CLASS 6512 EIGHTEEN YEAR OLD PASSED
OUT CERTIFICATION PAPER 2026 FULL
SOLUTIONS GRADED A+
⩥ Ectopic pregnancy. Answer: A 23-year-old nulligravida presents with
a 2-day history of sharp intermittent right lower quadrant abdominal
pain, nonradiating, without any alleviating factors, exacerbated with
movement, progressively worsening, and not associated with any
gastrointestinal symptoms. Her last menstrual period was 7 weeks ago.
She denies medical problems. Her gynecologic history is significant for
a prior chlamydia infection as a teenager, but is otherwise negative.
A 33-year-old gravida 3 para 2 presents with a 4-day history of vaginal
bleeding along with lower abdominal discomfort and nausea. She states
that her symptoms have worsened over the previous 24 hours. Her last
menstrual period was 6 weeks ago. She denies medical, gynecologic, or
social problems and her review of systems is negative except for the
above complaints. Her obstetric history includes an abortion and two
uncomplicated vaginal deliveries followed by an interval tubal ligation 1
year ago
⩥ diabetes insipidus. Answer: A 42-year-old man undergoes
transsphenoidal surgery for a large, nonfunctioning pituitary
macroadenoma. Preoperatively, dynamic pituitary hormone tests were
normal, as was his fluid intake and output. Two days following surgery
,he developed acute polyuria, extreme thirst, and polydipsia. His urine
output over the next 24 hours was 6 liters, with frequent nocturia.
A 75-year-old woman presents to her family physician with a 6-month
history of progressive fatigue and malaise with polyuria, polydipsia, and
nocturia. She has a longstanding history of bipolar affective disorder,
and has been receiving lithium for the past 15 years.
⩥ Graves disease. Answer: A 38-year-old woman, who in the past had
tried to lose weight without success, is happy to see that in the last 2
months she has lost 25 pounds. She also has difficulty sleeping at night.
Her husband complains that she is keeping the house very cool. She
recently consulted her ophthalmologist because of redness and watering
of the eyes. Eye drops were not helpful. She consults her doctor for
fatigue and anxiety, palpitations, and easy fatigability. On physical
examination, her pulse rate is 100 bpm and her thyroid is slightly
enlarged. Conjunctivae are red and she has a stare.
⩥ Primary hypothyroidism. Answer: A 45-year-old white woman
presents with symptoms of fatigue, depression, and mild weight gain.
Physical exam demonstrates heart rate of 58 beats per minute, coarse dry
skin, and bilateral eyelid edema. Serum thyroid-stimulating hormone
(TSH) is 40 mIU/L (normal range, subject to laboratory standards, 0.35
to 6.20 mIU/L), and free T4 is 0.5 nanograms/dL (usual normal range,
subject to laboratory standards, is 0.8 to 1.8 nanograms/dL). Therapy is
begun with levothyroxine 100 micrograms daily and the patient's
symptoms improve. Repeat testing 6 weeks later reveals a normal TSH
,(5 mIU/L). The patient is maintained on this dose and repeat TSH testing
is planned yearly or if symptoms recur.
⩥ diabetic ketoacidosis. Answer: A 20-year-old man is brought to the
emergency department with abdominal pain, nausea, and vomiting with
increasing polyuria, polydipsia, and drowsiness since the day before. He
was diagnosed with type 1 diabetes 2 years previously. He mentions that
he ran out of insulin 2 days ago. Vital signs at admission are: BP 106/67
mmHg, heart rate 123 beats per minute, respiratory rate 32 breaths per
minute, temperature 98.8°F (37.1°C). On mental status examination, he
is drowsy. Physical examination reveals Kussmaul breathing (deep and
rapid respiration due to ketoacidosis) with acetone odor and mild
generalized abdominal tenderness without guarding and rebound
tenderness. Initial laboratory data are: blood glucose 450 mg/dL, arterial
pH 7.24, pCO₂ 25 mmHg, bicarbonate 12 mEq/L, WBC count
18,500/microliter, sodium 128 mEq/L, potassium 5.2 mEq/L, chloride
97 mEq/L, BUN 32 mg/dL, creatinine 1.7 mg/dL, serum ketones
strongly positive
⩥ Primary hyperparathyroidism. Answer: At a routine exam, a 55-year-
old woman is discovered to have hypercalcemia. Follow-up laboratory
tests show synchronously elevated serum calcium and intact parathyroid
hormone, with low phosphorus and mildly elevated alkaline
phosphatase. 25-hydroxyvitamin D is in the low normal range. Past
medical history is significant for hypertension and coronary artery
disease. Review of symptoms includes complaints of fatigue, feeling
achy, and vague depression and mental fatigue. The patient has a history
of nephrolithiasis and newly detected osteopenia. Family history is
negative for renal stones or calcium disorders.
, ⩥ Secondary hyperparathyroidism. Answer: A 50-year-old obese woman
with longstanding, poorly controlled diabetes presents with lethargy and
fatigue. Screening labs report that she has a creatinine level of 2.5 mg/dL
and a BUN level of 40 mg/dL. Additional labs are ordered, which reveal
a calcium level of 7.4 mg/dL and a phosphorus level of 5.9 mg/dL. The
parathyroid hormone level is 400 picograms/mL.
An 85-year-old female nursing-home patient is being seen for
postmenopausal skeletal disease that has become a concern after she fell
and broke her wrist. Her bone densitometry reveals osteoporosis (T-
score: -3.5). Lab tests return with a calcium level of 8.8 mg/dL and a
parathyroid hormone level of 120 picograms/mL. These results prompt
vitamin D testing that returns a 25-hydroxyvitamin D level of 14
nanograms/mL.
⩥ Addison disease. Answer: A 48-year-old man has a 4-month history of
increasing fatigue and anorexia. He has lost 12.2 lb (5.5 kg) and noticed
increased skin pigmentation. He has been otherwise healthy. His mother
has Hashimoto thyroiditis and one of his sisters has type 1 diabetes. His
blood pressure is 110/85 mmHg (supine) and 92/60 mmHg (sitting). His
face shows signs of wasting and his skin has diffuse hyperpigmentation,
which is more pronounced in the oral mucosa, palmar creases, and
knuckles.
A 54-year-old woman with hypothyroidism complains of persistent
fatigue, despite adequate thyroxine replacement. She has noticed
OUT CERTIFICATION PAPER 2026 FULL
SOLUTIONS GRADED A+
⩥ Ectopic pregnancy. Answer: A 23-year-old nulligravida presents with
a 2-day history of sharp intermittent right lower quadrant abdominal
pain, nonradiating, without any alleviating factors, exacerbated with
movement, progressively worsening, and not associated with any
gastrointestinal symptoms. Her last menstrual period was 7 weeks ago.
She denies medical problems. Her gynecologic history is significant for
a prior chlamydia infection as a teenager, but is otherwise negative.
A 33-year-old gravida 3 para 2 presents with a 4-day history of vaginal
bleeding along with lower abdominal discomfort and nausea. She states
that her symptoms have worsened over the previous 24 hours. Her last
menstrual period was 6 weeks ago. She denies medical, gynecologic, or
social problems and her review of systems is negative except for the
above complaints. Her obstetric history includes an abortion and two
uncomplicated vaginal deliveries followed by an interval tubal ligation 1
year ago
⩥ diabetes insipidus. Answer: A 42-year-old man undergoes
transsphenoidal surgery for a large, nonfunctioning pituitary
macroadenoma. Preoperatively, dynamic pituitary hormone tests were
normal, as was his fluid intake and output. Two days following surgery
,he developed acute polyuria, extreme thirst, and polydipsia. His urine
output over the next 24 hours was 6 liters, with frequent nocturia.
A 75-year-old woman presents to her family physician with a 6-month
history of progressive fatigue and malaise with polyuria, polydipsia, and
nocturia. She has a longstanding history of bipolar affective disorder,
and has been receiving lithium for the past 15 years.
⩥ Graves disease. Answer: A 38-year-old woman, who in the past had
tried to lose weight without success, is happy to see that in the last 2
months she has lost 25 pounds. She also has difficulty sleeping at night.
Her husband complains that she is keeping the house very cool. She
recently consulted her ophthalmologist because of redness and watering
of the eyes. Eye drops were not helpful. She consults her doctor for
fatigue and anxiety, palpitations, and easy fatigability. On physical
examination, her pulse rate is 100 bpm and her thyroid is slightly
enlarged. Conjunctivae are red and she has a stare.
⩥ Primary hypothyroidism. Answer: A 45-year-old white woman
presents with symptoms of fatigue, depression, and mild weight gain.
Physical exam demonstrates heart rate of 58 beats per minute, coarse dry
skin, and bilateral eyelid edema. Serum thyroid-stimulating hormone
(TSH) is 40 mIU/L (normal range, subject to laboratory standards, 0.35
to 6.20 mIU/L), and free T4 is 0.5 nanograms/dL (usual normal range,
subject to laboratory standards, is 0.8 to 1.8 nanograms/dL). Therapy is
begun with levothyroxine 100 micrograms daily and the patient's
symptoms improve. Repeat testing 6 weeks later reveals a normal TSH
,(5 mIU/L). The patient is maintained on this dose and repeat TSH testing
is planned yearly or if symptoms recur.
⩥ diabetic ketoacidosis. Answer: A 20-year-old man is brought to the
emergency department with abdominal pain, nausea, and vomiting with
increasing polyuria, polydipsia, and drowsiness since the day before. He
was diagnosed with type 1 diabetes 2 years previously. He mentions that
he ran out of insulin 2 days ago. Vital signs at admission are: BP 106/67
mmHg, heart rate 123 beats per minute, respiratory rate 32 breaths per
minute, temperature 98.8°F (37.1°C). On mental status examination, he
is drowsy. Physical examination reveals Kussmaul breathing (deep and
rapid respiration due to ketoacidosis) with acetone odor and mild
generalized abdominal tenderness without guarding and rebound
tenderness. Initial laboratory data are: blood glucose 450 mg/dL, arterial
pH 7.24, pCO₂ 25 mmHg, bicarbonate 12 mEq/L, WBC count
18,500/microliter, sodium 128 mEq/L, potassium 5.2 mEq/L, chloride
97 mEq/L, BUN 32 mg/dL, creatinine 1.7 mg/dL, serum ketones
strongly positive
⩥ Primary hyperparathyroidism. Answer: At a routine exam, a 55-year-
old woman is discovered to have hypercalcemia. Follow-up laboratory
tests show synchronously elevated serum calcium and intact parathyroid
hormone, with low phosphorus and mildly elevated alkaline
phosphatase. 25-hydroxyvitamin D is in the low normal range. Past
medical history is significant for hypertension and coronary artery
disease. Review of symptoms includes complaints of fatigue, feeling
achy, and vague depression and mental fatigue. The patient has a history
of nephrolithiasis and newly detected osteopenia. Family history is
negative for renal stones or calcium disorders.
, ⩥ Secondary hyperparathyroidism. Answer: A 50-year-old obese woman
with longstanding, poorly controlled diabetes presents with lethargy and
fatigue. Screening labs report that she has a creatinine level of 2.5 mg/dL
and a BUN level of 40 mg/dL. Additional labs are ordered, which reveal
a calcium level of 7.4 mg/dL and a phosphorus level of 5.9 mg/dL. The
parathyroid hormone level is 400 picograms/mL.
An 85-year-old female nursing-home patient is being seen for
postmenopausal skeletal disease that has become a concern after she fell
and broke her wrist. Her bone densitometry reveals osteoporosis (T-
score: -3.5). Lab tests return with a calcium level of 8.8 mg/dL and a
parathyroid hormone level of 120 picograms/mL. These results prompt
vitamin D testing that returns a 25-hydroxyvitamin D level of 14
nanograms/mL.
⩥ Addison disease. Answer: A 48-year-old man has a 4-month history of
increasing fatigue and anorexia. He has lost 12.2 lb (5.5 kg) and noticed
increased skin pigmentation. He has been otherwise healthy. His mother
has Hashimoto thyroiditis and one of his sisters has type 1 diabetes. His
blood pressure is 110/85 mmHg (supine) and 92/60 mmHg (sitting). His
face shows signs of wasting and his skin has diffuse hyperpigmentation,
which is more pronounced in the oral mucosa, palmar creases, and
knuckles.
A 54-year-old woman with hypothyroidism complains of persistent
fatigue, despite adequate thyroxine replacement. She has noticed
