snapshot":"A 35-year-old man presents with hypertension, palpitations, and sweating. Biochemical testing confirms elevated catecholamine levels, and CT scan shows a left adrenal mass. Which of the following is the most appropriate management before surgical resection?","options_snapshot":"[{\"id\":381,\"question_id\":96,\"position\":1,\"letter\":\"A\",\"text\":\"Alpha-blockade followed by beta-blockade\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":382,\"question_id\":96,\"position\":2,\"letter\":\"B\",\"text\":\"Beta-blockade alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":383,\"question_id\":96,\"position\":3,\"letter\":\"C\",\"text\":\"Calcium channel blockers\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":384,\"question_id\":96,\"position\":4,\"letter\":\"D\",\"text\":\"No specific preoperative management needed\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":54,"position":66,"stem_snapshot":"In Zollinger-Ellison syndrome, the gastrinoma is most commonly located in the:","options_snapshot":"[{\"id\":213,\"question_id\":54,\"position\":1,\"letter\":\"A\",\"text\":\"Stomach body\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":214,\"question_id\":54,\"position\":2,\"letter\":\"B\",\"text\":\"Duodenal wall\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":215,\"question_id\":54,\"position\":3,\"letter\":\"C\",\"text\":\"Jejunum\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":216,\"question_id\":54,\"position\":4,\"letter\":\"D\",\"text\":\"Colon\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":59,"position":67,"stem_snapshot":"The Amsterdam criteria (Amsterdam II) are used to identify families with:","options_snapshot":"[{\"id\":233,\"question_id\":59,\"position\":1,\"letter\":\"A\",\"text\":\"Familial adenomatous polyposis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":234,\"question_id\":59,\"position\":2,\"letter\":\"B\",\"text\":\"Lynch syndrome\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":235,\"question_id\":59,\"position\":3,\"letter\":\"C\",\"text\":\"Peutz-Jeghers syndrome\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":236,\"question_id\":59,\"position\":4,\"letter\":\"D\",\"text\":\"Gardner syndrome\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":82,"position":68,"stem_snapshot":"A 45-year-old woman with Graves' disease has her hyperthyroidism well-controlled with antithyroid medications. She is scheduled for total thyroidectomy. Which of the following is the most important pre-operative management step to prevent complications?","options_snapshot":"[{\"id\":325,\"question_id\":82,\"position\":1,\"letter\":\"A\",\"text\":\"Administration of iodine to reduce thyroid vascularity\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":326,\"question_id\":82,\"position\":2,\"letter\":\"B\",\"text\":\"Correction of any electrolyte imbalances\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":327,\"question_id\":82,\"position\":3,\"letter\":\"C\",\"text\":\"Assessment of vocal cord function\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":328,\"question_id\":82,\"position\":4,\"letter\":\"D\",\"text\":\"Prophylactic antibiotics\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":81,"position":69,"stem_snapshot":"A 30-year-old male smoker presents with pain and discoloration of his left foot. On physical exam, his foot is cold, and there are no palpable pulses below the popliteal artery,Which of the following is the most likely diagnosis?","options_snapshot":"[{\"id\":321,\"question_id\":81,\"position\":1,\"letter\":\"A\",\"text\":\"Peripheral artery disease (PAD)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":322,\"question_id\":81,\"position\":2,\"letter\":\"B\",\"text\":\"Deep vein thrombosis (DVT)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":323,\"question_id\":81,\"position\":3,\"letter\":\"C\",\"text\":\"Thromboangitis obliterans (TAO)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":324,\"question_id\":81,\"position\":4,\"letter\":\"D\",\"text\":\"Raynaud's disease\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":8,"position":70,"stem_snapshot":"Characteristic histologic feature of invasive lobular carcinoma:","options_snapshot":"[{\"id\":29,\"question_id\":8,\"position\":1,\"letter\":\"A\",\"text\":\"Comedo necrosis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":30,\"question_id\":8,\"position\":2,\"letter\":\"B\",\"text\":\"Indian file pattern\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":31,\"question_id\":8,\"position\":3,\"letter\":\"C\",\"text\":\"Keratin pearls\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":32,\"question_id\":8,\"position\":4,\"letter\":\"D\",\"text\":\"Spindle cells\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":145,"position":71,"stem_snapshot":"Which of the following pancreatic cystic lesions is almost exclusively found in a young female?","options_snapshot":"[{\"id\":577,\"question_id\":145,\"position\":1,\"letter\":\"A\",\"text\":\"Mucinous cystic neoplasm\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":578,\"question_id\":145,\"position\":2,\"letter\":\"B\",\"text\":\"Side-duct IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":579,\"question_id\":145,\"position\":3,\"letter\":\"C\",\"text\":\"Main-duct IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":580,\"question_id\":145,\"position\":4,\"letter\":\"D\",\"text\":\"Solid pseudopapillary epithelial neoplasm\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":53,"position":72,"stem_snapshot":"Iatrogenic bile duct injury (Strasberg type E) discovered intraoperatively is best managed by:","options_snapshot":"[{\"id\":209,\"question_id\":53,\"position\":1,\"letter\":\"A\",\"text\":\"Place a T-tube and close\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":210,\"question_id\":53,\"position\":2,\"letter\":\"B\",\"text\":\"Roux-en-Y hepaticojejunostomy by an expert surgeon\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":211,\"question_id\":53,\"position\":3,\"letter\":\"C\",\"text\":\"Primary repair over a stent\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":212,\"question_id\":53,\"position\":4,\"letter\":\"D\",\"text\":\"Endoscopic sphincterotomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":65,"position":73,"stem_snapshot":"A transplant patient presenting with CMV disease should receive:","options_snapshot":"[{\"id\":257,\"question_id\":65,\"position\":1,\"letter\":\"A\",\"text\":\"Acyclovir\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":258,\"question_id\":65,\"position\":2,\"letter\":\"B\",\"text\":\"Fluconazole\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":259,\"question_id\":65,\"position\":3,\"letter\":\"C\",\"text\":\"Ganciclovir or valganciclovir\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":260,\"question_id\":65,\"position\":4,\"letter\":\"D\",\"text\":\"Reduction of immunosuppression alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":124,"position":74,"stem_snapshot":"A 70 years old male with atrial fibrillation, presents with sudden onset of severe abdominal Pain, CT angiography reveals occlusion of the S M A. what is the most appropriate initial Management?.","options_snapshot":"[{\"id\":493,\"question_id\":124,\"position\":1,\"letter\":\"A\",\"text\":\"intensive thrombolytic therapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":494,\"question_id\":124,\"position\":2,\"letter\":\"B\",\"text\":\"urgent mesenteric artery stenting\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":495,\"question_id\":124,\"position\":3,\"letter\":\"C\",\"text\":\"intravenous heparin and monitoring\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":496,\"question_id\":124,\"position\":4,\"letter\":\"D\",\"text\":\"laparotomy and embolectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":111,"position":75,"stem_snapshot":"A 30-year-old man has a 5 cm laceration on his arm with full-thickness skin loss but intact underlying muscle and fascia. The wound bed is clean and granulating. Which of the following is the most appropriate wound closure method?","options_snapshot":"[{\"id\":441,\"question_id\":111,\"position\":1,\"letter\":\"A\",\"text\":\"Primary closure with sutures\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":442,\"question_id\":111,\"position\":2,\"letter\":\"B\",\"text\":\"Secondary intention healing\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":443,\"question_id\":111,\"position\":3,\"letter\":\"C\",\"text\":\"Split-thickness skin graft (STSG)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":444,\"question_id\":111,\"position\":4,\"letter\":\"D\",\"text\":\"Flap reconstruction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":26,"position":76,"stem_snapshot":"A 35-year-old patient is intubated in the ICU after being exposed to smoke. He has thick yellow secretions that require frequent suctioning along with the administration of bronchodilators. On hospital day 5, he has a percutaneous central venous catheter placed through the right internal jugular vein. Several hours later, he undergoes respiratory arrest. His peak inspiratory pressure has risen from 24 to 41 cm H₂O. Choose the most likely reason for the respiratory arrest:","options_snapshot":"[{\"id\":101,\"question_id\":26,\"position\":1,\"letter\":\"A\",\"text\":\"Tension pneumothorax.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":102,\"question_id\":26,\"position\":2,\"letter\":\"B\",\"text\":\"Flash pulmonary edema.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":103,\"question_id\":26,\"position\":3,\"letter\":\"C\",\"text\":\"Pulmonary embolism (PE).\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":104,\"question_id\":26,\"position\":4,\"letter\":\"D\",\"text\":\"Endotracheal tube obstruction.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":150,"position":77,"stem_snapshot":"One of the following drugs may cause pyloric stenosis if administered to a premature infant:","options_snapshot":"[{\"id\":597,\"question_id\":150,\"position\":1,\"letter\":\"A\",\"text\":\"intravenous vitamin E\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":598,\"question_id\":150,\"position\":2,\"letter\":\"B\",\"text\":\"indomethacin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":599,\"question_id\":150,\"position\":3,\"letter\":\"C\",\"text\":\"enteric gentamicin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":600,\"question_id\":150,\"position\":4,\"letter\":\"D\",\"text\":\"prostaglandins\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":142,"position":78,"stem_snapshot":"Which of the following statements related to liver embryology is true?","options_snapshot":"[{\"id\":565,\"question_id\":142,\"position\":1,\"letter\":\"A\",\"text\":\"The liver is derived from the hindgut\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":566,\"question_id\":142,\"position\":2,\"letter\":\"B\",\"text\":\"Two umbilical veins carry placental blood to the liver\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":567,\"question_id\":142,\"position\":3,\"letter\":\"C\",\"text\":\"The ductus venosus shunts blood from the portal vein to the systemic circulation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":568,\"question_id\":142,\"position\":4,\"letter\":\"D\",\"text\":\"The falciform ligament is the obliterated ductus arteriosus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":6,"position":79,"stem_snapshot":"A 62-year-old man presents with a firm retroareolar breast mass associated with nipple retraction and ipsilateral axillary lymphadenopathy. Histopathology reveals invasive carcinoma. Which of the following statements is MOST accurate regarding the biology of this tumor?","options_snapshot":"[{\"id\":21,\"question_id\":6,\"position\":1,\"letter\":\"A\",\"text\":\"Lobular carcinoma is the most common histological subtype\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":22,\"question_id\":6,\"position\":2,\"letter\":\"B\",\"text\":\"The tumor is likely to be hormone receptor negative\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":23,\"question_id\":6,\"position\":3,\"letter\":\"C\",\"text\":\"Early involvement of pectoralis major\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":24,\"question_id\":6,\"position\":4,\"letter\":\"D\",\"text\":\"Axillary lymph node metastasis is rare\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":51,"position":80,"stem_snapshot":"The Milan criteria for HCC liver transplantation include:","options_snapshot":"[{\"id\":201,\"question_id\":51,\"position\":1,\"letter\":\"A\",\"text\":\"Single tumor ≤5 cm or up to 3 tumors each ≤3 cm, no vascular invasion\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":202,\"question_id\":51,\"position\":2,\"letter\":\"B\",\"text\":\"Single tumor up to 10 cm\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":203,\"question_id\":51,\"position\":3,\"letter\":\"C\",\"text\":\"Any number of tumors if AFP <400\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":204,\"question_id\":51,\"position\":4,\"letter\":\"D\",\"text\":\"Tumor confined to one lobe regardless of size\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":21,"position":81,"stem_snapshot":"Concerning anal fissure, one of the following is TRUE:","options_snapshot":"[{\"id\":81,\"question_id\":21,\"position\":1,\"letter\":\"A\",\"text\":\"Fissures away from the midline should be investigated.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":82,\"question_id\":21,\"position\":2,\"letter\":\"B\",\"text\":\"The results of chemical sphincterotomy are comparable to lateral sphincterotomy.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":83,\"question_id\":21,\"position\":3,\"letter\":\"C\",\"text\":\"Partial internal lateral sphincterotomy is best carried out at the site of the fissure.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":84,\"question_id\":21,\"position\":4,\"letter\":\"D\",\"text\":\"Pain following defecation is attributed to external anal sphincter spasm.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":103,"position":82,"stem_snapshot":"A 50-year-old man has a primary unilateral inguinal hernia. He has no history of previous surgery or comorbidities. Which of the following is the most appropriate surgical approach?","options_snapshot":"[{\"id\":409,\"question_id\":103,\"position\":1,\"letter\":\"A\",\"text\":\"Open inguinal herniorrhaphy with mesh\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":410,\"question_id\":103,\"position\":2,\"letter\":\"B\",\"text\":\"Laparoscopic transabdominal preperitoneal (TAPP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":411,\"question_id\":103,\"position\":3,\"letter\":\"C\",\"text\":\"Laparoscopic totally extraperitoneal (TEP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":412,\"question_id\":103,\"position\":4,\"letter\":\"D\",\"text\":\"Bassini repair without mesh\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":22,"position":83,"stem_snapshot":"One of the following drugs may cause pyloric stenosis if administered to a premature infant:","options_snapshot":"[{\"id\":85,\"question_id\":22,\"position\":1,\"letter\":\"A\",\"text\":\"Intravenous vitamin E\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":86,\"question_id\":22,\"position\":2,\"letter\":\"B\",\"text\":\"Indomethacin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":87,\"question_id\":22,\"position\":3,\"letter\":\"C\",\"text\":\"Enteric gentamicin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":88,\"question_id\":22,\"position\":4,\"letter\":\"D\",\"text\":\"Prostaglandins\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":5,"position":84,"stem_snapshot":"A 42-year-old woman presents with a rapidly enlarging, painless breast mass measuring 8 cm. On examination, the mass is mobile, bosselated, and there is stretching of the overlying skin without nipple retraction. Core biopsy suggests a fibroepithelial lesion. Which of the following features MOST strongly favors a diagnosis of malignant phyllodes tumor over fibroadenoma?","options_snapshot":"[{\"id\":17,\"question_id\":5,\"position\":1,\"letter\":\"A\",\"text\":\"Presence of cystic spaces on ultrasound\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":18,\"question_id\":5,\"position\":2,\"letter\":\"B\",\"text\":\"Monoclonal stromal cell proliferation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":19,\"question_id\":5,\"position\":3,\"letter\":\"C\",\"text\":\"Sharp demarcation from surrounding tissue\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":20,\"question_id\":5,\"position\":4,\"letter\":\"D\",\"text\":\"Absence of axillary lymphadenopathy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":9,"position":85,"stem_snapshot":"A tumor is negative for ER, PR, and HER2 but expresses CK5/6 and EGFR. Which subtype does this represent?","options_snapshot":"[{\"id\":33,\"question_id\":9,\"position\":1,\"letter\":\"A\",\"text\":\"Luminal A\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":34,\"question_id\":9,\"position\":2,\"letter\":\"B\",\"text\":\"Luminal B\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":35,\"question_id\":9,\"position\":3,\"letter\":\"C\",\"text\":\"Basal-like (TNBC)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":36,\"question_id\":9,\"position\":4,\"letter\":\"D\",\"text\":\"HER2-enriched\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":123,"position":86,"stem_snapshot":"A surgeon wants to know the best treatment for a particular condition. Which of the following provides the highest level of evidence?","options_snapshot":"[{\"id\":489,\"question_id\":123,\"position\":1,\"letter\":\"A\",\"text\":\"Randomized controlled trials (RCTs)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":490,\"question_id\":123,\"position\":2,\"letter\":\"B\",\"text\":\"Case reports\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":491,\"question_id\":123,\"position\":3,\"letter\":\"C\",\"text\":\"Expert opinion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":492,\"question_id\":123,\"position\":4,\"letter\":\"D\",\"text\":\"Retrospective cohort studies\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":73,"position":87,"stem_snapshot":"A surgeon's lifetime risk of a significant sharps injury during their career is estimated at:","options_snapshot":"[{\"id\":289,\"question_id\":73,\"position\":1,\"letter\":\"A\",\"text\":\"Less than 5%\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":290,\"question_id\":73,\"position\":2,\"letter\":\"B\",\"text\":\"15-25%\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":291,\"question_id\":73,\"position\":3,\"letter\":\"C\",\"text\":\"40-60%\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":292,\"question_id\":73,\"position\":4,\"letter\":\"D\",\"text\":\"Greater than 80%\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":113,"position":88,"stem_snapshot":"A 45-year-old man presents with colicky abdominal pain and bloody diarrhea. CT scan shows a segment of small bowel invaginated into another segment with a lead point mass. Which of the following is the most likely diagnosis?","options_snapshot":"[{\"id\":449,\"question_id\":113,\"position\":1,\"letter\":\"A\",\"text\":\"Crohn's disease\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":450,\"question_id\":113,\"position\":2,\"letter\":\"B\",\"text\":\"Intussusception\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":451,\"question_id\":113,\"position\":3,\"letter\":\"C\",\"text\":\"Volvulus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":452,\"question_id\":113,\"position\":4,\"letter\":\"D\",\"text\":\"Meckel's diverticulum\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":79,"position":89,"stem_snapshot":"A 25-year-old man is brought to the emergency department after a motor vehicle accident. He has a blood pressure of 80/40 mm Hg, heart rate of 120 beats per minute, and respiratory rate of 20 per minute. On physical exam, he has a distended abdomen and tenderness in the left upper quadrant. Which of the following is the most likely cause of his shock?","options_snapshot":"[{\"id\":313,\"question_id\":79,\"position\":1,\"letter\":\"A\",\"text\":\"Hypovolemic shock due to intra-abdominal bleeding\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":314,\"question_id\":79,\"position\":2,\"letter\":\"B\",\"text\":\"Neurogenic shock due to spinal cord injury\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":315,\"question_id\":79,\"position\":3,\"letter\":\"C\",\"text\":\"Septic shock due to peritonitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":316,\"question_id\":79,\"position\":4,\"letter\":\"D\",\"text\":\"Cardiogenic shock due to myocardial contusion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":141,"position":90,"stem_snapshot":"A 63-y/o female undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The pathology report states that there is a foci of carcinoma which invades, but does not penetrate through, the lamina propria. What is the most appropriate management?","options_snapshot":"[{\"id\":561,\"question_id\":141,\"position\":1,\"letter\":\"A\",\"text\":\"Laparoscopic resection of the gallbladder fossa\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":562,\"question_id\":141,\"position\":2,\"letter\":\"B\",\"text\":\"Open extended cholecystectomy including segment 4b and 5 liver resection as well as removal of porta hepatis lymph nodes\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":563,\"question_id\":141,\"position\":3,\"letter\":\"C\",\"text\":\"Cholecystectomy is sufficient\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":564,\"question_id\":141,\"position\":4,\"letter\":\"D\",\"text\":\"Radiation and chemotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":31,"position":91,"stem_snapshot":"A 25-year-old man is seen in the office with complaints of contracture of his left index finger after a burn injury. Which of the following statements is true about growth factors?","options_snapshot":"[{\"id\":121,\"question_id\":31,\"position\":1,\"letter\":\"A\",\"text\":\"Epidermal growth factor (EGF) stimulates the production of collagen.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":122,\"question_id\":31,\"position\":2,\"letter\":\"B\",\"text\":\"Vascular endothelial growth factor (VEGF) and PDGF both stimulate angiogenesis by binding to a common receptor.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":123,\"question_id\":31,\"position\":3,\"letter\":\"C\",\"text\":\"Fibroblast growth factor (FGF) stimulates wound contraction.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":124,\"question_id\":31,\"position\":4,\"letter\":\"D\",\"text\":\"Transforming growth factor-β (TGF-β) is stored in endothelial cells.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":84,"position":92,"stem_snapshot":"A 22-year-old man is involved in a motorcycle accident and presents with left upper quadrant pain and tenderness. His initial blood pressure is 90/50 mm Hg, and heart rate is 120 beats per minute. After fluid resuscitation, his blood pressure is 110/70 mm Hg, and heart rate is 90 beats per minute. CT scan shows a grade III splenic laceration with moderate hemoperitoneum. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":333,\"question_id\":84,\"position\":1,\"letter\":\"A\",\"text\":\"Observation and serial hemoglobin checks\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":334,\"question_id\":84,\"position\":2,\"letter\":\"B\",\"text\":\"Embolization of the splenic artery\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":335,\"question_id\":84,\"position\":3,\"letter\":\"C\",\"text\":\"Splenectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":336,\"question_id\":84,\"position\":4,\"letter\":\"D\",\"text\":\"Laparoscopic splenic repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":104,"position":93,"stem_snapshot":"A 65-year-old man with coronary artery disease is scheduled for elective colon resection. He has stable angina and is on beta-blockers and statins. Which of the following is the most appropriate preoperative cardiac evaluation?","options_snapshot":"[{\"id\":413,\"question_id\":104,\"position\":1,\"letter\":\"A\",\"text\":\"Exercise stress test\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":414,\"question_id\":104,\"position\":2,\"letter\":\"B\",\"text\":\"Dobutamine stress echocardiogram\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":415,\"question_id\":104,\"position\":3,\"letter\":\"C\",\"text\":\"Coronary angiography\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":416,\"question_id\":104,\"position\":4,\"letter\":\"D\",\"text\":\"No additional testing beyond history and physical exam\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":117,"position":94,"stem_snapshot":"A 18-year-old boy has a left varicocele noted on physical exam during a routine checkup. He has no symptoms or fertility concerns. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":465,\"question_id\":117,\"position\":1,\"letter\":\"A\",\"text\":\"Surgical repair via varicocelectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":466,\"question_id\":117,\"position\":2,\"letter\":\"B\",\"text\":\"Embolization of the testicular vein\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":467,\"question_id\":117,\"position\":3,\"letter\":\"C\",\"text\":\"Observation and follow-up if symptoms develop\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":468,\"question_id\":117,\"position\":4,\"letter\":\"D\",\"text\":\"Scrotal support and elevation to reduce discomfort\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":29,"position":95,"stem_snapshot":"Which of the following statements regarding interleukins (ILs) is true?","options_snapshot":"[{\"id\":113,\"question_id\":29,\"position\":1,\"letter\":\"A\",\"text\":\"All ILs upregulate the immune system.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":114,\"question_id\":29,\"position\":2,\"letter\":\"B\",\"text\":\"IL-8 is a neutrophil chemotactic factor.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":115,\"question_id\":29,\"position\":3,\"letter\":\"C\",\"text\":\"IL-10 produces fever and inflammation.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":116,\"question_id\":29,\"position\":4,\"letter\":\"D\",\"text\":\"Prednisone upregulates the effect of IL-1.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":66,"position":96,"stem_snapshot":"A patient with familial adenomatous polyposis should undergo prophylactic surgery ideally by age:","options_snapshot":"[{\"id\":261,\"question_id\":66,\"position\":1,\"letter\":\"A\",\"text\":\"10 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":262,\"question_id\":66,\"position\":2,\"letter\":\"B\",\"text\":\"20 years\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":263,\"question_id\":66,\"position\":3,\"letter\":\"C\",\"text\":\"30 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":264,\"question_id\":66,\"position\":4,\"letter\":\"D\",\"text\":\"40 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":33,"position":97,"stem_snapshot":"In a 40-year-old woman receiving TPN for small-bowel fistula, what finding can be attributed to hypophosphatemia?","options_snapshot":"[{\"id\":129,\"question_id\":33,\"position\":1,\"letter\":\"A\",\"text\":\"Increased cardiac output\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":130,\"question_id\":33,\"position\":2,\"letter\":\"B\",\"text\":\"Diarrhea\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":131,\"question_id\":33,\"position\":3,\"letter\":\"C\",\"text\":\"Increased energy production\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":132,\"question_id\":33,\"position\":4,\"letter\":\"D\",\"text\":\"Rhabdomyolysis\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":116,"position":98,"stem_snapshot":"A 30-year-old woman undergoes breast augmentation with silicone implants. Postoperatively, she develops fever, chest pain, and dyspnea. Chest X-ray shows a pneumothora x on the left side. Which of the following is the most likely cause?","options_snapshot":"[{\"id\":461,\"question_id\":116,\"position\":1,\"letter\":\"A\",\"text\":\"Infection of the implant pocket\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":462,\"question_id\":116,\"position\":2,\"letter\":\"B\",\"text\":\"Implant rupture during surgery\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":463,\"question_id\":116,\"position\":3,\"letter\":\"C\",\"text\":\"Perforation of the lung during implant placement\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":464,\"question_id\":116,\"position\":4,\"letter\":\"D\",\"text\":\"Allergic reaction to anesthesia\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":14,"position":99,"stem_snapshot":"A 63-y/o female undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The pathology report states that there is a focus of carcinoma which invades, but does not penetrate through, the lamina propria. What is the most appropriate management?","options_snapshot":"[{\"id\":53,\"question_id\":14,\"position\":1,\"letter\":\"A\",\"text\":\"Laparoscopic resection of the gallbladder fossa\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":54,\"question_id\":14,\"position\":2,\"letter\":\"B\",\"text\":\"Open extended cholecystectomy including segment 4b and 5 liver resection as well as removal of porta hepatis lymph nodes\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":55,\"question_id\":14,\"position\":3,\"letter\":\"C\",\"text\":\"Cholecystectomy is sufficient\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":56,\"question_id\":14,\"position\":4,\"letter\":\"D\",\"text\":\"Radiation and chemotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":1,"question_id":64,"position":100,"stem_snapshot":"Clavien-Dindo grade IIIb complication refers to:","options_snapshot":"[{\"id\":253,\"question_id\":64,\"position\":1,\"letter\":\"A\",\"text\":\"Pharmacological treatment required\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":254,\"question_id\":64,\"position\":2,\"letter\":\"B\",\"text\":\"Single organ dysfunction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":255,\"question_id\":64,\"position\":3,\"letter\":\"C\",\"text\":\"Intervention under general anesthesia\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":256,\"question_id\":64,\"position\":4,\"letter\":\"D\",\"text\":\"Death of the patient\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":48,"position":1,"stem_snapshot":"A 55-year-old presents with obstructive jaundice and a double-duct sign on CT. This is most suggestive of:","options_snapshot":"[{\"id\":189,\"question_id\":48,\"position\":1,\"letter\":\"A\",\"text\":\"Chronic pancreatitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":190,\"question_id\":48,\"position\":2,\"letter\":\"B\",\"text\":\"Periampullary or pancreatic head malignancy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":191,\"question_id\":48,\"position\":3,\"letter\":\"C\",\"text\":\"Choledocholithiasis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":192,\"question_id\":48,\"position\":4,\"letter\":\"D\",\"text\":\"Hepatitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":127,"position":2,"stem_snapshot":"55 years old man underwent low anterior resection for low rectal cancer,developed frequent Bowel motions, urgency and incontinence, which is the most appropriate to manage his Symptoms?","options_snapshot":"[{\"id\":505,\"question_id\":127,\"position\":1,\"letter\":\"A\",\"text\":\"Antidiarrialheal medications\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":506,\"question_id\":127,\"position\":2,\"letter\":\"B\",\"text\":\"Temporary ileostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":507,\"question_id\":127,\"position\":3,\"letter\":\"C\",\"text\":\"Pelvic floor rehabilitation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":508,\"question_id\":127,\"position\":4,\"letter\":\"D\",\"text\":\"High fiber diet\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":30,"position":3,"stem_snapshot":"In patients receiving massive blood transfusion for acute blood loss, which of the following is correct?","options_snapshot":"[{\"id\":117,\"question_id\":30,\"position\":1,\"letter\":\"A\",\"text\":\"Packed red blood cells and crystalloid solution should be infused to restore oxygen-carrying capacity and intravascular volume.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":118,\"question_id\":30,\"position\":2,\"letter\":\"B\",\"text\":\"Two units of FFP should be given with every 5 units of packed red blood cells in most cases.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":119,\"question_id\":30,\"position\":3,\"letter\":\"C\",\"text\":\"A \\\"six pack\\\" of platelets should be administered with every 10 units of packed red blood cells in most cases.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":120,\"question_id\":30,\"position\":4,\"letter\":\"D\",\"text\":\"One ampule of calcium chloride should be administered with every 5 units of packed red blood cells to avoid hypocalcaemia.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":75,"position":4,"stem_snapshot":"A 65-year-old woman with a history of multiple abdominal surgeries presents with small bowel obstruction. She has been on conservative management for 48 hours without improvement. A water-soluble contrast study is performed, and a follow-up radiograph after 24 hours shows contrast in the colon. Which of the following is the most appropriate next step?","options_snapshot":"[{\"id\":297,\"question_id\":75,\"position\":1,\"letter\":\"A\",\"text\":\"Continue conservative management\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":298,\"question_id\":75,\"position\":2,\"letter\":\"B\",\"text\":\"Proceed to laparotomy for surgical exploration\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":299,\"question_id\":75,\"position\":3,\"letter\":\"C\",\"text\":\"Start antibiotics for possible infection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":300,\"question_id\":75,\"position\":4,\"letter\":\"D\",\"text\":\"Perform a CT scan to look for complications\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":23,"position":5,"stem_snapshot":" a new born baby undergoes pyloromyotomy. During the procedure, a deep mucosal injury is noted at the distal aspect of the incision. How should this patient’s mucosal injury be managed?","options_snapshot":"[{\"id\":717,\"question_id\":23,\"position\":1,\"letter\":\"A\",\"text\":\"Closure of the mucosal defect with the myotomy intact\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":718,\"question_id\":23,\"position\":2,\"letter\":\"B\",\"text\":\"Closure of the mucosal and muscular defects with repeat myotomy at a later date\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":719,\"question_id\":23,\"position\":3,\"letter\":\"C\",\"text\":\"Closure of the mucosal and muscular defects with repeat myotomy on another side of the pylorus\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":720,\"question_id\":23,\"position\":4,\"letter\":\"D\",\"text\":\"Wide local drainage and antibiotics\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":130,"position":6,"stem_snapshot":"A 38-year-old woman presents with acute onset pain over the lateral aspect of the right breast. On examination, a tender, cord-like structure is palpable extending along the anterior chest wall. There is no overlying skin erythema or systemic symptoms. Ultrasound shows a superficial, non-compressible tubular structure without internal flow. Which of the following is the MOST appropriate next step in management?","options_snapshot":"[{\"id\":517,\"question_id\":130,\"position\":1,\"letter\":\"A\",\"text\":\"Immediate excisional biopsy of the lesion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":518,\"question_id\":130,\"position\":2,\"letter\":\"B\",\"text\":\"Start intravenous antibiotics and admit\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":519,\"question_id\":130,\"position\":3,\"letter\":\"C\",\"text\":\"Reassurance with NSAIDs and warm compresses\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":520,\"question_id\":130,\"position\":4,\"letter\":\"D\",\"text\":\"Initiate anticoagulation therapy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":2,"position":7,"stem_snapshot":"In a 2-week-old term infant with pyloric stenosis and dehydration, the appropriate fluid to be given IV is:","options_snapshot":"[{\"id\":5,\"question_id\":2,\"position\":1,\"letter\":\"A\",\"text\":\"5% dextrose with 0.45% saline\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":6,\"question_id\":2,\"position\":2,\"letter\":\"B\",\"text\":\"8.4% sodium bicarbonate\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":7,\"question_id\":2,\"position\":3,\"letter\":\"C\",\"text\":\"potassium chloride\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":8,\"question_id\":2,\"position\":4,\"letter\":\"D\",\"text\":\"calcium gluconate\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":89,"position":8,"stem_snapshot":"A 65-year-old man is diagnosed with a 3 cm adenocarcinoma in the sigmoid colon. The tumor is invading through the muscularis propria into the serosa, and there are no positive lymph nodes or distant metastases. Which of the following is the most appropriate stage and treatment?","options_snapshot":"[{\"id\":353,\"question_id\":89,\"position\":1,\"letter\":\"A\",\"text\":\"Stage II, surgical resection alone\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":354,\"question_id\":89,\"position\":2,\"letter\":\"B\",\"text\":\"Stage III, surgical resection and adjuvant chemotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":355,\"question_id\":89,\"position\":3,\"letter\":\"C\",\"text\":\"Stage I, surgical resection alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":356,\"question_id\":89,\"position\":4,\"letter\":\"D\",\"text\":\"Stage IV, palliative chemotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":119,"position":9,"stem_snapshot":"A 25-year-old man sustains a severe head injury in a motor vehicle accident and is declared brain dead. He has no history of significant medical conditions and is a potential organ donor. Which of the following conditions would exclude him from donating his liver?","options_snapshot":"[{\"id\":473,\"question_id\":119,\"position\":1,\"letter\":\"A\",\"text\":\"Positive hepatitis B surface antigen (HBsAg)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":474,\"question_id\":119,\"position\":2,\"letter\":\"B\",\"text\":\"History of hypertension controlled with medication\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":475,\"question_id\":119,\"position\":3,\"letter\":\"C\",\"text\":\"Family history of colorectal cancer\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":476,\"question_id\":119,\"position\":4,\"letter\":\"D\",\"text\":\"Previous tattooing without hepatitis testing\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":41,"position":10,"stem_snapshot":"The most common complication of massive blood transfusion is:","options_snapshot":"[{\"id\":161,\"question_id\":41,\"position\":1,\"letter\":\"A\",\"text\":\"Transfusion-related acute lung injury\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":162,\"question_id\":41,\"position\":2,\"letter\":\"B\",\"text\":\"Hypothermia and coagulopathy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":163,\"question_id\":41,\"position\":3,\"letter\":\"C\",\"text\":\"Anaphylaxis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":164,\"question_id\":41,\"position\":4,\"letter\":\"D\",\"text\":\"Graft-versus-host disease\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":107,"position":11,"stem_snapshot":"A 40-year-old man undergoes laparotomy for small bowel obstruction. He has severe pain postoperatively despite receiving intravenous morphine via PCA pump. Which of the following is the most appropriate next step?","options_snapshot":"[{\"id\":425,\"question_id\":107,\"position\":1,\"letter\":\"A\",\"text\":\"Increase the PCA morphine bolus dose\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":426,\"question_id\":107,\"position\":2,\"letter\":\"B\",\"text\":\"Add a continuous infusion to the PCA pump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":427,\"question_id\":107,\"position\":3,\"letter\":\"C\",\"text\":\"Switch to hydromorphone via PCA pump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":428,\"question_id\":107,\"position\":4,\"letter\":\"D\",\"text\":\"Add an NSAID for multimodal pain management\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":109,"position":12,"stem_snapshot":"A 60-year-old woman with stage IV ovarian cancer has a small bowel obstruction due to tumor progression. She has significant pain and nausea but is alert and oriented. Her performance status is Karnofsky score of 50. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":433,\"question_id\":109,\"position\":1,\"letter\":\"A\",\"text\":\"Surgical exploration and resection of obstructed bowel segment\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":434,\"question_id\":109,\"position\":2,\"letter\":\"B\",\"text\":\"Placement of a venting gastrostomy tube\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":435,\"question_id\":109,\"position\":3,\"letter\":\"C\",\"text\":\"Palliative care with opioids and antiemetics\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":436,\"question_id\":109,\"position\":4,\"letter\":\"D\",\"text\":\"Total parenteral nutrition (TPN) to bypass the obstruction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":76,"position":14,"stem_snapshot":"A 45-year-old woman with a BRCA1 mutation is diagnosed with a 2 cm invasive ductal carcinoma of the breast. The tumor is estrogen receptor-positive, progesterone receptor-positive, and HER2-negative. There is no evidence of metastatic disease. Which of the following is the most appropriate treatment?","options_snapshot":"[{\"id\":301,\"question_id\":76,\"position\":1,\"letter\":\"A\",\"text\":\"Lumpectomy followed by radiation therapy and tamoxifen\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":302,\"question_id\":76,\"position\":2,\"letter\":\"B\",\"text\":\"Bilateral mastectomy followed by tamoxifen\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":303,\"question_id\":76,\"position\":3,\"letter\":\"C\",\"text\":\"Lumpectomy followed by chemotherapy and tamoxifen\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":304,\"question_id\":76,\"position\":4,\"letter\":\"D\",\"text\":\"Bilateral mastectomy followed by chemotherapy and radiation therapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":50,"position":15,"stem_snapshot":"A Siewert type II gastroesophageal junction tumor is best treated with:","options_snapshot":"[{\"id\":197,\"question_id\":50,\"position\":1,\"letter\":\"A\",\"text\":\"Ivor Lewis esophagectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":198,\"question_id\":50,\"position\":2,\"letter\":\"B\",\"text\":\"Transhiatal esophagectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":199,\"question_id\":50,\"position\":3,\"letter\":\"C\",\"text\":\"Extended total gastrectomy with distal esophagectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":200,\"question_id\":50,\"position\":4,\"letter\":\"D\",\"text\":\"Endoscopic mucosal resection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":55,"position":16,"stem_snapshot":"Damage control surgery in abdominal trauma involves:","options_snapshot":"[{\"id\":217,\"question_id\":55,\"position\":1,\"letter\":\"A\",\"text\":\"Definitive repair of all injuries in one operation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":218,\"question_id\":55,\"position\":2,\"letter\":\"B\",\"text\":\"Abbreviated laparotomy with hemorrhage control, temporary closure, ICU resuscitation, then planned re-exploration\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":219,\"question_id\":55,\"position\":3,\"letter\":\"C\",\"text\":\"Non-operative management with serial imaging\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":220,\"question_id\":55,\"position\":4,\"letter\":\"D\",\"text\":\"Immediate bowel anastomosis and definitive fixation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":95,"position":17,"stem_snapshot":"A 55-year-old woman has elevated serum calcium and parathyroid hormone levels. Ultrasound shows a single enlarged parathyroid gland. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":377,\"question_id\":95,\"position\":1,\"letter\":\"A\",\"text\":\"Medical management with bisphosphonates\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":378,\"question_id\":95,\"position\":2,\"letter\":\"B\",\"text\":\"Surgical resection of the enlarged parathyroid gland\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":379,\"question_id\":95,\"position\":3,\"letter\":\"C\",\"text\":\"Radioactive ablation of the parathyroid gland\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":380,\"question_id\":95,\"position\":4,\"letter\":\"D\",\"text\":\"Observation and repeat testing in 6 months\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":80,"position":18,"stem_snapshot":"A 40-year-old woman sustains a burn injury to her right arm and chest. On exam, part of the burn has blistering and pain, while another part has charred skin with no pain. Which of the following best describes this burn?","options_snapshot":"[{\"id\":317,\"question_id\":80,\"position\":1,\"letter\":\"A\",\"text\":\"Second-degree burn\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":318,\"question_id\":80,\"position\":2,\"letter\":\"B\",\"text\":\"Third-degree burn\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":319,\"question_id\":80,\"position\":3,\"letter\":\"C\",\"text\":\"Mixed second and third-degree burn\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":320,\"question_id\":80,\"position\":4,\"letter\":\"D\",\"text\":\"Fourth-degree burn\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":61,"position":19,"stem_snapshot":"In the LRINEC score for necrotizing fasciitis, which parameter is most specific?","options_snapshot":"[{\"id\":241,\"question_id\":61,\"position\":1,\"letter\":\"A\",\"text\":\"White blood cell count\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":242,\"question_id\":61,\"position\":2,\"letter\":\"B\",\"text\":\"C-reactive protein level\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":243,\"question_id\":61,\"position\":3,\"letter\":\"C\",\"text\":\"Serum sodium\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":244,\"question_id\":61,\"position\":4,\"letter\":\"D\",\"text\":\"Hemoglobin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":134,"position":20,"stem_snapshot":"A 62-year-old man presents with a firm retroareolar breast mass associated with nipple retraction and ipsilateral axillary lymphadenopathy. Histopathology reveals invasive carcinoma. Which of the following statements is MOST accurate regarding the biology of this tumor?","options_snapshot":"[{\"id\":533,\"question_id\":134,\"position\":1,\"letter\":\"A\",\"text\":\"Lobular carcinoma is the most common histological subtype\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":534,\"question_id\":134,\"position\":2,\"letter\":\"B\",\"text\":\"The tumor is likely to be hormone receptor negative\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":535,\"question_id\":134,\"position\":3,\"letter\":\"C\",\"text\":\"Early involvement of pectoralis major\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":536,\"question_id\":134,\"position\":4,\"letter\":\"D\",\"text\":\"Axillary lymph node metastasis is rare\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":146,"position":21,"stem_snapshot":"A 60-year-old alcoholic man presents with chronic, vague abdominal pain. He denies a history of pancreatitis and is otherwise in good health. CT reveals a 6-cm multiloculated, septated cyst at the tail of the pancreas. FNA of the cyst is nondiagnostic. Fluid amylase and CEA are in the high normal range. Management consists of:","options_snapshot":"[{\"id\":581,\"question_id\":146,\"position\":1,\"letter\":\"A\",\"text\":\"Distal pancreatectomy with possible splenectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":582,\"question_id\":146,\"position\":2,\"letter\":\"B\",\"text\":\"CT-guided drainage of the cyst\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":583,\"question_id\":146,\"position\":3,\"letter\":\"C\",\"text\":\"Endoscopic cystogastrostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":584,\"question_id\":146,\"position\":4,\"letter\":\"D\",\"text\":\"Roux-en-Y cystojejunostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":92,"position":22,"stem_snapshot":"A 70-year-old man is found to have a 5 cm abdominal aorticaneurysm on routine screening ultrasound. He has hypertension and hyperlipidemia but no symptoms related to the AAA. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":365,\"question_id\":92,\"position\":1,\"letter\":\"A\",\"text\":\"Elective open surgical repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":366,\"question_id\":92,\"position\":2,\"letter\":\"B\",\"text\":\"Elective endovascular repair\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":367,\"question_id\":92,\"position\":3,\"letter\":\"C\",\"text\":\"Surveillance with ultrasound every 6 months\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":368,\"question_id\":92,\"position\":4,\"letter\":\"D\",\"text\":\"Beta-blocker therapy to reduce aortic wall stress\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":60,"position":23,"stem_snapshot":"The most common postoperative complication specific to pancreaticoduodenectomy is:","options_snapshot":"[{\"id\":237,\"question_id\":60,\"position\":1,\"letter\":\"A\",\"text\":\"Bile leak\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":238,\"question_id\":60,\"position\":2,\"letter\":\"B\",\"text\":\"Delayed gastric emptying\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":239,\"question_id\":60,\"position\":3,\"letter\":\"C\",\"text\":\"Pancreatic fistula (POPF)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":240,\"question_id\":60,\"position\":4,\"letter\":\"D\",\"text\":\"Wound infection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":138,"position":24,"stem_snapshot":"Which of the following BEST explains the increased risk of endometrial carcinoma with Tamoxifen?","options_snapshot":"[{\"id\":549,\"question_id\":138,\"position\":1,\"letter\":\"A\",\"text\":\"Complete estrogen receptor blockade in uterus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":550,\"question_id\":138,\"position\":2,\"letter\":\"B\",\"text\":\"Increased peripheral aromatization\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":551,\"question_id\":138,\"position\":3,\"letter\":\"C\",\"text\":\"Partial agonist effect on uterine estrogen receptors\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":552,\"question_id\":138,\"position\":4,\"letter\":\"D\",\"text\":\"Direct mutagenic effect on endometrium\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":58,"position":25,"stem_snapshot":"An 80-year-old male patient with a T2N0 squamous cell carcinoma of the anal canal should be treated with:","options_snapshot":"[{\"id\":229,\"question_id\":58,\"position\":1,\"letter\":\"A\",\"text\":\"Abdominoperineal resection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":230,\"question_id\":58,\"position\":2,\"letter\":\"B\",\"text\":\"Chemoradiotherapy (Nigro protocol)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":231,\"question_id\":58,\"position\":3,\"letter\":\"C\",\"text\":\"Wide local excision\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":232,\"question_id\":58,\"position\":4,\"letter\":\"D\",\"text\":\"Diverting colostomy alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":99,"position":26,"stem_snapshot":"A 60-year-old woman undergoes colorectal surgery and develops a wound infection on postoperative day 5. The wound is erythematous, tender, and has purulent drainage. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":393,\"question_id\":99,\"position\":1,\"letter\":\"A\",\"text\":\"Oral antibiotics and wound care\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":394,\"question_id\":99,\"position\":2,\"letter\":\"B\",\"text\":\"Intravenous antibiotics and wound debridement\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":395,\"question_id\":99,\"position\":3,\"letter\":\"C\",\"text\":\"Vacuum-assisted closure (VAC) therapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":396,\"question_id\":99,\"position\":4,\"letter\":\"D\",\"text\":\"Secondary closure of the wound\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":87,"position":27,"stem_snapshot":"A 60-year-old man presents with sudden onset of severe abdominal pain, rigidity, and hypotension. He has a history of peptic ulcer disease. Upright chest X-ray shows free air under the diaphragm. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":345,\"question_id\":87,\"position\":1,\"letter\":\"A\",\"text\":\"Intravenous proton pump inhibitors and antibiotics\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":346,\"question_id\":87,\"position\":2,\"letter\":\"B\",\"text\":\"Emergent laparotomy and repair of perforation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":347,\"question_id\":87,\"position\":3,\"letter\":\"C\",\"text\":\"Endoscopic clipping of the perforation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":348,\"question_id\":87,\"position\":4,\"letter\":\"D\",\"text\":\"Percutaneous drainage of any fluid collections\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":152,"position":28,"stem_snapshot":"The true statement about Ladd bands is","options_snapshot":"[{\"id\":605,\"question_id\":152,\"position\":1,\"letter\":\"A\",\"text\":\"Ladd bands obstruct the duodenum\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":606,\"question_id\":152,\"position\":2,\"letter\":\"B\",\"text\":\"Ladd bands can originate from the duodenum\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":607,\"question_id\":152,\"position\":3,\"letter\":\"C\",\"text\":\"Ladd bands are peritoneal bands that can be associated with an annular pancreas\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":608,\"question_id\":152,\"position\":4,\"letter\":\"D\",\"text\":\"Ladd bands can originate in the hepatic flexure\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":46,"position":29,"stem_snapshot":"A Meckel diverticulum is a remnant of the:","options_snapshot":"[{\"id\":181,\"question_id\":46,\"position\":1,\"letter\":\"A\",\"text\":\"Allantois\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":182,\"question_id\":46,\"position\":2,\"letter\":\"B\",\"text\":\"Vitelline (omphalomesenteric) duct\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":183,\"question_id\":46,\"position\":3,\"letter\":\"C\",\"text\":\"Urachus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":184,\"question_id\":46,\"position\":4,\"letter\":\"D\",\"text\":\"Wolffian duct\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":1,"position":30,"stem_snapshot":"Which of the following statements regarding rejection of solid organ transplants is true?","options_snapshot":"[{\"id\":1,\"question_id\":1,\"position\":1,\"letter\":\"A\",\"text\":\"Hyperacute rejection begins in the operating room with the reperfusion of the transplanted organ.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":2,\"question_id\":1,\"position\":2,\"letter\":\"B\",\"text\":\"Liver transplants are especially susceptible to hyperacute rejection.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":3,\"question_id\":1,\"position\":3,\"letter\":\"C\",\"text\":\"Most immunosuppressive medications are used to prevent chronic rejection.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":4,\"question_id\":1,\"position\":4,\"letter\":\"D\",\"text\":\"The major cause of graft failure is acute rejection.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":3,"position":31,"stem_snapshot":"In ductography, intraductal papilloma typically appears as:","options_snapshot":"[{\"id\":9,\"question_id\":3,\"position\":1,\"letter\":\"A\",\"text\":\"Irregular spiculated mass\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":10,\"question_id\":3,\"position\":2,\"letter\":\"B\",\"text\":\"Dilated cystic duct\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":11,\"question_id\":3,\"position\":3,\"letter\":\"C\",\"text\":\"Filling defect surrounded by contrast\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":12,\"question_id\":3,\"position\":4,\"letter\":\"D\",\"text\":\"Homogeneous opacity\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":25,"position":32,"stem_snapshot":"Regarding gastric duplications, which of the following is true?","options_snapshot":"[{\"id\":97,\"question_id\":25,\"position\":1,\"letter\":\"A\",\"text\":\"Gastric duplication cysts account for 20% of all duplications of the gastrointestinal tract.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":98,\"question_id\":25,\"position\":2,\"letter\":\"B\",\"text\":\"Gastric duplication tends to occur along the greater curvature.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":99,\"question_id\":25,\"position\":3,\"letter\":\"C\",\"text\":\"Gastric duplications usually communicate with the gastric lumen.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":100,\"question_id\":25,\"position\":4,\"letter\":\"D\",\"text\":\"Gastric duplications are more common in males.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":128,"position":33,"stem_snapshot":"A patient with FAP, undergoes prophylactic proctocolectomy with IPAA. Post operatively he developed pelvic absecc, which is the most likely cause?","options_snapshot":"[{\"id\":509,\"question_id\":128,\"position\":1,\"letter\":\"A\",\"text\":\"Paucities\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":510,\"question_id\":128,\"position\":2,\"letter\":\"B\",\"text\":\"infected pelvic hematoma\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":511,\"question_id\":128,\"position\":3,\"letter\":\"C\",\"text\":\"leak\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":512,\"question_id\":128,\"position\":4,\"letter\":\"D\",\"text\":\"injury of the urinary bladder\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":32,"position":34,"stem_snapshot":"The most common fluid disorder in surgical patients is:","options_snapshot":"[{\"id\":125,\"question_id\":32,\"position\":1,\"letter\":\"A\",\"text\":\"Extracellular fluid deficit\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":126,\"question_id\":32,\"position\":2,\"letter\":\"B\",\"text\":\"Hyperkalemia\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":127,\"question_id\":32,\"position\":3,\"letter\":\"C\",\"text\":\"Hyponatremia\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":128,\"question_id\":32,\"position\":4,\"letter\":\"D\",\"text\":\"Metabolic acidosis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":62,"position":35,"stem_snapshot":"In adrenocortical carcinoma, the most important prognostic factor after complete resection is:","options_snapshot":"[{\"id\":245,\"question_id\":62,\"position\":1,\"letter\":\"A\",\"text\":\"Tumor grade (Ki-67 index and mitotic rate)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":246,\"question_id\":62,\"position\":2,\"letter\":\"B\",\"text\":\"Patient age\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":247,\"question_id\":62,\"position\":3,\"letter\":\"C\",\"text\":\"Cortisol level\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":248,\"question_id\":62,\"position\":4,\"letter\":\"D\",\"text\":\"Tumor laterality\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":67,"position":36,"stem_snapshot":"In GIST, the molecular target for imatinib therapy is:","options_snapshot":"[{\"id\":265,\"question_id\":67,\"position\":1,\"letter\":\"A\",\"text\":\"EGFR mutation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":266,\"question_id\":67,\"position\":2,\"letter\":\"B\",\"text\":\"BRAF V600E mutation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":267,\"question_id\":67,\"position\":3,\"letter\":\"C\",\"text\":\"HER2 overexpression\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":268,\"question_id\":67,\"position\":4,\"letter\":\"D\",\"text\":\"PDGFRA mutation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":63,"position":37,"stem_snapshot":"Robotic surgery provides the greatest advantage over conventional laparoscopy in:","options_snapshot":"[{\"id\":249,\"question_id\":63,\"position\":1,\"letter\":\"A\",\"text\":\"Appendectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":250,\"question_id\":63,\"position\":2,\"letter\":\"B\",\"text\":\"Low pelvic dissection (e.g., low rectal cancer, prostatectomy)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":251,\"question_id\":63,\"position\":3,\"letter\":\"C\",\"text\":\"Open hernia repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":252,\"question_id\":63,\"position\":4,\"letter\":\"D\",\"text\":\"Diagnostic laparoscopy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":15,"position":38,"stem_snapshot":"Which of the following statements related to liver embryology is true?","options_snapshot":"[{\"id\":57,\"question_id\":15,\"position\":1,\"letter\":\"A\",\"text\":\"The liver is derived from the hindgut.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":58,\"question_id\":15,\"position\":2,\"letter\":\"B\",\"text\":\"Two umbilical veins carry placental blood to the liver.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":59,\"question_id\":15,\"position\":3,\"letter\":\"C\",\"text\":\"The ductus venosus shunts blood from the portal vein to the systemic circulation.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":60,\"question_id\":15,\"position\":4,\"letter\":\"D\",\"text\":\"The falciform ligament is the obliterated ductus arteriosus.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":72,"position":39,"stem_snapshot":"Definitive fixation of a femoral shaft fracture in polytrauma with pulmonary contusion is optimally timed:","options_snapshot":"[{\"id\":285,\"question_id\":72,\"position\":1,\"letter\":\"A\",\"text\":\"Within 6 hours regardless of pulmonary status\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":286,\"question_id\":72,\"position\":2,\"letter\":\"B\",\"text\":\"After 4 weeks of skeletal traction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":287,\"question_id\":72,\"position\":3,\"letter\":\"C\",\"text\":\"After stabilization, typically day 5-10 (damage control orthopedics)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":288,\"question_id\":72,\"position\":4,\"letter\":\"D\",\"text\":\"Only after all other injuries have healed\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":17,"position":40,"stem_snapshot":"Which of the following features of IPMN of the pancreas is associated with the lowest risk for cancer?","options_snapshot":"[{\"id\":65,\"question_id\":17,\"position\":1,\"letter\":\"A\",\"text\":\"Branch duct type with mural nodularity\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":66,\"question_id\":17,\"position\":2,\"letter\":\"B\",\"text\":\"Branch duct type smaller than 3 cm\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":67,\"question_id\":17,\"position\":3,\"letter\":\"C\",\"text\":\"Main duct type with segmental dilation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":68,\"question_id\":17,\"position\":4,\"letter\":\"D\",\"text\":\"Multifocal IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":12,"position":41,"stem_snapshot":"BRCA-1 gene is located on:","options_snapshot":"[{\"id\":45,\"question_id\":12,\"position\":1,\"letter\":\"A\",\"text\":\"Chromosome 13\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":46,\"question_id\":12,\"position\":2,\"letter\":\"B\",\"text\":\"Chromosome 17\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":47,\"question_id\":12,\"position\":3,\"letter\":\"C\",\"text\":\"Chromosome 21\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":48,\"question_id\":12,\"position\":4,\"letter\":\"D\",\"text\":\"Chromosome X\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":37,"position":42,"stem_snapshot":"A patient on warfarin requires emergency surgery. The fastest way to reverse anticoagulation is:","options_snapshot":"[{\"id\":145,\"question_id\":37,\"position\":1,\"letter\":\"A\",\"text\":\"Vitamin K oral administration\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":146,\"question_id\":37,\"position\":2,\"letter\":\"B\",\"text\":\"Fresh frozen plasma or prothrombin complex concentrate\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":147,\"question_id\":37,\"position\":3,\"letter\":\"C\",\"text\":\"Withholding warfarin for 3 days\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":148,\"question_id\":37,\"position\":4,\"letter\":\"D\",\"text\":\"Platelet transfusion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":153,"position":43,"stem_snapshot":"Regarding gastric duplications, which of the following is true?","options_snapshot":"[{\"id\":609,\"question_id\":153,\"position\":1,\"letter\":\"A\",\"text\":\"Gastric duplication cysts account for 20% of all duplications of the gastrointestinal tract\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":610,\"question_id\":153,\"position\":2,\"letter\":\"B\",\"text\":\"Gastric duplication tends to occur along the greater curvature\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":611,\"question_id\":153,\"position\":3,\"letter\":\"C\",\"text\":\"Gastric duplications usually communicate with the gastric lumen\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":612,\"question_id\":153,\"position\":4,\"letter\":\"D\",\"text\":\"Gastric duplications are more common in males\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":106,"position":44,"stem_snapshot":"A 50-year-old woman undergoes total abdominal hysterectomy and develops shortness of breath and chest pain on postoperative day 3. Her oxygen saturation is 88% on room air. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":421,\"question_id\":106,\"position\":1,\"letter\":\"A\",\"text\":\"Chest X-ray to rule out pneumonia\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":422,\"question_id\":106,\"position\":2,\"letter\":\"B\",\"text\":\"CT pulmonary angiogram to confirm PE\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":423,\"question_id\":106,\"position\":3,\"letter\":\"C\",\"text\":\"Administration of oxygen and anticoagulation pending further evaluation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":424,\"question_id\":106,\"position\":4,\"letter\":\"D\",\"text\":\"Ventilation-perfusion scan to evaluate for PE\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":85,"position":45,"stem_snapshot":"A 40-year-old woman presents with right upper quadrant pain, fever, and jaundice. Ultrasound shows gallstones and a dilated common bile duct. Her WBC count is 15,000/mm³, and she has a positive Murphy's sign. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":337,\"question_id\":85,\"position\":1,\"letter\":\"A\",\"text\":\"Laparoscopic cholecystectomy with intraoperative cholangiography\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":338,\"question_id\":85,\"position\":2,\"letter\":\"B\",\"text\":\"ERCP for possible stone extraction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":339,\"question_id\":85,\"position\":3,\"letter\":\"C\",\"text\":\"Percutaneous cholecystostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":340,\"question_id\":85,\"position\":4,\"letter\":\"D\",\"text\":\"Intravenous antibiotics and observation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":47,"position":46,"stem_snapshot":"Informed surgical consent must include discussion of:","options_snapshot":"[{\"id\":185,\"question_id\":47,\"position\":1,\"letter\":\"A\",\"text\":\"Surgical technique details only\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":186,\"question_id\":47,\"position\":2,\"letter\":\"B\",\"text\":\"Risks, benefits, alternatives, and expected outcomes\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":187,\"question_id\":47,\"position\":3,\"letter\":\"C\",\"text\":\"Hospital administrative policies\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":188,\"question_id\":47,\"position\":4,\"letter\":\"D\",\"text\":\"Insurance coverage details\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":144,"position":47,"stem_snapshot":"Which of the following features of IPMN of the pancreas is associated with the lowest risk for cancer?","options_snapshot":"[{\"id\":573,\"question_id\":144,\"position\":1,\"letter\":\"A\",\"text\":\"Branch duct type with mural nodularity\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":574,\"question_id\":144,\"position\":2,\"letter\":\"B\",\"text\":\"Branch duct type smaller than 3 cm\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":575,\"question_id\":144,\"position\":3,\"letter\":\"C\",\"text\":\"Main duct type with segmental dilation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":576,\"question_id\":144,\"position\":4,\"letter\":\"D\",\"text\":\"Multifocal IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":10,"position":48,"stem_snapshot":"Which of the following BEST explains the increased risk of endometrial carcinoma with Tamoxifen?","options_snapshot":"[{\"id\":37,\"question_id\":10,\"position\":1,\"letter\":\"A\",\"text\":\"Complete estrogen receptor blockade in uterus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":38,\"question_id\":10,\"position\":2,\"letter\":\"B\",\"text\":\"Increased peripheral aromatization\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":39,\"question_id\":10,\"position\":3,\"letter\":\"C\",\"text\":\"Partial agonist effect on uterine estrogen receptors\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":40,\"question_id\":10,\"position\":4,\"letter\":\"D\",\"text\":\"Direct mutagenic effect on endometrium\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":100,"position":49,"stem_snapshot":"A 35-year-old man presents with pain and swelling in his perianal region. On exam, there is a fluctuant mass at the 3 o'clock position near the anal verge. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":397,\"question_id\":100,\"position\":1,\"letter\":\"A\",\"text\":\"Incision and drainage under local anesthesia\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":398,\"question_id\":100,\"position\":2,\"letter\":\"B\",\"text\":\"Intravenous antibiotics alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":399,\"question_id\":100,\"position\":3,\"letter\":\"C\",\"text\":\"Surgical exploration and seton placement for fistula-in-ano\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":400,\"question_id\":100,\"position\":4,\"letter\":\"D\",\"text\":\"Sitz baths and stool softeners\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":93,"position":50,"stem_snapshot":"A 65-year-old man with diabetes and smoking history presents with rest pain and a non-healing ulcer on his left foot. His ABI is 0.4. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":369,\"question_id\":93,\"position\":1,\"letter\":\"A\",\"text\":\"Surgical bypass grafting or endovascular intervention\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":370,\"question_id\":93,\"position\":2,\"letter\":\"B\",\"text\":\"Cilostazol and risk factor modification\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":371,\"question_id\":93,\"position\":3,\"letter\":\"C\",\"text\":\"Amputation of the affected limb\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":372,\"question_id\":93,\"position\":4,\"letter\":\"D\",\"text\":\"Hyperbaric oxygen therapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":74,"position":51,"stem_snapshot":"A 25-year-old man presents with right lower quadrant pain, fever, and leukocytosis. CT scan shows a perforated appendix with an abdominal abscesses. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":293,\"question_id\":74,\"position\":1,\"letter\":\"A\",\"text\":\"Immediate appendectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":294,\"question_id\":74,\"position\":2,\"letter\":\"B\",\"text\":\"Percutaneous drainage of the abscesses followed by interval appendectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":295,\"question_id\":74,\"position\":3,\"letter\":\"C\",\"text\":\"Intravenous antibiotics alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":296,\"question_id\":74,\"position\":4,\"letter\":\"D\",\"text\":\"Laparoscopic appendectomy with intraoperative irrigation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":98,"position":52,"stem_snapshot":"A 30-year-old man sustains a crush injury to his right leg. He has severe pain, pallor, and paresthesias in the leg. His compartment pressure is 30 mm Hg. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":389,\"question_id\":98,\"position\":1,\"letter\":\"A\",\"text\":\"Elevation of the leg and ice packs\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":390,\"question_id\":98,\"position\":2,\"letter\":\"B\",\"text\":\"Fasciotomy of the affected compartments\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":391,\"question_id\":98,\"position\":3,\"letter\":\"C\",\"text\":\"Intravenous fluids and pain management\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":392,\"question_id\":98,\"position\":4,\"letter\":\"D\",\"text\":\"Doppler ultrasound to assess blood flow\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":77,"position":53,"stem_snapshot":"A 50-year-old man presents with a right inguinal hernia. On physical exam, the hernia is indirect and reducible. He has no comorbidities. Which of the following is the most appropriate surgical approach?","options_snapshot":"[{\"id\":305,\"question_id\":77,\"position\":1,\"letter\":\"A\",\"text\":\"Open inguinal herniorrhaphy with mesh\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":306,\"question_id\":77,\"position\":2,\"letter\":\"B\",\"text\":\"Laparoscopic transabdominal preperitoneal (TAPP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":307,\"question_id\":77,\"position\":3,\"letter\":\"C\",\"text\":\"Laparoscopic totally extraperitoneal (TEP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":308,\"question_id\":77,\"position\":4,\"letter\":\"D\",\"text\":\"Bassini repair without mesh\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":147,"position":54,"stem_snapshot":"A 35-year-old patient is intubated in the ICU after being exposed to smoke. He has thick yellow secretions that require frequent suctioning along with the administration of bronchodilators. On hospital day 5, he has a percutaneous central venous catheter placed through the right internal jugular vein. Several hours later, he undergoes respiratory arrest. His peak inspiratory pressure has risen from 24 to 41 cm H2O. Choose which of the following is the most likely reason for the respiratory arrest:","options_snapshot":"[{\"id\":585,\"question_id\":147,\"position\":1,\"letter\":\"A\",\"text\":\"Tension pneumothorax\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":586,\"question_id\":147,\"position\":2,\"letter\":\"B\",\"text\":\"Flash pulmonary edema\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":587,\"question_id\":147,\"position\":3,\"letter\":\"C\",\"text\":\"Pulmonary embolism (PE)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":588,\"question_id\":147,\"position\":4,\"letter\":\"D\",\"text\":\"Endotracheal tube obstruction\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":108,"position":55,"stem_snapshot":"A 75-year-old man with dementia is admitted with acute appendicitis. He is confused and disoriented. His wife is present and wants to give consent for surgery. Which of the following is the most appropriate action?","options_snapshot":"[{\"id\":429,\"question_id\":108,\"position\":1,\"letter\":\"A\",\"text\":\"Proceed with surgery based on the wife's consent\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":430,\"question_id\":108,\"position\":2,\"letter\":\"B\",\"text\":\"Obtain consent from the patient's primary care physician\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":431,\"question_id\":108,\"position\":3,\"letter\":\"C\",\"text\":\"Wait until the patient regains capacity to give consent\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":432,\"question_id\":108,\"position\":4,\"letter\":\"D\",\"text\":\"Seek court approval for surgery\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":136,"position":56,"stem_snapshot":"Characteristic histologic feature of invasive lobular carcinoma:","options_snapshot":"[{\"id\":541,\"question_id\":136,\"position\":1,\"letter\":\"A\",\"text\":\"Comedo necrosis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":542,\"question_id\":136,\"position\":2,\"letter\":\"B\",\"text\":\"Indian file pattern\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":543,\"question_id\":136,\"position\":3,\"letter\":\"C\",\"text\":\"Keratin pearls\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":544,\"question_id\":136,\"position\":4,\"letter\":\"D\",\"text\":\"Spindle cells\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":135,"position":57,"stem_snapshot":"Ductal carcinoma in situ (DCIS) most commonly presents as:","options_snapshot":"[{\"id\":537,\"question_id\":135,\"position\":1,\"letter\":\"A\",\"text\":\"Palpable lump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":538,\"question_id\":135,\"position\":2,\"letter\":\"B\",\"text\":\"Skin ulceration\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":539,\"question_id\":135,\"position\":3,\"letter\":\"C\",\"text\":\"Mammographic calcifications\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":540,\"question_id\":135,\"position\":4,\"letter\":\"D\",\"text\":\"Axillary lymphadenopathy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":149,"position":58,"stem_snapshot":"In a 2-week-old term infant with pyloric stenosis and dehydration the appropriate fluid to be given iv is :","options_snapshot":"[{\"id\":593,\"question_id\":149,\"position\":1,\"letter\":\"A\",\"text\":\"5% dextrose with 0.45% saline\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":594,\"question_id\":149,\"position\":2,\"letter\":\"B\",\"text\":\"8.4% sodium bicarbonate\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":595,\"question_id\":149,\"position\":3,\"letter\":\"C\",\"text\":\"potassium chloride\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":596,\"question_id\":149,\"position\":4,\"letter\":\"D\",\"text\":\"calcium gluconate\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":102,"position":59,"stem_snapshot":"A 45-year-old woman with symptomatic gallstones requests cholecystectomy. She has no history of previous abdominal surgery or comorbidities. Which of the following is the most appropriate surgical approach?","options_snapshot":"[{\"id\":405,\"question_id\":102,\"position\":1,\"letter\":\"A\",\"text\":\"Open cholecystectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":406,\"question_id\":102,\"position\":2,\"letter\":\"B\",\"text\":\"Laparoscopic cholecystectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":407,\"question_id\":102,\"position\":3,\"letter\":\"C\",\"text\":\"Robotic-assisted cholecystectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":408,\"question_id\":102,\"position\":4,\"letter\":\"D\",\"text\":\"Natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":20,"position":60,"stem_snapshot":"The most appropriate chemotherapy regimen to accompany radiation therapy in stage 3 epidermoid anal cancer would be:","options_snapshot":"[{\"id\":77,\"question_id\":20,\"position\":1,\"letter\":\"A\",\"text\":\"Carboplatin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":78,\"question_id\":20,\"position\":2,\"letter\":\"B\",\"text\":\"Gemcitabine\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":79,\"question_id\":20,\"position\":3,\"letter\":\"C\",\"text\":\"Leucovarin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":80,\"question_id\":20,\"position\":4,\"letter\":\"D\",\"text\":\"Mytomycin C\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":27,"position":61,"stem_snapshot":"A 35-year-old woman is rescued from a house fire during which she was trapped in a smoke-filled bedroom for 30 minutes. On arrival in the Emergency Room, she has marked facial burns and hoarseness of voice but no stridor. She is expectorating carbonaceous sputum, appears confused and has a cherry-red visage. Which statement is FALSE about this case?","options_snapshot":"[{\"id\":105,\"question_id\":27,\"position\":1,\"letter\":\"A\",\"text\":\"Early intubation is advisable.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":106,\"question_id\":27,\"position\":2,\"letter\":\"B\",\"text\":\"A significant thermal injury to the trachea is likely.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":107,\"question_id\":27,\"position\":3,\"letter\":\"C\",\"text\":\"Lavage with sodium bicarbonate 1.4% has a role in the management of this patient.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":108,\"question_id\":27,\"position\":4,\"letter\":\"D\",\"text\":\"Lung function is likely to worsen over the next 12 hours.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":57,"position":62,"stem_snapshot":"In gastric cancer, the Borrmann type IV (linitis plastica) is characterized by:","options_snapshot":"[{\"id\":225,\"question_id\":57,\"position\":1,\"letter\":\"A\",\"text\":\"Polypoid growth\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":226,\"question_id\":57,\"position\":2,\"letter\":\"B\",\"text\":\"Ulcerative lesion with well-defined margins\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":227,\"question_id\":57,\"position\":3,\"letter\":\"C\",\"text\":\"Diffuse infiltration of the gastric wall with thickening\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":228,\"question_id\":57,\"position\":4,\"letter\":\"D\",\"text\":\"Superficial spreading lesion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":118,"position":63,"stem_snapshot":"A 40-year-old woman with a body mass index (BMI) of 45 kg/m² has tried multiple weight loss programs without success. She has type 2 diabetes and hypertension. Which of the following bariatric procedures has the highest risk of nutritional deficiencies?","options_snapshot":"[{\"id\":469,\"question_id\":118,\"position\":1,\"letter\":\"A\",\"text\":\"Gastric bypass (Roux-en-Y)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":470,\"question_id\":118,\"position\":2,\"letter\":\"B\",\"text\":\"Sleeve gastrectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":471,\"question_id\":118,\"position\":3,\"letter\":\"C\",\"text\":\"Adjustable gastric banding\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":472,\"question_id\":118,\"position\":4,\"letter\":\"D\",\"text\":\"Biliopancreatic diversion with duodenal switch (BPD-DS)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":97,"position":64,"stem_snapshot":"A 25-year-old man sustains a stab wound to the chest. He has decreased breath sounds on the left side and subcutaneous emphysema. Chest X-ray shows a large left pneumothora x. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":385,\"question_id\":97,\"position\":1,\"letter\":\"A\",\"text\":\"Observation and repeat X-ray in 2 hours\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":386,\"question_id\":97,\"position\":2,\"letter\":\"B\",\"text\":\"Placement of a chest tube\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":387,\"question_id\":97,\"position\":3,\"letter\":\"C\",\"text\":\"Immediate thoracotomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":388,\"question_id\":97,\"position\":4,\"letter\":\"D\",\"text\":\"Needle aspiration of the pneumothora x\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":96,"position":65,"stem_snapshot":"A 35-year-old man presents with hypertension, palpitations, and sweating. Biochemical testing confirms elevated catecholamine levels, and CT scan shows a left adrenal mass. Which of the following is the most appropriate management before surgical resection?","options_snapshot":"[{\"id\":381,\"question_id\":96,\"position\":1,\"letter\":\"A\",\"text\":\"Alpha-blockade followed by beta-blockade\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":382,\"question_id\":96,\"position\":2,\"letter\":\"B\",\"text\":\"Beta-blockade alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":383,\"question_id\":96,\"position\":3,\"letter\":\"C\",\"text\":\"Calcium channel blockers\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":384,\"question_id\":96,\"position\":4,\"letter\":\"D\",\"text\":\"No specific preoperative management needed\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":54,"position":66,"stem_snapshot":"In Zollinger-Ellison syndrome, the gastrinoma is most commonly located in the:","options_snapshot":"[{\"id\":213,\"question_id\":54,\"position\":1,\"letter\":\"A\",\"text\":\"Stomach body\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":214,\"question_id\":54,\"position\":2,\"letter\":\"B\",\"text\":\"Duodenal wall\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":215,\"question_id\":54,\"position\":3,\"letter\":\"C\",\"text\":\"Jejunum\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":216,\"question_id\":54,\"position\":4,\"letter\":\"D\",\"text\":\"Colon\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":59,"position":67,"stem_snapshot":"The Amsterdam criteria (Amsterdam II) are used to identify families with:","options_snapshot":"[{\"id\":233,\"question_id\":59,\"position\":1,\"letter\":\"A\",\"text\":\"Familial adenomatous polyposis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":234,\"question_id\":59,\"position\":2,\"letter\":\"B\",\"text\":\"Lynch syndrome\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":235,\"question_id\":59,\"position\":3,\"letter\":\"C\",\"text\":\"Peutz-Jeghers syndrome\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":236,\"question_id\":59,\"position\":4,\"letter\":\"D\",\"text\":\"Gardner syndrome\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":82,"position":68,"stem_snapshot":"A 45-year-old woman with Graves' disease has her hyperthyroidism well-controlled with antithyroid medications. She is scheduled for total thyroidectomy. Which of the following is the most important pre-operative management step to prevent complications?","options_snapshot":"[{\"id\":325,\"question_id\":82,\"position\":1,\"letter\":\"A\",\"text\":\"Administration of iodine to reduce thyroid vascularity\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":326,\"question_id\":82,\"position\":2,\"letter\":\"B\",\"text\":\"Correction of any electrolyte imbalances\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":327,\"question_id\":82,\"position\":3,\"letter\":\"C\",\"text\":\"Assessment of vocal cord function\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":328,\"question_id\":82,\"position\":4,\"letter\":\"D\",\"text\":\"Prophylactic antibiotics\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":81,"position":69,"stem_snapshot":"A 30-year-old male smoker presents with pain and discoloration of his left foot. On physical exam, his foot is cold, and there are no palpable pulses below the popliteal artery,Which of the following is the most likely diagnosis?","options_snapshot":"[{\"id\":321,\"question_id\":81,\"position\":1,\"letter\":\"A\",\"text\":\"Peripheral artery disease (PAD)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":322,\"question_id\":81,\"position\":2,\"letter\":\"B\",\"text\":\"Deep vein thrombosis (DVT)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":323,\"question_id\":81,\"position\":3,\"letter\":\"C\",\"text\":\"Thromboangitis obliterans (TAO)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":324,\"question_id\":81,\"position\":4,\"letter\":\"D\",\"text\":\"Raynaud's disease\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":8,"position":70,"stem_snapshot":"Characteristic histologic feature of invasive lobular carcinoma:","options_snapshot":"[{\"id\":29,\"question_id\":8,\"position\":1,\"letter\":\"A\",\"text\":\"Comedo necrosis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":30,\"question_id\":8,\"position\":2,\"letter\":\"B\",\"text\":\"Indian file pattern\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":31,\"question_id\":8,\"position\":3,\"letter\":\"C\",\"text\":\"Keratin pearls\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":32,\"question_id\":8,\"position\":4,\"letter\":\"D\",\"text\":\"Spindle cells\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":145,"position":71,"stem_snapshot":"Which of the following pancreatic cystic lesions is almost exclusively found in a young female?","options_snapshot":"[{\"id\":577,\"question_id\":145,\"position\":1,\"letter\":\"A\",\"text\":\"Mucinous cystic neoplasm\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":578,\"question_id\":145,\"position\":2,\"letter\":\"B\",\"text\":\"Side-duct IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":579,\"question_id\":145,\"position\":3,\"letter\":\"C\",\"text\":\"Main-duct IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":580,\"question_id\":145,\"position\":4,\"letter\":\"D\",\"text\":\"Solid pseudopapillary epithelial neoplasm\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":53,"position":72,"stem_snapshot":"Iatrogenic bile duct injury (Strasberg type E) discovered intraoperatively is best managed by:","options_snapshot":"[{\"id\":209,\"question_id\":53,\"position\":1,\"letter\":\"A\",\"text\":\"Place a T-tube and close\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":210,\"question_id\":53,\"position\":2,\"letter\":\"B\",\"text\":\"Roux-en-Y hepaticojejunostomy by an expert surgeon\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":211,\"question_id\":53,\"position\":3,\"letter\":\"C\",\"text\":\"Primary repair over a stent\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":212,\"question_id\":53,\"position\":4,\"letter\":\"D\",\"text\":\"Endoscopic sphincterotomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":65,"position":73,"stem_snapshot":"A transplant patient presenting with CMV disease should receive:","options_snapshot":"[{\"id\":257,\"question_id\":65,\"position\":1,\"letter\":\"A\",\"text\":\"Acyclovir\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":258,\"question_id\":65,\"position\":2,\"letter\":\"B\",\"text\":\"Fluconazole\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":259,\"question_id\":65,\"position\":3,\"letter\":\"C\",\"text\":\"Ganciclovir or valganciclovir\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":260,\"question_id\":65,\"position\":4,\"letter\":\"D\",\"text\":\"Reduction of immunosuppression alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":124,"position":74,"stem_snapshot":"A 70 years old male with atrial fibrillation, presents with sudden onset of severe abdominal Pain, CT angiography reveals occlusion of the S M A. what is the most appropriate initial Management?.","options_snapshot":"[{\"id\":493,\"question_id\":124,\"position\":1,\"letter\":\"A\",\"text\":\"intensive thrombolytic therapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":494,\"question_id\":124,\"position\":2,\"letter\":\"B\",\"text\":\"urgent mesenteric artery stenting\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":495,\"question_id\":124,\"position\":3,\"letter\":\"C\",\"text\":\"intravenous heparin and monitoring\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":496,\"question_id\":124,\"position\":4,\"letter\":\"D\",\"text\":\"laparotomy and embolectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":111,"position":75,"stem_snapshot":"A 30-year-old man has a 5 cm laceration on his arm with full-thickness skin loss but intact underlying muscle and fascia. The wound bed is clean and granulating. Which of the following is the most appropriate wound closure method?","options_snapshot":"[{\"id\":441,\"question_id\":111,\"position\":1,\"letter\":\"A\",\"text\":\"Primary closure with sutures\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":442,\"question_id\":111,\"position\":2,\"letter\":\"B\",\"text\":\"Secondary intention healing\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":443,\"question_id\":111,\"position\":3,\"letter\":\"C\",\"text\":\"Split-thickness skin graft (STSG)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":444,\"question_id\":111,\"position\":4,\"letter\":\"D\",\"text\":\"Flap reconstruction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":26,"position":76,"stem_snapshot":"A 35-year-old patient is intubated in the ICU after being exposed to smoke. He has thick yellow secretions that require frequent suctioning along with the administration of bronchodilators. On hospital day 5, he has a percutaneous central venous catheter placed through the right internal jugular vein. Several hours later, he undergoes respiratory arrest. His peak inspiratory pressure has risen from 24 to 41 cm H₂O. Choose the most likely reason for the respiratory arrest:","options_snapshot":"[{\"id\":101,\"question_id\":26,\"position\":1,\"letter\":\"A\",\"text\":\"Tension pneumothorax.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":102,\"question_id\":26,\"position\":2,\"letter\":\"B\",\"text\":\"Flash pulmonary edema.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":103,\"question_id\":26,\"position\":3,\"letter\":\"C\",\"text\":\"Pulmonary embolism (PE).\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":104,\"question_id\":26,\"position\":4,\"letter\":\"D\",\"text\":\"Endotracheal tube obstruction.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":150,"position":77,"stem_snapshot":"One of the following drugs may cause pyloric stenosis if administered to a premature infant:","options_snapshot":"[{\"id\":597,\"question_id\":150,\"position\":1,\"letter\":\"A\",\"text\":\"intravenous vitamin E\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":598,\"question_id\":150,\"position\":2,\"letter\":\"B\",\"text\":\"indomethacin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":599,\"question_id\":150,\"position\":3,\"letter\":\"C\",\"text\":\"enteric gentamicin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":600,\"question_id\":150,\"position\":4,\"letter\":\"D\",\"text\":\"prostaglandins\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":142,"position":78,"stem_snapshot":"Which of the following statements related to liver embryology is true?","options_snapshot":"[{\"id\":565,\"question_id\":142,\"position\":1,\"letter\":\"A\",\"text\":\"The liver is derived from the hindgut\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":566,\"question_id\":142,\"position\":2,\"letter\":\"B\",\"text\":\"Two umbilical veins carry placental blood to the liver\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":567,\"question_id\":142,\"position\":3,\"letter\":\"C\",\"text\":\"The ductus venosus shunts blood from the portal vein to the systemic circulation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":568,\"question_id\":142,\"position\":4,\"letter\":\"D\",\"text\":\"The falciform ligament is the obliterated ductus arteriosus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":6,"position":79,"stem_snapshot":"A 62-year-old man presents with a firm retroareolar breast mass associated with nipple retraction and ipsilateral axillary lymphadenopathy. Histopathology reveals invasive carcinoma. Which of the following statements is MOST accurate regarding the biology of this tumor?","options_snapshot":"[{\"id\":21,\"question_id\":6,\"position\":1,\"letter\":\"A\",\"text\":\"Lobular carcinoma is the most common histological subtype\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":22,\"question_id\":6,\"position\":2,\"letter\":\"B\",\"text\":\"The tumor is likely to be hormone receptor negative\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":23,\"question_id\":6,\"position\":3,\"letter\":\"C\",\"text\":\"Early involvement of pectoralis major\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":24,\"question_id\":6,\"position\":4,\"letter\":\"D\",\"text\":\"Axillary lymph node metastasis is rare\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":51,"position":80,"stem_snapshot":"The Milan criteria for HCC liver transplantation include:","options_snapshot":"[{\"id\":201,\"question_id\":51,\"position\":1,\"letter\":\"A\",\"text\":\"Single tumor ≤5 cm or up to 3 tumors each ≤3 cm, no vascular invasion\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":202,\"question_id\":51,\"position\":2,\"letter\":\"B\",\"text\":\"Single tumor up to 10 cm\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":203,\"question_id\":51,\"position\":3,\"letter\":\"C\",\"text\":\"Any number of tumors if AFP <400\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":204,\"question_id\":51,\"position\":4,\"letter\":\"D\",\"text\":\"Tumor confined to one lobe regardless of size\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":21,"position":81,"stem_snapshot":"Concerning anal fissure, one of the following is TRUE:","options_snapshot":"[{\"id\":81,\"question_id\":21,\"position\":1,\"letter\":\"A\",\"text\":\"Fissures away from the midline should be investigated.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":82,\"question_id\":21,\"position\":2,\"letter\":\"B\",\"text\":\"The results of chemical sphincterotomy are comparable to lateral sphincterotomy.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":83,\"question_id\":21,\"position\":3,\"letter\":\"C\",\"text\":\"Partial internal lateral sphincterotomy is best carried out at the site of the fissure.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":84,\"question_id\":21,\"position\":4,\"letter\":\"D\",\"text\":\"Pain following defecation is attributed to external anal sphincter spasm.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":103,"position":82,"stem_snapshot":"A 50-year-old man has a primary unilateral inguinal hernia. He has no history of previous surgery or comorbidities. Which of the following is the most appropriate surgical approach?","options_snapshot":"[{\"id\":409,\"question_id\":103,\"position\":1,\"letter\":\"A\",\"text\":\"Open inguinal herniorrhaphy with mesh\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":410,\"question_id\":103,\"position\":2,\"letter\":\"B\",\"text\":\"Laparoscopic transabdominal preperitoneal (TAPP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":411,\"question_id\":103,\"position\":3,\"letter\":\"C\",\"text\":\"Laparoscopic totally extraperitoneal (TEP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":412,\"question_id\":103,\"position\":4,\"letter\":\"D\",\"text\":\"Bassini repair without mesh\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":22,"position":83,"stem_snapshot":"One of the following drugs may cause pyloric stenosis if administered to a premature infant:","options_snapshot":"[{\"id\":85,\"question_id\":22,\"position\":1,\"letter\":\"A\",\"text\":\"Intravenous vitamin E\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":86,\"question_id\":22,\"position\":2,\"letter\":\"B\",\"text\":\"Indomethacin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":87,\"question_id\":22,\"position\":3,\"letter\":\"C\",\"text\":\"Enteric gentamicin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":88,\"question_id\":22,\"position\":4,\"letter\":\"D\",\"text\":\"Prostaglandins\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":5,"position":84,"stem_snapshot":"A 42-year-old woman presents with a rapidly enlarging, painless breast mass measuring 8 cm. On examination, the mass is mobile, bosselated, and there is stretching of the overlying skin without nipple retraction. Core biopsy suggests a fibroepithelial lesion. Which of the following features MOST strongly favors a diagnosis of malignant phyllodes tumor over fibroadenoma?","options_snapshot":"[{\"id\":17,\"question_id\":5,\"position\":1,\"letter\":\"A\",\"text\":\"Presence of cystic spaces on ultrasound\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":18,\"question_id\":5,\"position\":2,\"letter\":\"B\",\"text\":\"Monoclonal stromal cell proliferation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":19,\"question_id\":5,\"position\":3,\"letter\":\"C\",\"text\":\"Sharp demarcation from surrounding tissue\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":20,\"question_id\":5,\"position\":4,\"letter\":\"D\",\"text\":\"Absence of axillary lymphadenopathy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":9,"position":85,"stem_snapshot":"A tumor is negative for ER, PR, and HER2 but expresses CK5/6 and EGFR. Which subtype does this represent?","options_snapshot":"[{\"id\":33,\"question_id\":9,\"position\":1,\"letter\":\"A\",\"text\":\"Luminal A\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":34,\"question_id\":9,\"position\":2,\"letter\":\"B\",\"text\":\"Luminal B\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":35,\"question_id\":9,\"position\":3,\"letter\":\"C\",\"text\":\"Basal-like (TNBC)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":36,\"question_id\":9,\"position\":4,\"letter\":\"D\",\"text\":\"HER2-enriched\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":123,"position":86,"stem_snapshot":"A surgeon wants to know the best treatment for a particular condition. Which of the following provides the highest level of evidence?","options_snapshot":"[{\"id\":489,\"question_id\":123,\"position\":1,\"letter\":\"A\",\"text\":\"Randomized controlled trials (RCTs)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":490,\"question_id\":123,\"position\":2,\"letter\":\"B\",\"text\":\"Case reports\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":491,\"question_id\":123,\"position\":3,\"letter\":\"C\",\"text\":\"Expert opinion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":492,\"question_id\":123,\"position\":4,\"letter\":\"D\",\"text\":\"Retrospective cohort studies\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":73,"position":87,"stem_snapshot":"A surgeon's lifetime risk of a significant sharps injury during their career is estimated at:","options_snapshot":"[{\"id\":289,\"question_id\":73,\"position\":1,\"letter\":\"A\",\"text\":\"Less than 5%\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":290,\"question_id\":73,\"position\":2,\"letter\":\"B\",\"text\":\"15-25%\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":291,\"question_id\":73,\"position\":3,\"letter\":\"C\",\"text\":\"40-60%\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":292,\"question_id\":73,\"position\":4,\"letter\":\"D\",\"text\":\"Greater than 80%\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":113,"position":88,"stem_snapshot":"A 45-year-old man presents with colicky abdominal pain and bloody diarrhea. CT scan shows a segment of small bowel invaginated into another segment with a lead point mass. Which of the following is the most likely diagnosis?","options_snapshot":"[{\"id\":449,\"question_id\":113,\"position\":1,\"letter\":\"A\",\"text\":\"Crohn's disease\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":450,\"question_id\":113,\"position\":2,\"letter\":\"B\",\"text\":\"Intussusception\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":451,\"question_id\":113,\"position\":3,\"letter\":\"C\",\"text\":\"Volvulus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":452,\"question_id\":113,\"position\":4,\"letter\":\"D\",\"text\":\"Meckel's diverticulum\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":79,"position":89,"stem_snapshot":"A 25-year-old man is brought to the emergency department after a motor vehicle accident. He has a blood pressure of 80/40 mm Hg, heart rate of 120 beats per minute, and respiratory rate of 20 per minute. On physical exam, he has a distended abdomen and tenderness in the left upper quadrant. Which of the following is the most likely cause of his shock?","options_snapshot":"[{\"id\":313,\"question_id\":79,\"position\":1,\"letter\":\"A\",\"text\":\"Hypovolemic shock due to intra-abdominal bleeding\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":314,\"question_id\":79,\"position\":2,\"letter\":\"B\",\"text\":\"Neurogenic shock due to spinal cord injury\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":315,\"question_id\":79,\"position\":3,\"letter\":\"C\",\"text\":\"Septic shock due to peritonitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":316,\"question_id\":79,\"position\":4,\"letter\":\"D\",\"text\":\"Cardiogenic shock due to myocardial contusion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":141,"position":90,"stem_snapshot":"A 63-y/o female undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The pathology report states that there is a foci of carcinoma which invades, but does not penetrate through, the lamina propria. What is the most appropriate management?","options_snapshot":"[{\"id\":561,\"question_id\":141,\"position\":1,\"letter\":\"A\",\"text\":\"Laparoscopic resection of the gallbladder fossa\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":562,\"question_id\":141,\"position\":2,\"letter\":\"B\",\"text\":\"Open extended cholecystectomy including segment 4b and 5 liver resection as well as removal of porta hepatis lymph nodes\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":563,\"question_id\":141,\"position\":3,\"letter\":\"C\",\"text\":\"Cholecystectomy is sufficient\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":564,\"question_id\":141,\"position\":4,\"letter\":\"D\",\"text\":\"Radiation and chemotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":31,"position":91,"stem_snapshot":"A 25-year-old man is seen in the office with complaints of contracture of his left index finger after a burn injury. Which of the following statements is true about growth factors?","options_snapshot":"[{\"id\":121,\"question_id\":31,\"position\":1,\"letter\":\"A\",\"text\":\"Epidermal growth factor (EGF) stimulates the production of collagen.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":122,\"question_id\":31,\"position\":2,\"letter\":\"B\",\"text\":\"Vascular endothelial growth factor (VEGF) and PDGF both stimulate angiogenesis by binding to a common receptor.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":123,\"question_id\":31,\"position\":3,\"letter\":\"C\",\"text\":\"Fibroblast growth factor (FGF) stimulates wound contraction.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":124,\"question_id\":31,\"position\":4,\"letter\":\"D\",\"text\":\"Transforming growth factor-β (TGF-β) is stored in endothelial cells.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":84,"position":92,"stem_snapshot":"A 22-year-old man is involved in a motorcycle accident and presents with left upper quadrant pain and tenderness. His initial blood pressure is 90/50 mm Hg, and heart rate is 120 beats per minute. After fluid resuscitation, his blood pressure is 110/70 mm Hg, and heart rate is 90 beats per minute. CT scan shows a grade III splenic laceration with moderate hemoperitoneum. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":333,\"question_id\":84,\"position\":1,\"letter\":\"A\",\"text\":\"Observation and serial hemoglobin checks\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":334,\"question_id\":84,\"position\":2,\"letter\":\"B\",\"text\":\"Embolization of the splenic artery\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":335,\"question_id\":84,\"position\":3,\"letter\":\"C\",\"text\":\"Splenectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":336,\"question_id\":84,\"position\":4,\"letter\":\"D\",\"text\":\"Laparoscopic splenic repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":104,"position":93,"stem_snapshot":"A 65-year-old man with coronary artery disease is scheduled for elective colon resection. He has stable angina and is on beta-blockers and statins. Which of the following is the most appropriate preoperative cardiac evaluation?","options_snapshot":"[{\"id\":413,\"question_id\":104,\"position\":1,\"letter\":\"A\",\"text\":\"Exercise stress test\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":414,\"question_id\":104,\"position\":2,\"letter\":\"B\",\"text\":\"Dobutamine stress echocardiogram\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":415,\"question_id\":104,\"position\":3,\"letter\":\"C\",\"text\":\"Coronary angiography\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":416,\"question_id\":104,\"position\":4,\"letter\":\"D\",\"text\":\"No additional testing beyond history and physical exam\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":117,"position":94,"stem_snapshot":"A 18-year-old boy has a left varicocele noted on physical exam during a routine checkup. He has no symptoms or fertility concerns. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":465,\"question_id\":117,\"position\":1,\"letter\":\"A\",\"text\":\"Surgical repair via varicocelectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":466,\"question_id\":117,\"position\":2,\"letter\":\"B\",\"text\":\"Embolization of the testicular vein\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":467,\"question_id\":117,\"position\":3,\"letter\":\"C\",\"text\":\"Observation and follow-up if symptoms develop\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":468,\"question_id\":117,\"position\":4,\"letter\":\"D\",\"text\":\"Scrotal support and elevation to reduce discomfort\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":29,"position":95,"stem_snapshot":"Which of the following statements regarding interleukins (ILs) is true?","options_snapshot":"[{\"id\":113,\"question_id\":29,\"position\":1,\"letter\":\"A\",\"text\":\"All ILs upregulate the immune system.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":114,\"question_id\":29,\"position\":2,\"letter\":\"B\",\"text\":\"IL-8 is a neutrophil chemotactic factor.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":115,\"question_id\":29,\"position\":3,\"letter\":\"C\",\"text\":\"IL-10 produces fever and inflammation.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":116,\"question_id\":29,\"position\":4,\"letter\":\"D\",\"text\":\"Prednisone upregulates the effect of IL-1.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":66,"position":96,"stem_snapshot":"A patient with familial adenomatous polyposis should undergo prophylactic surgery ideally by age:","options_snapshot":"[{\"id\":261,\"question_id\":66,\"position\":1,\"letter\":\"A\",\"text\":\"10 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":262,\"question_id\":66,\"position\":2,\"letter\":\"B\",\"text\":\"20 years\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":263,\"question_id\":66,\"position\":3,\"letter\":\"C\",\"text\":\"30 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":264,\"question_id\":66,\"position\":4,\"letter\":\"D\",\"text\":\"40 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":33,"position":97,"stem_snapshot":"In a 40-year-old woman receiving TPN for small-bowel fistula, what finding can be attributed to hypophosphatemia?","options_snapshot":"[{\"id\":129,\"question_id\":33,\"position\":1,\"letter\":\"A\",\"text\":\"Increased cardiac output\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":130,\"question_id\":33,\"position\":2,\"letter\":\"B\",\"text\":\"Diarrhea\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":131,\"question_id\":33,\"position\":3,\"letter\":\"C\",\"text\":\"Increased energy production\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":132,\"question_id\":33,\"position\":4,\"letter\":\"D\",\"text\":\"Rhabdomyolysis\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":116,"position":98,"stem_snapshot":"A 30-year-old woman undergoes breast augmentation with silicone implants. Postoperatively, she develops fever, chest pain, and dyspnea. Chest X-ray shows a pneumothora x on the left side. Which of the following is the most likely cause?","options_snapshot":"[{\"id\":461,\"question_id\":116,\"position\":1,\"letter\":\"A\",\"text\":\"Infection of the implant pocket\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":462,\"question_id\":116,\"position\":2,\"letter\":\"B\",\"text\":\"Implant rupture during surgery\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":463,\"question_id\":116,\"position\":3,\"letter\":\"C\",\"text\":\"Perforation of the lung during implant placement\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":464,\"question_id\":116,\"position\":4,\"letter\":\"D\",\"text\":\"Allergic reaction to anesthesia\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":14,"position":99,"stem_snapshot":"A 63-y/o female undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The pathology report states that there is a focus of carcinoma which invades, but does not penetrate through, the lamina propria. What is the most appropriate management?","options_snapshot":"[{\"id\":53,\"question_id\":14,\"position\":1,\"letter\":\"A\",\"text\":\"Laparoscopic resection of the gallbladder fossa\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":54,\"question_id\":14,\"position\":2,\"letter\":\"B\",\"text\":\"Open extended cholecystectomy including segment 4b and 5 liver resection as well as removal of porta hepatis lymph nodes\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":55,\"question_id\":14,\"position\":3,\"letter\":\"C\",\"text\":\"Cholecystectomy is sufficient\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":56,\"question_id\":14,\"position\":4,\"letter\":\"D\",\"text\":\"Radiation and chemotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":4,"question_id":64,"position":100,"stem_snapshot":"Clavien-Dindo grade IIIb complication refers to:","options_snapshot":"[{\"id\":253,\"question_id\":64,\"position\":1,\"letter\":\"A\",\"text\":\"Pharmacological treatment required\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":254,\"question_id\":64,\"position\":2,\"letter\":\"B\",\"text\":\"Single organ dysfunction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":255,\"question_id\":64,\"position\":3,\"letter\":\"C\",\"text\":\"Intervention under general anesthesia\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":256,\"question_id\":64,\"position\":4,\"letter\":\"D\",\"text\":\"Death of the patient\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":23,"position":1,"stem_snapshot":" a new born baby undergoes pyloromyotomy. During the procedure, a deep mucosal injury is noted at the distal aspect of the incision. How should this patient’s mucosal injury be managed?","options_snapshot":"[{\"id\":717,\"question_id\":23,\"position\":1,\"letter\":\"A\",\"text\":\"Closure of the mucosal defect with the myotomy intact\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":718,\"question_id\":23,\"position\":2,\"letter\":\"B\",\"text\":\"Closure of the mucosal and muscular defects with repeat myotomy at a later date\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":719,\"question_id\":23,\"position\":3,\"letter\":\"C\",\"text\":\"Closure of the mucosal and muscular defects with repeat myotomy on another side of the pylorus\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":720,\"question_id\":23,\"position\":4,\"letter\":\"D\",\"text\":\"Wide local drainage and antibiotics\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":4,"position":2,"stem_snapshot":"A 38-year-old woman presents with acute onset pain over the lateral aspect of the right breast. On examination, a tender, cord-like structure is palpable extending along the anterior chest wall. There is no overlying skin erythema or systemic symptoms. Ultrasound shows a superficial, non-compressible tubular structure without internal flow. Which of the following is the MOST appropriate next step in management?","options_snapshot":"[{\"id\":13,\"question_id\":4,\"position\":1,\"letter\":\"A\",\"text\":\"Immediate excisional biopsy of the lesion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":14,\"question_id\":4,\"position\":2,\"letter\":\"B\",\"text\":\"Start intravenous antibiotics and admit\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":15,\"question_id\":4,\"position\":3,\"letter\":\"C\",\"text\":\"Reassurance with NSAIDs and warm compresses\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":16,\"question_id\":4,\"position\":4,\"letter\":\"D\",\"text\":\"Initiate anticoagulation therapy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":6,"position":3,"stem_snapshot":"A 62-year-old man presents with a firm retroareolar breast mass associated with nipple retraction and ipsilateral axillary lymphadenopathy. Histopathology reveals invasive carcinoma. Which of the following statements is MOST accurate regarding the biology of this tumor?","options_snapshot":"[{\"id\":21,\"question_id\":6,\"position\":1,\"letter\":\"A\",\"text\":\"Lobular carcinoma is the most common histological subtype\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":22,\"question_id\":6,\"position\":2,\"letter\":\"B\",\"text\":\"The tumor is likely to be hormone receptor negative\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":23,\"question_id\":6,\"position\":3,\"letter\":\"C\",\"text\":\"Early involvement of pectoralis major\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":24,\"question_id\":6,\"position\":4,\"letter\":\"D\",\"text\":\"Axillary lymph node metastasis is rare\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":7,"position":4,"stem_snapshot":"Ductal carcinoma in situ (DCIS) most commonly presents as:","options_snapshot":"[{\"id\":25,\"question_id\":7,\"position\":1,\"letter\":\"A\",\"text\":\"Palpable lump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":26,\"question_id\":7,\"position\":2,\"letter\":\"B\",\"text\":\"Skin ulceration\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":27,\"question_id\":7,\"position\":3,\"letter\":\"C\",\"text\":\"Mammographic calcifications\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":28,\"question_id\":7,\"position\":4,\"letter\":\"D\",\"text\":\"Axillary lymphadenopathy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":9,"position":5,"stem_snapshot":"A tumor is negative for ER, PR, and HER2 but expresses CK5/6 and EGFR. Which subtype does this represent?","options_snapshot":"[{\"id\":33,\"question_id\":9,\"position\":1,\"letter\":\"A\",\"text\":\"Luminal A\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":34,\"question_id\":9,\"position\":2,\"letter\":\"B\",\"text\":\"Luminal B\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":35,\"question_id\":9,\"position\":3,\"letter\":\"C\",\"text\":\"Basal-like (TNBC)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":36,\"question_id\":9,\"position\":4,\"letter\":\"D\",\"text\":\"HER2-enriched\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":11,"position":6,"stem_snapshot":"Which of the following statements BEST differentiates Oncotype DX from MammaPrint?","options_snapshot":"[{\"id\":41,\"question_id\":11,\"position\":1,\"letter\":\"A\",\"text\":\"Oncotype DX provides binary risk (low/high)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":42,\"question_id\":11,\"position\":2,\"letter\":\"B\",\"text\":\"MammaPrint evaluates fewer genes than Oncotype DX\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":43,\"question_id\":11,\"position\":3,\"letter\":\"C\",\"text\":\"Oncotype DX provides a quantitative recurrence score\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":44,\"question_id\":11,\"position\":4,\"letter\":\"D\",\"text\":\"MammaPrint is limited to node-negative patients only\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":12,"position":7,"stem_snapshot":"BRCA-1 gene is located on:","options_snapshot":"[{\"id\":45,\"question_id\":12,\"position\":1,\"letter\":\"A\",\"text\":\"Chromosome 13\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":46,\"question_id\":12,\"position\":2,\"letter\":\"B\",\"text\":\"Chromosome 17\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":47,\"question_id\":12,\"position\":3,\"letter\":\"C\",\"text\":\"Chromosome 21\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":48,\"question_id\":12,\"position\":4,\"letter\":\"D\",\"text\":\"Chromosome X\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":15,"position":8,"stem_snapshot":"Which of the following statements related to liver embryology is true?","options_snapshot":"[{\"id\":57,\"question_id\":15,\"position\":1,\"letter\":\"A\",\"text\":\"The liver is derived from the hindgut.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":58,\"question_id\":15,\"position\":2,\"letter\":\"B\",\"text\":\"Two umbilical veins carry placental blood to the liver.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":59,\"question_id\":15,\"position\":3,\"letter\":\"C\",\"text\":\"The ductus venosus shunts blood from the portal vein to the systemic circulation.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":60,\"question_id\":15,\"position\":4,\"letter\":\"D\",\"text\":\"The falciform ligament is the obliterated ductus arteriosus.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":17,"position":9,"stem_snapshot":"Which of the following features of IPMN of the pancreas is associated with the lowest risk for cancer?","options_snapshot":"[{\"id\":65,\"question_id\":17,\"position\":1,\"letter\":\"A\",\"text\":\"Branch duct type with mural nodularity\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":66,\"question_id\":17,\"position\":2,\"letter\":\"B\",\"text\":\"Branch duct type smaller than 3 cm\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":67,\"question_id\":17,\"position\":3,\"letter\":\"C\",\"text\":\"Main duct type with segmental dilation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":68,\"question_id\":17,\"position\":4,\"letter\":\"D\",\"text\":\"Multifocal IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":18,"position":10,"stem_snapshot":"Which of the following pancreatic cystic lesions is almost exclusively found in a young female?","options_snapshot":"[{\"id\":69,\"question_id\":18,\"position\":1,\"letter\":\"A\",\"text\":\"Mucinous cystic neoplasm\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":70,\"question_id\":18,\"position\":2,\"letter\":\"B\",\"text\":\"Side-duct IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":71,\"question_id\":18,\"position\":3,\"letter\":\"C\",\"text\":\"Main-duct IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":72,\"question_id\":18,\"position\":4,\"letter\":\"D\",\"text\":\"Solid pseudopapillary epithelial neoplasm\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":20,"position":11,"stem_snapshot":"The most appropriate chemotherapy regimen to accompany radiation therapy in stage 3 epidermoid anal cancer would be:","options_snapshot":"[{\"id\":77,\"question_id\":20,\"position\":1,\"letter\":\"A\",\"text\":\"Carboplatin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":78,\"question_id\":20,\"position\":2,\"letter\":\"B\",\"text\":\"Gemcitabine\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":79,\"question_id\":20,\"position\":3,\"letter\":\"C\",\"text\":\"Leucovarin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":80,\"question_id\":20,\"position\":4,\"letter\":\"D\",\"text\":\"Mytomycin C\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":22,"position":12,"stem_snapshot":"One of the following drugs may cause pyloric stenosis if administered to a premature infant:","options_snapshot":"[{\"id\":85,\"question_id\":22,\"position\":1,\"letter\":\"A\",\"text\":\"Intravenous vitamin E\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":86,\"question_id\":22,\"position\":2,\"letter\":\"B\",\"text\":\"Indomethacin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":87,\"question_id\":22,\"position\":3,\"letter\":\"C\",\"text\":\"Enteric gentamicin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":88,\"question_id\":22,\"position\":4,\"letter\":\"D\",\"text\":\"Prostaglandins\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":25,"position":13,"stem_snapshot":"Regarding gastric duplications, which of the following is true?","options_snapshot":"[{\"id\":97,\"question_id\":25,\"position\":1,\"letter\":\"A\",\"text\":\"Gastric duplication cysts account for 20% of all duplications of the gastrointestinal tract.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":98,\"question_id\":25,\"position\":2,\"letter\":\"B\",\"text\":\"Gastric duplication tends to occur along the greater curvature.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":99,\"question_id\":25,\"position\":3,\"letter\":\"C\",\"text\":\"Gastric duplications usually communicate with the gastric lumen.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":100,\"question_id\":25,\"position\":4,\"letter\":\"D\",\"text\":\"Gastric duplications are more common in males.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":27,"position":14,"stem_snapshot":"A 35-year-old woman is rescued from a house fire during which she was trapped in a smoke-filled bedroom for 30 minutes. On arrival in the Emergency Room, she has marked facial burns and hoarseness of voice but no stridor. She is expectorating carbonaceous sputum, appears confused and has a cherry-red visage. Which statement is FALSE about this case?","options_snapshot":"[{\"id\":105,\"question_id\":27,\"position\":1,\"letter\":\"A\",\"text\":\"Early intubation is advisable.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":106,\"question_id\":27,\"position\":2,\"letter\":\"B\",\"text\":\"A significant thermal injury to the trachea is likely.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":107,\"question_id\":27,\"position\":3,\"letter\":\"C\",\"text\":\"Lavage with sodium bicarbonate 1.4% has a role in the management of this patient.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":108,\"question_id\":27,\"position\":4,\"letter\":\"D\",\"text\":\"Lung function is likely to worsen over the next 12 hours.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":28,"position":15,"stem_snapshot":"Five days following percutaneous drainage of a pelvic collection after right hemicolectomy for Crohn’s disease, the catheter output remains > 100 mL/day. What should be done next?","options_snapshot":"[{\"id\":109,\"question_id\":28,\"position\":1,\"letter\":\"A\",\"text\":\"Perform abscessogram\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":110,\"question_id\":28,\"position\":2,\"letter\":\"B\",\"text\":\"Connect the tube to a low-pressure suction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":111,\"question_id\":28,\"position\":3,\"letter\":\"C\",\"text\":\"Intermittent tube clamping\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":112,\"question_id\":28,\"position\":4,\"letter\":\"D\",\"text\":\"Open surgery for diversion.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":33,"position":16,"stem_snapshot":"In a 40-year-old woman receiving TPN for small-bowel fistula, what finding can be attributed to hypophosphatemia?","options_snapshot":"[{\"id\":129,\"question_id\":33,\"position\":1,\"letter\":\"A\",\"text\":\"Increased cardiac output\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":130,\"question_id\":33,\"position\":2,\"letter\":\"B\",\"text\":\"Diarrhea\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":131,\"question_id\":33,\"position\":3,\"letter\":\"C\",\"text\":\"Increased energy production\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":132,\"question_id\":33,\"position\":4,\"letter\":\"D\",\"text\":\"Rhabdomyolysis\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":14,"position":17,"stem_snapshot":"A 63-y/o female undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The pathology report states that there is a focus of carcinoma which invades, but does not penetrate through, the lamina propria. What is the most appropriate management?","options_snapshot":"[{\"id\":53,\"question_id\":14,\"position\":1,\"letter\":\"A\",\"text\":\"Laparoscopic resection of the gallbladder fossa\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":54,\"question_id\":14,\"position\":2,\"letter\":\"B\",\"text\":\"Open extended cholecystectomy including segment 4b and 5 liver resection as well as removal of porta hepatis lymph nodes\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":55,\"question_id\":14,\"position\":3,\"letter\":\"C\",\"text\":\"Cholecystectomy is sufficient\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":56,\"question_id\":14,\"position\":4,\"letter\":\"D\",\"text\":\"Radiation and chemotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":29,"position":18,"stem_snapshot":"Which of the following statements regarding interleukins (ILs) is true?","options_snapshot":"[{\"id\":113,\"question_id\":29,\"position\":1,\"letter\":\"A\",\"text\":\"All ILs upregulate the immune system.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":114,\"question_id\":29,\"position\":2,\"letter\":\"B\",\"text\":\"IL-8 is a neutrophil chemotactic factor.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":115,\"question_id\":29,\"position\":3,\"letter\":\"C\",\"text\":\"IL-10 produces fever and inflammation.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":116,\"question_id\":29,\"position\":4,\"letter\":\"D\",\"text\":\"Prednisone upregulates the effect of IL-1.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":40,"position":19,"stem_snapshot":"The most reliable method to confirm correct endotracheal tube placement intraoperatively is:","options_snapshot":"[{\"id\":157,\"question_id\":40,\"position\":1,\"letter\":\"A\",\"text\":\"Chest X-ray\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":158,\"question_id\":40,\"position\":2,\"letter\":\"B\",\"text\":\"Auscultation of bilateral breath sounds\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":159,\"question_id\":40,\"position\":3,\"letter\":\"C\",\"text\":\"End-tidal CO2 capnography\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":160,\"question_id\":40,\"position\":4,\"letter\":\"D\",\"text\":\"Pulse oximetry\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":45,"position":20,"stem_snapshot":"The most common location for a carcinoid tumor is the:","options_snapshot":"[{\"id\":177,\"question_id\":45,\"position\":1,\"letter\":\"A\",\"text\":\"Stomach\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":178,\"question_id\":45,\"position\":2,\"letter\":\"B\",\"text\":\"Appendix\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":179,\"question_id\":45,\"position\":3,\"letter\":\"C\",\"text\":\"Small intestine (ileum)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":180,\"question_id\":45,\"position\":4,\"letter\":\"D\",\"text\":\"Rectum\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":46,"position":21,"stem_snapshot":"A Meckel diverticulum is a remnant of the:","options_snapshot":"[{\"id\":181,\"question_id\":46,\"position\":1,\"letter\":\"A\",\"text\":\"Allantois\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":182,\"question_id\":46,\"position\":2,\"letter\":\"B\",\"text\":\"Vitelline (omphalomesenteric) duct\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":183,\"question_id\":46,\"position\":3,\"letter\":\"C\",\"text\":\"Urachus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":184,\"question_id\":46,\"position\":4,\"letter\":\"D\",\"text\":\"Wolffian duct\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":50,"position":22,"stem_snapshot":"A Siewert type II gastroesophageal junction tumor is best treated with:","options_snapshot":"[{\"id\":197,\"question_id\":50,\"position\":1,\"letter\":\"A\",\"text\":\"Ivor Lewis esophagectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":198,\"question_id\":50,\"position\":2,\"letter\":\"B\",\"text\":\"Transhiatal esophagectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":199,\"question_id\":50,\"position\":3,\"letter\":\"C\",\"text\":\"Extended total gastrectomy with distal esophagectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":200,\"question_id\":50,\"position\":4,\"letter\":\"D\",\"text\":\"Endoscopic mucosal resection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":51,"position":23,"stem_snapshot":"The Milan criteria for HCC liver transplantation include:","options_snapshot":"[{\"id\":201,\"question_id\":51,\"position\":1,\"letter\":\"A\",\"text\":\"Single tumor ≤5 cm or up to 3 tumors each ≤3 cm, no vascular invasion\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":202,\"question_id\":51,\"position\":2,\"letter\":\"B\",\"text\":\"Single tumor up to 10 cm\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":203,\"question_id\":51,\"position\":3,\"letter\":\"C\",\"text\":\"Any number of tumors if AFP <400\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":204,\"question_id\":51,\"position\":4,\"letter\":\"D\",\"text\":\"Tumor confined to one lobe regardless of size\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":52,"position":24,"stem_snapshot":"A 4 cm soft tissue sarcoma of the thigh is best treated with:","options_snapshot":"[{\"id\":205,\"question_id\":52,\"position\":1,\"letter\":\"A\",\"text\":\"Amputation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":206,\"question_id\":52,\"position\":2,\"letter\":\"B\",\"text\":\"Wide local excision with R0 resection, and adjuvant radiotherapy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":207,\"question_id\":52,\"position\":3,\"letter\":\"C\",\"text\":\"Chemotherapy alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":208,\"question_id\":52,\"position\":4,\"letter\":\"D\",\"text\":\"Incisional biopsy followed by radiotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":53,"position":25,"stem_snapshot":"Iatrogenic bile duct injury (Strasberg type E) discovered intraoperatively is best managed by:","options_snapshot":"[{\"id\":209,\"question_id\":53,\"position\":1,\"letter\":\"A\",\"text\":\"Place a T-tube and close\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":210,\"question_id\":53,\"position\":2,\"letter\":\"B\",\"text\":\"Roux-en-Y hepaticojejunostomy by an expert surgeon\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":211,\"question_id\":53,\"position\":3,\"letter\":\"C\",\"text\":\"Primary repair over a stent\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":212,\"question_id\":53,\"position\":4,\"letter\":\"D\",\"text\":\"Endoscopic sphincterotomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":56,"position":26,"stem_snapshot":"A Breslow thickness of 2.5 mm melanoma is classified as:","options_snapshot":"[{\"id\":221,\"question_id\":56,\"position\":1,\"letter\":\"A\",\"text\":\"T1\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":222,\"question_id\":56,\"position\":2,\"letter\":\"B\",\"text\":\"T2\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":223,\"question_id\":56,\"position\":3,\"letter\":\"C\",\"text\":\"T3\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":224,\"question_id\":56,\"position\":4,\"letter\":\"D\",\"text\":\"T4\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":58,"position":27,"stem_snapshot":"An 80-year-old male patient with a T2N0 squamous cell carcinoma of the anal canal should be treated with:","options_snapshot":"[{\"id\":229,\"question_id\":58,\"position\":1,\"letter\":\"A\",\"text\":\"Abdominoperineal resection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":230,\"question_id\":58,\"position\":2,\"letter\":\"B\",\"text\":\"Chemoradiotherapy (Nigro protocol)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":231,\"question_id\":58,\"position\":3,\"letter\":\"C\",\"text\":\"Wide local excision\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":232,\"question_id\":58,\"position\":4,\"letter\":\"D\",\"text\":\"Diverting colostomy alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":61,"position":28,"stem_snapshot":"In the LRINEC score for necrotizing fasciitis, which parameter is most specific?","options_snapshot":"[{\"id\":241,\"question_id\":61,\"position\":1,\"letter\":\"A\",\"text\":\"White blood cell count\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":242,\"question_id\":61,\"position\":2,\"letter\":\"B\",\"text\":\"C-reactive protein level\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":243,\"question_id\":61,\"position\":3,\"letter\":\"C\",\"text\":\"Serum sodium\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":244,\"question_id\":61,\"position\":4,\"letter\":\"D\",\"text\":\"Hemoglobin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":59,"position":29,"stem_snapshot":"The Amsterdam criteria (Amsterdam II) are used to identify families with:","options_snapshot":"[{\"id\":233,\"question_id\":59,\"position\":1,\"letter\":\"A\",\"text\":\"Familial adenomatous polyposis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":234,\"question_id\":59,\"position\":2,\"letter\":\"B\",\"text\":\"Lynch syndrome\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":235,\"question_id\":59,\"position\":3,\"letter\":\"C\",\"text\":\"Peutz-Jeghers syndrome\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":236,\"question_id\":59,\"position\":4,\"letter\":\"D\",\"text\":\"Gardner syndrome\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":63,"position":30,"stem_snapshot":"Robotic surgery provides the greatest advantage over conventional laparoscopy in:","options_snapshot":"[{\"id\":249,\"question_id\":63,\"position\":1,\"letter\":\"A\",\"text\":\"Appendectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":250,\"question_id\":63,\"position\":2,\"letter\":\"B\",\"text\":\"Low pelvic dissection (e.g., low rectal cancer, prostatectomy)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":251,\"question_id\":63,\"position\":3,\"letter\":\"C\",\"text\":\"Open hernia repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":252,\"question_id\":63,\"position\":4,\"letter\":\"D\",\"text\":\"Diagnostic laparoscopy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":70,"position":31,"stem_snapshot":"Complex perianal fistula in Crohn disease is best managed initially with:","options_snapshot":"[{\"id\":277,\"question_id\":70,\"position\":1,\"letter\":\"A\",\"text\":\"Fistulotomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":278,\"question_id\":70,\"position\":2,\"letter\":\"B\",\"text\":\"Seton placement with optimization of medical therapy (biologics)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":279,\"question_id\":70,\"position\":3,\"letter\":\"C\",\"text\":\"Diverting colostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":280,\"question_id\":70,\"position\":4,\"letter\":\"D\",\"text\":\"Fibrin glue injection alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":67,"position":32,"stem_snapshot":"In GIST, the molecular target for imatinib therapy is:","options_snapshot":"[{\"id\":265,\"question_id\":67,\"position\":1,\"letter\":\"A\",\"text\":\"EGFR mutation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":266,\"question_id\":67,\"position\":2,\"letter\":\"B\",\"text\":\"BRAF V600E mutation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":267,\"question_id\":67,\"position\":3,\"letter\":\"C\",\"text\":\"HER2 overexpression\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":268,\"question_id\":67,\"position\":4,\"letter\":\"D\",\"text\":\"PDGFRA mutation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":66,"position":33,"stem_snapshot":"A patient with familial adenomatous polyposis should undergo prophylactic surgery ideally by age:","options_snapshot":"[{\"id\":261,\"question_id\":66,\"position\":1,\"letter\":\"A\",\"text\":\"10 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":262,\"question_id\":66,\"position\":2,\"letter\":\"B\",\"text\":\"20 years\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":263,\"question_id\":66,\"position\":3,\"letter\":\"C\",\"text\":\"30 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":264,\"question_id\":66,\"position\":4,\"letter\":\"D\",\"text\":\"40 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":130,"position":34,"stem_snapshot":"A 38-year-old woman presents with acute onset pain over the lateral aspect of the right breast. On examination, a tender, cord-like structure is palpable extending along the anterior chest wall. There is no overlying skin erythema or systemic symptoms. Ultrasound shows a superficial, non-compressible tubular structure without internal flow. Which of the following is the MOST appropriate next step in management?","options_snapshot":"[{\"id\":517,\"question_id\":130,\"position\":1,\"letter\":\"A\",\"text\":\"Immediate excisional biopsy of the lesion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":518,\"question_id\":130,\"position\":2,\"letter\":\"B\",\"text\":\"Start intravenous antibiotics and admit\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":519,\"question_id\":130,\"position\":3,\"letter\":\"C\",\"text\":\"Reassurance with NSAIDs and warm compresses\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":520,\"question_id\":130,\"position\":4,\"letter\":\"D\",\"text\":\"Initiate anticoagulation therapy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":133,"position":35,"stem_snapshot":"BRCA-1 gene is located on:","options_snapshot":"[{\"id\":529,\"question_id\":133,\"position\":1,\"letter\":\"A\",\"text\":\"Chromosome 13\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":530,\"question_id\":133,\"position\":2,\"letter\":\"B\",\"text\":\"Chromosome 17\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":531,\"question_id\":133,\"position\":3,\"letter\":\"C\",\"text\":\"Chromosome 21\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":532,\"question_id\":133,\"position\":4,\"letter\":\"D\",\"text\":\"Chromosome X\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":126,"position":36,"stem_snapshot":"A 65 years old patient, has iron deficiency anemia, during colonoscopy 3 cm ulcerated Mass, 2 cm below hepatic flexure, that proved to be adenocarcinoma and –ve for metastasis what is the most appropriate surgical management?","options_snapshot":"[{\"id\":501,\"question_id\":126,\"position\":1,\"letter\":\"A\",\"text\":\"RT. hemicolectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":502,\"question_id\":126,\"position\":2,\"letter\":\"B\",\"text\":\"Expended RT hemicolectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":503,\"question_id\":126,\"position\":3,\"letter\":\"C\",\"text\":\"Subtotal colectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":504,\"question_id\":126,\"position\":4,\"letter\":\"D\",\"text\":\"Segmental resection of the ascending colon\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":127,"position":37,"stem_snapshot":"55 years old man underwent low anterior resection for low rectal cancer,developed frequent Bowel motions, urgency and incontinence, which is the most appropriate to manage his Symptoms?","options_snapshot":"[{\"id\":505,\"question_id\":127,\"position\":1,\"letter\":\"A\",\"text\":\"Antidiarrialheal medications\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":506,\"question_id\":127,\"position\":2,\"letter\":\"B\",\"text\":\"Temporary ileostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":507,\"question_id\":127,\"position\":3,\"letter\":\"C\",\"text\":\"Pelvic floor rehabilitation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":508,\"question_id\":127,\"position\":4,\"letter\":\"D\",\"text\":\"High fiber diet\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":77,"position":38,"stem_snapshot":"A 50-year-old man presents with a right inguinal hernia. On physical exam, the hernia is indirect and reducible. He has no comorbidities. Which of the following is the most appropriate surgical approach?","options_snapshot":"[{\"id\":305,\"question_id\":77,\"position\":1,\"letter\":\"A\",\"text\":\"Open inguinal herniorrhaphy with mesh\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":306,\"question_id\":77,\"position\":2,\"letter\":\"B\",\"text\":\"Laparoscopic transabdominal preperitoneal (TAPP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":307,\"question_id\":77,\"position\":3,\"letter\":\"C\",\"text\":\"Laparoscopic totally extraperitoneal (TEP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":308,\"question_id\":77,\"position\":4,\"letter\":\"D\",\"text\":\"Bassini repair without mesh\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":78,"position":39,"stem_snapshot":"A 35-year-old man undergoes emergency appendectomy for acute appendicitis. Postoperatively, he develops fever, abdominal pain, and leukocytosis. CT scan shows a 5 cm fluid collection in the right lower quadrant with air pockets. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":309,\"question_id\":78,\"position\":1,\"letter\":\"A\",\"text\":\"Continue intravenous antibiotics and observe\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":310,\"question_id\":78,\"position\":2,\"letter\":\"B\",\"text\":\"Percutaneous drainage of the fluid collection\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":311,\"question_id\":78,\"position\":3,\"letter\":\"C\",\"text\":\"Exploratory laparotomy and washout\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":312,\"question_id\":78,\"position\":4,\"letter\":\"D\",\"text\":\"Repeat CT scan in 24 hours\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":83,"position":40,"stem_snapshot":"A 60-year-old man is admitted with acute pancreatitis. He has a history of alcohol abuse and is currently confused and disoriented. His vital signs are stable, but he has a GCS of 13. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":329,\"question_id\":83,\"position\":1,\"letter\":\"A\",\"text\":\"CT scan of the head to rule out hemorrhage\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":330,\"question_id\":83,\"position\":2,\"letter\":\"B\",\"text\":\"Blood alcohol level to assess intoxication\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":331,\"question_id\":83,\"position\":3,\"letter\":\"C\",\"text\":\"Intravenous fluids and pain management\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":332,\"question_id\":83,\"position\":4,\"letter\":\"D\",\"text\":\"Psychiatric consultation for delirium\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":85,"position":41,"stem_snapshot":"A 40-year-old woman presents with right upper quadrant pain, fever, and jaundice. Ultrasound shows gallstones and a dilated common bile duct. Her WBC count is 15,000/mm³, and she has a positive Murphy's sign. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":337,\"question_id\":85,\"position\":1,\"letter\":\"A\",\"text\":\"Laparoscopic cholecystectomy with intraoperative cholangiography\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":338,\"question_id\":85,\"position\":2,\"letter\":\"B\",\"text\":\"ERCP for possible stone extraction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":339,\"question_id\":85,\"position\":3,\"letter\":\"C\",\"text\":\"Percutaneous cholecystostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":340,\"question_id\":85,\"position\":4,\"letter\":\"D\",\"text\":\"Intravenous antibiotics and observation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":88,"position":42,"stem_snapshot":"A 55-year-old woman presents with left lower quadrant pain, fever, and leukocytosis. CT scan shows sigmoid colon diverticulitis with a 5 cm pericolonic abscesses. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":349,\"question_id\":88,\"position\":1,\"letter\":\"A\",\"text\":\"Intravenous antibiotics and bowel rest\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":350,\"question_id\":88,\"position\":2,\"letter\":\"B\",\"text\":\"Percutaneous drainage of the abscesses followed by elective resection\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":351,\"question_id\":88,\"position\":3,\"letter\":\"C\",\"text\":\"Emergent sigmoidectomy with colostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":352,\"question_id\":88,\"position\":4,\"letter\":\"D\",\"text\":\"Oral antibiotics and dietary modification\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":92,"position":43,"stem_snapshot":"A 70-year-old man is found to have a 5 cm abdominal aorticaneurysm on routine screening ultrasound. He has hypertension and hyperlipidemia but no symptoms related to the AAA. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":365,\"question_id\":92,\"position\":1,\"letter\":\"A\",\"text\":\"Elective open surgical repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":366,\"question_id\":92,\"position\":2,\"letter\":\"B\",\"text\":\"Elective endovascular repair\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":367,\"question_id\":92,\"position\":3,\"letter\":\"C\",\"text\":\"Surveillance with ultrasound every 6 months\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":368,\"question_id\":92,\"position\":4,\"letter\":\"D\",\"text\":\"Beta-blocker therapy to reduce aortic wall stress\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":97,"position":44,"stem_snapshot":"A 25-year-old man sustains a stab wound to the chest. He has decreased breath sounds on the left side and subcutaneous emphysema. Chest X-ray shows a large left pneumothora x. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":385,\"question_id\":97,\"position\":1,\"letter\":\"A\",\"text\":\"Observation and repeat X-ray in 2 hours\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":386,\"question_id\":97,\"position\":2,\"letter\":\"B\",\"text\":\"Placement of a chest tube\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":387,\"question_id\":97,\"position\":3,\"letter\":\"C\",\"text\":\"Immediate thoracotomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":388,\"question_id\":97,\"position\":4,\"letter\":\"D\",\"text\":\"Needle aspiration of the pneumothora x\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":98,"position":45,"stem_snapshot":"A 30-year-old man sustains a crush injury to his right leg. He has severe pain, pallor, and paresthesias in the leg. His compartment pressure is 30 mm Hg. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":389,\"question_id\":98,\"position\":1,\"letter\":\"A\",\"text\":\"Elevation of the leg and ice packs\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":390,\"question_id\":98,\"position\":2,\"letter\":\"B\",\"text\":\"Fasciotomy of the affected compartments\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":391,\"question_id\":98,\"position\":3,\"letter\":\"C\",\"text\":\"Intravenous fluids and pain management\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":392,\"question_id\":98,\"position\":4,\"letter\":\"D\",\"text\":\"Doppler ultrasound to assess blood flow\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":101,"position":46,"stem_snapshot":"A 70-year-old woman undergoes emergency surgery for perforated diverticulitis. Postoperatively, she develops fever, hypotension, and leukocytosis. Blood cultures are positive for gram-negative rods. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":401,\"question_id\":101,\"position\":1,\"letter\":\"A\",\"text\":\"Broad-spectrum intravenous antibiotics and fluid resuscitation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":402,\"question_id\":101,\"position\":2,\"letter\":\"B\",\"text\":\"Exploratory laparotomy to check for anastomic leak\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":403,\"question_id\":101,\"position\":3,\"letter\":\"C\",\"text\":\"CT scan to look for fluid collections or abscesses\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":404,\"question_id\":101,\"position\":4,\"letter\":\"D\",\"text\":\"Vasopressor support and mechanical ventilation if needed\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":104,"position":47,"stem_snapshot":"A 65-year-old man with coronary artery disease is scheduled for elective colon resection. He has stable angina and is on beta-blockers and statins. Which of the following is the most appropriate preoperative cardiac evaluation?","options_snapshot":"[{\"id\":413,\"question_id\":104,\"position\":1,\"letter\":\"A\",\"text\":\"Exercise stress test\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":414,\"question_id\":104,\"position\":2,\"letter\":\"B\",\"text\":\"Dobutamine stress echocardiogram\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":415,\"question_id\":104,\"position\":3,\"letter\":\"C\",\"text\":\"Coronary angiography\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":416,\"question_id\":104,\"position\":4,\"letter\":\"D\",\"text\":\"No additional testing beyond history and physical exam\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":107,"position":48,"stem_snapshot":"A 40-year-old man undergoes laparotomy for small bowel obstruction. He has severe pain postoperatively despite receiving intravenous morphine via PCA pump. Which of the following is the most appropriate next step?","options_snapshot":"[{\"id\":425,\"question_id\":107,\"position\":1,\"letter\":\"A\",\"text\":\"Increase the PCA morphine bolus dose\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":426,\"question_id\":107,\"position\":2,\"letter\":\"B\",\"text\":\"Add a continuous infusion to the PCA pump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":427,\"question_id\":107,\"position\":3,\"letter\":\"C\",\"text\":\"Switch to hydromorphone via PCA pump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":428,\"question_id\":107,\"position\":4,\"letter\":\"D\",\"text\":\"Add an NSAID for multimodal pain management\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":109,"position":49,"stem_snapshot":"A 60-year-old woman with stage IV ovarian cancer has a small bowel obstruction due to tumor progression. She has significant pain and nausea but is alert and oriented. Her performance status is Karnofsky score of 50. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":433,\"question_id\":109,\"position\":1,\"letter\":\"A\",\"text\":\"Surgical exploration and resection of obstructed bowel segment\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":434,\"question_id\":109,\"position\":2,\"letter\":\"B\",\"text\":\"Placement of a venting gastrostomy tube\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":435,\"question_id\":109,\"position\":3,\"letter\":\"C\",\"text\":\"Palliative care with opioids and antiemetics\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":436,\"question_id\":109,\"position\":4,\"letter\":\"D\",\"text\":\"Total parenteral nutrition (TPN) to bypass the obstruction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":111,"position":50,"stem_snapshot":"A 30-year-old man has a 5 cm laceration on his arm with full-thickness skin loss but intact underlying muscle and fascia. The wound bed is clean and granulating. Which of the following is the most appropriate wound closure method?","options_snapshot":"[{\"id\":441,\"question_id\":111,\"position\":1,\"letter\":\"A\",\"text\":\"Primary closure with sutures\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":442,\"question_id\":111,\"position\":2,\"letter\":\"B\",\"text\":\"Secondary intention healing\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":443,\"question_id\":111,\"position\":3,\"letter\":\"C\",\"text\":\"Split-thickness skin graft (STSG)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":444,\"question_id\":111,\"position\":4,\"letter\":\"D\",\"text\":\"Flap reconstruction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":112,"position":51,"stem_snapshot":"A 70-year-old woman presents with severe abdominal pain disproportionate to physical findings. She has a history of atrial fibrillation and is not anticoagulated. CT scan shows pneumatosis intestinalis and portal venous gas. Which of the following is the most likely diagnosis?","options_snapshot":"[{\"id\":445,\"question_id\":112,\"position\":1,\"letter\":\"A\",\"text\":\"Acute appendicitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":446,\"question_id\":112,\"position\":2,\"letter\":\"B\",\"text\":\"Acute mesenteric ischemia\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":447,\"question_id\":112,\"position\":3,\"letter\":\"C\",\"text\":\"Diverticulitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":448,\"question_id\":112,\"position\":4,\"letter\":\"D\",\"text\":\"Pancreatitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":115,"position":52,"stem_snapshot":"A 2-year-old boy has an undescended left testis. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":457,\"question_id\":115,\"position\":1,\"letter\":\"A\",\"text\":\"Observation until puberty\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":458,\"question_id\":115,\"position\":2,\"letter\":\"B\",\"text\":\"Orchiopexy before age 2 years\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":459,\"question_id\":115,\"position\":3,\"letter\":\"C\",\"text\":\"Hormonal therapy to induce descent\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":460,\"question_id\":115,\"position\":4,\"letter\":\"D\",\"text\":\"Removal of the undescended testis to prevent malignancy risk\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":118,"position":53,"stem_snapshot":"A 40-year-old woman with a body mass index (BMI) of 45 kg/m² has tried multiple weight loss programs without success. She has type 2 diabetes and hypertension. Which of the following bariatric procedures has the highest risk of nutritional deficiencies?","options_snapshot":"[{\"id\":469,\"question_id\":118,\"position\":1,\"letter\":\"A\",\"text\":\"Gastric bypass (Roux-en-Y)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":470,\"question_id\":118,\"position\":2,\"letter\":\"B\",\"text\":\"Sleeve gastrectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":471,\"question_id\":118,\"position\":3,\"letter\":\"C\",\"text\":\"Adjustable gastric banding\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":472,\"question_id\":118,\"position\":4,\"letter\":\"D\",\"text\":\"Biliopancreatic diversion with duodenal switch (BPD-DS)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":122,"position":54,"stem_snapshot":"In a surgical department, what is the purpose of morbidity and mortality conferences?","options_snapshot":"[{\"id\":485,\"question_id\":122,\"position\":1,\"letter\":\"A\",\"text\":\"To assign blame for adverse outcomes\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":486,\"question_id\":122,\"position\":2,\"letter\":\"B\",\"text\":\"To educate and improve patient care\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":487,\"question_id\":122,\"position\":3,\"letter\":\"C\",\"text\":\"To satisfy regulatory requirements\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":488,\"question_id\":122,\"position\":4,\"letter\":\"D\",\"text\":\"To compare surgeons' performance\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":6,"question_id":123,"position":55,"stem_snapshot":"A surgeon wants to know the best treatment for a particular condition. Which of the following provides the highest level of evidence?","options_snapshot":"[{\"id\":489,\"question_id\":123,\"position\":1,\"letter\":\"A\",\"text\":\"Randomized controlled trials (RCTs)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":490,\"question_id\":123,\"position\":2,\"letter\":\"B\",\"text\":\"Case reports\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":491,\"question_id\":123,\"position\":3,\"letter\":\"C\",\"text\":\"Expert opinion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":492,\"question_id\":123,\"position\":4,\"letter\":\"D\",\"text\":\"Retrospective cohort studies\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":23,"position":1,"stem_snapshot":" a new born baby undergoes pyloromyotomy. During the procedure, a deep mucosal injury is noted at the distal aspect of the incision. How should this patient’s mucosal injury be managed?","options_snapshot":"[{\"id\":717,\"question_id\":23,\"position\":1,\"letter\":\"A\",\"text\":\"Closure of the mucosal defect with the myotomy intact\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":718,\"question_id\":23,\"position\":2,\"letter\":\"B\",\"text\":\"Closure of the mucosal and muscular defects with repeat myotomy at a later date\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":719,\"question_id\":23,\"position\":3,\"letter\":\"C\",\"text\":\"Closure of the mucosal and muscular defects with repeat myotomy on another side of the pylorus\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":720,\"question_id\":23,\"position\":4,\"letter\":\"D\",\"text\":\"Wide local drainage and antibiotics\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":4,"position":2,"stem_snapshot":"A 38-year-old woman presents with acute onset pain over the lateral aspect of the right breast. On examination, a tender, cord-like structure is palpable extending along the anterior chest wall. There is no overlying skin erythema or systemic symptoms. Ultrasound shows a superficial, non-compressible tubular structure without internal flow. Which of the following is the MOST appropriate next step in management?","options_snapshot":"[{\"id\":13,\"question_id\":4,\"position\":1,\"letter\":\"A\",\"text\":\"Immediate excisional biopsy of the lesion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":14,\"question_id\":4,\"position\":2,\"letter\":\"B\",\"text\":\"Start intravenous antibiotics and admit\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":15,\"question_id\":4,\"position\":3,\"letter\":\"C\",\"text\":\"Reassurance with NSAIDs and warm compresses\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":16,\"question_id\":4,\"position\":4,\"letter\":\"D\",\"text\":\"Initiate anticoagulation therapy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":6,"position":3,"stem_snapshot":"A 62-year-old man presents with a firm retroareolar breast mass associated with nipple retraction and ipsilateral axillary lymphadenopathy. Histopathology reveals invasive carcinoma. Which of the following statements is MOST accurate regarding the biology of this tumor?","options_snapshot":"[{\"id\":21,\"question_id\":6,\"position\":1,\"letter\":\"A\",\"text\":\"Lobular carcinoma is the most common histological subtype\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":22,\"question_id\":6,\"position\":2,\"letter\":\"B\",\"text\":\"The tumor is likely to be hormone receptor negative\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":23,\"question_id\":6,\"position\":3,\"letter\":\"C\",\"text\":\"Early involvement of pectoralis major\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":24,\"question_id\":6,\"position\":4,\"letter\":\"D\",\"text\":\"Axillary lymph node metastasis is rare\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":7,"position":4,"stem_snapshot":"Ductal carcinoma in situ (DCIS) most commonly presents as:","options_snapshot":"[{\"id\":25,\"question_id\":7,\"position\":1,\"letter\":\"A\",\"text\":\"Palpable lump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":26,\"question_id\":7,\"position\":2,\"letter\":\"B\",\"text\":\"Skin ulceration\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":27,\"question_id\":7,\"position\":3,\"letter\":\"C\",\"text\":\"Mammographic calcifications\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":28,\"question_id\":7,\"position\":4,\"letter\":\"D\",\"text\":\"Axillary lymphadenopathy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":9,"position":5,"stem_snapshot":"A tumor is negative for ER, PR, and HER2 but expresses CK5/6 and EGFR. Which subtype does this represent?","options_snapshot":"[{\"id\":33,\"question_id\":9,\"position\":1,\"letter\":\"A\",\"text\":\"Luminal A\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":34,\"question_id\":9,\"position\":2,\"letter\":\"B\",\"text\":\"Luminal B\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":35,\"question_id\":9,\"position\":3,\"letter\":\"C\",\"text\":\"Basal-like (TNBC)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":36,\"question_id\":9,\"position\":4,\"letter\":\"D\",\"text\":\"HER2-enriched\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":11,"position":6,"stem_snapshot":"Which of the following statements BEST differentiates Oncotype DX from MammaPrint?","options_snapshot":"[{\"id\":41,\"question_id\":11,\"position\":1,\"letter\":\"A\",\"text\":\"Oncotype DX provides binary risk (low/high)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":42,\"question_id\":11,\"position\":2,\"letter\":\"B\",\"text\":\"MammaPrint evaluates fewer genes than Oncotype DX\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":43,\"question_id\":11,\"position\":3,\"letter\":\"C\",\"text\":\"Oncotype DX provides a quantitative recurrence score\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":44,\"question_id\":11,\"position\":4,\"letter\":\"D\",\"text\":\"MammaPrint is limited to node-negative patients only\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":12,"position":7,"stem_snapshot":"BRCA-1 gene is located on:","options_snapshot":"[{\"id\":45,\"question_id\":12,\"position\":1,\"letter\":\"A\",\"text\":\"Chromosome 13\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":46,\"question_id\":12,\"position\":2,\"letter\":\"B\",\"text\":\"Chromosome 17\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":47,\"question_id\":12,\"position\":3,\"letter\":\"C\",\"text\":\"Chromosome 21\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":48,\"question_id\":12,\"position\":4,\"letter\":\"D\",\"text\":\"Chromosome X\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":15,"position":8,"stem_snapshot":"Which of the following statements related to liver embryology is true?","options_snapshot":"[{\"id\":57,\"question_id\":15,\"position\":1,\"letter\":\"A\",\"text\":\"The liver is derived from the hindgut.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":58,\"question_id\":15,\"position\":2,\"letter\":\"B\",\"text\":\"Two umbilical veins carry placental blood to the liver.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":59,\"question_id\":15,\"position\":3,\"letter\":\"C\",\"text\":\"The ductus venosus shunts blood from the portal vein to the systemic circulation.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":60,\"question_id\":15,\"position\":4,\"letter\":\"D\",\"text\":\"The falciform ligament is the obliterated ductus arteriosus.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":17,"position":9,"stem_snapshot":"Which of the following features of IPMN of the pancreas is associated with the lowest risk for cancer?","options_snapshot":"[{\"id\":65,\"question_id\":17,\"position\":1,\"letter\":\"A\",\"text\":\"Branch duct type with mural nodularity\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":66,\"question_id\":17,\"position\":2,\"letter\":\"B\",\"text\":\"Branch duct type smaller than 3 cm\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":67,\"question_id\":17,\"position\":3,\"letter\":\"C\",\"text\":\"Main duct type with segmental dilation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":68,\"question_id\":17,\"position\":4,\"letter\":\"D\",\"text\":\"Multifocal IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":18,"position":10,"stem_snapshot":"Which of the following pancreatic cystic lesions is almost exclusively found in a young female?","options_snapshot":"[{\"id\":69,\"question_id\":18,\"position\":1,\"letter\":\"A\",\"text\":\"Mucinous cystic neoplasm\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":70,\"question_id\":18,\"position\":2,\"letter\":\"B\",\"text\":\"Side-duct IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":71,\"question_id\":18,\"position\":3,\"letter\":\"C\",\"text\":\"Main-duct IPMN\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":72,\"question_id\":18,\"position\":4,\"letter\":\"D\",\"text\":\"Solid pseudopapillary epithelial neoplasm\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":20,"position":11,"stem_snapshot":"The most appropriate chemotherapy regimen to accompany radiation therapy in stage 3 epidermoid anal cancer would be:","options_snapshot":"[{\"id\":77,\"question_id\":20,\"position\":1,\"letter\":\"A\",\"text\":\"Carboplatin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":78,\"question_id\":20,\"position\":2,\"letter\":\"B\",\"text\":\"Gemcitabine\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":79,\"question_id\":20,\"position\":3,\"letter\":\"C\",\"text\":\"Leucovarin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":80,\"question_id\":20,\"position\":4,\"letter\":\"D\",\"text\":\"Mytomycin C\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":22,"position":12,"stem_snapshot":"One of the following drugs may cause pyloric stenosis if administered to a premature infant:","options_snapshot":"[{\"id\":85,\"question_id\":22,\"position\":1,\"letter\":\"A\",\"text\":\"Intravenous vitamin E\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":86,\"question_id\":22,\"position\":2,\"letter\":\"B\",\"text\":\"Indomethacin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":87,\"question_id\":22,\"position\":3,\"letter\":\"C\",\"text\":\"Enteric gentamicin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":88,\"question_id\":22,\"position\":4,\"letter\":\"D\",\"text\":\"Prostaglandins\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":25,"position":13,"stem_snapshot":"Regarding gastric duplications, which of the following is true?","options_snapshot":"[{\"id\":97,\"question_id\":25,\"position\":1,\"letter\":\"A\",\"text\":\"Gastric duplication cysts account for 20% of all duplications of the gastrointestinal tract.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":98,\"question_id\":25,\"position\":2,\"letter\":\"B\",\"text\":\"Gastric duplication tends to occur along the greater curvature.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":99,\"question_id\":25,\"position\":3,\"letter\":\"C\",\"text\":\"Gastric duplications usually communicate with the gastric lumen.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":100,\"question_id\":25,\"position\":4,\"letter\":\"D\",\"text\":\"Gastric duplications are more common in males.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":27,"position":14,"stem_snapshot":"A 35-year-old woman is rescued from a house fire during which she was trapped in a smoke-filled bedroom for 30 minutes. On arrival in the Emergency Room, she has marked facial burns and hoarseness of voice but no stridor. She is expectorating carbonaceous sputum, appears confused and has a cherry-red visage. Which statement is FALSE about this case?","options_snapshot":"[{\"id\":105,\"question_id\":27,\"position\":1,\"letter\":\"A\",\"text\":\"Early intubation is advisable.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":106,\"question_id\":27,\"position\":2,\"letter\":\"B\",\"text\":\"A significant thermal injury to the trachea is likely.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":107,\"question_id\":27,\"position\":3,\"letter\":\"C\",\"text\":\"Lavage with sodium bicarbonate 1.4% has a role in the management of this patient.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":108,\"question_id\":27,\"position\":4,\"letter\":\"D\",\"text\":\"Lung function is likely to worsen over the next 12 hours.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":28,"position":15,"stem_snapshot":"Five days following percutaneous drainage of a pelvic collection after right hemicolectomy for Crohn’s disease, the catheter output remains > 100 mL/day. What should be done next?","options_snapshot":"[{\"id\":109,\"question_id\":28,\"position\":1,\"letter\":\"A\",\"text\":\"Perform abscessogram\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":110,\"question_id\":28,\"position\":2,\"letter\":\"B\",\"text\":\"Connect the tube to a low-pressure suction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":111,\"question_id\":28,\"position\":3,\"letter\":\"C\",\"text\":\"Intermittent tube clamping\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":112,\"question_id\":28,\"position\":4,\"letter\":\"D\",\"text\":\"Open surgery for diversion.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":33,"position":16,"stem_snapshot":"In a 40-year-old woman receiving TPN for small-bowel fistula, what finding can be attributed to hypophosphatemia?","options_snapshot":"[{\"id\":129,\"question_id\":33,\"position\":1,\"letter\":\"A\",\"text\":\"Increased cardiac output\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":130,\"question_id\":33,\"position\":2,\"letter\":\"B\",\"text\":\"Diarrhea\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":131,\"question_id\":33,\"position\":3,\"letter\":\"C\",\"text\":\"Increased energy production\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":132,\"question_id\":33,\"position\":4,\"letter\":\"D\",\"text\":\"Rhabdomyolysis\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":14,"position":17,"stem_snapshot":"A 63-y/o female undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The pathology report states that there is a focus of carcinoma which invades, but does not penetrate through, the lamina propria. What is the most appropriate management?","options_snapshot":"[{\"id\":53,\"question_id\":14,\"position\":1,\"letter\":\"A\",\"text\":\"Laparoscopic resection of the gallbladder fossa\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":54,\"question_id\":14,\"position\":2,\"letter\":\"B\",\"text\":\"Open extended cholecystectomy including segment 4b and 5 liver resection as well as removal of porta hepatis lymph nodes\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":55,\"question_id\":14,\"position\":3,\"letter\":\"C\",\"text\":\"Cholecystectomy is sufficient\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":56,\"question_id\":14,\"position\":4,\"letter\":\"D\",\"text\":\"Radiation and chemotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":29,"position":18,"stem_snapshot":"Which of the following statements regarding interleukins (ILs) is true?","options_snapshot":"[{\"id\":113,\"question_id\":29,\"position\":1,\"letter\":\"A\",\"text\":\"All ILs upregulate the immune system.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":114,\"question_id\":29,\"position\":2,\"letter\":\"B\",\"text\":\"IL-8 is a neutrophil chemotactic factor.\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":115,\"question_id\":29,\"position\":3,\"letter\":\"C\",\"text\":\"IL-10 produces fever and inflammation.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":116,\"question_id\":29,\"position\":4,\"letter\":\"D\",\"text\":\"Prednisone upregulates the effect of IL-1.\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":40,"position":19,"stem_snapshot":"The most reliable method to confirm correct endotracheal tube placement intraoperatively is:","options_snapshot":"[{\"id\":157,\"question_id\":40,\"position\":1,\"letter\":\"A\",\"text\":\"Chest X-ray\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":158,\"question_id\":40,\"position\":2,\"letter\":\"B\",\"text\":\"Auscultation of bilateral breath sounds\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":159,\"question_id\":40,\"position\":3,\"letter\":\"C\",\"text\":\"End-tidal CO2 capnography\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":160,\"question_id\":40,\"position\":4,\"letter\":\"D\",\"text\":\"Pulse oximetry\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":45,"position":20,"stem_snapshot":"The most common location for a carcinoid tumor is the:","options_snapshot":"[{\"id\":177,\"question_id\":45,\"position\":1,\"letter\":\"A\",\"text\":\"Stomach\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":178,\"question_id\":45,\"position\":2,\"letter\":\"B\",\"text\":\"Appendix\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":179,\"question_id\":45,\"position\":3,\"letter\":\"C\",\"text\":\"Small intestine (ileum)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":180,\"question_id\":45,\"position\":4,\"letter\":\"D\",\"text\":\"Rectum\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":46,"position":21,"stem_snapshot":"A Meckel diverticulum is a remnant of the:","options_snapshot":"[{\"id\":181,\"question_id\":46,\"position\":1,\"letter\":\"A\",\"text\":\"Allantois\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":182,\"question_id\":46,\"position\":2,\"letter\":\"B\",\"text\":\"Vitelline (omphalomesenteric) duct\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":183,\"question_id\":46,\"position\":3,\"letter\":\"C\",\"text\":\"Urachus\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":184,\"question_id\":46,\"position\":4,\"letter\":\"D\",\"text\":\"Wolffian duct\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":50,"position":22,"stem_snapshot":"A Siewert type II gastroesophageal junction tumor is best treated with:","options_snapshot":"[{\"id\":197,\"question_id\":50,\"position\":1,\"letter\":\"A\",\"text\":\"Ivor Lewis esophagectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":198,\"question_id\":50,\"position\":2,\"letter\":\"B\",\"text\":\"Transhiatal esophagectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":199,\"question_id\":50,\"position\":3,\"letter\":\"C\",\"text\":\"Extended total gastrectomy with distal esophagectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":200,\"question_id\":50,\"position\":4,\"letter\":\"D\",\"text\":\"Endoscopic mucosal resection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":51,"position":23,"stem_snapshot":"The Milan criteria for HCC liver transplantation include:","options_snapshot":"[{\"id\":201,\"question_id\":51,\"position\":1,\"letter\":\"A\",\"text\":\"Single tumor ≤5 cm or up to 3 tumors each ≤3 cm, no vascular invasion\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":202,\"question_id\":51,\"position\":2,\"letter\":\"B\",\"text\":\"Single tumor up to 10 cm\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":203,\"question_id\":51,\"position\":3,\"letter\":\"C\",\"text\":\"Any number of tumors if AFP <400\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":204,\"question_id\":51,\"position\":4,\"letter\":\"D\",\"text\":\"Tumor confined to one lobe regardless of size\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":52,"position":24,"stem_snapshot":"A 4 cm soft tissue sarcoma of the thigh is best treated with:","options_snapshot":"[{\"id\":205,\"question_id\":52,\"position\":1,\"letter\":\"A\",\"text\":\"Amputation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":206,\"question_id\":52,\"position\":2,\"letter\":\"B\",\"text\":\"Wide local excision with R0 resection, and adjuvant radiotherapy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":207,\"question_id\":52,\"position\":3,\"letter\":\"C\",\"text\":\"Chemotherapy alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":208,\"question_id\":52,\"position\":4,\"letter\":\"D\",\"text\":\"Incisional biopsy followed by radiotherapy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":53,"position":25,"stem_snapshot":"Iatrogenic bile duct injury (Strasberg type E) discovered intraoperatively is best managed by:","options_snapshot":"[{\"id\":209,\"question_id\":53,\"position\":1,\"letter\":\"A\",\"text\":\"Place a T-tube and close\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":210,\"question_id\":53,\"position\":2,\"letter\":\"B\",\"text\":\"Roux-en-Y hepaticojejunostomy by an expert surgeon\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":211,\"question_id\":53,\"position\":3,\"letter\":\"C\",\"text\":\"Primary repair over a stent\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":212,\"question_id\":53,\"position\":4,\"letter\":\"D\",\"text\":\"Endoscopic sphincterotomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":56,"position":26,"stem_snapshot":"A Breslow thickness of 2.5 mm melanoma is classified as:","options_snapshot":"[{\"id\":221,\"question_id\":56,\"position\":1,\"letter\":\"A\",\"text\":\"T1\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":222,\"question_id\":56,\"position\":2,\"letter\":\"B\",\"text\":\"T2\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":223,\"question_id\":56,\"position\":3,\"letter\":\"C\",\"text\":\"T3\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":224,\"question_id\":56,\"position\":4,\"letter\":\"D\",\"text\":\"T4\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":58,"position":27,"stem_snapshot":"An 80-year-old male patient with a T2N0 squamous cell carcinoma of the anal canal should be treated with:","options_snapshot":"[{\"id\":229,\"question_id\":58,\"position\":1,\"letter\":\"A\",\"text\":\"Abdominoperineal resection\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":230,\"question_id\":58,\"position\":2,\"letter\":\"B\",\"text\":\"Chemoradiotherapy (Nigro protocol)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":231,\"question_id\":58,\"position\":3,\"letter\":\"C\",\"text\":\"Wide local excision\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":232,\"question_id\":58,\"position\":4,\"letter\":\"D\",\"text\":\"Diverting colostomy alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":61,"position":28,"stem_snapshot":"In the LRINEC score for necrotizing fasciitis, which parameter is most specific?","options_snapshot":"[{\"id\":241,\"question_id\":61,\"position\":1,\"letter\":\"A\",\"text\":\"White blood cell count\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":242,\"question_id\":61,\"position\":2,\"letter\":\"B\",\"text\":\"C-reactive protein level\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":243,\"question_id\":61,\"position\":3,\"letter\":\"C\",\"text\":\"Serum sodium\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":244,\"question_id\":61,\"position\":4,\"letter\":\"D\",\"text\":\"Hemoglobin\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":59,"position":29,"stem_snapshot":"The Amsterdam criteria (Amsterdam II) are used to identify families with:","options_snapshot":"[{\"id\":233,\"question_id\":59,\"position\":1,\"letter\":\"A\",\"text\":\"Familial adenomatous polyposis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":234,\"question_id\":59,\"position\":2,\"letter\":\"B\",\"text\":\"Lynch syndrome\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":235,\"question_id\":59,\"position\":3,\"letter\":\"C\",\"text\":\"Peutz-Jeghers syndrome\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":236,\"question_id\":59,\"position\":4,\"letter\":\"D\",\"text\":\"Gardner syndrome\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":63,"position":30,"stem_snapshot":"Robotic surgery provides the greatest advantage over conventional laparoscopy in:","options_snapshot":"[{\"id\":249,\"question_id\":63,\"position\":1,\"letter\":\"A\",\"text\":\"Appendectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":250,\"question_id\":63,\"position\":2,\"letter\":\"B\",\"text\":\"Low pelvic dissection (e.g., low rectal cancer, prostatectomy)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":251,\"question_id\":63,\"position\":3,\"letter\":\"C\",\"text\":\"Open hernia repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":252,\"question_id\":63,\"position\":4,\"letter\":\"D\",\"text\":\"Diagnostic laparoscopy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":70,"position":31,"stem_snapshot":"Complex perianal fistula in Crohn disease is best managed initially with:","options_snapshot":"[{\"id\":277,\"question_id\":70,\"position\":1,\"letter\":\"A\",\"text\":\"Fistulotomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":278,\"question_id\":70,\"position\":2,\"letter\":\"B\",\"text\":\"Seton placement with optimization of medical therapy (biologics)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":279,\"question_id\":70,\"position\":3,\"letter\":\"C\",\"text\":\"Diverting colostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":280,\"question_id\":70,\"position\":4,\"letter\":\"D\",\"text\":\"Fibrin glue injection alone\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":67,"position":32,"stem_snapshot":"In GIST, the molecular target for imatinib therapy is:","options_snapshot":"[{\"id\":265,\"question_id\":67,\"position\":1,\"letter\":\"A\",\"text\":\"EGFR mutation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":266,\"question_id\":67,\"position\":2,\"letter\":\"B\",\"text\":\"BRAF V600E mutation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":267,\"question_id\":67,\"position\":3,\"letter\":\"C\",\"text\":\"HER2 overexpression\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":268,\"question_id\":67,\"position\":4,\"letter\":\"D\",\"text\":\"PDGFRA mutation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":66,"position":33,"stem_snapshot":"A patient with familial adenomatous polyposis should undergo prophylactic surgery ideally by age:","options_snapshot":"[{\"id\":261,\"question_id\":66,\"position\":1,\"letter\":\"A\",\"text\":\"10 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":262,\"question_id\":66,\"position\":2,\"letter\":\"B\",\"text\":\"20 years\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":263,\"question_id\":66,\"position\":3,\"letter\":\"C\",\"text\":\"30 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":264,\"question_id\":66,\"position\":4,\"letter\":\"D\",\"text\":\"40 years\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":130,"position":34,"stem_snapshot":"A 38-year-old woman presents with acute onset pain over the lateral aspect of the right breast. On examination, a tender, cord-like structure is palpable extending along the anterior chest wall. There is no overlying skin erythema or systemic symptoms. Ultrasound shows a superficial, non-compressible tubular structure without internal flow. Which of the following is the MOST appropriate next step in management?","options_snapshot":"[{\"id\":517,\"question_id\":130,\"position\":1,\"letter\":\"A\",\"text\":\"Immediate excisional biopsy of the lesion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":518,\"question_id\":130,\"position\":2,\"letter\":\"B\",\"text\":\"Start intravenous antibiotics and admit\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":519,\"question_id\":130,\"position\":3,\"letter\":\"C\",\"text\":\"Reassurance with NSAIDs and warm compresses\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":520,\"question_id\":130,\"position\":4,\"letter\":\"D\",\"text\":\"Initiate anticoagulation therapy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":133,"position":35,"stem_snapshot":"BRCA-1 gene is located on:","options_snapshot":"[{\"id\":529,\"question_id\":133,\"position\":1,\"letter\":\"A\",\"text\":\"Chromosome 13\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":530,\"question_id\":133,\"position\":2,\"letter\":\"B\",\"text\":\"Chromosome 17\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":531,\"question_id\":133,\"position\":3,\"letter\":\"C\",\"text\":\"Chromosome 21\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":532,\"question_id\":133,\"position\":4,\"letter\":\"D\",\"text\":\"Chromosome X\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":126,"position":36,"stem_snapshot":"A 65 years old patient, has iron deficiency anemia, during colonoscopy 3 cm ulcerated Mass, 2 cm below hepatic flexure, that proved to be adenocarcinoma and –ve for metastasis what is the most appropriate surgical management?","options_snapshot":"[{\"id\":501,\"question_id\":126,\"position\":1,\"letter\":\"A\",\"text\":\"RT. hemicolectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":502,\"question_id\":126,\"position\":2,\"letter\":\"B\",\"text\":\"Expended RT hemicolectomy\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":503,\"question_id\":126,\"position\":3,\"letter\":\"C\",\"text\":\"Subtotal colectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":504,\"question_id\":126,\"position\":4,\"letter\":\"D\",\"text\":\"Segmental resection of the ascending colon\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":127,"position":37,"stem_snapshot":"55 years old man underwent low anterior resection for low rectal cancer,developed frequent Bowel motions, urgency and incontinence, which is the most appropriate to manage his Symptoms?","options_snapshot":"[{\"id\":505,\"question_id\":127,\"position\":1,\"letter\":\"A\",\"text\":\"Antidiarrialheal medications\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":506,\"question_id\":127,\"position\":2,\"letter\":\"B\",\"text\":\"Temporary ileostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":507,\"question_id\":127,\"position\":3,\"letter\":\"C\",\"text\":\"Pelvic floor rehabilitation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":508,\"question_id\":127,\"position\":4,\"letter\":\"D\",\"text\":\"High fiber diet\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":77,"position":38,"stem_snapshot":"A 50-year-old man presents with a right inguinal hernia. On physical exam, the hernia is indirect and reducible. He has no comorbidities. Which of the following is the most appropriate surgical approach?","options_snapshot":"[{\"id\":305,\"question_id\":77,\"position\":1,\"letter\":\"A\",\"text\":\"Open inguinal herniorrhaphy with mesh\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":306,\"question_id\":77,\"position\":2,\"letter\":\"B\",\"text\":\"Laparoscopic transabdominal preperitoneal (TAPP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":307,\"question_id\":77,\"position\":3,\"letter\":\"C\",\"text\":\"Laparoscopic totally extraperitoneal (TEP) repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":308,\"question_id\":77,\"position\":4,\"letter\":\"D\",\"text\":\"Bassini repair without mesh\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":78,"position":39,"stem_snapshot":"A 35-year-old man undergoes emergency appendectomy for acute appendicitis. Postoperatively, he develops fever, abdominal pain, and leukocytosis. CT scan shows a 5 cm fluid collection in the right lower quadrant with air pockets. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":309,\"question_id\":78,\"position\":1,\"letter\":\"A\",\"text\":\"Continue intravenous antibiotics and observe\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":310,\"question_id\":78,\"position\":2,\"letter\":\"B\",\"text\":\"Percutaneous drainage of the fluid collection\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":311,\"question_id\":78,\"position\":3,\"letter\":\"C\",\"text\":\"Exploratory laparotomy and washout\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":312,\"question_id\":78,\"position\":4,\"letter\":\"D\",\"text\":\"Repeat CT scan in 24 hours\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":83,"position":40,"stem_snapshot":"A 60-year-old man is admitted with acute pancreatitis. He has a history of alcohol abuse and is currently confused and disoriented. His vital signs are stable, but he has a GCS of 13. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":329,\"question_id\":83,\"position\":1,\"letter\":\"A\",\"text\":\"CT scan of the head to rule out hemorrhage\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":330,\"question_id\":83,\"position\":2,\"letter\":\"B\",\"text\":\"Blood alcohol level to assess intoxication\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":331,\"question_id\":83,\"position\":3,\"letter\":\"C\",\"text\":\"Intravenous fluids and pain management\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":332,\"question_id\":83,\"position\":4,\"letter\":\"D\",\"text\":\"Psychiatric consultation for delirium\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":85,"position":41,"stem_snapshot":"A 40-year-old woman presents with right upper quadrant pain, fever, and jaundice. Ultrasound shows gallstones and a dilated common bile duct. Her WBC count is 15,000/mm³, and she has a positive Murphy's sign. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":337,\"question_id\":85,\"position\":1,\"letter\":\"A\",\"text\":\"Laparoscopic cholecystectomy with intraoperative cholangiography\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":338,\"question_id\":85,\"position\":2,\"letter\":\"B\",\"text\":\"ERCP for possible stone extraction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":339,\"question_id\":85,\"position\":3,\"letter\":\"C\",\"text\":\"Percutaneous cholecystostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":340,\"question_id\":85,\"position\":4,\"letter\":\"D\",\"text\":\"Intravenous antibiotics and observation\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":88,"position":42,"stem_snapshot":"A 55-year-old woman presents with left lower quadrant pain, fever, and leukocytosis. CT scan shows sigmoid colon diverticulitis with a 5 cm pericolonic abscesses. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":349,\"question_id\":88,\"position\":1,\"letter\":\"A\",\"text\":\"Intravenous antibiotics and bowel rest\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":350,\"question_id\":88,\"position\":2,\"letter\":\"B\",\"text\":\"Percutaneous drainage of the abscesses followed by elective resection\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":351,\"question_id\":88,\"position\":3,\"letter\":\"C\",\"text\":\"Emergent sigmoidectomy with colostomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":352,\"question_id\":88,\"position\":4,\"letter\":\"D\",\"text\":\"Oral antibiotics and dietary modification\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":92,"position":43,"stem_snapshot":"A 70-year-old man is found to have a 5 cm abdominal aorticaneurysm on routine screening ultrasound. He has hypertension and hyperlipidemia but no symptoms related to the AAA. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":365,\"question_id\":92,\"position\":1,\"letter\":\"A\",\"text\":\"Elective open surgical repair\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":366,\"question_id\":92,\"position\":2,\"letter\":\"B\",\"text\":\"Elective endovascular repair\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":367,\"question_id\":92,\"position\":3,\"letter\":\"C\",\"text\":\"Surveillance with ultrasound every 6 months\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":368,\"question_id\":92,\"position\":4,\"letter\":\"D\",\"text\":\"Beta-blocker therapy to reduce aortic wall stress\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":97,"position":44,"stem_snapshot":"A 25-year-old man sustains a stab wound to the chest. He has decreased breath sounds on the left side and subcutaneous emphysema. Chest X-ray shows a large left pneumothora x. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":385,\"question_id\":97,\"position\":1,\"letter\":\"A\",\"text\":\"Observation and repeat X-ray in 2 hours\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":386,\"question_id\":97,\"position\":2,\"letter\":\"B\",\"text\":\"Placement of a chest tube\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":387,\"question_id\":97,\"position\":3,\"letter\":\"C\",\"text\":\"Immediate thoracotomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":388,\"question_id\":97,\"position\":4,\"letter\":\"D\",\"text\":\"Needle aspiration of the pneumothora x\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":98,"position":45,"stem_snapshot":"A 30-year-old man sustains a crush injury to his right leg. He has severe pain, pallor, and paresthesias in the leg. His compartment pressure is 30 mm Hg. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":389,\"question_id\":98,\"position\":1,\"letter\":\"A\",\"text\":\"Elevation of the leg and ice packs\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":390,\"question_id\":98,\"position\":2,\"letter\":\"B\",\"text\":\"Fasciotomy of the affected compartments\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":391,\"question_id\":98,\"position\":3,\"letter\":\"C\",\"text\":\"Intravenous fluids and pain management\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":392,\"question_id\":98,\"position\":4,\"letter\":\"D\",\"text\":\"Doppler ultrasound to assess blood flow\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":101,"position":46,"stem_snapshot":"A 70-year-old woman undergoes emergency surgery for perforated diverticulitis. Postoperatively, she develops fever, hypotension, and leukocytosis. Blood cultures are positive for gram-negative rods. Which of the following is the most appropriate initial management?","options_snapshot":"[{\"id\":401,\"question_id\":101,\"position\":1,\"letter\":\"A\",\"text\":\"Broad-spectrum intravenous antibiotics and fluid resuscitation\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":402,\"question_id\":101,\"position\":2,\"letter\":\"B\",\"text\":\"Exploratory laparotomy to check for anastomic leak\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":403,\"question_id\":101,\"position\":3,\"letter\":\"C\",\"text\":\"CT scan to look for fluid collections or abscesses\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":404,\"question_id\":101,\"position\":4,\"letter\":\"D\",\"text\":\"Vasopressor support and mechanical ventilation if needed\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"A","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":104,"position":47,"stem_snapshot":"A 65-year-old man with coronary artery disease is scheduled for elective colon resection. He has stable angina and is on beta-blockers and statins. Which of the following is the most appropriate preoperative cardiac evaluation?","options_snapshot":"[{\"id\":413,\"question_id\":104,\"position\":1,\"letter\":\"A\",\"text\":\"Exercise stress test\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":414,\"question_id\":104,\"position\":2,\"letter\":\"B\",\"text\":\"Dobutamine stress echocardiogram\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":415,\"question_id\":104,\"position\":3,\"letter\":\"C\",\"text\":\"Coronary angiography\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":416,\"question_id\":104,\"position\":4,\"letter\":\"D\",\"text\":\"No additional testing beyond history and physical exam\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":107,"position":48,"stem_snapshot":"A 40-year-old man undergoes laparotomy for small bowel obstruction. He has severe pain postoperatively despite receiving intravenous morphine via PCA pump. Which of the following is the most appropriate next step?","options_snapshot":"[{\"id\":425,\"question_id\":107,\"position\":1,\"letter\":\"A\",\"text\":\"Increase the PCA morphine bolus dose\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":426,\"question_id\":107,\"position\":2,\"letter\":\"B\",\"text\":\"Add a continuous infusion to the PCA pump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":427,\"question_id\":107,\"position\":3,\"letter\":\"C\",\"text\":\"Switch to hydromorphone via PCA pump\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":428,\"question_id\":107,\"position\":4,\"letter\":\"D\",\"text\":\"Add an NSAID for multimodal pain management\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":109,"position":49,"stem_snapshot":"A 60-year-old woman with stage IV ovarian cancer has a small bowel obstruction due to tumor progression. She has significant pain and nausea but is alert and oriented. Her performance status is Karnofsky score of 50. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":433,\"question_id\":109,\"position\":1,\"letter\":\"A\",\"text\":\"Surgical exploration and resection of obstructed bowel segment\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":434,\"question_id\":109,\"position\":2,\"letter\":\"B\",\"text\":\"Placement of a venting gastrostomy tube\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":435,\"question_id\":109,\"position\":3,\"letter\":\"C\",\"text\":\"Palliative care with opioids and antiemetics\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":436,\"question_id\":109,\"position\":4,\"letter\":\"D\",\"text\":\"Total parenteral nutrition (TPN) to bypass the obstruction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":111,"position":50,"stem_snapshot":"A 30-year-old man has a 5 cm laceration on his arm with full-thickness skin loss but intact underlying muscle and fascia. The wound bed is clean and granulating. Which of the following is the most appropriate wound closure method?","options_snapshot":"[{\"id\":441,\"question_id\":111,\"position\":1,\"letter\":\"A\",\"text\":\"Primary closure with sutures\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":442,\"question_id\":111,\"position\":2,\"letter\":\"B\",\"text\":\"Secondary intention healing\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":443,\"question_id\":111,\"position\":3,\"letter\":\"C\",\"text\":\"Split-thickness skin graft (STSG)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":444,\"question_id\":111,\"position\":4,\"letter\":\"D\",\"text\":\"Flap reconstruction\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"C","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":112,"position":51,"stem_snapshot":"A 70-year-old woman presents with severe abdominal pain disproportionate to physical findings. She has a history of atrial fibrillation and is not anticoagulated. CT scan shows pneumatosis intestinalis and portal venous gas. Which of the following is the most likely diagnosis?","options_snapshot":"[{\"id\":445,\"question_id\":112,\"position\":1,\"letter\":\"A\",\"text\":\"Acute appendicitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":446,\"question_id\":112,\"position\":2,\"letter\":\"B\",\"text\":\"Acute mesenteric ischemia\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":447,\"question_id\":112,\"position\":3,\"letter\":\"C\",\"text\":\"Diverticulitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":448,\"question_id\":112,\"position\":4,\"letter\":\"D\",\"text\":\"Pancreatitis\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":115,"position":52,"stem_snapshot":"A 2-year-old boy has an undescended left testis. Which of the following is the most appropriate management?","options_snapshot":"[{\"id\":457,\"question_id\":115,\"position\":1,\"letter\":\"A\",\"text\":\"Observation until puberty\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":458,\"question_id\":115,\"position\":2,\"letter\":\"B\",\"text\":\"Orchiopexy before age 2 years\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":459,\"question_id\":115,\"position\":3,\"letter\":\"C\",\"text\":\"Hormonal therapy to induce descent\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":460,\"question_id\":115,\"position\":4,\"letter\":\"D\",\"text\":\"Removal of the undescended testis to prevent malignancy risk\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":118,"position":53,"stem_snapshot":"A 40-year-old woman with a body mass index (BMI) of 45 kg/m² has tried multiple weight loss programs without success. She has type 2 diabetes and hypertension. Which of the following bariatric procedures has the highest risk of nutritional deficiencies?","options_snapshot":"[{\"id\":469,\"question_id\":118,\"position\":1,\"letter\":\"A\",\"text\":\"Gastric bypass (Roux-en-Y)\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":470,\"question_id\":118,\"position\":2,\"letter\":\"B\",\"text\":\"Sleeve gastrectomy\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":471,\"question_id\":118,\"position\":3,\"letter\":\"C\",\"text\":\"Adjustable gastric banding\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":472,\"question_id\":118,\"position\":4,\"letter\":\"D\",\"text\":\"Biliopancreatic diversion with duodenal switch (BPD-DS)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"D","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":122,"position":54,"stem_snapshot":"In a surgical department, what is the purpose of morbidity and mortality conferences?","options_snapshot":"[{\"id\":485,\"question_id\":122,\"position\":1,\"letter\":\"A\",\"text\":\"To assign blame for adverse outcomes\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":486,\"question_id\":122,\"position\":2,\"letter\":\"B\",\"text\":\"To educate and improve patient care\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":487,\"question_id\":122,\"position\":3,\"letter\":\"C\",\"text\":\"To satisfy regulatory requirements\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":488,\"question_id\":122,\"position\":4,\"letter\":\"D\",\"text\":\"To compare surgeons' performance\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null}]","correct_snapshot":"B","p_value":null,"d_index":null,"point_biserial":null},{"exam_id":7,"question_id":123,"position":55,"stem_snapshot":"A surgeon wants to know the best treatment for a particular condition. Which of the following provides the highest level of evidence?","options_snapshot":"[{\"id\":489,\"question_id\":123,\"position\":1,\"letter\":\"A\",\"text\":\"Randomized controlled trials (RCTs)\",\"is_correct\":1,\"rationale\":null,\"pick_count\":null},{\"id\":490,\"question_id\":123,\"position\":2,\"letter\":\"B\",\"text\":\"Case reports\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":491,\"question_id\":123,\"position\":3,\"letter\":\"C\",\"text\":\"Expert opinion\",\"is_correct\":0,\"rationale\":null,\"pick_count\":null},{\"id\":492,\"question_id\":123,\"position\":4,\"letter\":\"D\",\"text\":\"Retrospective cohort 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Characteristic histologic feature of invasive lobular carcinoma:\",\"after\":\"Characteristic histologic feature of invasive lobular carcinoma:\"}"},{"id":83,"ts":1778436310000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":9,"diff_json":"{\"before\":\"✔ Answer: B   (detected by: \\\"Answer: B\\\")\\nQ9. A tumor is negative for ER, PR, and HER2 but expresses CK5/6 and EGFR. Which subtype does this represent?\",\"after\":\"A tumor is negative for ER, PR, and HER2 but expresses CK5/6 and EGFR. Which subtype does this represent?\"}"},{"id":84,"ts":1778436310000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":10,"diff_json":"{\"before\":\"✔ Answer: C   (detected by: bold \\\"Answer: C\\\")\\nQ10. Which of the following BEST explains the increased risk of endometrial carcinoma with Tamoxifen?\",\"after\":\"Which of the following BEST explains the increased risk of endometrial carcinoma with Tamoxifen?\"}"},{"id":85,"ts":1778436310000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":11,"diff_json":"{\"before\":\"✔ Answer: C   (detected by: bold \\\"Answer: C\\\")\\nQ11. Which of the following statements BEST differentiates Oncotype DX from MammaPrint?\",\"after\":\"Which of the following statements BEST differentiates Oncotype DX from MammaPrint?\"}"},{"id":86,"ts":1778436362000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":12,"diff_json":"{\"before\":\"✔ Answer: C   (detected by: \\\"Answer: C\\\")\\nQ12. BRCA-1 gene is located on:\",\"after\":\"BRCA-1 gene is located on:\"}"},{"id":87,"ts":1778436362000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":13,"diff_json":"{\"before\":\"✔ Answer: B   (detected by: \\\"Answer: B\\\")\\n⚑ Editor’s note: Appeared twice (verbatim duplicate) in the source — kept once.\\nHepatobiliary / Pancreas\\nQ13. The most common cause of benign bile duct stricture is:\",\"after\":\"The most common cause of benign bile duct stricture is:\"}"},{"id":88,"ts":1778436362000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":14,"diff_json":"{\"before\":\"✔ Answer: A   (detected by: \\\"Answer: A\\\")\\nQ14. A 63-y/o female undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The pathology report states that there is a focus of carcinoma which invades, but does not penetrate through, the lamina propria. What is the most appropriate management?\",\"after\":\"A 63-y/o female undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The pathology report states that there is a focus of carcinoma which invades, but does not penetrate through, the lamina propria. What is the most appropriate management?\"}"},{"id":89,"ts":1778436362000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":15,"diff_json":"{\"before\":\"✔ Answer: C   (detected by: \\\"Answer: C\\\")\\nQ15. Which of the following statements related to liver embryology is true?\",\"after\":\"Which of the following statements related to liver embryology is true?\"}"},{"id":90,"ts":1778436362000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":16,"diff_json":"{\"before\":\"✔ Answer: C   (detected by: \\\"Answer: C\\\")\\n⚑ Editor’s note: Strictly, the ductus venosus shunts blood from the umbilical vein (not portal vein) to the IVC. Source key marks C — confirm if this is the desired key.\\nQ16. Which of the following is true regarding comparisons of amebic and pyogenic liver abscesses?\",\"after\":\"Which of the following is true regarding comparisons of amebic and pyogenic liver abscesses?\"}"},{"id":91,"ts":1778436362000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":17,"diff_json":"{\"before\":\"✔ Answer: D   (detected by: \\\"Answer: D\\\")\\nQ17. Which of the following features of IPMN of the pancreas is associated with the lowest risk for cancer?\",\"after\":\"Which of the following features of IPMN of the pancreas is associated with the lowest risk for cancer?\"}"},{"id":92,"ts":1778436362000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":18,"diff_json":"{\"before\":\"✔ Answer: B   (detected by: \\\"Answer: B\\\")\\nQ18. Which of the following pancreatic cystic lesions is almost exclusively found in a young female?\",\"after\":\"Which of the following pancreatic cystic lesions is almost exclusively found in a young female?\"}"},{"id":93,"ts":1778436362000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":19,"diff_json":"{\"before\":\"✔ Answer: D   (detected by: \\\"Answer: D\\\")\\nQ19. A 60-year-old alcoholic man presents with chronic, vague abdominal pain. He denies a history of pancreatitis and is otherwise in good health. CT reveals a 6-cm multiloculated, septated cyst at the tail of the pancreas. FNA of the cyst is nondiagnostic. Fluid amylase and CEA are in the high normal range. Management consists of:\",\"after\":\"A 60-year-old alcoholic man presents with chronic, vague abdominal pain. He denies a history of pancreatitis and is otherwise in good health. CT reveals a 6-cm multiloculated, septated cyst at the tail of the pancreas. FNA of the cyst is nondiagnostic. Fluid amylase and CEA are in the high normal range. Management consists of:\"}"},{"id":94,"ts":1778436362000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":20,"diff_json":"{\"before\":\"✔ Answer: A   (detected by: \\\"Answer: A\\\")\\nAnorectal / GI\\nQ20. The most appropriate chemotherapy regimen to accompany radiation therapy in stage 3 epidermoid anal cancer would be:\",\"after\":\"The most appropriate chemotherapy regimen to accompany radiation therapy in stage 3 epidermoid anal cancer would be:\"}"},{"id":95,"ts":1778436362000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":21,"diff_json":"{\"before\":\"✔ Answer: D   (detected by: red color (FF0000) on option D)\\n⚑ Editor’s note: A near-duplicate of this question appeared earlier in source with the stem itself awkwardly bolded as \\\"...would be flurouracil (5-Fu)\\\" and 5 options including Paclitaxel — kept only this cleaner version.\\nQ21. Concerning anal fissure, one of the following is TRUE:\",\"after\":\"Concerning anal fissure, one of the following is TRUE:\"}"},{"id":96,"ts":1778436416000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":22,"diff_json":"{\"before\":\"✔ Answer: A   (detected by: trailing \\\"**\\\" star marker on option A)\\n⚑ Editor’s note: The \\\"**\\\" marker in the source was on option A — interpreted as the correct answer marker (atypical/off-midline fissures must be investigated for Crohn's, TB, HIV, malignancy). Confirm if intended.\\nQ22. One of the following drugs may cause pyloric stenosis if administered to a premature infant:\",\"after\":\"One of the following drugs may cause pyloric stenosis if administered to a premature infant:\"}"},{"id":97,"ts":1778436416000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":23,"diff_json":"{\"before\":\"✔ Answer: D   (detected by: \\\"answer d\\\")\\nQ23. The patient undergoes pyloromyotomy. During the procedure, a deep mucosal injury is noted at the distal aspect of the incision. How should this patient’s mucosal injury be managed?\",\"after\":\"The patient undergoes pyloromyotomy. During the procedure, a deep mucosal injury is noted at the distal aspect of the incision. How should this patient’s mucosal injury be managed?\"}"},{"id":98,"ts":1778436416000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":24,"diff_json":"{\"before\":\"✔ Answer: C   (detected by: \\\"Answer C\\\")\\nQ24. The true statement about Ladd bands is:\",\"after\":\"The true statement about Ladd bands is:\"}"},{"id":99,"ts":1778436416000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":25,"diff_json":"{\"before\":\"✔ Answer: A   (detected by: \\\"Answer A\\\")\\nQ25. Regarding gastric duplications, which of the following is true?\",\"after\":\"Regarding gastric duplications, which of the following is true?\"}"},{"id":100,"ts":1778436416000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":26,"diff_json":"{\"before\":\"✔ Answer: B   (detected by: \\\"answer B\\\")\\nCritical Care / Burns\\nQ26. A 35-year-old patient is intubated in the ICU after being exposed to smoke. He has thick yellow secretions that require frequent suctioning along with the administration of bronchodilators. On hospital day 5, he has a percutaneous central venous catheter placed through the right internal jugular vein. Several hours later, he undergoes respiratory arrest. His peak inspiratory pressure has risen from 24 to 41 cm H₂O. Choose the most likely reason for the respiratory arrest:\",\"after\":\"A 35-year-old patient is intubated in the ICU after being exposed to smoke. He has thick yellow secretions that require frequent suctioning along with the administration of bronchodilators. On hospital day 5, he has a percutaneous central venous catheter placed through the right internal jugular vein. Several hours later, he undergoes respiratory arrest. His peak inspiratory pressure has risen from 24 to 41 cm H₂O. Choose the most likely reason for the respiratory arrest:\"}"},{"id":101,"ts":1778436416000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":27,"diff_json":"{\"before\":\"✔ Answer: D   (detected by: \\\"ANSWER D\\\")\\nQ27. A 35-year-old woman is rescued from a house fire during which she was trapped in a smoke-filled bedroom for 30 minutes. On arrival in the Emergency Room, she has marked facial burns and hoarseness of voice but no stridor. She is expectorating carbonaceous sputum, appears confused and has a cherry-red visage. Which statement is FALSE about this case?\",\"after\":\"A 35-year-old woman is rescued from a house fire during which she was trapped in a smoke-filled bedroom for 30 minutes. On arrival in the Emergency Room, she has marked facial burns and hoarseness of voice but no stridor. She is expectorating carbonaceous sputum, appears confused and has a cherry-red visage. Which statement is FALSE about this case?\"}"},{"id":102,"ts":1778436416000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":28,"diff_json":"{\"before\":\"✔ Answer: B   (detected by: \\\"ANSWER B\\\")\\nQ28. Five days following percutaneous drainage of a pelvic collection after right hemicolectomy for Crohn’s disease, the catheter output remains > 100 mL/day. What should be done next?\",\"after\":\"Five days following percutaneous drainage of a pelvic collection after right hemicolectomy for Crohn’s disease, the catheter output remains > 100 mL/day. What should be done next?\"}"},{"id":103,"ts":1778436416000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":29,"diff_json":"{\"before\":\"✔ Answer: A   (detected by: triple-asterisk \\\"***\\\" star marker on option A)\\nSurgical Physiology\\nQ29. Which of the following statements regarding interleukins (ILs) is true?\",\"after\":\"Which of the following statements regarding interleukins (ILs) is true?\"}"},{"id":104,"ts":1778436416000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":30,"diff_json":"{\"before\":\"✔ Answer: B   (detected by: bold on option B)\\n⚑ Editor’s note: Source listed letters A, B, D, E (skipped C). Re-lettered A–D in this version for clarity.\\nQ30. In patients receiving massive blood transfusion for acute blood loss, which of the following is correct?\",\"after\":\"In patients receiving massive blood transfusion for acute blood loss, which of the following is correct?\"}"},{"id":105,"ts":1778436416000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":31,"diff_json":"{\"before\":\"✔ Answer: A   (detected by: bold on option A)\\n⚑ Editor’s note: Original source had a garbled option D combining sodium bicarbonate (D) and calcium chloride (E) into one line — split/cleaned. Question appeared twice — kept once.\\nQ31. A 25-year-old man is seen in the office with complaints of contracture of his left index finger after a burn injury. Which of the following statements is true about growth factors?\",\"after\":\"A 25-year-old man is seen in the office with complaints of contracture of his left index finger after a burn injury. Which of the following statements is true about growth factors?\"}"},{"id":106,"ts":1778436455000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":32,"diff_json":"{\"before\":\"✔ Answer: C   (detected by: bold on option C)\\nQ32. The most common fluid disorder in surgical patients is:\",\"after\":\"The most common fluid disorder in surgical patients is:\"}"},{"id":107,"ts":1778436455000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":33,"diff_json":"{\"before\":\"✔ Answer: A   (detected by: bold on stem and option A)\\n⚑ Editor’s note: Question appeared twice (identical) — kept once.\\nQ33. In a 40-year-old woman receiving TPN for small-bowel fistula, what finding can be attributed to hypophosphatemia?\",\"after\":\"In a 40-year-old woman receiving TPN for small-bowel fistula, what finding can be attributed to hypophosphatemia?\"}"},{"id":108,"ts":1778436455000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":34,"diff_json":"{\"before\":\"Q1. A cirrhotic patient presents with massive hematemesis. Best initial management?\",\"after\":\"A cirrhotic patient presents with massive hematemesis. Best initial management?\"}"},{"id":109,"ts":1778436455000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":35,"diff_json":"{\"before\":\"Q2. A 58-year-old patient is diagnosed with adenocarcinoma of the distal esophagus. After a PET-CT shows no distant metastasis, what is the most appropriate next step for staging to guide treatment decisions (e.g., neoadjuvant chemotherapy)?\",\"after\":\"A 58-year-old patient is diagnosed with adenocarcinoma of the distal esophagus. After a PET-CT shows no distant metastasis, what is the most appropriate next step for staging to guide treatment decisions (e.g., neoadjuvant chemotherapy)?\"}"},{"id":110,"ts":1778436455000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":36,"diff_json":"{\"before\":\"Q3. A 28-year-old male undergoes emergency laparotomy. Which tissue layer provides the main tensile strength for abdominal wall closure?\",\"after\":\"A 28-year-old male undergoes emergency laparotomy. Which tissue layer provides the main tensile strength for abdominal wall closure?\"}"},{"id":111,"ts":1778436455000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":37,"diff_json":"{\"before\":\"Q4. A patient on warfarin requires emergency surgery. The fastest way to reverse anticoagulation is:\",\"after\":\"A patient on warfarin requires emergency surgery. The fastest way to reverse anticoagulation is:\"}"},{"id":112,"ts":1778436455000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":38,"diff_json":"{\"before\":\"Q5. The most important preoperative tool to predict cardiac risk in non-cardiac surgery is the:\",\"after\":\"The most important preoperative tool to predict cardiac risk in non-cardiac surgery is the:\"}"},{"id":113,"ts":1778436455000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":39,"diff_json":"{\"before\":\"Q6. In a clean surgical wound, the expected surgical site infection rate is less than:\",\"after\":\"In a clean surgical wound, the expected surgical site infection rate is less than:\"}"},{"id":114,"ts":1778436455000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":40,"diff_json":"{\"before\":\"Q7. The most reliable method to confirm correct endotracheal tube placement intraoperatively is:\",\"after\":\"The most reliable method to confirm correct endotracheal tube placement intraoperatively is:\"}"},{"id":115,"ts":1778436455000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":41,"diff_json":"{\"before\":\"Q8. The most common complication of massive blood transfusion is:\",\"after\":\"The most common complication of massive blood transfusion is:\"}"},{"id":116,"ts":1778436495000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":42,"diff_json":"{\"before\":\"Q9. The most common cause of postoperative fever on day 3-5 is:\",\"after\":\"The most common cause of postoperative fever on day 3-5 is:\"}"},{"id":117,"ts":1778436495000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":43,"diff_json":"{\"before\":\"Q10. Fine needle aspiration of a thyroid nodule shows follicular neoplasm (Bethesda IV). The recommended management is:\",\"after\":\"Fine needle aspiration of a thyroid nodule shows follicular neoplasm (Bethesda IV). The recommended management is:\"}"},{"id":118,"ts":1778436495000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":44,"diff_json":"{\"before\":\"Q11. The most common complication of laparoscopic cholecystectomy is:\",\"after\":\"The most common complication of laparoscopic cholecystectomy is:\"}"},{"id":119,"ts":1778436495000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":45,"diff_json":"{\"before\":\"Q12. The most common location for a carcinoid tumor is the:\",\"after\":\"The most common location for a carcinoid tumor is the:\"}"},{"id":120,"ts":1778436495000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":46,"diff_json":"{\"before\":\"Q13. A Meckel diverticulum is a remnant of the:\",\"after\":\"A Meckel diverticulum is a remnant of the:\"}"},{"id":121,"ts":1778436495000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":47,"diff_json":"{\"before\":\"Q14. Informed surgical consent must include discussion of:\",\"after\":\"Informed surgical consent must include discussion of:\"}"},{"id":122,"ts":1778436495000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":48,"diff_json":"{\"before\":\"Q15. A 55-year-old presents with obstructive jaundice and a double-duct sign on CT. This is most suggestive of:\",\"after\":\"A 55-year-old presents with obstructive jaundice and a double-duct sign on CT. This is most suggestive of:\"}"},{"id":123,"ts":1778436495000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":49,"diff_json":"{\"before\":\"Q16. In low anterior resection for rectal cancer, the minimum distal margin required is:\",\"after\":\"In low anterior resection for rectal cancer, the minimum distal margin required is:\"}"},{"id":124,"ts":1778436495000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":50,"diff_json":"{\"before\":\"Q17. A Siewert type II gastroesophageal junction tumor is best treated with:\",\"after\":\"A Siewert type II gastroesophageal junction tumor is best treated with:\"}"},{"id":125,"ts":1778436495000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":51,"diff_json":"{\"before\":\"Q18. The Milan criteria for HCC liver transplantation include:\",\"after\":\"The Milan criteria for HCC liver transplantation include:\"}"},{"id":126,"ts":1778436530000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":52,"diff_json":"{\"before\":\"Q19. A 4 cm soft tissue sarcoma of the thigh is best treated with:\",\"after\":\"A 4 cm soft tissue sarcoma of the thigh is best treated with:\"}"},{"id":127,"ts":1778436530000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":53,"diff_json":"{\"before\":\"Q20. Iatrogenic bile duct injury (Strasberg type E) discovered intraoperatively is best managed by:\",\"after\":\"Iatrogenic bile duct injury (Strasberg type E) discovered intraoperatively is best managed by:\"}"},{"id":128,"ts":1778436530000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":54,"diff_json":"{\"before\":\"Q21. In Zollinger-Ellison syndrome, the gastrinoma is most commonly located in the:\",\"after\":\"In Zollinger-Ellison syndrome, the gastrinoma is most commonly located in the:\"}"},{"id":129,"ts":1778436530000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":55,"diff_json":"{\"before\":\"Q22. Damage control surgery in abdominal trauma involves:\",\"after\":\"Damage control surgery in abdominal trauma involves:\"}"},{"id":130,"ts":1778436530000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":56,"diff_json":"{\"before\":\"Q23. A Breslow thickness of 2.5 mm melanoma is classified as:\",\"after\":\"A Breslow thickness of 2.5 mm melanoma is classified as:\"}"},{"id":131,"ts":1778436530000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":57,"diff_json":"{\"before\":\"Q24. In gastric cancer, the Borrmann type IV (linitis plastica) is characterized by:\",\"after\":\"In gastric cancer, the Borrmann type IV (linitis plastica) is characterized by:\"}"},{"id":132,"ts":1778436530000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":58,"diff_json":"{\"before\":\"Q25. An 80-year-old male patient with a T2N0 squamous cell carcinoma of the anal canal should be treated with:\",\"after\":\"An 80-year-old male patient with a T2N0 squamous cell carcinoma of the anal canal should be treated with:\"}"},{"id":133,"ts":1778436530000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":59,"diff_json":"{\"before\":\"Q26. The Amsterdam criteria (Amsterdam II) are used to identify families with:\",\"after\":\"The Amsterdam criteria (Amsterdam II) are used to identify families with:\"}"},{"id":134,"ts":1778436530000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":60,"diff_json":"{\"before\":\"Q27. The most common postoperative complication specific to pancreaticoduodenectomy is:\",\"after\":\"The most common postoperative complication specific to pancreaticoduodenectomy is:\"}"},{"id":135,"ts":1778436530000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":61,"diff_json":"{\"before\":\"Q28. In the LRINEC score for necrotizing fasciitis, which parameter is most specific?\",\"after\":\"In the LRINEC score for necrotizing fasciitis, which parameter is most specific?\"}"},{"id":136,"ts":1778436566000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":62,"diff_json":"{\"before\":\"Q29. In adrenocortical carcinoma, the most important prognostic factor after complete resection is:\",\"after\":\"In adrenocortical carcinoma, the most important prognostic factor after complete resection is:\"}"},{"id":137,"ts":1778436566000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":63,"diff_json":"{\"before\":\"Q30. Robotic surgery provides the greatest advantage over conventional laparoscopy in:\",\"after\":\"Robotic surgery provides the greatest advantage over conventional laparoscopy in:\"}"},{"id":138,"ts":1778436566000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":64,"diff_json":"{\"before\":\"Q31. Clavien-Dindo grade IIIb complication refers to:\",\"after\":\"Clavien-Dindo grade IIIb complication refers to:\"}"},{"id":139,"ts":1778436566000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":65,"diff_json":"{\"before\":\"Q32. A transplant patient presenting with CMV disease should receive:\",\"after\":\"A transplant patient presenting with CMV disease should receive:\"}"},{"id":140,"ts":1778436566000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":66,"diff_json":"{\"before\":\"Q33. A patient with familial adenomatous polyposis should undergo prophylactic surgery ideally by age:\",\"after\":\"A patient with familial adenomatous polyposis should undergo prophylactic surgery ideally by age:\"}"},{"id":141,"ts":1778436566000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":67,"diff_json":"{\"before\":\"Q34. In GIST, the molecular target for imatinib therapy is:\",\"after\":\"In GIST, the molecular target for imatinib therapy is:\"}"},{"id":142,"ts":1778436566000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":68,"diff_json":"{\"before\":\"Q35. The most critical factor determining survival after esophagectomy for cancer is:\",\"after\":\"The most critical factor determining survival after esophagectomy for cancer is:\"}"},{"id":143,"ts":1778436566000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":69,"diff_json":"{\"before\":\"Q36. The POSSUM scoring system predicts:\",\"after\":\"The POSSUM scoring system predicts:\"}"},{"id":144,"ts":1778436566000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":70,"diff_json":"{\"before\":\"Q37. Complex perianal fistula in Crohn disease is best managed initially with:\",\"after\":\"Complex perianal fistula in Crohn disease is best managed initially with:\"}"},{"id":145,"ts":1778436566000,"actor":"cleanup-stems-script","action":"cleanup_stem","entity":"question","entity_id":71,"diff_json":"{\"before\":\"Q38. 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