Transcript Slide 1

Writing Effective Test Questions for
the Basic and Clinical Sciences
Carolyn L. Cambor, M.D.
Department of Pathology
Jennifer R. Kogan, M.D.
Department of Medicine
FAPD Series
September 29, 2010
Materials adapted from the National Board of Medical Examiners
Objectives
Describe the item types currently used by the NBME &
the rationale for their use
Describe the steps in writing A-type items
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Basic Sciences
Clinical Sciences
Identify technical flaws in test items & understand the
importance of avoiding them
Advance your skills in writing A-type test items
If time permits, describe and practice writing
R-type test items
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Steps in Test Development
Test purpose
Testing time and method of administration
Test standardization
Test content
Number of items
Item format
Develop items
Item selection and evaluation
3
Why learn how to write test items?
Ensure that your items are:




Clear & understandable
Test what you want to test
Fair
Provide reproducible results
Avoid technical “flaws”



Create confusion
Add unnecessary difficulty
May aid the “testwise student”
4
“Alphabet Soup” of Item Types
True-false
 X (simple true/false)
 K (complex true/false) “1,2,3”, “1,3”, “2,4” “all”
 C (A/B/Both/Neither)
In general, not recommended; not used in Mod1,2
If used, must be clear, unambiguous with options that are
100% T or 100% F
One-best answer
 A (4 or more options)
 B (4 or 5 option matching sets in sets of 2–5 items)
 R (extended matching items in sets of 2-20 items)
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A-Type Item: Components

Stem
Longest part of the item
Sufficient information to
answer the lead-in question.

Lead-in
The question being asked

Options
The correct answer and
3-4 distractors
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A-type Item
Stem:
A 65-year-old man has difficulty rising
from a seated position and straightening
his trunk, but he has no difficulty flexing
his leg.
Lead-in:
Which of the following muscles is most
likely to have been injured?
Options:
A. Gluteus maximus*
B. Gluteus minimus
C. Hamstrings
D. Iliopsoas
E. Obturator internus
Answer
Distractors
7
Good, A-Type Items Have a Distinctive Shape
Stem
Lead In
Option A (distractor)
Option B (answer)
Option C (distractor)
Option D (distractor)
Option E (distractor)
8
Poorly shaped A-type item
Short stem & lead-in
a. Long option
b. Long option
c. Long option
d. Long option
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6 Rules for Writing A-type Items
Basic Sciences
1)
Focus on important topics.
Ideally based on your objectives.
2)
Pose problems, or clinical decision-making tasks that are within the
education/experience of examinees.
3)
Assess application of knowledge, not recall.
4)
Provide sufficient information in the stem and pose a clear question
in the lead-in. “Cover the options rule”
5)
Use homogeneous distractors
6)
Avoid technical flaws and unnecessary difficulty
10
6 Rules for Writing A-type Items:
Basic Sciences
1)
Focus on important topics.
Ideally based on your objectives.
2)
Pose problems, or clinical decision-making tasks that are within
the education/experience of examinees.
3)
Assess application of knowledge, not recall.
4)
Provide sufficient information in the stem and pose a clear question
in the lead-in. “Cover the options rule”
5)
Use homogeneous distractors
6)
Avoid technical flaws and unnecessary difficulty
11
6 Rules for Writing A-type Items:
Basic Sciences
1)
Focus on important topics.
Ideally based on your objectives.
2)
Pose problems, or clinical decision-making tasks that are within the
education/experience of examinees.
3)
Assess application of knowledge, not recall.
4)
Provide sufficient information in the stem and pose a clear question
in the lead-in. “Cover the options rule”
5)
Use homogeneous distractors
6)
Avoid technical flaws and unnecessary difficulty
12
Example – Recall or Application?
What area of the brain is supplied by blood from the
posterior inferior cerebellar artery?
A) Location 1
B) Location 2
C) Location 3
D) Location 4
Recall item: rote memory of isolated fact
13
Example – Recall or Application?
A 62-year-old man develops left sided limb ataxia,
Horner’s syndrome, nystagmus, and loss of
appreciation of facial pain and temperature
sensations.
Which artery is most likely to be occluded?
A) Artery A
B) Artery B
C) Artery C
D) Artery D
Application of knowledge:
Reach a conclusion, make a prediction,
select a course of action
14
6 Rules for Writing A-type Items:
Basic Sciences
1)
Focus on important topics.
Ideally based on your objectives.
2)
Pose problems, or clinical decision-making tasks that are within the
education/experience of examinees.
3)
Assess application of knowledge, not recall.
4)
Provide sufficient information in the stem and pose a clear
question in the lead-in. “Cover the options rule”
5)
Use homogeneous distractors
6)
Avoid technical flaws and unnecessary difficulty
15
Cover the Options Rule
Stem
Lead in
Options
a-e
16
Example – Cover the Options
A 62-year-old man develops left sided limb ataxia,
Horner’s syndrome, nystagmus, and loss of
appreciation of facial pain and temperature
sensations.
Which artery is most likely to be occluded?
A) Artery A
B) Artery B
C) Artery C
D) Artery D
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Example – Cover the Options
A 62-year-old man develops left sided limb ataxia,
Horner’s syndrome, nystagmus, and loss of
appreciation of facial pain and temperature
sensations.
Which artery is most likely to be occluded?
A) Artery A
B) Artery B
C) Artery C
D) Artery D
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Writing the Stem
Avoid
“Which of the following statements is correct?”
“Each of the following statements is correct
EXCEPT…”
Because
Unfocused stems
Don’t follow “cover the options” rule
Heterogeneous options
mix of epidemiology, genetics, mechanisms etc
19
Poorly worded stem:

True statements about cystic fibrosis (CF)
include:
1.
2.
3.
4.
The incidence of CF is 1:2000
Children with CF usually die in their teens.
Males with CF are sterile
CF is an autosomal recessive disease
20
Patient vignettes are good for “stems”
Patient vignettes (stem)
 brief for basic sciences
• should not require patient care expertise
• age
gender
site of care
presenting complaint
duration
• +/- family history
• +/- results of diagnostic tests; initial treatment, etc
 material needs to be taught with clinical relevance
Lead in

Clearly focused question
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Patient Vignette Templates: Basic Sciences

A (patient description) has a (type of injury, location).
Which of the following structures is most likely to be
affected?

A (patient description) has (signs & symptoms).
These observations suggest that the disease is a
result of the (absence or presence) of which of the
following (enzymes, mechanisms)?

A (patient description) dies of (disease). Which of the
following is the most likely finding on autopsy?
22
Patient Vignette Templates: Basic Sciences

Which of the following is the most likely mechanism
of the therapeutic effect of this (drug class) in patients
with (disease)?

(time period) after a (event, such as a trip or meal w/
certain foods) a (patient or group description)
became ill with (symptoms and signs).
Which of the following (organisms, agents) is most
likely to be found on analysis of (food)?
23
Physiology: Patient Vignette
During an operation, the arterial PCO2, and pH of an anesthetized
patient are monitored. The patient is being ventilated by a
mechanical respirator, and the initial values are normal (PCO2=40
mm Hg; pH=7.42).
If the ventilation is decreased, which of the following is most likely to
occur?
pH
Arterial pCO2
A.
B.
C.
D.
E.
F.
decrease
decrease
decrease
increase *
increase
increase
A.
B.
C.
D.
E.
F.
decrease
increase
no change
decrease *
increase
no change
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Microbiology: Patient Vignette
At a banquet, the menu included fried chicken, homefried
potatoes, peas, chocolate eclairs and coffee. Within 2 hours
most of the diners became violently ill, with nausea, vomiting and
abdominal pain.
Analysis of the contaminated food is most likely to yield large
numbers of which of the following organisms?
A.
B.
C.
D.
E.
Escherechia coli
Proteus mirabilis
Salmonella typhimurium
Staphylococcus aureus*
Streptococcus faecalis
25
Lab Vignettes are good for Basic Sciences
“Lab”-vignettes




laboratory examples
research examples
biochemical pathways
drug metabolism
26
Biochemistry: Lab Vignette
A
II
I
E
B
III
C
IV
D
V
IV
In the branched metabolic pathway, a different
single enzyme catalyzes each of the individual
steps. The enzyme that would be expected to be
most severely inhibited by compound V is enzyme:
A.
B.
C.
D.
E.
A
B *
C
D
E
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Pharmacology: Lab Vignette
Drug Y has a volume of distribution of 75 L in both younger
and older adult men. In younger adults, it has a clearance rate of
15L / h, 50% of which is via the liver and 50% via the kidneys. For
younger men, the maintenance regimen is 100 mg every 6 hours.
Which of the following regimens will produce essentially the same
steady-state concentration in an older man, whose creatinine clearance
is half that of younger men, but whose hepatic function is unimpaired?
A.
B.
C.
D.
E.
F.
75 mg every 3 hrs
75 mg every 6 hrs *
75 mg every 9 hours
100 mg every 3 hours
100 mg every 6 hours
100 mg every 12 hours
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Basic Sciences: Integrated Items
Physiology / Pharmacology
Microbiology / Pharmacology
Pathology / Pharmacology
Pathology / Pathophysiology

Stem describes one component, options ask about another

1 stem is used for 2+ questions, on different topics

Guidelines:
 Team preparation
 Avoid “cueing”
 Avoid “hinging”
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Integrated Items - Example
An unresponsive 58 year old woman is brought to the ED after
collapsing at a local shopping center.
More history. Physical signs describe a neurologic deficit.
1.
The dilated, unreactive left pupil is most consistent with
injury to the left
List of anatomic structures
2.
The extensor posturing on the right is most consistent
with injury to the left
List of anatomic structures
3.
Which of the following herniation syndromes is most
consistent with her clinical presentation?
List of herniation syndromes
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Patient Vignettes: Clinical Sciences
Include
– age, gender
– site of care
– presenting complaint
– duration
– patient history
– physical findings
– +/- diagnostic studies
– +/- initial treatment
Stems should
– not be completely based
on real patients
– include reference
material when it would be
realistic in practice
– not use the patient’s or
doctor’s own words
– not include patients who
lie
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Non-vignettes in the Clinical Sciences
The most likely renal abnormality
in children with nephrotic
syndrome and normal renal
function is
A.
B.
C.
D.
E.
Acute poststreptococcal
glomerulonephritis
Hemolytic-uremic syndrome
Minimal change disease
Focal and segmental
glomerulosclerosis
Schonlein-Henoch purpura
A
B
C
D
E
Hi
1
0
99
0
0
Lo
8
1
90
1
0
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Short Vignette
A 2 year old boy has a 1
week history of edema. His
blood pressure is 100/60
mmHg and there is
generalized edema and
ascites. Labs show Cr 0.4
mg/dL, albumin 1.4 g/dL and
cholesterol of 569 mg/dL.
UA shows 4+ protein and no
blood. The most likely
diagnosis is
A
B
C
D
E
Hi
0
0
98
2
0
Lo
5
2
82
8
1
33
Long Vignette
A 2 year old black child developed
swelling of his eyes and ankles
over the past week. Blood pressure
is 100/60 mmHg, pulse 110/min
respirations 28/min. Exam shows
swelling of eyes, abdominal
distention and a positive fluid wave.
Labs show Cr 0.4 mg/dL, albumin
1.4 g/dL and cholesterol of 569
mg/dL.UA shows 4+ protein and no
blood. The most likely diagnosis is
A
B
C
D
E
Hi
0
1
98
1
0
Lo
10
9
66
10
5
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Writing the Lead-In: Clinical Sciences
Diagnosis
 Which of the following is the most likely diagnosis?
 Which of the following is the most appropriate next step in
diagnosis?
Management
 Which of the following is the most appropriate next step in
patient care?
Mechanisms of disease
 Which of the following is the most likely pathogen?
 Which of the following is the most likely explanation for the
findings?
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6 Rules for Writing A-type Questions
1)
Focus on important topics.
Ideally based on course / activity objectives.
2)
Pose problems, or clinical decision-making tasks that are within the
education/experience of examinees.
3)
Assess application of knowledge, not recall.
4)
Provide sufficient information in the stem and pose a clear question
in the lead-in. “Cover the options rule”
5)
Use homogeneous distractors
6)
Avoid technical flaws and unnecessary difficulty
36
Writing the Options

Homogeneous in content

Grammatically consistent with stem

Similar in construction and length

Alphabetized or logically ordered

Incorrect/inferior to the correct answer
 choice affects question difficulty

Plausible/attractive to uninformed
 no distracter should be obviously incorrect

Each should be chosen by some
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Easy Distractors
Who was the primary author of the
Declaration of Independence?
A.
B.
C.
D.
E.
Abraham Lincoln
Thomas Jefferson*
Franklin Roosevelt
King George II
Catherine the Great
38
More Difficult Distractors
Who was the primary author of the
Declaration of Independence?
A.
B.
C.
D.
E.
George Washington
Thomas Jefferson*
Alexander Hamilton
Benjamin Franklin
James Madison
39
6 Rules for Writing A-type Questions
1)
Focus on important topics.
Ideally based on course / activity objectives.
2)
Pose problems, or clinical decision-making tasks that are within the
education/experience of examinees.
3)
Assess application of knowledge, not recall.
4)
Provide sufficient information in the stem and pose a clear question
in the lead-in. “Cover the options rule”
5)
Use homogeneous distractors
6)
Avoid technical flaws and unnecessary difficulty
40
Technical Item Flaws
Issues Related to
“Testwiseness”
Issues related to
Irrelevant Difficulty
41
Assess Your “Testwiseness”
Testwise Analysis
The primary purpose of the stam is to
remove the





carm
denton
menace
stam bar
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Testwise Analysis
The primary purpose of the stam is to
remove the





carm
denton
menace
stam bar
“Word repeats” in stem and answer
44
Testwise Analysis

Which of the following pairs has won the
greatest number of Abby awards?




Jones and Smith
Smith and Taylor
Smith and White
White and Allen
45
Testwise Analysis

Which of the following pairs has won the
greatest number of Abby awards?




Jones and Smith
Smith and Taylor
Smith and White
White and Allen
Convergence: correct answer has the
most in common with other choices
46
Testwise Analysis
How many pounds of pressure are exerted
by a callam?





2.6
150
260
2600
47
Testwise Analysis
How many pounds of pressure are exerted
by a callam?





2.6
150
260
2600
Convergence: Correct answer has the most
in common with other choices
48
Testwise Analysis
The stanon is aided by a





instel
immon
octal
port
49
Testwise Analysis
The stanon is aided by a





instel
immon
octal
port
Grammatical cues: only “port” follows
grammatically from the stem
50
Testwise Analysis
The stanon frequently overheats because





all grestels are bilious
no immon are directly fectitious
octals are usually casable
ports are always critical
51
Testwise Analysis
The stanon frequently overheats because





all grestels are bilious
no immon are directly fectitious
octals are usually casable
ports are always critical
Absolute terms: never found in the correct answer
52
Testwise Analysis
Stammation normally occurs when the





anstels rupture
immon falls and the denton is in place
octal rotates easily
ports pass over the carm
53
Testwise Analysis
Stammation normally occurs when the





anstels rupture
immon falls and the denton is in place
octal rotates easily
ports pass over the carm
Longest answer is usually the correct answer
54
Testwiseness: Grammatical Cues
The option(s) does not flow from the stem
Example
The minor differences among organisms of the
same kind are known as
A. Heredity
B. Variations
C. Adaptation
D. Natural selection
55
Testwiseness: Logical Cues
A subset of options are collectively exhaustive
Example
Crime is
A. Equally distributed among the social classes
B. Overrepresented among the poor
C. Overrepresented among the middle class and rich
D. Primarily an indication of psychosexual maladjustment
E. Reaching a plateau of tolerability for the nation
56
Testwiseness: Absolute Terms
Terms such as ‘always’ or ‘never’ are used in options
Example
In patients with advanced dementia, Alzheimer’s type, the
memory defect
A. Can be treated adequately with lecithin
B. Could be a sequela of early parkinsonism
C. Is never seen in patients with neurofibrillary tangles
C. Is never severe
D. Possibly involves the cholinergic system
57
Testwiseness:
Long Correct Answer
The correct answer is longer, more specific, or more
complete than the other options.
Example:
Secondary gain is
A. Synonymous with malingering
B. A frequent problem in obsessive-compulsive disorder
C. A complication of a variety of illnesses and tends to prolong many of
them
D. Never seen in organic brain damage
58
Testwiseness: Word Repeats
A word or phrase is included in the stem and
correct answer.
Example:
A 58-year-old man with a history of heavy alcohol use and
previous psychiatric hospitalization is confused and agitated.
He speaks of experiencing the world as unreal. This
symptom is called
A. Depersonalization
B. Derailment
C. Derealization*
D. Focal memory defect
59
Testwiseness: Convergence
The correct answer includes the most elements in
common with the other options
Example:
Local anesthetics are most effective in the
A. Anionic form, acting from inside the nerve membrane
B. Cationic form, acting from inside the nerve membrane*
C. Cationic form, acting from outside the nerve membrane
D. Uncharged form, acting from inside the nerve membrane
E. Uncharged form, acting from outside the nerve membrane
60
Technical Item Flaws
Issues Related to
“Testwiseness”
Issues related to
Irrelevant Difficulty
61
Irrelevant Difficulty:
Options are long, complicated or doubled
Systematic geography differs from regional geography in
that
A. Systematic geography deals, in the main, with physical
geography, while regional geography concerns itself essentially
with the field of human geography
B.
Systematic geography studies a region systematically while
regional geography is concerned only with descriptive account of
a region
C.
Systematic geography studies a single phenomenon in its
distribution over the earth in order to supply generalizations for
regional geography, which studies the arrangement of
phenomena in one given area*
62
Irrelevant Difficulty:
Numeric data are not stated consistently
Following a second episode of infection, what is the
likelihood that a woman is infertile?
A. Less than 20%
B. 20% to 30%
C. Greater than 50%
D. 90%
E. 75%
63
Irrelevant Difficulty:
Frequency terms in options are vague
Severe obesity in early adolescence
A.
Usually responds dramatically to dietary regimens
B.
Often is related to endocrine disorders
C.
Has a 75% change of clearing spontaneously
D.
Shows a poor prognosis
E.
Usually responds to pharmacotherapy and intensive
psychotherapy
64
Irrelevant Difficulty:
Language in options not parallel
In a vaccine trial, 200 2-year-old boys were given a vaccine
against a certain disease and then monitored for five years for
occurrence of disease. Of this group, 85% never contracted the
disease.
Which of the following statements concerning these results is
correct?
A.
No conclusions can be drawn since no follow-up was made of
non-vaccinated children
B.
The number of cases (I.e. 30 cases over five years) is too
small for statistically meaningful conclusions
C.
No conclusions can be drawn because the trial involved only
boys
D.
Vaccine efficacy (%) is calculated as 85-15/100
65
Irrelevant Difficulty:
Options in an non-logical order
The population of Denmark is
A. 2 million
B. 15 million
C. 4 million
D. 7 million
66
Irrelevant Difficulty:
“None of the Above” used as option
Which city is closest to New York City?
A. Boston
B. Chicago
C. Dallas
D. Los Angeles
E. None of the above
67
Irrelevant Difficulty:
Complicated Stems and Options
Arrange the parents of the following children with Down’s
syndrome in order of highest to lowest risk of recurrence.
Assume that the maternal age in all cases is 22 years and
that a subsequent pregnancy occurs within 5 years.
The karyotypes of the daughters are (see next slide)
68
Complicated Stems and Answers
I.
II.
III.
IV.
V.
46, XX, -14, +T (14q21q)pat
46, XX, -14, +T(14q21q) de novo
46, XX, -14, +T (14q21q) mat
46, XX, -21, +T (14q21q)pat
47, XX, -21, +T (21q21q) parents not typed
A.
B.
C.
D.
E.
III, IV, I, V, II
IV, III, V, I, II
III, I, IV, V, II
IV, III, I, V, II
III, IV, I II, V
69
Irrelevant Difficulty
“Window Dressing”
“Red Herrings”
70
Basic Science Examples
for Discussion
Which one of the following sets of laboratory
studies is most consistent with a diagnosis of
anemia of chronic inflammation?
(Inc means increased level, Dec means decreased
level)
Ferritin
A.
B.
C.
D.
Inc
Dec
Inc
Inc
TIBC
Inc
Inc
Dec
Dec
Serum Iron
Soluble Transferrin Receptor
Dec
Dec
Dec
Dec
Dec
Inc
Inc
Normal
72
A 16 year old girl presents with a sore throat of 4 months
duration. She describes feeling a lump in her throat.
Physical exam reveals a 1 cm cystic lesion at the base of
the tongue.
This developmental lesion most likely arises as a remnant
of which of the following anatomic structures?
A.
B.
C.
D.
E.
Auditory tube
Branchial arches
Facial fusion lines
Rudimentary thymus
Thyroglossal duct
73
All of the carbons in cholesterol are derived
from:
A.
B.
C.
D.
E.
choline
sphingosine
acetyl CoA
HMG-CoA reductase
CO2
74
What is the most likely inheritance pattern
of the following pedigree?
A.
B.
C.
D.
E.
Autosomal recessive
Autosomal dominant
X-linked recessive
X-linked dominant
Mitochondrial
75
Clinical Science
Examples
A 64 year old male is admitted to the hospital with 3 days of
progressive shortness of breath. He has a medical history of poorly
controlled hypertension. He denies tobacco or alcohol use. On physical
examination he is afebrile, pulse 100, respiratory rate 26, blood
pressure 180/110 mmHg and room air oxygen saturation 91%.
Examination of the lungs reveals bilateral crackles and his cardiac
exam reveals a diffuse, laterally displaced point of maximal impulse, a
soft S3 and loud S4. Abdominal exam and extremity exams are normal.
A chest Xray reveals bilateral alveolar infiltrates and an
electrocardiogram is remarkable for left ventricular hypertrophy. Which
of the following is the next best step in management?
A.
B.
C.
D.
E.
Administer intravenous furosemide for diuresis
Administer oral morphine
Start oral beta blocker
Administer chewable aspirin
None of the above
77
A 72 year old female presents to her physician with progressive bilateral
knee pain for 3 months. The pain is worse with ambulation and
increases in severity during the day. She denies trauma or pain in other
joints. On physical examination she is afebrile. Her body mass index is
31. Her knees are warm bilaterally but without effusion. There is
bilateral crepitus. There is no instability. The remainder of her
examination is normal. Plain xrays of the knees demonstrates
narrowing of the joint space, marginal osteophytes and subcondral
sclerosis. Which of the following is the most likely diagnosis?
A. Osteoporosis
B. Osteoarthritis
C. Osteogenesis imperfecta
D. Rheumatoid arthritis
E. Pseudogout
78
A 42 year old female presents to her physician for a routine medical
examination. She has no specific concerns. Her blood pressure is
noted to be 170/80 mm Hg. Which of the following sounds
auscultatory findings corresponds to the systolic and diastolic
readings?
A.
The systolic reading is the first appearance of the Korotkoff
sounds and the diastolic reading is the disappearance of the
Korotkoff sounds
B.
The systolic reading is the regular appearance of the Korotkoff
sounds and the diastolic reading is the muffling of the Korotkoff
sounds.
C.
The systolic reading is the regular appearance of the Korotkoff
sounds and the diastolic reading is the disappearance of the
Korotkoff sounds
D.
The systolic reading is the first appearance of the Korotkoff sounds
and the diastolic reading is the muffling of the Korotkoff sounds.
79
A 42 year old female presents to her physician for a routine medical
examination. She has no specific concerns. Her blood pressure is
noted to be 170/80 mm Hg.
Which of the following sounds best corresponds to the
blood pressure reading?
A.
B.
C.
D.
170
First Korotkoff sound
Regular Korotkoff sounds
Regular Korotkoff sounds
First Korotkoff sounds
80
Disappearance of Korotkoff sounds
Muffling of Korotkoff sounds
Disappearance of Korotkoff sounds
Muffling of Korotkoff sounds.
80
Practice Time!
R-Type Items
Extended Matching
Extended Matching: R-type Items
Four components
1.
2.
3.
4.
A theme
An option list
A lead-in statement
At least 2 item stems
83
R-type item-Theme: Cerebrovascular anatomy
A. Left anterior cerebral artery
B. Right anterior cerebral artery
C. Left middle cerebral artery
D. Right middle cerebral artery
E. Left posterior cerebral artery
F. Right posterior cerebral artery
G. Left lenticulostriate arteries
H. Right lenticulostriate arteries
For each patient with neurological abnormalities presented below, select
the artery that is most likely to be involved from the list above.
1. A 72-year-old right-handed man has weakness and hyperreflexia of the right
lower limb, an extensor plantar response on the right, normal strength of the
right arm, and normal facial movements. Answer: A
2. A 68-year-old right-handed man has right spastic hemiparesis, an extensor
plantar response on the right, and paralysis of the lower two-thirds of his face
on the right. His speech is fluent, and he has normal comprehension of verbal
and written commands. Answer: G
84
Sample Lead-ins and Topics for Option Lists
For each of the following patients, select the most likely (cause).
 Underlying mechanism of disease, medications, toxic
agents…
For each of the following patients select the (eg, nerve) that is
most like to be (abnormal, defective, deficient, nonfunctioning).
-lists of nerves, muscles, enzymes, hormones, proteins, types
of cells, pathologic processes, neurotransmitters
For each of the following patients, select the (finding) that would
be expected.
 Laboratory results, physical signs…
85
More sample lead-ins & topics for option lists

For each of the following patients, select the
[ eg, drug] that should be administered.

For each of the following patients with [chief
complaint], select the most likely diagnosis.

For each of the following patients, select the
most appropriate next step in patient care.
(drugs, lab tests, disposition choices)
86
Options Sets in R-Type Items











Arteries
Nerves
Muscles
Amino acids
Peptides
Hormones
Enzymes
Cell components
Cell types
Blood components
Diagnoses











Karyotypes
Proteins
Lipids
Pathogens
Cytokines
Anatomic structures
Metabolic defects
Organelles
Drugs/drug classes
ECM components
Diagnostic tests
87
Writing the Item Stems for R-Type Items
Patient vignettes
 Use for basic & clinical science questions
 Homogeneous in construction



Include same demographic features in each one
All the same age group
 Make
sure only one best answer and usually
4 distractors
88
Steps in writing R-type items
Identify the theme first
 Write the lead-in statement
 List all the options
 Write the vignettes (stems)
 Review the item



Be sure there is only ONE single best answer for
each stem
Be sure each item has several distractors
89
R-Type Item: Good Example

Theme: Fatigue

Lead in: For each patient with fatigue, select
the most likely diagnosis.

Options: Many causes of fatigue (anemia,
CHF, depression, infections etc)
 Vignettes:
2 or more that correspond to
diagnoses in your list
90