ABIM Internal Medicine Board Exam — Questions and Answers

Question 1: A 34-year-old woman has episodic hypertension, headaches, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines and normetanephrines. What is the most important pre-operative medication to initiate?

Alpha-blocker (phenoxybenzamine) (Correct answer)
ACE inhibitor (lisinopril)
Beta-blocker (metoprolol)
Calcium channel blocker (amlodipine)

Correct answer: Alpha-blocker (phenoxybenzamine)

Alpha-blockade must be established before beta-blockade to prevent unopposed alpha-adrenergic vasoconstriction and hypertensive crisis during pheochromocytoma resection.

Question 2: A 38-year-old woman with SLE develops worsening dyspnea and bilateral pleural effusions. Lab work shows complement levels C3 45 mg/dL (low) and anti-dsDNA 1:640. Urine protein is 4.2 g/24h. What is the most likely cause of her effusions?

Pulmonary embolism
Nephrotic syndrome with hypoalbuminemia (Correct answer)
Congestive heart failure
Tuberculous pleuritis

Correct answer: Nephrotic syndrome with hypoalbuminemia

Markedly elevated proteinuria with low complement in SLE indicates active nephritis causing nephrotic syndrome; hypoalbuminemia from protein loss leads to transudative effusions.

Question 3: A 73-year-old woman is admitted with decompensated heart failure. She is started on IV furosemide but develops worsening creatinine (1.4 → 2.1 mg/dL) despite improving pulmonary congestion. What is this phenomenon called and what should be done?

Prerenal azotemia — give IV fluids
Contrast nephropathy — hydrate aggressively
Acute kidney injury — stop diuretics immediately
Cardiorenal syndrome — continue diuresis if congestion persists (Correct answer)

Correct answer: Cardiorenal syndrome — continue diuresis if congestion persists

Cardiorenal syndrome type 1 involves AKI from decompensated HF; continued gentle diuresis is appropriate if the patient remains fluid overloaded, as congestion itself harms the kidneys.

Question 4: To make the diagnosis, imaging using an MRI is required for early-stage diseases, whereas simple radiographs are required for late-stage diseases.

Oncogenic osteomalacia is characterized by
In MS, use this for the pharmacologic treatment of Spasticity
Osteonecrosis (avascular necrosis) of the femoral head dx (Correct answer)

Correct answer: Osteonecrosis (avascular necrosis) of the femoral head dx

To establish the diagnosis of osteonecrosis (avascular necrosis) of the femoral head, imaging studies are necessary. The choice of imaging modality depends on the stage of the disease and the specific clinical scenario.

Question 5: A 35-year-old woman presents with recurrent episodes of severe abdominal pain, vomiting, and port-wine colored urine precipitated by fasting and oral contraceptive use. Urine porphobilinogen is markedly elevated during attacks. What is the most appropriate acute treatment?

IV hemin (heme arginate) and glucose loading (Correct answer)
Plasmapheresis
IV morphine and ondansetron only
Pyridoxine supplementation

Correct answer: IV hemin (heme arginate) and glucose loading

Acute attacks of acute intermittent porphyria are treated with IV hemin, which represses ALA synthase, and high glucose loading to suppress the heme biosynthesis pathway.

Question 6: A 58-year-old woman with no prior cardiac history presents with acute chest pain. ECG shows ST depressions in V4-V6 and elevated troponin. Angiography reveals 95% stenosis of the left circumflex artery. She is hemodynamically stable. What is the optimal timing for PCI?

PCI only if she develops hemodynamic instability
Immediate PCI within 2 hours
Medical therapy alone without PCI
PCI within 24–72 hours (early invasive strategy) (Correct answer)

Correct answer: PCI within 24–72 hours (early invasive strategy)

NSTEMI with high-risk features (elevated troponin, ST changes) is managed with an early invasive strategy with PCI within 24–72 hours per ACC/AHA guidelines.

Question 7: A patient with SLE, lupus anticoagulant, and anticardiolipin antibodies has a history of two miscarriages. What is the recommended anticoagulation strategy during her next pregnancy?

Low molecular weight heparin (LMWH) plus low-dose aspirin (Correct answer)
Warfarin throughout pregnancy
No anticoagulation needed
Low-dose aspirin alone

Correct answer: Low molecular weight heparin (LMWH) plus low-dose aspirin

In antiphospholipid syndrome with obstetric complications, low-dose aspirin plus LMWH throughout pregnancy is standard of care; warfarin is teratogenic in the first trimester.

Question 8: A 48-year-old woman with rheumatoid arthritis on methotrexate and prednisone presents with subacute onset of fever, non-productive cough, and dyspnea. CT shows bilateral ground-glass opacities. LDH is elevated. Which pathogen is most likely?

Pneumocystis jirovecii (Correct answer)
Mycobacterium tuberculosis
Aspergillus fumigatus
Cytomegalovirus

Correct answer: Pneumocystis jirovecii

Immunosuppressed patients on chronic corticosteroids are at high risk for Pneumocystis jirovecii pneumonia, which presents with bilateral ground-glass opacities and elevated LDH.

Question 9: A patient presents with oliguria after surgery. BUN is 42 mg/dL, creatinine is 1.4 mg/dL (BUN:Cr ratio = 30). Urine sodium is 8 mEq/L and FENa is 0.5%. What is the most likely diagnosis?

Acute tubular necrosis
Prerenal azotemia (Correct answer)
Glomerulonephritis
Postrenal obstruction

Correct answer: Prerenal azotemia

Prerenal azotemia is characterized by elevated BUN:Cr ratio (>20), low urine sodium (<20 mEq/L), and FENa <1%, reflecting intact tubular function with avid sodium reabsorption.

Question 10: Which antibody is most specific for rheumatoid arthritis?

Anti-double-stranded DNA (anti-dsDNA)
Antineutrophil cytoplasmic antibody (ANCA)
Antinuclear antibody (ANA)
Anti-cyclic citrullinated peptide (anti-CCP) (Correct answer)

Correct answer: Anti-cyclic citrullinated peptide (anti-CCP)

Anti-cyclic citrullinated peptide (anti-CCP) antibody has approximately 95% specificity for rheumatoid arthritis, making it more specific than rheumatoid factor.

Question 11: A 50-year-old woman with primary biliary cholangitis presents with fatigue, pruritus, and elevated alkaline phosphatase. Which therapy is first-line and has been shown to slow disease progression?

Methotrexate
Ursodeoxycholic acid (Correct answer)
Colchicine
Prednisone

Correct answer: Ursodeoxycholic acid

Ursodeoxycholic acid (UDCA) improves liver biochemistry, delays histologic progression, and improves transplant-free survival in primary biliary cholangitis.

Question 12: A 72-year-old woman with a history of MI 6 months ago is found to have a left ventricular apical thrombus on echocardiography. Which treatment is most appropriate?

Surgical thrombectomy
Aspirin and clopidogrel dual antiplatelet therapy
Anticoagulation with warfarin or DOAC for 3–6 months (Correct answer)
No treatment needed if asymptomatic

Correct answer: Anticoagulation with warfarin or DOAC for 3–6 months

LV thrombus after MI requires anticoagulation (warfarin or DOAC) for at least 3–6 months to reduce the risk of systemic embolization and stroke.

Question 13: A patient with COPD exacerbation is on 2L/min O2 and has arterial blood gas: pH 7.29, PaCO2 62 mmHg, PaO2 58 mmHg. He is drowsy but cooperative. What is the next intervention?

Immediate intubation
Non-invasive positive pressure ventilation (BiPAP) (Correct answer)
IV methylprednisolone only
Increase FiO2 to 100%

Correct answer: Non-invasive positive pressure ventilation (BiPAP)

Non-invasive positive pressure ventilation (BiPAP) is the preferred initial intervention for acute hypercapnic respiratory failure in COPD before resorting to intubation.

Question 14: A 45-year-old woman with Graves' disease is started on methimazole. Six weeks later she develops a fever, sore throat, and absolute neutrophil count of 200/µL. What is the most appropriate next step?

Switch to propylthiouracil
Add prophylactic antibiotics and continue methimazole
Reduce methimazole dose by 50%
Discontinue methimazole immediately and initiate G-CSF (Correct answer)

Correct answer: Discontinue methimazole immediately and initiate G-CSF

Agranulocytosis is a rare but life-threatening complication of methimazole; the drug must be stopped immediately, and G-CSF may be used to accelerate neutrophil recovery.

Question 15: A 48-year-old woman presents with a 3-week history of productive cough, night sweats, and 12-pound weight loss. She emigrated from Southeast Asia 2 years ago. Chest X-ray shows right upper lobe cavitary infiltrate. AFB smear of sputum is positive. How many negative sputum cultures are required before she can be removed from airborne isolation?

One negative culture
One negative smear on consecutive days
Two negative smears collected 8 hours apart
Three consecutive negative smears collected 8 hours apart (Correct answer)

Correct answer: Three consecutive negative smears collected 8 hours apart

CDC guidelines require three consecutive negative AFB smears from respiratory specimens collected at least 8 hours apart before discontinuing airborne infection isolation.

Question 16: A 58-year-old man with type 2 diabetes presents with a serum creatinine of 2.4 mg/dL and a urine albumin-to-creatinine ratio of 450 mg/g. Which medication class provides the greatest kidney-protective benefit beyond blood pressure control in this patient?

Beta-blocker
SGLT2 inhibitor (Correct answer)
Thiazide diuretic
Calcium channel blocker

Correct answer: SGLT2 inhibitor

SGLT2 inhibitors (e.g., empagliflozin, canagliflozin) have demonstrated significant cardiorenal protection in diabetic kidney disease independent of glycemic control.

Question 17: A 71-year-old man with cirrhosis (Child-Pugh B) presents with confusion, asterixis, and a serum ammonia of 140 µmol/L. He recently started a high-protein diet. What is the most appropriate treatment?

Protein restriction to <40 g/day indefinitely
Lactulose titrated to 2–3 soft stools per day (Correct answer)
Rifaximin alone
Neomycin and metronidazole

Correct answer: Lactulose titrated to 2–3 soft stools per day

Lactulose is first-line for acute hepatic encephalopathy, acidifying colonic contents and trapping ammonia for fecal excretion; rifaximin is added for secondary prophylaxis.

Question 18: A 68-year-old man is found to have a monoclonal IgG spike of 3.8 g/dL, bone marrow plasma cells 25%, serum calcium 11.8 mg/dL, and multiple lytic bone lesions on skeletal survey. Creatinine is 1.9 mg/dL. What is the diagnosis?

Waldenstrom macroglobulinemia
Solitary plasmacytoma
Multiple myeloma (Correct answer)
Monoclonal gammopathy of undetermined significance (MGUS)

Correct answer: Multiple myeloma

Multiple myeloma is diagnosed by ≥10% clonal plasma cells plus at least one CRAB criterion (hyperCalcemia, Renal insufficiency, Anemia, Bone lesions).

Question 19: A 38-year-old woman presents with episodic severe headache, diaphoresis, and palpitations. Her blood pressure during an episode is 210/120 mmHg. 24-hour urine metanephrines are markedly elevated. Which antihypertensive should be initiated first?

Metoprolol
Lisinopril
Phenoxybenzamine (Correct answer)
Hydrochlorothiazide

Correct answer: Phenoxybenzamine

Alpha-blockade with phenoxybenzamine must be established before beta-blockade in pheochromocytoma to prevent unopposed alpha-mediated hypertensive crisis.

Question 20: Which medication is the first-line treatment for hypertension in a patient with CKD and proteinuria >300 mg/day?

Amlodipine
ACE inhibitor or ARB (Correct answer)
Thiazide diuretic
Metoprolol

Correct answer: ACE inhibitor or ARB

ACE inhibitors and ARBs reduce intraglomerular pressure and proteinuria through efferent arteriolar dilation, slowing CKD progression and are first-line in proteinuric CKD.

Question 21: A patient with moderate persistent asthma is well controlled on low-dose ICS plus LABA. During pregnancy, her asthma worsens. What is the safest approach?

Switch to oral prednisone only
Step up asthma therapy as needed to maintain control (Correct answer)
Use only short-acting beta-agonists
Discontinue all medications to protect the fetus

Correct answer: Step up asthma therapy as needed to maintain control

Maintaining adequate asthma control during pregnancy is essential; uncontrolled asthma carries greater risk to the fetus than properly managed pharmacotherapy.

Question 22: A patient with dilated cardiomyopathy and EF of 30% is already on maximally tolerated doses of ACE inhibitor and beta-blocker. What additional medication reduces mortality?

Digoxin
Isosorbide mononitrate
Amiodarone
Spironolactone (Correct answer)

Correct answer: Spironolactone

Spironolactone (or eplerenone), a mineralocorticoid receptor antagonist, reduces mortality in HFrEF when added to ACE inhibitor and beta-blocker in patients with EF ≤35%.

Question 23: Which finding on echocardiography is most consistent with cardiac tamponade?

Aortic stenosis with reduced gradient
Mitral valve prolapse
Right ventricular diastolic collapse (Correct answer)
Left ventricular hypertrophy

Correct answer: Right ventricular diastolic collapse

Right ventricular diastolic collapse is the classic echocardiographic sign of cardiac tamponade, caused by elevated pericardial pressure exceeding RV diastolic pressure.

Question 24: A patient with alcoholic hepatitis has a Maddrey discriminant function of 38. He has no infection or GI bleeding. What is the most appropriate treatment?

Pentoxifylline
Prednisolone 40 mg/day for 28 days (Correct answer)
Abstinence alone
N-acetylcysteine

Correct answer: Prednisolone 40 mg/day for 28 days

Prednisolone is recommended for severe alcoholic hepatitis (Maddrey DF ≥32) in the absence of contraindications (infection, GI bleeding, renal failure), reducing short-term mortality.

Question 25: A 29-year-old woman presents with amenorrhea, galactorrhea, and a serum prolactin of 180 ng/mL. MRI shows a 12-mm pituitary lesion. Which treatment is most appropriate?

Cabergoline (Correct answer)
Bromocriptine
Transsphenoidal surgery
Observation only

Correct answer: Cabergoline

Cabergoline is the preferred dopamine agonist for macroprolactinomas due to superior efficacy and tolerability compared to bromocriptine.

Question 26: A 52-year-old woman presents with a 3-month history of early satiety, dysphagia to solids and liquids, and regurgitation of undigested food. Esophageal manometry shows absent peristalsis and failure of LES relaxation. What is the diagnosis?

Scleroderma esophagus
GERD with peptic stricture
Achalasia (Correct answer)
Diffuse esophageal spasm

Correct answer: Achalasia

Achalasia is characterized by aperistalsis and incomplete lower esophageal sphincter relaxation on manometry, causing progressive dysphagia to both solids and liquids.

Question 27: A 28-year-old man presents with episodic gross hematuria following upper respiratory infections. Renal biopsy shows mesangial IgA deposits. What is the diagnosis?

Membranoproliferative GN
IgA nephropathy (Berger disease) (Correct answer)
Post-streptococcal glomerulonephritis
Henoch-Schönlein purpura nephritis

Correct answer: IgA nephropathy (Berger disease)

IgA nephropathy (Berger disease) presents with episodic gross hematuria coinciding with mucosal infections and is defined by mesangial IgA deposits on immunofluorescence.

Question 28: A 58-year-old man with type 2 diabetes presents with progressive exertional dyspnea and a reduced ejection fraction of 35%. His current medications include metformin and linagliptin. Which antidiabetic agent has been shown to reduce hospitalization for heart failure in this patient population?

Pioglitazone
Glipizide
Sitagliptin
Empagliflozin (Correct answer)

Correct answer: Empagliflozin

SGLT2 inhibitors like empagliflozin reduce hospitalization for heart failure and cardiovascular death in patients with type 2 diabetes and established cardiovascular disease.

Question 29: A 44-year-old woman presents with proximal muscle weakness, elevated CK of 4,200 U/L, and an erythematous rash over her knuckles (Gottron's papules) and eyelids (heliotrope rash). What malignancy must be screened for?

Multiple myeloma
Brain tumor
Ovarian cancer (Correct answer)
Leukemia

Correct answer: Ovarian cancer

Dermatomyositis is strongly associated with internal malignancy, most commonly ovarian, lung, breast, and GI cancers; age- and sex-appropriate cancer screening is mandatory at diagnosis.

Question 30: A 55-year-old man with gout and recurrent uric acid kidney stones has a 24-hour urine uric acid of 900 mg. What is the most appropriate preventive treatment?

Allopurinol (Correct answer)
Colchicine
Probenecid
Increase dietary protein

Correct answer: Allopurinol

Allopurinol (xanthine oxidase inhibitor) reduces uric acid production and is the treatment of choice for uric acid nephrolithiasis with hyperuricosuria or hyperuricemia.

Question 31: A 32-year-old female non-smoker appears with a few months' worth of exertion-related dyspnea. She has experienced a spontaneous pneumothorax in the past. A typical CT picture is displayed. Which diagnosis is more likely?

Emphysema due to alpha-1-antitrypsin deficiency
Pulmonary lymphangioleiomyomatosis (LAM) (Correct answer)
Sarcoidosis
Lymphocytic interstitial pneumonia (LIP)
Pulmonary Langerhans cell histiocytosis (PLCH)

Correct answer: Pulmonary lymphangioleiomyomatosis (LAM)

Pulmonary lymphangioleiomyomatosis (LAM) is a rare lung disease characterized pathologically by cyst formation and multifocal, nodular proliferation of immature smooth muscle and perivascular epithelioid cells (LAM cells). High-resolution CT scans show characteristic diffuse thin-walled cysts. In a relatively young female non-smoker of child-bearing age, this is the most likely diagnosis. Most patients are symptomatic at presentation, with dyspnea being the most common complaint. Complications include pneumothorax, hemoptysis, chylothorax, chyloperitoneum, chylopericardium, and development of lymphangioleiomyomas of the lymph vessels.

Question 32: A 72-year-old man with hypertension and hyperlipidemia presents with sudden painless loss of vision in his left eye. Fundoscopy shows a pale, edematous retina with a 'cherry-red spot' at the macula. What is the most likely diagnosis?

Acute angle-closure glaucoma
Central retinal artery occlusion (Correct answer)
Anterior ischemic optic neuropathy
Central retinal vein occlusion

Correct answer: Central retinal artery occlusion

Central retinal artery occlusion causes sudden painless monocular vision loss with a pale retina and cherry-red spot due to preserved choroidal circulation at the fovea.

Question 33: A 69-year-old woman with no history of illness shows up with a terrible headache and a temperature of up to 104°F after just one day. She also reports sporadic episodes of expressive aphasia, nausea, and phono- and phonophobia. A physical examination is noteworthy for a lady who appears sick and has a fever of 103.8°F orally, a blood pressure of 150/70, and a pulse of 100. She keeps her eyes closed, seems to be slightly uncomfortable with the headache, and fights off passive neck flexion. The motor and sensory system exams are routine and show no signs of papilledema. The patient has a "normal" head CT after taking two blood cultures and starting therapy. 380 mg/dL of protein, 35 mg/dL of glucose, 400 WBC, 42% neutrophils, 35% lymphocytes, and 6% monocytes can all be found in the hazy CSF obtained through lumbar puncture. Few polymorphonuclear cells and Gram-positive bacilli are seen in the CSF Gram stain. What would be a risk factor for meningitis in this patient?

Exposure to 2-year old granddaughter who is unvaccinated against Haemophilus influenza type b
Age>50 and consumption of soft cheese (Correct answer)
Age>65 and lack of immunization against Strep. Pneumoniae
Lack of vaccination to Neisseria meningitidis

Correct answer: Age>50 and consumption of soft cheese

Gram-positive bacteria associated with Listeria monocytogenes meningitis can be seen in the CSF Gram stain. Gram-positive diplococci include Streptococcus pneumonia and H. influenzae, whereas Gram-negative diplococci include Neisseria meningitidis. Respiratory diseases, including Strep pneumonia, N meningitidis, and H influenzae type b, can spread from person to person by airborne droplets. Listeria monocytogenes is spread trans-placentally to fetuses and by consumption of infected foods (meats, vegetables, and cheeses have all been linked in the past). The CDC website may find a current list of contaminated items and their producers. Extreme ages (adults >50 and infants one month), pregnancy, immunosuppressed states, alcoholism, CKD, chronic liver disease, and diabetes mellitus are the only risk factors for Listeria monocytogenes. This patient would be at risk for Listeria meningitis due to her advanced age and intake of tainted food. (B) This patient does not have a history of asplenia, has not traveled to a location where meningococcal disease is endemic, and does not have complement deficiency, so immunization is unnecessary. It will not protect Listeria monocytogenes. (C) Starting at age 65, this patient should have had routine immunizations against Strep. Pneumonia. He is now 69 years old. Currently, ACIP guidelines advise conjugated Prevnar 13 followed by Pneumovax23 six to twelve months later, but this won't protect against Listeria monocytogenes. (D) Since routine vaccination against Haemophilus influenza type b was introduced in 1990, HIB meningitis has significantly decreased in children and (through herd immunity) in adults. Currently, H. influenzae type b meningitis mainly affects youngsters without vaccinations and seldom affects adults. This patient may be at risk for H. influenzae meningitis but not Listeria monocytogenes meningitis due to exposure to an unvaccinated youngster.

Question 34: A patient with asthma requires daily short-acting beta-agonist use and has nighttime symptoms 3–4 times per month. FEV1 is 78% predicted. What step of asthma therapy does this represent?

Step 4: Severe persistent asthma
Step 2: Mild persistent asthma (Correct answer)
Step 3: Moderate persistent asthma
Step 1: Intermittent asthma

Correct answer: Step 2: Mild persistent asthma

Mild persistent asthma (Step 2) is defined by symptoms >2 days/week but not daily, nighttime symptoms 3–4 times/month, and FEV1 ≥80% predicted.

Question 35: A 55-year-old woman presents with palpitations. ECG shows absent P waves and irregularly irregular rhythm. What is the most appropriate initial anticoagulation strategy if she has a CHA₂DS₂-VASc score of 3?

No anticoagulation needed
Aspirin alone
Heparin infusion only
Oral anticoagulation with a DOAC (Correct answer)

Correct answer: Oral anticoagulation with a DOAC

A CHA₂DS₂-VASc score ≥2 in women with atrial fibrillation warrants oral anticoagulation, and DOACs are preferred over warfarin for non-valvular AF.

Question 36: A 48-year-old man presents with progressive fatigue and is found to have iron-deficiency anemia (Hgb 9.2 g/dL). Colonoscopy is negative. Upper endoscopy shows no lesion. Celiac serology is negative. Small bowel capsule endoscopy shows bleeding from the jejunum. What is the most likely diagnosis?

Gastrointestinal angiodysplasia (Correct answer)
Small bowel lymphoma
Crohn's disease
Meckel's diverticulum

Correct answer: Gastrointestinal angiodysplasia

Angiodysplasia is the most common cause of small bowel bleeding in middle-aged to older adults when upper and lower endoscopy are negative.

Question 37: A 72-year-old woman presents with sudden-onset severe headache, neck stiffness, and photophobia. CT head is negative. CSF shows xanthochromia and 8,500 red blood cells/µL that do not clear. What is the most likely diagnosis?

Hypertensive encephalopathy
Bacterial meningitis
Viral meningitis
Subarachnoid hemorrhage (Correct answer)

Correct answer: Subarachnoid hemorrhage

Xanthochromia with a bloody, non-clearing CSF tap in the context of a thunderclap headache is pathognomonic for subarachnoid hemorrhage.

Question 38: A 55-year-old man with known coronary artery disease has an LDL of 95 mg/dL on high-intensity statin therapy. What is the most appropriate next step to further reduce his cardiovascular risk?

No additional therapy needed
Add ezetimibe (Correct answer)
Switch to a moderate-intensity statin plus fibrate
Add niacin

Correct answer: Add ezetimibe

Ezetimibe added to statin therapy was shown in IMPROVE-IT to further reduce major cardiovascular events in high-risk patients, making it the preferred add-on agent.

Question 39: A 55-year-old woman with rheumatoid arthritis on methotrexate 20 mg/week presents with progressive dyspnea and a dry cough. HRCT shows bilateral ground-glass opacities and fine reticulations. Her PFTs show a restrictive pattern. What is the most likely diagnosis?

Methotrexate-induced pneumonitis (Correct answer)
Rheumatoid arthritis-associated interstitial lung disease
Pulmonary embolism
Community-acquired pneumonia

Correct answer: Methotrexate-induced pneumonitis

Methotrexate pneumonitis is a hypersensitivity reaction that can occur at any dose and time; it presents with dry cough, dyspnea, fever, and bilateral infiltrates on imaging.

Question 40: A 30-year-old man develops arthritis, urethritis, and conjunctivitis 2-4 weeks after a Salmonella gastroenteritis. What is the most likely diagnosis?

Ankylosing spondylitis
Disseminated gonococcal arthritis
Reactive arthritis (Correct answer)
Septic arthritis

Correct answer: Reactive arthritis

Reactive arthritis presents with the classic triad of arthritis, urethritis, and conjunctivitis following a genitourinary or gastrointestinal infection.

Question 41: A 68-year-old man with a history of MI presents with exertional chest pain. Nuclear stress test shows a large reversible perfusion defect in the LAD territory. EF is 45%. Coronary angiography reveals 80% stenosis of the proximal LAD. What is the preferred revascularization strategy?

Coronary artery bypass grafting (CABG) (Correct answer)
Cardiac rehabilitation without revascularization
Medical management alone
Percutaneous coronary intervention (PCI)

Correct answer: Coronary artery bypass grafting (CABG)

CABG is preferred over PCI for proximal LAD disease, especially with reduced EF, due to superior long-term survival and reduced repeat revascularization rates.

Question 42: A patient with type 2 diabetes has a foot ulcer that probes to bone. X-ray shows periosteal reaction and bone erosion. What is the most appropriate next step?

Immediate surgical debridement
Empiric oral antibiotics for 2 weeks
MRI of the foot (Correct answer)
Topical antibiotic therapy only

Correct answer: MRI of the foot

MRI is the gold standard for diagnosing diabetic osteomyelitis, offering high sensitivity and specificity for bone marrow involvement when plain X-rays are inconclusive.

Question 43: A patient with cirrhosis and ascites presents with fever, abdominal pain, and confusion. Paracentesis shows PMN count of 350 cells/mm³. What is the diagnosis and treatment?

Hepatorenal syndrome — start terlipressin
Spontaneous bacterial peritonitis — start IV cefotaxime (Correct answer)
Hepatic encephalopathy — start lactulose
Secondary peritonitis — emergency surgery

Correct answer: Spontaneous bacterial peritonitis — start IV cefotaxime

SBP is diagnosed by ascitic fluid PMN count ≥250 cells/mm³ and treated empirically with IV third-generation cephalosporin (cefotaxime) without waiting for culture results.

Question 44: A 50-year-old man presents with symmetric proximal muscle weakness, elevated CK of 4,800 U/L, and an erythematous rash on his upper eyelids and knuckles. What autoantibody is most specifically associated with this condition?

Anti-centromere
Anti-Jo-1 (Correct answer)
Anti-Sm
Anti-dsDNA

Correct answer: Anti-Jo-1

Anti-Jo-1 (anti-synthetase) antibody is associated with dermatomyositis and polymyositis, often with interstitial lung disease as part of the antisynthetase syndrome.

Question 45: A patient presents with dyspnea, orthopnea, and bilateral lower extremity edema. BNP is 1,200 pg/mL. Which diuretic is the first-line treatment for acute decompensated heart failure?

Acetazolamide
Furosemide (Correct answer)
Spironolactone
Hydrochlorothiazide

Correct answer: Furosemide

Furosemide (a loop diuretic) is the first-line agent for acute decompensated heart failure due to its rapid onset of diuresis and venodilatory effects.

Question 46: A 40-year-old man with HIV (CD4 count 85/µL, not on ART) develops subacute fever, headache, and altered mental status over 3 weeks. CSF India ink preparation is positive. What is the best initial treatment?

Caspofungin
Liposomal amphotericin B plus flucytosine induction (Correct answer)
Fluconazole monotherapy
Voriconazole

Correct answer: Liposomal amphotericin B plus flucytosine induction

Cryptococcal meningitis in HIV is treated with liposomal amphotericin B plus flucytosine for at least 2 weeks induction before transitioning to fluconazole consolidation.

Question 47: A patient with chronic kidney disease stage 4 presents with hyperkalemia of 6.1 mEq/L, peaked T waves on ECG, and normal QRS duration. What is the first-line treatment to stabilize the cardiac membrane?

Intravenous calcium gluconate (Correct answer)
Sodium polystyrene sulfonate
Regular insulin with dextrose
Sodium bicarbonate infusion

Correct answer: Intravenous calcium gluconate

IV calcium gluconate stabilizes the cardiac membrane within minutes and is always the first step when ECG changes are present, before any treatment to lower potassium.

Question 48: A 33-year-old woman at 10 weeks gestation develops palpitations, tremor, and heat intolerance. TSH is undetectable and free T4 is elevated. She is diagnosed with Graves' disease. Which treatment is preferred in the first trimester?

Total thyroidectomy
Radioactive iodine ablation
Methimazole
Propylthiouracil (PTU) (Correct answer)

Correct answer: Propylthiouracil (PTU)

PTU is preferred in the first trimester because methimazole is associated with teratogenic effects (aplasia cutis, choanal atresia) during organogenesis.

Question 49: A 60-year-old man with type 2 diabetes has HbA1c of 8.9% on metformin monotherapy. He has CKD stage 3a (GFR 48 mL/min) and no cardiovascular disease. What is the best add-on therapy?

SGLT-2 inhibitor
GLP-1 receptor agonist (Correct answer)
Insulin glargine
Sulfonylurea

Correct answer: GLP-1 receptor agonist

GLP-1 receptor agonists have cardiovascular and renal benefits, are effective at all GFR levels (most agents), and reduce HbA1c significantly, making them preferred add-on therapy.

Question 50: A patient with known mitral stenosis develops progressive dyspnea. Echocardiography shows a mitral valve area of 1.3 cm² with elevated pulmonary artery pressure. What is the preferred intervention?

Medical management with diuretics only
Percutaneous mitral balloon commissurotomy (PMBC) (Correct answer)
Mitral valve replacement with bioprosthetic valve
Mitral valve replacement with mechanical valve

Correct answer: Percutaneous mitral balloon commissurotomy (PMBC)

Percutaneous mitral balloon commissurotomy is the preferred intervention for symptomatic mitral stenosis with favorable valve morphology and no significant mitral regurgitation.

Question 51: A 62-year-old woman with rheumatoid arthritis on methotrexate and a TNF inhibitor presents with two weeks of fever, night sweats, and cough. CXR shows right upper lobe infiltrate. QuantiFERON-Gold is positive. What is the most appropriate next step?

Hold TNF inhibitor and start full TB treatment empirically
Bronchoscopy with BAL
Start empiric isoniazid and pyrazinamide
Sputum for AFB smear and culture (Correct answer)

Correct answer: Sputum for AFB smear and culture

Active TB must be ruled out with sputum AFB smear and culture before initiating treatment, as the distinction between latent and active TB changes the regimen.

Question 52: A 45-year-old woman is found to have a TSH of 0.02 mIU/L and free T4 of 2.8 ng/dL. She reports palpitations, heat intolerance, and a 10-lb weight loss. Thyroid uptake scan shows diffusely increased uptake. What is the most appropriate next step?

Start methimazole (Correct answer)
Obtain thyroid ultrasound only
Start levothyroxine
Perform thyroid biopsy

Correct answer: Start methimazole

Diffusely increased radioiodine uptake in the setting of hyperthyroidism is consistent with Graves' disease; methimazole is the preferred first-line antithyroid drug in non-pregnant adults.

Question 53: A 68-year-old man with jaundice, weight loss, and painless jaundice has a CT showing a mass in the head of the pancreas with dilated biliary and pancreatic ducts (double duct sign). What is the next step?

EUS-guided FNA for tissue diagnosis (Correct answer)
CA 19-9 level only
ERCP with brushings and biliary stent placement
Immediate Whipple procedure

Correct answer: EUS-guided FNA for tissue diagnosis

EUS-guided FNA provides tissue diagnosis for pancreatic masses with high sensitivity and specificity while simultaneously staging local extension before definitive surgery.

Question 54: A 65-year-old man is found to have a 1.5 cm polyp removed during colonoscopy. Pathology shows a tubular adenoma with low-grade dysplasia. When should his next surveillance colonoscopy be performed?

5–10 years
3 years (Correct answer)
No follow-up needed
1 year

Correct answer: 3 years

A single tubular adenoma <10 mm with low-grade dysplasia warrants repeat colonoscopy in 3 years per current surveillance guidelines.

Question 55: A 50-year-old woman presents with dry eyes, dry mouth, anti-Ro/SSA antibodies, and anti-La/SSB antibodies. Which condition is most likely?

Primary Sjögren's syndrome (Correct answer)
Rheumatoid arthritis
Dermatomyositis
Systemic lupus erythematosus

Correct answer: Primary Sjögren's syndrome

Anti-Ro/SSA and anti-La/SSB antibodies are characteristically associated with primary Sjögren's syndrome, which presents with sicca symptoms (dry eyes and dry mouth).

Question 56: A 40-year-old African American woman presents with bilateral hilar lymphadenopathy, erythema nodosum, and polyarthritis. Serum ACE is elevated. What is the most likely diagnosis?

Tuberculosis
Histoplasmosis
Sarcoidosis (Correct answer)
Lymphoma

Correct answer: Sarcoidosis

Löfgren syndrome (bilateral hilar lymphadenopathy, erythema nodosum, and periarthritis/arthritis) is an acute presentation of sarcoidosis with a favorable prognosis.

Question 57: A 29-year-old woman in the third trimester of pregnancy presents with right upper quadrant pain, nausea, and hypertension of 158/104 mmHg. Labs show AST 320 U/L, platelets 85,000/µL, and LDH 950 U/L. What is the diagnosis?

Cholestasis of pregnancy
HELLP syndrome (Correct answer)
Acute fatty liver of pregnancy
Preeclampsia without severe features

Correct answer: HELLP syndrome

HELLP syndrome is characterized by hemolysis (elevated LDH), elevated liver enzymes, and low platelets in the setting of hypertensive disorders of pregnancy.

Question 58: A 28-year-old woman presents with heat intolerance, tremor, weight loss, and a diffuse goiter with a bruit. TSH is undetectable. What is the most likely cause?

Graves disease (Correct answer)
Toxic adenoma
Toxic multinodular goiter
Subacute (de Quervain) thyroiditis

Correct answer: Graves disease

Graves disease is the most common cause of hyperthyroidism in young women and is characterized by diffuse goiter, thyroid bruit, and often extrathyroidal manifestations like ophthalmopathy.

Question 59: A 40-year-old woman presents with watery diarrhea, flushing, and wheezing. Urinary 5-HIAA is markedly elevated. CT scan shows a liver mass and ileal mass. What is the diagnosis?

VIPoma
Carcinoid tumor (neuroendocrine tumor) with carcinoid syndrome (Correct answer)
Glucagonoma
Gastrinoma

Correct answer: Carcinoid tumor (neuroendocrine tumor) with carcinoid syndrome

Carcinoid syndrome (flushing, diarrhea, wheezing) occurs when neuroendocrine tumors with liver metastases secrete serotonin directly into systemic circulation, elevated urinary 5-HIAA confirms the diagnosis.

Question 60: A 45-year-old man with chronic hepatitis C (genotype 1a) is started on direct-acting antiviral therapy. Twelve weeks after completing treatment, HCV RNA is undetectable. What does this represent?

End-of-treatment response only
Partial response requiring retreatment
Virological response (VR) at 12 weeks of treatment
Sustained virological response (SVR) — considered cured (Correct answer)

Correct answer: Sustained virological response (SVR) — considered cured

Sustained virological response (SVR) is defined as undetectable HCV RNA 12 weeks after completing therapy and is considered a cure with >99% durability.

Question 61: A 25-year-old man presents with recurrent painful oral ulcers, genital ulcers, and uveitis. What is the most likely diagnosis?

Behçet's disease (Correct answer)
Crohn's disease
Reactive arthritis
Sarcoidosis

Correct answer: Behçet's disease

Behçet's disease is characterized by the triad of recurrent oral ulcers, genital ulcers, and uveitis, with higher prevalence along the ancient Silk Road regions.

Question 62: A patient with community-acquired pneumonia (CAP) is admitted to the hospital (non-ICU). Blood cultures are negative. What is the preferred antibiotic regimen?

Oseltamivir plus amoxicillin
TMP-SMX alone
Beta-lactam plus macrolide, or respiratory fluoroquinolone (Correct answer)
Vancomycin alone

Correct answer: Beta-lactam plus macrolide, or respiratory fluoroquinolone

IDSA/ATS guidelines recommend a beta-lactam plus macrolide combination or a respiratory fluoroquinolone monotherapy for hospitalized non-ICU CAP.

Question 63: A 60-year-old woman has symmetric polyarthritis involving MCPs and PIPs, morning stiffness greater than 1 hour, and radiographs showing periarticular osteopenia and joint space narrowing. Which DMARD is the cornerstone of treatment?

Hydroxychloroquine
Sulfasalazine
Methotrexate (Correct answer)
Leflunomide

Correct answer: Methotrexate

Methotrexate is the anchor DMARD for rheumatoid arthritis, used as first-line therapy due to its proven efficacy, tolerability, and role as the foundation of combination regimens.

Question 64: A 44-year-old man presents with a 3-month history of dysphagia to solids and liquids, regurgitation of undigested food, and weight loss of 12 lbs. Barium swallow shows a 'bird beak' narrowing at the gastroesophageal junction. Esophageal manometry confirms absent peristalsis. What is the diagnosis?

Diffuse esophageal spasm
Eosinophilic esophagitis
Scleroderma esophagus
Achalasia (Correct answer)

Correct answer: Achalasia

Achalasia is characterized by absent esophageal peristalsis and failure of the lower esophageal sphincter to relax, confirmed by manometry and showing 'bird beak' sign on barium swallow.

Question 65: A 67-year-old man with CLL presents with worsening fatigue and pallor. Hemoglobin is 7.1 g/dL, MCV 92, reticulocyte count 8%. Direct antiglobulin test (DAT) is positive for IgG. LDH is elevated. What is the diagnosis?

Aplastic anemia
Autoimmune hemolytic anemia (AIHA) (Correct answer)
Myelodysplastic syndrome
Iron deficiency anemia

Correct answer: Autoimmune hemolytic anemia (AIHA)

Warm AIHA is the most common hematologic complication of CLL, presenting with a positive DAT for IgG, elevated LDH, and increased reticulocyte count reflecting hemolysis.

Question 66: A patient with Graves disease is planning pregnancy. Which treatment is preferred in the first trimester?

Methimazole
Propylthiouracil (PTU) (Correct answer)
Total thyroidectomy
Radioactive iodine

Correct answer: Propylthiouracil (PTU)

PTU is preferred over methimazole in the first trimester of pregnancy because methimazole is associated with aplasia cutis and choanal atresia in the fetus.

Question 67: An emergency department (ED) referral brings a 24-year-old patient in for a diagnosis of shortness of breath. Reviewing the ED data revealed that the patient had minor respiratory distress, intermittent stridor, and frequent episodes of shortness of breath over the previous four months. At each presentation, oxygen saturation levels were normal. Intramuscular epinephrine and albuterol administered as empiric therapy did not affect the symptoms. The symptoms always went away on their own. The patient's prior medical history is uneventful, and they are taking no drugs. The vital signs and physical exams are also typical right now. Which of the subsequent diagnoses is more likely?

Laryngospasm
Paradoxical vocal cord motion (Correct answer)
Reactive airways disease
Chronic rhinosinusitis
Angioedema

Correct answer: Paradoxical vocal cord motion

The intermittent symptoms of this patient are most consistent with upper respiratory obstruction. The diagnosis most likely to be made is paradoxical vocal cord movements. Due to improper adduction of the vocal cords during inspiration in patients with paradoxical vocal cord motion, stridor, and respiratory discomfort ensue. One sign of this potential diagnosis is a history of repeated visits to the ED for respiratory distress without any other obvious explanation. Exercise, among other things, can cause the symptoms to appear, and they usually go away independently. Although spirometry will show normal expiration and aberrant inspiratory function, it may be mistaken as asthma. The preferred diagnostic technique is laryngoscopy, which makes it possible to see the unusual cord movement in real-time.

Question 68: Which ANCA pattern and target antigen is most specific for granulomatosis with polyangiitis (formerly Wegener's granulomatosis)?

Antinuclear antibody (ANA)
c-ANCA directed against proteinase 3 (PR3) (Correct answer)
Anti-glomerular basement membrane (anti-GBM) antibody
p-ANCA directed against myeloperoxidase (MPO)

Correct answer: c-ANCA directed against proteinase 3 (PR3)

c-ANCA directed against proteinase 3 (PR3) is the characteristic and highly specific antibody in granulomatosis with polyangiitis.

Question 69: A 70-year-old woman with atrial fibrillation is on warfarin with a stable INR of 2.4. She is scheduled for a colonoscopy with polypectomy. What is the most appropriate peri-procedural anticoagulation strategy?

Continue warfarin without interruption
Switch to aspirin 5 days before
Hold warfarin 5 days prior; bridge with LMWH if high stroke risk (Correct answer)
Hold warfarin 1 day prior only

Correct answer: Hold warfarin 5 days prior; bridge with LMWH if high stroke risk

High-bleed-risk procedures like polypectomy require warfarin to be held 5 days prior; bridging with LMWH is indicated for high thromboembolic risk (e.g., CHA₂DS₂-VASc ≥5 or mechanical valve).

Question 70: A 34-year-old woman presents with symmetric proximal muscle weakness, elevated CK (3,200 U/L), and a heliotrope rash. EMG shows myopathic changes. What is the most important next diagnostic step?

Anti-Jo-1 antibody testing
Muscle biopsy
Malignancy screening (Correct answer)
MRI of affected muscles

Correct answer: Malignancy screening

Dermatomyositis is strongly associated with occult malignancy (especially in adults >40), making cancer screening a priority after diagnosis.

Question 71: A patient presents with pulse rate of 180 bpm and ECG showing a narrow complex regular tachycardia that terminates with adenosine. What is the most likely diagnosis?

Atrial flutter with 2:1 block
AV nodal reentrant tachycardia (AVNRT) (Correct answer)
Multifocal atrial tachycardia
Ventricular tachycardia

Correct answer: AV nodal reentrant tachycardia (AVNRT)

AVNRT is the most common form of paroxysmal supraventricular tachycardia, presenting as a regular narrow complex tachycardia that terminates with adenosine.

Question 72: A patient on hemodialysis has persistent hypertension despite ultrafiltration. The most common cause is:

Dialysis-related amyloidosis
Secondary hyperparathyroidism
Volume overload between sessions (Correct answer)
Excessive erythropoietin use

Correct answer: Volume overload between sessions

Volume overload from interdialytic fluid and salt intake is the most common cause of hypertension in dialysis patients.

Question 73: A 55-year-old woman with Cushing disease undergoes transsphenoidal surgery but has persistent hypercortisolism. What is the next treatment option?

Cabergoline monotherapy
Repeat transsphenoidal surgery or radiotherapy (Correct answer)
Bilateral adrenalectomy as first choice
High-dose dexamethasone suppression

Correct answer: Repeat transsphenoidal surgery or radiotherapy

For persistent Cushing disease after failed transsphenoidal surgery, repeat surgery or pituitary radiation is the preferred next step before bilateral adrenalectomy.

Question 74: A patient with a history of recurrent kidney stones has 24-hour urine showing hypercalciuria with normal serum calcium. What is the most likely diagnosis?

Idiopathic hypercalciuria (Correct answer)
Vitamin D toxicity
Primary hyperparathyroidism
Sarcoidosis

Correct answer: Idiopathic hypercalciuria

Idiopathic hypercalciuria (with normal serum calcium) is the most common cause of calcium oxalate nephrolithiasis and is treated with thiazide diuretics.

Question 75: A 38-year-old woman with systemic sclerosis develops progressive dyspnea. Echocardiography shows RSVP of 55 mmHg. Right heart catheterization confirms mean PAP of 32 mmHg with normal PCWP. What is the diagnosis?

PH due to lung disease (Group 3)
Pulmonary venous hypertension (Group 2)
Pulmonary arterial hypertension (Group 1) (Correct answer)
Chronic thromboembolic PH (Group 4)

Correct answer: Pulmonary arterial hypertension (Group 1)

Pulmonary arterial hypertension (Group 1 WHO) is defined by mean PAP ≥25 mmHg with normal PCWP (≤15 mmHg) and pulmonary vascular resistance >3 WU, common in connective tissue diseases.

Question 76: A 65-year-old woman presents with bilateral aching in her shoulders and hips, an ESR of 85 mm/hr, markedly elevated CRP, but no true synovitis on examination. What is the most likely diagnosis?

Rheumatoid arthritis
Giant cell arteritis
Polymyalgia rheumatica (Correct answer)
Fibromyalgia

Correct answer: Polymyalgia rheumatica

Polymyalgia rheumatica typically presents in patients over 50 with bilateral proximal girdle pain, markedly elevated inflammatory markers, and no true synovitis.

Question 77: A patient with Clostridium difficile (CDI) has a third recurrence of mild-to-moderate disease. What is the preferred treatment?

Oral vancomycin taper
Fidaxomicin short course
Fecal microbiota transplantation (FMT) (Correct answer)
IV metronidazole

Correct answer: Fecal microbiota transplantation (FMT)

FMT is highly effective for recurrent CDI (>90% cure rate) and is recommended by guidelines for patients with multiple recurrences.

Question 78: A patient has an anion gap of 22 mEq/L, arterial pH of 7.28, and serum bicarbonate of 14 mEq/L. Which condition is NOT a cause of high anion gap metabolic acidosis?

Diabetic ketoacidosis
Renal failure
Diarrhea (Correct answer)
Lactic acidosis

Correct answer: Diarrhea

Diarrhea causes a non-anion gap (normal anion gap, hyperchloremic) metabolic acidosis due to bicarbonate loss, not accumulation of unmeasured anions.

Question 79: A 30-year-old woman presents with polyuria, polydipsia, and a serum sodium of 148 mEq/L. Her urine osmolality is 95 mOsm/kg after overnight water deprivation. After desmopressin (DDAVP) administration, urine osmolality increases to 680 mOsm/kg. What is the diagnosis?

Central diabetes insipidus (Correct answer)
Primary polydipsia
Syndrome of inappropriate ADH
Nephrogenic diabetes insipidus

Correct answer: Central diabetes insipidus

A robust response to exogenous desmopressin (urine osmolality >50% increase) confirms central diabetes insipidus, where the kidney is intact but ADH secretion is deficient.

Question 80: Which finding best distinguishes acute tubular necrosis (ATN) from prerenal azotemia?

Muddy brown granular casts in urine (Correct answer)
Decreased urine output
Elevated serum creatinine
Elevated BUN

Correct answer: Muddy brown granular casts in urine

Muddy brown granular casts (renal tubular epithelial cell casts) in the urine are pathognomonic of ATN and reflect tubular epithelial cell injury and sloughing.

Question 81: A 70-year-old woman presents with acute dyspnea, pleuritic chest pain, and tachycardia after hip replacement surgery. CT pulmonary angiography shows filling defects in the right pulmonary artery. What is the immediate treatment?

IVC filter placement
Thrombolytic therapy immediately
Anticoagulation with unfractionated heparin or LMWH (Correct answer)
Embolectomy

Correct answer: Anticoagulation with unfractionated heparin or LMWH

Anticoagulation with heparin (unfractionated or LMWH) is the immediate treatment for hemodynamically stable pulmonary embolism to prevent clot propagation.

Question 82: A 55-year-old man with a history of peptic ulcer disease presents with melena and hemodynamic instability. After resuscitation, upper endoscopy reveals a Forrest Ia (active spurting) duodenal ulcer. What is the most appropriate endoscopic therapy?

Combination therapy: epinephrine injection plus thermal coagulation or clip (Correct answer)
Hemostatic spray only
Thermal coagulation alone
Injection of epinephrine alone

Correct answer: Combination therapy: epinephrine injection plus thermal coagulation or clip

Combination endoscopic therapy (epinephrine injection plus a second modality such as thermal coagulation or hemoclip) is superior to monotherapy for high-risk stigmata including active spurting.

Question 83: A 67-year-old woman with a 40 pack-year smoking history has a 6-cm abdominal aortic aneurysm discovered incidentally on ultrasound. She is asymptomatic with no hemodynamic instability. What is the most appropriate management?

Medical management with beta-blockers only
Repeat ultrasound in 6 months
Endovascular aortic repair (EVAR) electively (Correct answer)
Urgent surgical repair

Correct answer: Endovascular aortic repair (EVAR) electively

AAAs ≥5.5 cm in women (and ≥5.5 cm in men) require repair; EVAR is the preferred approach when anatomy is suitable, performed electively in stable patients.

Question 84: Which antibody is most specific for systemic lupus erythematosus (SLE)?

Anti-double-stranded DNA (anti-dsDNA)
Anti-Ro/SSA
Anti-histone
Anti-Smith (anti-Sm) (Correct answer)

Correct answer: Anti-Smith (anti-Sm)

Anti-Smith (anti-Sm) antibodies are the most specific antibody for SLE (~99% specific), though they have lower sensitivity than anti-dsDNA.

Question 85: A 62-year-old smoker presents with a 3.5 cm spiculated lung nodule on CT. PET scan shows hypermetabolic activity. What is the next step?

CT-guided biopsy or surgical resection (Correct answer)
Bronchoscopy with BAL only
Empiric antibiotics for 4 weeks
Repeat CT in 3 months

Correct answer: CT-guided biopsy or surgical resection

A spiculated >3 cm pulmonary nodule with PET hypermetabolic activity in a smoker is highly suspicious for malignancy and requires tissue diagnosis via biopsy or surgical resection.

Question 86: A 50-year-old man is found to have hemochromatosis (HFE C282Y homozygous) with ferritin 1,800 ng/mL and transferrin saturation 75%. Liver biopsy shows grade 2 fibrosis. What is the first-line treatment?

Low-iron diet only
Therapeutic phlebotomy weekly (Correct answer)
Deferoxamine chelation therapy
Liver transplantation

Correct answer: Therapeutic phlebotomy weekly

Therapeutic phlebotomy (venesection) is the first-line treatment for hereditary hemochromatosis, effectively depleting iron stores and preventing progression of organ damage.

Question 87: Pulmonary function tests show: FEV1/FVC 0.82, FVC 58% predicted, TLC 65% predicted. DLCO is 50% of predicted. What pattern is present?

Obstructive pattern
Mixed obstructive-restrictive
Restrictive pattern (Correct answer)
Normal spirometry

Correct answer: Restrictive pattern

Restrictive lung disease is characterized by reduced FVC and TLC with a normal or elevated FEV1/FVC ratio, with reduced DLCO indicating parenchymal involvement.

Question 88: A 66-year-old man with atrial fibrillation and CHA₂DS₂-VASc score of 4 is on warfarin (INR 2.4). He develops hematuria and hemoglobin drops from 13 to 10 g/dL. What is the most appropriate management of anticoagulation?

Continue warfarin at the same dose
Hold warfarin and reverse with vitamin K; resume after source identified and treated (Correct answer)
Permanently discontinue warfarin
Switch to aspirin only

Correct answer: Hold warfarin and reverse with vitamin K; resume after source identified and treated

Significant bleeding warrants holding anticoagulation and identifying the source; warfarin should be resumed once hemostasis is achieved given his high stroke risk.

Question 89: A 65-year-old man with COPD on tiotropium presents with an acute exacerbation with increased dyspnea, purulent sputum, and reduced exercise tolerance. SpO₂ is 88% on room air. What is the appropriate target SpO₂ during oxygen supplementation?

88–92% (Correct answer)
98–100%
94–96%
80–85%

Correct answer: 88–92%

In COPD exacerbations, controlled oxygen therapy targeting SpO₂ 88–92% prevents hypercapnic respiratory failure by preserving hypoxic drive in CO₂ retainers.

Question 90: A 62-year-old man presents with crushing chest pain radiating to his left arm. ECG shows ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Left main coronary artery
Left anterior descending artery
Right coronary artery (Correct answer)
Left circumflex artery

Correct answer: Right coronary artery

ST elevation in leads II, III, and aVF indicates an inferior STEMI, which is most commonly caused by occlusion of the right coronary artery.

Question 91: After today's mechanical fall from ground level, a 71-year-old man with a right hip fracture is admitted to the hospital. Surgery is scheduled for the evening and will be followed by orthopedic surgery. His prior medical history includes osteoarthritis, diabetes mellitus, hypertension, dyslipidemia, coronary artery disease, and hypertension. He uses insulin 70/30, metformin, lisinopril, atorvastatin, aspirin, metoprolol, and insulin. He used to be self-sufficient at home and go shopping by himself. His nuclear myocardial perfusion imaging, performed six months previously for chronic atypical chest discomfort, revealed no evidence of ischemia. He expresses discomfort in his right hip. Temperature is 36.8 degrees Celsius, blood pressure is 156/81 millimeters of mercury, pulse rate is 69 beats per minute, and respiration rate is 18 beats per minute. Without radiation, hearing a grade II/VI early-peaking systolic murmur above the left sternal boundary is easiest. His right hip joint is painful, and his right lower extremity is rotated outward. He can wiggle his toes and has good feeling in his right lower extremities. The electrocardiogram displays a typical sinus rhythm with a few ventricular contractions that are premature. The below laboratory workup is displayed. The best course of action is which of the following?

Repeat stress testing
Proceed with surgery without testing or delays (Correct answer)
Consult cardiology
Cancel surgery

Correct answer: Proceed with surgery without testing or delays

If surgery is put off for older patients with hip fractures, there is a higher risk of morbidity and death. Avoid using conservative therapy until the risks of surgery outweigh the advantages. According to data, having hip surgery within 48 hours of admission improves the prognosis. Delaying the procedure increases the risk of mortality and pressure sores even while the glucose is not under control. Instead of postponing surgery, it is preferable to manage the hyperglycemia (for instance, with an intravenous insulin drip).

Question 92: A 34-year-old woman presents with recurrent DVTs and a miscarriage at 16 weeks gestation. Laboratory workup reveals prolonged aPTT that does not correct with mixing study, positive lupus anticoagulant, and anti-cardiolipin IgG elevated on two occasions 12 weeks apart. What is the most likely diagnosis?

Protein C deficiency
Factor V Leiden deficiency
Antiphospholipid syndrome (Correct answer)
Systemic lupus erythematosus

Correct answer: Antiphospholipid syndrome

Antiphospholipid syndrome is diagnosed with clinical criteria (thrombosis or pregnancy morbidity) and positive antiphospholipid antibodies on two occasions at least 12 weeks apart.

Question 93: A 40-year-old HIV-positive man (CD4 count 80 cells/µL, viral load detectable) develops confusion, fever, and nuchal rigidity. CSF shows elevated opening pressure, 20 WBC/µL (mostly lymphocytes), low glucose, and India ink stain is positive. What is the treatment of choice?

Fluconazole 400 mg daily
Amphotericin B deoxycholate plus flucytosine for 2 weeks (Correct answer)
Liposomal amphotericin B monotherapy
Voriconazole plus micafungin

Correct answer: Amphotericin B deoxycholate plus flucytosine for 2 weeks

IDSA guidelines recommend amphotericin B deoxycholate plus flucytosine for 2 weeks as induction therapy for cryptococcal meningitis in HIV-infected patients.

Question 94: A patient presents with a spontaneous pneumothorax. CXR shows 30% lung collapse. He is hemodynamically stable with mild dyspnea. What is the appropriate management?

Observation only
Supplemental O2 and aspiration or small-bore chest tube (Correct answer)
Thoracoscopic pleurodesis immediately
Emergency large-bore chest tube thoracostomy

Correct answer: Supplemental O2 and aspiration or small-bore chest tube

A large (≥20%) first-episode spontaneous pneumothorax with symptoms warrants oxygen supplementation and simple aspiration or small-bore chest tube drainage.

Question 95: A 55-year-old woman presents with epigastric pain, early satiety, and unintentional weight loss for 4 months. Upper endoscopy shows a gastric ulcer. What is the most critical next step?

Start PPI and recheck in 8 weeks
Test for H. pylori only
Immediate gastrectomy
Biopsy the ulcer edges to exclude malignancy (Correct answer)

Correct answer: Biopsy the ulcer edges to exclude malignancy

All gastric ulcers require biopsy to exclude gastric cancer, as malignant ulcers can appear benign endoscopically.

Question 96: A 41-year-old woman presents with fatigue, weight gain, dry skin, and constipation. TSH is 12.4 mIU/L and free T4 is 0.6 ng/dL. Anti-TPO antibodies are markedly elevated. What is the treatment of choice?

Desiccated thyroid extract
Levothyroxine monotherapy (Correct answer)
Levothyroxine plus liothyronine (T3)
Observation with repeat TSH in 6 months

Correct answer: Levothyroxine monotherapy

Levothyroxine is the standard treatment for Hashimoto's hypothyroidism due to its consistent potency, long half-life, and established safety profile.

Question 97: A 55-year-old man with a 30 pack-year smoking history presents with a 3 cm right upper lobe lung nodule discovered on CT. PET scan shows avid FDG uptake. Mediastinal lymph nodes appear normal. What is the most appropriate next step?

CT-guided biopsy of the lung lesion (Correct answer)
Bronchoscopy with BAL
Surgical resection without biopsy
Repeat CT in 3 months

Correct answer: CT-guided biopsy of the lung lesion

CT-guided biopsy provides tissue diagnosis before treatment planning for a suspicious solitary lung nodule in a high-risk patient, especially when mediastinal staging is needed.

Question 98: A patient presents with fever, flank pain, and dysuria. Blood cultures grow E. coli. CT scan shows a gas-forming infection within the renal parenchyma. What is the diagnosis?

Xanthogranulomatous pyelonephritis
Renal abscess
Perinephric abscess
Emphysematous pyelonephritis (Correct answer)

Correct answer: Emphysematous pyelonephritis

Emphysematous pyelonephritis is a life-threatening necrotizing infection of the renal parenchyma with gas formation, occurring predominantly in diabetic patients.

Question 99: A 48-year-old woman with known mitral stenosis and atrial fibrillation presents with acute onset left hemiplegia and facial droop. MRI brain confirms ischemic stroke. She is outside the tPA window. Her INR was 1.4 yesterday. What is the most appropriate anticoagulation strategy going forward?

Low-molecular-weight heparin long-term
Aspirin plus clopidogrel
Warfarin with goal INR 2.0-3.0 (Correct answer)
Apixaban 5 mg twice daily

Correct answer: Warfarin with goal INR 2.0-3.0

Rheumatic mitral stenosis with atrial fibrillation is an indication for warfarin; DOACs like apixaban are not approved for this indication due to inferior outcomes in valvular AF.

Question 100: A 60-year-old man has an MELD score of 28 and is listed for liver transplantation. He develops acute kidney injury with a creatinine rise from 0.9 to 2.8 mg/dL over 2 weeks. Urine sediment is bland. What is the diagnosis?

Prerenal azotemia from diuretics
Hepatorenal syndrome type 1 (HRS-AKI) (Correct answer)
Acute tubular necrosis
Obstructive uropathy

Correct answer: Hepatorenal syndrome type 1 (HRS-AKI)

HRS-AKI (formerly type 1 HRS) is a rapid functional renal failure in cirrhosis with bland urine sediment, no response to volume challenge, and absence of other AKI causes.

Question 101: A 48-year-old man is found to have a fasting glucose of 130 mg/dL on two separate occasions. His HbA1c is 7.4%. He has BMI 31 and no cardiovascular disease. What is the preferred initial pharmacologic therapy?

Insulin glargine
GLP-1 receptor agonist
Metformin (Correct answer)
Sulfonylurea (glipizide)

Correct answer: Metformin

Metformin is the recommended first-line pharmacologic agent for type 2 diabetes unless contraindicated, given its efficacy, safety profile, low cost, and weight neutrality.

Question 102: A 72-year-old woman is hospitalized for pneumonia. On day 3 she develops a maculopapular rash, eosinophilia, and rising creatinine. Urinalysis shows WBC casts and eosinophiluria. Which diagnosis is most likely?

Minimal change disease
Contrast nephropathy
Acute interstitial nephritis (Correct answer)
Post-infectious glomerulonephritis

Correct answer: Acute interstitial nephritis

The triad of rash, eosinophilia, and eosinophiluria with WBC casts after antibiotic exposure is classic for acute interstitial nephritis.

Question 103: A 40-year-old woman presents with proximal muscle weakness, heliotrope rash over the eyelids, and Gottron papules on her knuckles. Which laboratory finding most supports the diagnosis of dermatomyositis?

Positive anti-Smith antibody
Elevated alkaline phosphatase
Elevated creatine kinase (CK) (Correct answer)
Elevated serum uric acid

Correct answer: Elevated creatine kinase (CK)

Elevated creatine kinase (CK) is characteristic of inflammatory myopathies like dermatomyositis, reflecting ongoing muscle cell injury.

Question 104: A 50-year-old man with Barrett esophagus (non-dysplastic, confirmed on two endoscopies) asks about surveillance. What is the recommended surveillance interval?

Every 3–5 years (Correct answer)
Every 1 year
No further surveillance needed
Every 6 months

Correct answer: Every 3–5 years

Non-dysplastic Barrett esophagus has a low malignant potential (~0.3% per year), and current guidelines recommend surveillance endoscopy every 3–5 years.

Question 105: When ascites is observed, an ultrasound should be followed by a diagnostic paracentesis. Albumin and total protein should be measured as part of the ascitic fluid study, and when infection is suspected, bacterial cultures and cell counts should be evaluated.

most cost-effective study to detect the presence of ascites (Correct answer)
Patients with acute ipilimumab toxicity should receive
surveillance upper endoscopy in a patient with familial adenomatous polyposis
anti-N-methyl-D-aspartate receptor (anti-NMDAR) antibody encephalitis tx

Correct answer: most cost-effective study to detect the presence of ascites

The most cost-effective study to detect the presence of ascites is a physical examination combined with a simple imaging technique called ultrasound. Ultrasound is a non-invasive and widely available imaging modality that can accurately detect the presence of ascites by visualizing fluid accumulation in the abdominal cavity.

Question 106: A 55-year-old man with heart failure (EF 30%) is found to have a potassium of 3.0 mEq/L. He is on lisinopril, carvedilol, and furosemide. Which potassium-sparing intervention has demonstrated a mortality benefit in this population?

Oral potassium chloride supplementation
Spironolactone (Correct answer)
Amiloride
Triamterene

Correct answer: Spironolactone

Spironolactone (and eplerenone) are aldosterone antagonists shown in RALES and EPHESUS trials to reduce mortality in heart failure with reduced ejection fraction.

Question 107: A 55-year-old man with known cirrhosis develops confusion, asterixis, and jaundice. His INR is 2.1, bilirubin 8.4 mg/dL, and creatinine 2.8 mg/dL. By which scoring system is he best stratified for transplant priority?

Child-Pugh score
APACHE II
MELD-Na score (Correct answer)
Glasgow Coma Scale

Correct answer: MELD-Na score

MELD-Na (Model for End-stage Liver Disease with sodium) is the standard scoring system used by UNOS to prioritize liver transplant candidates.

Question 108: A 55-year-old man presents with sudden-onset severe pain and swelling of his right great toe with a serum uric acid of 9.2 mg/dL. What is the most appropriate first-line treatment for this acute attack?

Probenecid
Colchicine (Correct answer)
Allopurinol
Febuxostat

Correct answer: Colchicine

Colchicine (along with NSAIDs or corticosteroids) is first-line for acute gout; urate-lowering agents like allopurinol should never be initiated during an acute attack.

Question 109: A 70-year-old man presents with a 2-day history of fever and severe knee pain. Synovial fluid analysis shows WBC 95,000/mm³ with 95% PMNs. What is the most appropriate immediate next step?

Start IV antibiotics empirically (Correct answer)
Start NSAIDs and repeat aspiration in 48 hours
Order serum uric acid level to rule out gout
Perform MRI of the knee

Correct answer: Start IV antibiotics empirically

A synovial WBC >50,000/mm³ with predominantly PMNs is highly suggestive of septic arthritis, requiring immediate empiric antibiotics and joint drainage to prevent rapid joint destruction.

Question 110: A 65-year-old woman with type 2 diabetes develops peripheral neuropathy with burning pain. Her HbA1c is well controlled at 7.1%. What is the first-line pharmacotherapy for her neuropathic pain?

Topical capsaicin alone
NSAIDs
Gabapentin or pregabalin (Correct answer)
Opioid analgesics

Correct answer: Gabapentin or pregabalin

Gabapentin, pregabalin, and duloxetine are first-line agents for painful diabetic peripheral neuropathy based on efficacy evidence and guideline recommendations.

Question 111: A 38-year-old woman presents with bilateral ankle edema, dyspnea on exertion, and syncope. Echocardiography shows right ventricular dilation, RV systolic pressure of 65 mmHg, and normal left heart. Right heart catheterization confirms mPAP 42 mmHg with PCWP 10 mmHg. What initial therapy is indicated for WHO Group I PAH?

Endothelin receptor antagonist (e.g., ambrisentan) or PDE-5 inhibitor (e.g., sildenafil) (Correct answer)
High-dose systemic corticosteroids
Loop diuretics only
ACE inhibitor and beta-blocker

Correct answer: Endothelin receptor antagonist (e.g., ambrisentan) or PDE-5 inhibitor (e.g., sildenafil)

WHO Group I PAH with elevated PVR and normal PCWP is treated with pulmonary vasodilators including ERA, PDE-5 inhibitors, or prostacyclin analogs based on risk stratification.

Question 112: A 30-year-old woman presents with oligomenorrhea, galactorrhea, and visual field defects. MRI shows a 1.5 cm pituitary mass. Serum prolactin is 320 ng/mL. What is the first-line treatment?

Observation only
Radiation therapy
Transsphenoidal surgery
Dopamine agonist (cabergoline or bromocriptine) (Correct answer)

Correct answer: Dopamine agonist (cabergoline or bromocriptine)

Dopamine agonists (cabergoline preferred) are the first-line treatment for prolactinomas of all sizes, effectively reducing prolactin levels and tumor size in most patients.

Question 113: The best method for determining a food allergy is:

History and lhE bloodwork
Oral challenge
History and skin testing
Skin testing only (Correct answer)
lgE bloodwork only

Correct answer: Skin testing only

Among the listed choices, skin (prick) testing is selected as the best method because it directly detects IgE-mediated immediate hypersensitivity to specific allergens. (Worth noting: the textbook gold standard for confirming a true food allergy is the oral food challenge, which here is marked wrong — review this key if your source emphasizes that standard.)

Question 114: A 38-year-old man with systemic lupus erythematosus presents with pleuritic chest pain and a friction rub. Echo shows a small pericardial effusion with no tamponade physiology. ESR is 88 mm/hr and CRP is elevated. What is the first-line treatment?

High-dose prednisone 1 mg/kg/day
Pericardiocentesis
Hydroxychloroquine dose increase
NSAIDs plus colchicine (Correct answer)

Correct answer: NSAIDs plus colchicine

NSAIDs combined with colchicine are first-line for acute pericarditis regardless of etiology, with corticosteroids reserved for refractory or autoimmune-specific cases.

Question 115: A 62-year-old man is found to have a 3-cm solid pulmonary nodule on CT. PET scan shows no FDG uptake. Bronchoscopy is non-diagnostic. What is the most appropriate next step according to evidence-based guidelines?

Empiric radiation therapy
Video-assisted thoracoscopic surgery (VATS) resection (Correct answer)
CT-guided needle biopsy
Observation with repeat CT in 12 months

Correct answer: Video-assisted thoracoscopic surgery (VATS) resection

A solid nodule ≥3 cm with a non-diagnostic bronchoscopy warrants surgical resection (VATS) because malignancy risk is high regardless of PET negativity.

Question 116: A 32-year-old fit female patient comes in for a general checkup. She has no recognized medical conditions, either. Every day, she runs 5 kilometers. Recently, she experienced dizziness while working out at the gym. She claims that she has never experienced something comparable before. She did say that it was a warm day with plenty of sunshine and that she had worked out a lot more than usual. She denies experiencing any palpitations, syncopal episodes, or chest discomfort. One of her relatives, who is a medical student, quickly checked her vital signs. Her heart rate was constantly in the low 50s, which worried him. He recommended that she see a doctor for a checkup and additional investigation. Her EKG is shown. Which statement is accurate?

Sinus bradycardia occurs in healthy patients as an adaptive response, particularly in well-conditioned persons or while sleeping. (Correct answer)
Infections almost never cause bradycardia.
The prognosis is guarded.
The diagnosis warrants immediate holter monitor.

Correct answer: Sinus bradycardia occurs in healthy patients as an adaptive response, particularly in well-conditioned persons or while sleeping.

Sinus bradycardia can occur as a pathogenic reaction in several illnesses, but it also happens in healthy people as an adaptive response, especially in well-conditioned individuals or during sleeping. Sinus bradycardia is a common and typical finding in healthy children and adults, especially during sleep when rates may briefly dip as low as 30 beats per minute and pauses of up to two seconds are not unusual. Sinoatrial (SA) node dysfunction, sick sinus syndrome, an abrupt myocardial infarction, obstructive sleep apnea, and infections may all present with sinus bradycardia as their initial symptoms. The patient was generally healthy, but the clinical history is consistent with a vasovagal near-syncope.

Question 117: A 60-year-old man undergoes bronchoscopy for a centrally located lung mass. BAL and bronchial biopsy show small cells with high nuclear-to-cytoplasmic ratio and neuroendocrine markers. What is the most important initial staging test?

PET-CT and brain MRI (Correct answer)
Pleural biopsy
CT chest and abdomen only
Bone scan only

Correct answer: PET-CT and brain MRI

Small cell lung cancer (SCLC) is staged as limited or extensive disease; PET-CT plus brain MRI is recommended for comprehensive staging given SCLC's early metastatic behavior.

Question 118: A 30-year-old man presents with recurrent abdominal pain, weight loss, and terminal ileal involvement on imaging showing 'cobblestone' mucosa and skip lesions. What is the diagnosis?

Ulcerative colitis
Crohn disease (Correct answer)
Ischemic colitis
Infectious colitis

Correct answer: Crohn disease

Crohn disease characteristically involves any part of the GI tract with transmural inflammation, skip lesions, and cobblestoning, most commonly affecting the terminal ileum.

Question 119: A patient with type 1 diabetes presents with DKA: glucose 520 mg/dL, pH 7.18, bicarbonate 10 mEq/L, potassium 5.8 mEq/L. When should insulin be started?

After blood glucose is below 200 mg/dL
After fluid resuscitation and potassium is ≥3.5 mEq/L (Correct answer)
Only after bicarbonate normalizes
Immediately before fluid resuscitation

Correct answer: After fluid resuscitation and potassium is ≥3.5 mEq/L

Insulin infusion should not be started until potassium is ≥3.5 mEq/L, because insulin drives potassium intracellularly and can precipitate life-threatening hypokalemia.

Question 120: A 50-year-old woman is found to have an LDL of 195 mg/dL despite lifestyle modifications. She has no cardiovascular disease or diabetes. What is the most appropriate next step?

Start low-intensity statin therapy
Refer for genetic testing only
Reassure and recheck in 1 year
Start high-intensity statin therapy (Correct answer)

Correct answer: Start high-intensity statin therapy

An LDL ≥190 mg/dL meets the threshold for initiating high-intensity statin therapy regardless of 10-year ASCVD risk score.

Question 121: A 40-year-old man has an incidentally found 2.5 cm adrenal mass. It appears lipid-rich on CT (HU < 10). He is normotensive with normal electrolytes. What should be done?

PET scan immediately
Biochemical evaluation for hormonal hypersecretion (Correct answer)
Immediate adrenalectomy
Repeat CT in 5 years

Correct answer: Biochemical evaluation for hormonal hypersecretion

All adrenal incidentalomas require biochemical evaluation for pheochromocytoma, subclinical Cushing syndrome, and primary aldosteronism, regardless of imaging characteristics.

Question 122: A 66-year-old man with COPD presents with a 2-day history of increased sputum production, purulent sputum, and worsening dyspnea. SpO2 is 88% on room air. ABG shows pH 7.32, PaCO2 58 mmHg, PaO2 52 mmHg. What is the most appropriate respiratory support?

Simple face mask at 10 L/min
High-flow nasal cannula
Non-invasive positive pressure ventilation (NIPPV) (Correct answer)
Intubation and mechanical ventilation

Correct answer: Non-invasive positive pressure ventilation (NIPPV)

NIPPV (BiPAP) is the preferred intervention for acute hypercapnic respiratory failure in COPD exacerbations, reducing intubation rates and mortality.

Question 123: A 75-year-old man presents with progressive fatigue, macrocytic anemia (MCV 110 fL), and symmetric paresthesias of the lower extremities. Serum B12 is 98 pg/mL. Anti-intrinsic factor antibodies are positive. Which finding would confirm the underlying diagnosis?

Low serum folate level
Elevated methylmalonic acid and homocysteine (Correct answer)
Iron deficiency on bone marrow biopsy
Hypersegmented neutrophils only

Correct answer: Elevated methylmalonic acid and homocysteine

Elevated methylmalonic acid (MMA) and homocysteine confirm functional B12 deficiency and are pathognomonic for pernicious anemia when anti-intrinsic factor antibodies are present.

Question 124: Anemia due to a lack of iron Typically, transferrin saturation is lower.

> With a serotonin-norepinephrine reuptake inhibitor, such as duloxetine > A notable benefit also was seen with pregabalin and gabapentin
>20<
15% (Correct answer)
2nd

Correct answer: 15%

In iron deficiency anemia, transferrin saturation is usually less than 15%. Transferrin saturation is a measure of the amount of iron bound to transferrin, a protein that transports iron in the blood. It is calculated by dividing the serum iron level by the total iron-binding capacity (TIBC) and multiplying by 100.

Question 125: A 45-year-old woman has Raynaud's phenomenon, dysphagia, skin thickening limited to her fingers and face, and telangiectasias. Which antibody is most associated with limited cutaneous systemic sclerosis?

Anti-dsDNA
Anti-Scl-70 (anti-topoisomerase I)
Anti-Jo-1
Anti-centromere (Correct answer)

Correct answer: Anti-centromere

Anti-centromere antibodies are highly associated with limited cutaneous systemic sclerosis (CREST syndrome), while anti-Scl-70 is associated with diffuse cutaneous disease.

Question 126: A 35-year-old woman has a TSH of 6.8 mIU/L (normal 0.5–4.5) with normal free T4. She has no symptoms. Anti-TPO antibodies are positive. What is the most appropriate management?

Start levothyroxine immediately
Repeat TSH in 6–12 months and consider treatment if TSH >10 (Correct answer)
Start methimazole
Refer for thyroid biopsy

Correct answer: Repeat TSH in 6–12 months and consider treatment if TSH >10

Subclinical hypothyroidism with TSH 5–10 mIU/L is monitored with repeat testing; treatment is generally recommended when TSH >10 or symptoms are present.

Question 127: A 60-year-old diabetic patient has proteinuria of 3.5 g/day, hypoalbuminemia, and peripheral edema. Serum creatinine is normal. What is the diagnosis?

Prerenal azotemia
Nephritic syndrome
Acute tubular necrosis
Nephrotic syndrome (Correct answer)

Correct answer: Nephrotic syndrome

Nephrotic syndrome is defined by proteinuria >3.5 g/day, hypoalbuminemia, edema, and hyperlipidemia, often with lipiduria.

Question 128: A 38-year-old woman presents with episodic hypertension, diaphoresis, and palpitations. 24-hour urine metanephrines are 4x the upper limit of normal. CT abdomen shows a 3.5 cm right adrenal mass. Before surgical resection, which medication must be initiated first?

Calcium channel blocker (amlodipine)
Beta-blocker (propranolol)
Alpha-blocker (phenoxybenzamine) (Correct answer)
ACE inhibitor (lisinopril)

Correct answer: Alpha-blocker (phenoxybenzamine)

Alpha-blockade must be established before beta-blockade in pheochromocytoma to prevent unopposed alpha-mediated hypertensive crisis from beta-blockade alone.

Question 129: A 70-year-old man has a resting heart rate of 48 bpm and an ECG showing PR interval of 280 ms with all P waves followed by QRS complexes. What is the diagnosis?

Second-degree AV block Mobitz I
First-degree AV block (Correct answer)
Complete heart block
Second-degree AV block Mobitz II

Correct answer: First-degree AV block

A PR interval greater than 200 ms with every P wave followed by a QRS complex and no dropped beats defines first-degree AV block.

Question 130: A 44-year-old woman presents with polyuria, polydipsia, and a serum sodium of 148 mEq/L. Water deprivation test fails to concentrate urine (Uosm 180 mOsm/kg). After desmopressin administration, urine osmolality rises to 680 mOsm/kg. What is the diagnosis?

Primary polydipsia
Nephrogenic diabetes insipidus
SIADH
Central diabetes insipidus (Correct answer)

Correct answer: Central diabetes insipidus

A robust response to desmopressin (urine Osm >50% increase) confirms central DI, where ADH is deficient but renal tubules respond normally.

Question 131: A 45-year-old woman presents with weight gain, fatigue, constipation, and cold intolerance. TSH is 12 mIU/L and free T4 is low. What is the most appropriate treatment?

Liothyronine (T3) alone
Radioactive iodine
Levothyroxine (T4) (Correct answer)
Methimazole

Correct answer: Levothyroxine (T4)

Levothyroxine is the standard treatment for primary hypothyroidism and is titrated to normalize TSH levels.

Question 132: A 65-year-old man with aortic stenosis has a valve area of 0.7 cm², mean gradient of 55 mmHg, and LVEF of 60%. He is asymptomatic. What is the most appropriate management?

Balloon aortic valvuloplasty
Start ACE inhibitor
Immediate aortic valve replacement
Watchful waiting with close follow-up (Correct answer)

Correct answer: Watchful waiting with close follow-up

Asymptomatic severe aortic stenosis with preserved EF is managed with watchful waiting and close surveillance every 6–12 months, with valve replacement upon symptom development.

Question 133: A patient with alcohol-related cirrhosis has hepatic encephalopathy. Ammonia is elevated. Which treatment reduces recurrence of hepatic encephalopathy?

Branched-chain amino acid supplementation only
Long-term oral antibiotics with metronidazole
Rifaximin plus lactulose (Correct answer)
Zinc supplementation only

Correct answer: Rifaximin plus lactulose

Rifaximin (a non-absorbable antibiotic) combined with lactulose is more effective than lactulose alone in preventing recurrence of overt hepatic encephalopathy.

Question 134: Which medication should be avoided or dose-adjusted in a patient with GFR of 20 mL/min/1.73m²?

Amlodipine
Ondansetron
Metformin (Correct answer)
Acetaminophen

Correct answer: Metformin

Metformin is contraindicated when GFR <30 mL/min due to the risk of lactic acidosis from drug accumulation in the setting of reduced renal clearance.

Question 135: An occasional burning sensation in the lower extremities has been prevalent in the patient for the past 50 years. The patient routinely exercises and follows a strict vegan diet. The previous medical history is not noteworthy. The physical examination went as expected. The results of pertinent tests are displayed below. Which of the following best represents the evaluation's next phase?

Computed tomography of the lumbosacral spine
Electromyelography and nerve conduction studies
Therapeutic trial of vitamin B12
Serum methylmalonic acid and homocysteine levels (Correct answer)
Bone marrow examination

Correct answer: Serum methylmalonic acid and homocysteine levels

Clinical signs of vitamin B12 insufficiency in this patient include macrocytic anemia, neurological symptoms, a strict vegan diet, and borderline blood B12 levels. Methylmalonic acid and homocysteine levels can be checked in this situation to confirm the diagnosis. Due to their buildup in the setting of vitamin B12 insufficiency, both intermediates will grow. (In folate insufficiency, just homocysteine will be raised). The next step would be to look for the cause of a vitamin B12 insufficiency diagnosis to be made and confirmed. The patient's strict vegan diet is the most likely cause in this case. Even while electromyography and nerve conduction testing would show that neuropathy existed, they would not give the required details to identify the cause. Similarly, if other causes are ruled out, a computed tomography (CT) of the lumbosacral spine can be necessary. However, there are better courses of action than this when enough clinical data points to a vitamin shortage. The best way to define the patient's folate and vitamin B12 levels is borderline. Therefore, there are better courses of action than administering a therapeutic dose of vitamin B12 without first determining what is causing the neurological symptoms. A bone marrow analysis would not be required now because the peripheral blood smear and complete blood count showed no further related cellular abnormalities. The cause is more likely to be discovered by less invasive tests (such as serum metabolite intermediates).

Question 136: Angiography, since it allows for therapeutic intervention by embolization and can detect bleeding.

Patients with IgG MGUS, an M protein level less than .5 g/dL, and a normal serum FLC ratio may undergo follow-up once every
In patients with gout, continuation of flare prophylaxis and urate-lowering therapy is currently indicated if there is any evidence of
In patients with active overt gastrointestinal bleeding, the treatment is (Correct answer)
Patients with chronic liver disease and portosystemic shunting can develop a form of PAH referred to as

Correct answer: In patients with active overt gastrointestinal bleeding, the treatment is

In a patient with active, overt gastrointestinal bleeding, angiography is the treatment of choice because it can localize the bleeding source and stop it via embolization in the same procedure, particularly when endoscopy fails. The other options describe unrelated conditions (MGUS follow-up, gout therapy, portopulmonary hypertension) and don't address active GI bleeding.

Question 137: A 55-year-old woman with COPD uses a long-acting bronchodilator. She continues to have dyspnea and frequent exacerbations. Which add-on therapy has been shown to reduce COPD exacerbations?

Short-acting anticholinergic as needed
Inhaled corticosteroid (ICS) with LABA (Correct answer)
Nebulized N-acetylcysteine
Oral theophylline

Correct answer: Inhaled corticosteroid (ICS) with LABA

Adding ICS to LABA (or LABA/LAMA combination) reduces exacerbation frequency in COPD patients with frequent exacerbations or eosinophilia.

Question 138: A 52-year-old man with cirrhosis due to NASH presents with increasing ascites despite diuretic therapy. Paracentesis reveals 680 PMN cells/mm³ in ascitic fluid. He has no abdominal pain. What is the diagnosis and treatment?

Malignant ascites — cytology and palliative care
Secondary peritonitis — emergent surgery
Chylous ascites — low-fat diet
Spontaneous bacterial peritonitis — start cefotaxime IV (Correct answer)

Correct answer: Spontaneous bacterial peritonitis — start cefotaxime IV

SBP is diagnosed with ascitic PMN ≥250 cells/mm³ and treated with IV cefotaxime; albumin infusion reduces hepatorenal syndrome risk.

Question 139: A patient with end-stage renal disease on hemodialysis develops itching, periorbital edema, and a facial rash with hypercalcemia. Serum PTH is very low. What is the diagnosis?

Adynamic bone disease (Correct answer)
Calciphylaxis
Aluminum toxicity
Secondary hyperparathyroidism

Correct answer: Adynamic bone disease

Adynamic bone disease in ESRD patients is characterized by low PTH, impaired bone turnover, and often results from over-suppression of PTH with calcium or vitamin D therapy.

Question 140: Which ECG finding is most characteristic of Wolff-Parkinson-White (WPW) syndrome during sinus rhythm?

Delta waves with short PR interval (Correct answer)
ST depression in lateral leads
Right bundle branch block
Prolonged QT interval

Correct answer: Delta waves with short PR interval

WPW is characterized by a delta wave (slurred upstroke of the QRS), short PR interval (<120 ms), and wide QRS due to ventricular pre-excitation via an accessory pathway.

Question 141: A 67-year-old man with diabetes and hypertension presents with acute-onset flank pain radiating to the groin, microscopic hematuria, and a 6-mm ureteral stone on CT. He has no fever and his creatinine is at baseline. What is the most appropriate initial management?

Emergency urologic intervention
Immediate extracorporeal shock wave lithotripsy
Medical expulsive therapy with tamsulosin and analgesics (Correct answer)
IV antibiotics and admission

Correct answer: Medical expulsive therapy with tamsulosin and analgesics

Uncomplicated ureteral stones ≤10 mm without infection or obstruction are managed with medical expulsive therapy; tamsulosin relaxes ureteral smooth muscle to facilitate passage.

Question 142: A 48-year-old man develops bilateral pulmonary infiltrates, fever, and hypoxemia 6 hours after a massive blood transfusion. He has never had prior transfusions. What is the diagnosis?

Pulmonary embolism
Hospital-acquired pneumonia
Transfusion-associated circulatory overload (TACO)
Transfusion-related acute lung injury (TRALI) (Correct answer)

Correct answer: Transfusion-related acute lung injury (TRALI)

TRALI presents within 6 hours of transfusion with non-cardiogenic pulmonary edema (bilateral infiltrates, hypoxemia, normal PCWP) caused by donor antibodies activating recipient neutrophils.

Question 143: A 50-year-old man presents with hypertension, hypokalemia, and metabolic alkalosis. Plasma aldosterone-to-renin ratio is markedly elevated. What is the most appropriate next step?

CT scan of the adrenal glands (Correct answer)
Start spironolactone empirically
24-hour urine aldosterone
Adrenal vein sampling

Correct answer: CT scan of the adrenal glands

Once primary aldosteronism is confirmed biochemically, CT scan of the adrenal glands is the first imaging step to identify an adenoma versus bilateral hyperplasia.

Question 144: A patient with CKD stage 3b has a hemoglobin of 9.5 g/dL with low reticulocyte count and low iron stores. What is the correct sequence of treatment?

Start erythropoiesis-stimulating agent (ESA) immediately
Start folic acid supplementation
Replete iron first, then reassess for ESA therapy (Correct answer)
Transfuse packed red blood cells

Correct answer: Replete iron first, then reassess for ESA therapy

Iron deficiency must be corrected before initiating ESA therapy in CKD-related anemia, as functional iron deficiency blunts ESA response.

Question 145: Which statement about DDAVP (desmopressin) is accurate?

It should not be given chronically to prevent bleeding in patients with moderate von Willebrand disease (vWD). (Correct answer)
It does not have efficacy in several mild platelet disorders, such as storage pool defect.
It can be used in all causes of vWD.
It is an analog of vasopressin and can cause hypernatremia.

Correct answer: It should not be given chronically to prevent bleeding in patients with moderate von Willebrand disease (vWD).

DDAVP, a vasopressin analog, can increase the ADH axis's activity and result in hyponatremia. Additionally, it has been demonstrated to promote endothelial cell release of von Willebrand factor. However, this medication might cause tachyphylaxis, and its effectiveness usually wears off after two or three consecutive doses. As a result, it cannot be administered again. When von Willebrand factor attaches to glycoprotein 1, related to type IIB vWD, more platelets are cleared from the body. In individuals with type IIB vWD, DDAVP, which increases the release of von Willebrand factor, can result in thrombosis and severe thrombocytopenia and shouldn't be administered in this situation.

Question 146: A 60-year-old man with stage IV non-small cell lung cancer (NSCLC) is found to have an EGFR exon 19 deletion on molecular profiling. He has an ECOG performance status of 1. What is the preferred first-line therapy?

Osimertinib (third-generation EGFR TKI) (Correct answer)
Carboplatin plus pemetrexed chemotherapy
Pembrolizumab immunotherapy
Erlotinib (first-generation EGFR TKI)

Correct answer: Osimertinib (third-generation EGFR TKI)

Osimertinib demonstrated superior PFS and OS versus first/second-generation EGFR TKIs in the FLAURA trial and is now the standard first-line agent for EGFR-mutant NSCLC.

Question 147: Which feature of psoriatic arthritis most distinctly differentiates it from rheumatoid arthritis?

Morning stiffness lasting more than 1 hour
Positive rheumatoid factor
Dactylitis (sausage digits) (Correct answer)
Symmetric joint involvement

Correct answer: Dactylitis (sausage digits)

Dactylitis (diffuse swelling of an entire digit giving a 'sausage digit' appearance) is a hallmark of psoriatic arthritis and is not seen in rheumatoid arthritis.

Question 148: A 29-year-old man presents with fever, arthritis of the knee, and a painless penile ulcer. Urethral culture is negative for gonorrhea. He also has conjunctivitis and hyperkeratotic lesions on his palms. What is the most likely diagnosis?

Behcet's disease
Reactive arthritis (formerly Reiter's syndrome) (Correct answer)
Disseminated gonococcal infection
Secondary syphilis

Correct answer: Reactive arthritis (formerly Reiter's syndrome)

Reactive arthritis classically follows a GI or urogenital infection and presents with arthritis, urethritis, conjunctivitis, and skin/mucous membrane lesions (keratoderma blennorrhagicum).

Question 149: A 55-year-old man presents with melena and hematemesis. Upper endoscopy shows a duodenal ulcer with a visible vessel. What is the most appropriate endoscopic treatment?

Biopsy the ulcer and observe
Observe and start PPI only
Epinephrine injection plus thermal coagulation or clip (Correct answer)
Epinephrine injection alone

Correct answer: Epinephrine injection plus thermal coagulation or clip

Combination therapy (epinephrine plus thermal therapy or clips) is superior to epinephrine injection alone for high-risk ulcers with visible vessels or active bleeding.

Question 150: Which synovial fluid finding is most characteristic of gout?

WBC count >100,000/mm³ with 95% PMNs
Turbid fluid with glucose <25 mg/dL
Negatively birefringent needle-shaped crystals (Correct answer)
Positively birefringent rhomboid crystals

Correct answer: Negatively birefringent needle-shaped crystals

Gout is characterized by monosodium urate crystals that are needle-shaped and negatively birefringent under polarized light microscopy.

Question 151: A 60-year-old man undergoes colonoscopy and is found to have a 6-mm tubular adenoma. He has no family history of colorectal cancer. When should his next surveillance colonoscopy be performed?

1 year
15 years
3–5 years (Correct answer)
7–10 years

Correct answer: 3–5 years

ACG/ACS guidelines recommend repeat colonoscopy in 3–5 years for patients with 1–2 small (<10 mm) tubular adenomas without high-grade dysplasia.

Question 152: A 65-year-old man with a 50-pack-year smoking history has FEV1/FVC ratio of 0.60 (post-bronchodilator). FEV1 is 55% predicted. What GOLD stage of COPD does he have?

GOLD 1 (mild)
GOLD 3 (severe)
GOLD 4 (very severe)
GOLD 2 (moderate) (Correct answer)

Correct answer: GOLD 2 (moderate)

GOLD stage 2 (moderate COPD) is defined by FEV1 50–79% predicted with FEV1/FVC <0.70 post-bronchodilator.

Question 153: A 35-year-old woman with ulcerative colitis has been on mesalamine for 2 years. She develops worsening diarrhea and rectal bleeding despite treatment. Colonoscopy shows pancolitis. What is the next step?

Increase mesalamine dose only
Start antibiotics alone
Add oral corticosteroids for acute flare management (Correct answer)
Proceed immediately to colectomy

Correct answer: Add oral corticosteroids for acute flare management

Moderate-to-severe UC flares unresponsive to mesalamine are managed with oral corticosteroids to induce remission, followed by consideration of immunomodulators or biologics.

Question 154: You are meeting a 20-year-old male complaining for the previous two months about "puffy eyes" and "swollen ankles." Additionally, he says that his pee "sort of looks frothy and foamy." His vital signs during the examination are within normal ranges, and the funduscopy is uneventful but for minor bilateral edema 2+ in the bilateral feet to the ankle. He has never experienced any health issues or operations. His tests show an average serum creatinine level and a considerable 4-plus protein level without blood or bacteria in the urine. He has a kidney biopsy, which on light microscopy appears normal, but, on electron microscopy, reveals widespread podocyte effacement. Negative immunofluorescence results. Which medical intervention is ideal for this patient?

Rituximab
Corticosteroids (Correct answer)
Cyclosporine
Cyclophosphamide
Tacrolimus

Correct answer: Corticosteroids

Minimal Change Disease most likely affects this patient. Minimal Change Disease most frequently affects very young children, while it can also affect older kids and teenagers. Because no apparent signs of pathology are detectable with light microscopy alone, minimal change illness is unusual. On the visceral epithelial cells, characteristic electron microscopy observations include podocyte effacement, vacuolation, and development of microvilli. The first line of therapy should always be corticosteroids. Prednisone oral tablets should be used once every other day for the first 8 to 16 weeks (or until remission is established), after which the dosage should be decreased if proteinuria disappears or drops to a superficial level. Relapses frequently occur even after remission (only one-third of individuals experience a single episode). If it is discovered that the patient has steroid resistance (which 25% of patients have), tacrolimus, cyclosporine, or cyclophosphamide would be utilized. Patients who experience relapses often might also utilize these.

Question 155: A 53-year-old man presents with confusion and asterixis. His wife notes he has been drinking heavily for 20 years. Labs reveal ammonia 142 µmol/L, total bilirubin 4.2 mg/dL, and INR 2.1. What precipitating factor should be investigated first in hepatic encephalopathy?

High-protein meal
Gastrointestinal bleeding (Correct answer)
Spontaneous bacterial peritonitis
Constipation

Correct answer: Gastrointestinal bleeding

GI bleeding is the most common precipitant of hepatic encephalopathy in cirrhotics, as blood in the gut is a large nitrogenous load that dramatically raises ammonia.

Question 156: A 55-year-old woman with postmenopausal osteoporosis has a T-score of −2.8 at the lumbar spine. She cannot tolerate oral bisphosphonates. What is the most appropriate alternative?

Calcitonin nasal spray
Calcium and vitamin D alone
Zoledronic acid IV annually (Correct answer)
Estrogen replacement therapy

Correct answer: Zoledronic acid IV annually

Zoledronic acid (annual IV infusion) is an effective alternative for patients who cannot tolerate oral bisphosphonates and reduces fracture risk significantly.

Question 157: A 29-year-old woman at 32 weeks gestation presents with severe headache, visual changes, and BP 160/110 mmHg on two readings 4 hours apart. Urine protein is 3+ on dipstick. What complication must be urgently prevented?

Eclamptic seizure (Correct answer)
Placental abruption
Preterm labor
Deep vein thrombosis

Correct answer: Eclamptic seizure

Severe-range preeclampsia requires IV magnesium sulfate for seizure prophylaxis and urgent antihypertensive therapy to prevent eclampsia and end-organ damage.

Question 158: What is the primary mechanism of action of colchicine in the treatment of acute gout?

Blocking of IL-1β signaling
Promotion of renal uric acid excretion
Inhibition of neutrophil microtubule polymerization (Correct answer)
Inhibition of xanthine oxidase to reduce uric acid synthesis

Correct answer: Inhibition of neutrophil microtubule polymerization

Colchicine works by inhibiting microtubule polymerization in neutrophils, thereby impairing their migration and activation at sites of urate crystal deposition.

Question 159: Each year, upper endoscopy is recommended for individuals with familial adenomatous polyposis and MYH-associated polyposis to monitor the development of duodenal cancer.

> Follow-up CT at around 3, 9, and 24 months; > Dynamic contrast-enhanced CT, PET, and/or biopsy
1 to 5 years at an interval based on the stage of the duodenal polyposis. (Correct answer)
Their dose increased to twice daily.
Stop smoking because of the increased risk of aneurysmal rupture.

Correct answer: 1 to 5 years at an interval based on the stage of the duodenal polyposis.

Question 160: A 72-year-old man with atrial fibrillation on warfarin presents with INR of 8.2 and no active bleeding. Which is the most appropriate immediate management?

Give 4-factor PCC immediately
Hold warfarin only
Give fresh frozen plasma
Hold warfarin and give oral vitamin K (Correct answer)

Correct answer: Hold warfarin and give oral vitamin K

For elevated INR >8 without bleeding, holding warfarin and giving low-dose oral vitamin K (1-2.5 mg) safely and predictably reverses supratherapeutic anticoagulation.

Question 161: Synovial fluid from a patient with acute monoarthritis of the knee shows positively birefringent rhomboid-shaped crystals. Which metabolic disorder is most characteristically associated with this finding?

Hyperuricemia
Hyperparathyroidism (Correct answer)
Type 2 diabetes mellitus
Hyperthyroidism

Correct answer: Hyperparathyroidism

Calcium pyrophosphate deposition disease (pseudogout), characterized by positively birefringent rhomboid crystals, is associated with hyperparathyroidism, hemochromatosis, and hypomagnesemia.

Question 162: A patient with chronic stable angina is intolerant to beta-blockers and has preserved LV function. Which agent is the best alternative for anti-anginal therapy?

Ranolazine as monotherapy
Aspirin
Long-acting nitrates alone
Non-dihydropyridine calcium channel blockers (Correct answer)

Correct answer: Non-dihydropyridine calcium channel blockers

Non-dihydropyridine calcium channel blockers (diltiazem or verapamil) are acceptable alternatives to beta-blockers for chronic stable angina when beta-blockers are contraindicated or not tolerated.

Question 163: A 50-year-old man presents with recurrent episodes of crampy abdominal pain, non-bloody diarrhea, and a 15-lb weight loss over 6 months. Colonoscopy shows skip lesions with cobblestoning from terminal ileum to ascending colon. Histology reveals non-caseating granulomas. Which medication class is most appropriate for inducing remission?

5-aminosalicylates (mesalamine)
Antibiotics (ciprofloxacin)
Antifungals (fluconazole)
Corticosteroids (prednisone) (Correct answer)

Correct answer: Corticosteroids (prednisone)

Corticosteroids remain the standard induction therapy for moderate-to-severe Crohn's disease flares, though they are not used for maintenance.

Question 164: A 48-year-old man is found to have a serum calcium of 11.4 mg/dL and a PTH of 92 pg/mL (elevated). He is asymptomatic with normal renal function and bone density T-score of -1.8. What is the recommended management?

Start cinacalcet
Immediate parathyroidectomy
Observation with annual monitoring (Correct answer)
Start alendronate

Correct answer: Observation with annual monitoring

Asymptomatic primary hyperparathyroidism without surgical criteria (Ca <1 mg/dL above ULN, age >50, T-score >-2.5, GFR >60) is managed with surveillance per AAES guidelines.

Question 165: A 57-year-old man with HIV on ART (CD4 450 cells/µL, undetectable viral load) presents with progressive vision loss in his right eye. Ophthalmology exam shows a 'pizza pie' fundus appearance with perivascular hemorrhages and exudates. What is the most likely diagnosis?

CMV retinitis (Correct answer)
Syphilitic uveitis
Cryptococcal choroiditis
Toxoplasma chorioretinitis

Correct answer: CMV retinitis

CMV retinitis presents with the classic 'pizza pie' or 'scrambled eggs and ketchup' fundus appearance and occurs in severe immunosuppression, though can rarely occur at higher CD4 counts.

Question 166: A 61-year-old man with type 2 diabetes (HbA1c 8.4%) and CKD stage 3 (eGFR 42 mL/min) presents for glucose management optimization. Which agent provides cardiovascular and renoprotective benefits supported by outcomes trials in this population?

Empagliflozin (Correct answer)
Sitagliptin
Pioglitazone
Glipizide

Correct answer: Empagliflozin

SGLT2 inhibitors like empagliflozin have demonstrated cardiovascular mortality reduction and slowed CKD progression in outcome trials (EMPA-REG, CREDENCE, DAPA-CKD).

Question 167: A 45-year-old woman with primary biliary cholangitis has an alkaline phosphatase of 4x normal and pruritus. Which medication is first-line?

Prednisolone
Cholestyramine
Methotrexate
Ursodeoxycholic acid (UDCA) (Correct answer)

Correct answer: Ursodeoxycholic acid (UDCA)

UDCA is the first-line treatment for PBC, improving liver biochemistry, slowing histological progression, and improving transplant-free survival.

Question 168: Near the medial plantar heel surface, there is pain and discomfort. Pain often strikes right after waking up and after a lengthy period of relaxation.

Occupational therapy
Vibrio species
Plantar fasciitis (Correct answer)
Behçet syndrome

Correct answer: Plantar fasciitis

The symptoms you described are consistent with plantar fasciitis. Plantar fasciitis is a common condition characterized by pain and tenderness near the medial plantar heel surface. The pain is often most noticeable in the morning upon awakening or after prolonged periods of rest, and it can gradually improve with walking and activity.

Question 169: A patient with polymyalgia rheumatica develops new-onset unilateral temporal headache, scalp tenderness, and jaw claudication. What is the most feared complication if giant cell arteritis is not promptly treated?

Irreversible blindness (Correct answer)
Stroke
Sensorineural deafness
Renal failure

Correct answer: Irreversible blindness

Giant cell arteritis can cause ischemic optic neuropathy via involvement of the ophthalmic arteries, leading to irreversible blindness if high-dose corticosteroids are not started immediately.

Question 170: A 70-year-old man with chronic constipation presents with acute onset left-sided colonic pain and CT showing a 12 cm sigmoid loop with a 'whirl sign'. What is the diagnosis?

Sigmoid diverticulitis
Ischemic colitis
Ogilvie syndrome
Sigmoid volvulus (Correct answer)

Correct answer: Sigmoid volvulus

Sigmoid volvulus presents with a massively dilated sigmoid colon and characteristic whirl sign or 'coffee bean' sign on imaging; urgent endoscopic decompression is the initial treatment.

Question 171: In patients with limited cutaneous systemic sclerosis, which complication is the leading cause of morbidity and mortality?

Scleroderma renal crisis
Pulmonary fibrosis (ILD)
GI malabsorption
Pulmonary arterial hypertension (Correct answer)

Correct answer: Pulmonary arterial hypertension

Pulmonary arterial hypertension is the leading cause of death in limited cutaneous systemic sclerosis, while interstitial lung disease predominates in diffuse cutaneous disease.

Question 172: A 45-year-old man with HIV (CD4 count 60 cells/µL) presents with progressive dyspnea, dry cough, and LDH of 580 U/L. Chest X-ray shows bilateral interstitial infiltrates. What is the most likely diagnosis?

Pneumocystis jirovecii pneumonia (PCP) (Correct answer)
Kaposi sarcoma lung involvement
Cytomegalovirus pneumonitis
Bacterial pneumonia

Correct answer: Pneumocystis jirovecii pneumonia (PCP)

PCP is the most common opportunistic pulmonary infection in HIV patients with CD4 <200 cells/µL, presenting with subacute dyspnea, dry cough, and elevated LDH.

Question 173: What is the preferred treatment for a hemodynamically stable patient with new-onset atrial flutter with a ventricular rate of 140 bpm?

Adenosine IV push
Immediate electrical cardioversion
Digoxin loading
Rate control with IV diltiazem (Correct answer)

Correct answer: Rate control with IV diltiazem

For hemodynamically stable atrial flutter with rapid ventricular response, IV diltiazem or beta-blockers provide rapid rate control while anticoagulation and rhythm control are planned.

Question 174: During an asthma attack, confusion, bradycardia, and paradoxical breathing signify:

Moderate exacerbation
Co-existing myocardial infarction
Imminent respiratory arrest (Correct answer)
Impending stroke

Correct answer: Imminent respiratory arrest

During an asthma attack, confusion, bradycardia (slow heart rate), and paradoxical breathing (inward movement of the abdomen during inhalation instead of the normal outward movement) are signs of severe respiratory distress and impending respiratory arrest. These symptoms indicate that the person's airway is severely constricted, and their breathing is becoming inadequate, which can lead to a complete cessation of breathing if not promptly addressed. Immediate medical intervention is crucial in such cases to prevent respiratory arrest and potentially save the person's life.

Question 175: A 45-year-old man presents with sudden onset of tearing chest pain radiating to the back. BP is 180/100 mmHg in right arm and 140/80 mmHg in left arm. CXR shows widened mediastinum. What is the most appropriate immediate management?

Thrombolytic therapy
IV labetalol to target HR <60 and SBP <120 mmHg (Correct answer)
Emergent pericardiocentesis
IV nitroglycerin infusion

Correct answer: IV labetalol to target HR <60 and SBP <120 mmHg

Type A aortic dissection management begins with IV beta-blockade (labetalol) to reduce aortic wall stress by lowering heart rate and blood pressure before urgent surgery.

Question 176: A patient with CKD stage 4 has a serum potassium of 6.2 mEq/L with peaked T waves on ECG. What is the immediate treatment?

Sodium polystyrene sulfonate
Furosemide IV
IV calcium gluconate (Correct answer)
Kayexalate enema

Correct answer: IV calcium gluconate

IV calcium gluconate stabilizes the cardiac membrane immediately in hyperkalemia with ECG changes, though it does not lower potassium levels.

Question 177: An emergency department (ED) referral brings a 24-year-old patient in for a diagnosis of shortness of breath. Reviewing the ED data revealed that the patient had minor respiratory distress, intermittent stridor, and frequent episodes of shortness of breath over the previous four months. At each presentation, oxygen saturation levels were normal. Intramuscular epinephrine and albuterol administered as empiric therapy did not affect the symptoms. The symptoms always went away on their own. The patient's prior medical history is uneventful, and they are taking no drugs. The vital signs and physical exams are also typical right now. Which of the subsequent diagnoses is more likely?

Reactive airways disease
Paradoxical vocal cord motion (Correct answer)
Angioedema
Laryngospasm
Chronic rhinosinusitis

Correct answer: Paradoxical vocal cord motion

The intermittent symptoms of this patient are most consistent with upper respiratory obstruction. The diagnosis most likely to be made is paradoxical vocal cord movements. Due to improper adduction of the vocal cords during inspiration in patients with paradoxical vocal cord motion, stridor, and respiratory discomfort ensue. One sign of this potential diagnosis is a history of repeated visits to the ED for respiratory distress without any other obvious explanation. Exercise, among other things, can cause the symptoms to appear, and they usually go away independently. Although spirometry will show normal expiration and perhaps aberrant inspiratory function, it may be mistaken for asthma. The preferred diagnostic technique is laryngoscopy, which makes it possible to see the unusual cord movement in real-time.

Question 178: A 25-year-old woman is referred for evaluation of iron-deficiency anemia unresponsive to oral iron supplementation. She reports loose stools and a 10-pound weight loss. IgA anti-tissue transglutaminase antibody is markedly elevated. What is the gold-standard confirmatory test?

Small bowel biopsy via upper endoscopy (Correct answer)
Trial of gluten-free diet with symptom assessment
Capsule endoscopy
HLA-DQ2/DQ8 genotyping

Correct answer: Small bowel biopsy via upper endoscopy

Duodenal biopsy showing villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis remains the gold standard for confirming celiac disease.

Question 179: A 55-year-old man with known alcoholic cirrhosis (Child-Pugh B) presents with acute onset abdominal pain and fever. Diagnostic paracentesis shows PMN count of 350 cells/µL. What is the most appropriate treatment?

IV vancomycin and piperacillin-tazobactam
Repeat paracentesis in 48 hours before starting antibiotics
IV cefotaxime (or ceftriaxone) plus IV albumin (Correct answer)
Oral ciprofloxacin and discontinue diuretics

Correct answer: IV cefotaxime (or ceftriaxone) plus IV albumin

Spontaneous bacterial peritonitis (PMN ≥250/µL) is treated with IV third-generation cephalosporin plus albumin infusion (1.5 g/kg at diagnosis, 1 g/kg on day 3) to prevent hepatorenal syndrome.

Question 180: A 42-year-old woman presents with episodic hypertension, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines and normetanephrines. What is the next step?

Repeat urine studies in 3 months
Surgical adrenalectomy without imaging
CT or MRI of the adrenal glands (Correct answer)
Start phenoxybenzamine immediately

Correct answer: CT or MRI of the adrenal glands

After biochemical confirmation of pheochromocytoma, imaging (CT or MRI) of the adrenal glands is required to localize the tumor before surgical resection.

Question 181: A 45-year-old man presents with acute pericarditis. Which finding on ECG is most characteristic?

Q waves in multiple leads
Diffuse ST elevation with PR depression (Correct answer)
ST elevation in a single territory with reciprocal changes
Complete left bundle branch block

Correct answer: Diffuse ST elevation with PR depression

Acute pericarditis classically causes diffuse ST elevation (saddle-shaped) in multiple leads with PR segment depression, distinguishing it from focal myocardial infarction.

Question 182: A 35-year-old woman with SLE develops nephrotic-range proteinuria and hematuria. Renal biopsy shows wire-loop lesions on light microscopy. What is the most likely diagnosis?

Lupus nephritis class IV (diffuse proliferative) (Correct answer)
Focal segmental glomerulosclerosis
Membranous nephropathy
IgA nephropathy

Correct answer: Lupus nephritis class IV (diffuse proliferative)

Wire-loop lesions on renal biopsy represent subendothelial immune complex deposits and are pathognomonic of diffuse proliferative (class IV) lupus nephritis.

Question 183: A 77-year-old woman with hypertension and atrial fibrillation is started on amiodarone for rhythm control. Six months later, she presents with dyspnea and is found to have bilateral interstitial infiltrates on CXR. PFTs show a restrictive pattern with reduced DLCO. What is the most likely cause?

Amiodarone pulmonary toxicity (Correct answer)
Pulmonary embolism
Pneumonia
Congestive heart failure exacerbation

Correct answer: Amiodarone pulmonary toxicity

Amiodarone pulmonary toxicity typically presents months to years after initiation and causes interstitial pneumonitis, manifesting as dyspnea with restrictive physiology and reduced DLCO.

Question 184: A 50-year-old woman with obstructive sleep apnea (OSA) has an AHI of 28 events/hour. She is symptomatic with daytime sleepiness. What is the first-line treatment?

Mandibular advancement device
Uvulopalatopharyngoplasty
Supplemental oxygen at night
Continuous positive airway pressure (CPAP) (Correct answer)

Correct answer: Continuous positive airway pressure (CPAP)

CPAP is the first-line treatment for moderate-to-severe OSA (AHI >15) and is the most effective therapy for reducing apnea events and improving symptoms.

Question 185: A 58-year-old man with type 2 diabetes presents with a serum creatinine of 2.1 mg/dL (baseline 1.0) after starting an NSAID for knee pain two weeks ago. Which mechanism best explains this acute kidney injury?

Allergic interstitial nephritis
Inhibition of prostaglandin-mediated afferent arteriolar dilation (Correct answer)
Renal vein thrombosis
Direct tubular toxicity

Correct answer: Inhibition of prostaglandin-mediated afferent arteriolar dilation

NSAIDs inhibit prostaglandin synthesis, reducing afferent arteriolar dilation that is critical for maintaining GFR in states of low effective circulating volume (as in diabetic nephropathy).

Question 186: Antimicrobial medications and bismuth should be avoided for ____ before testing in order to increase the diagnostic precision of the urea breath test and fecal antigen test.

plavix
28 days (Correct answer)
q0.5-1y
4.5 cm

Correct answer: 28 days

To improve the diagnostic accuracy of the urea breath test and fecal antigen test for detecting Helicobacter pylori infection, antimicrobial agents and bismuth should be avoided for 28 days before testing. These substances can interfere with the accuracy of the tests and may lead to false-negative results. It is important to withhold any antibiotics, proton pump inhibitors (PPIs), bismuth-containing medications, and other medications that can suppress or eradicate H. pylori during this period to ensure accurate test results. The specific duration of avoidance may vary depending on the specific test being used and the recommendations of the healthcare provider. It's always best to consult with a healthcare professional for specific instructions regarding medication and dietary restrictions before undergoing H. pylori diagnostic testing.

Question 187: A 66-year-old woman with heart failure (EF 25%) presents with worsening dyspnea. She is already on carvedilol, lisinopril, and furosemide. Her potassium is 4.2 mEq/L. What additional medication most reduces mortality in this patient?

Amlodipine
Spironolactone (aldosterone antagonist) (Correct answer)
Hydralazine
Digoxin

Correct answer: Spironolactone (aldosterone antagonist)

Aldosterone antagonists (spironolactone or eplerenone) are a pillar of HFrEF therapy with proven mortality benefit in patients with EF ≤35% and adequate renal function/potassium.

Question 188: A 64-year-old man with long-standing hypertension presents with sudden severe tearing chest pain radiating to the back. BP is 180/100 mmHg in the right arm and 140/85 in the left. CT angiography shows a type A aortic dissection. What is the definitive management?

Endovascular stent grafting
Thrombolytic therapy
Intravenous labetalol and sodium nitroprusside targeting systolic BP <120 mmHg
Emergency surgical repair (Correct answer)

Correct answer: Emergency surgical repair

Stanford type A aortic dissection involving the ascending aorta is a surgical emergency; medical management alone carries a mortality of approximately 1–2% per hour.

Question 189: Which acid-base disorder is most commonly associated with diarrhea?

Non-anion gap metabolic acidosis (Correct answer)
Metabolic alkalosis
Respiratory acidosis
High anion gap metabolic acidosis

Correct answer: Non-anion gap metabolic acidosis

Diarrhea causes loss of bicarbonate-rich intestinal secretions, resulting in non-anion gap (hyperchloremic) metabolic acidosis.

Question 190: A patient presents with unilateral pleural effusion. Thoracentesis shows: protein 4.5 g/dL (serum protein 7.0 g/dL), LDH 280 U/L (serum LDH 200 U/L). What type of effusion is this?

Chylothorax
Exudate (Correct answer)
Transudate
Hemothorax

Correct answer: Exudate

By Light's criteria, an exudate is diagnosed when pleural fluid/serum protein ratio >0.5, pleural fluid/serum LDH ratio >0.6, or pleural LDH >2/3 upper limit of normal serum LDH.

Question 191: Based on radiographic findings, including the collapse of the subchondral bone in the afflicted joints and the presence of core erosions (as opposed to the marginal erosions of rheumatoid and psoriatic arthritis).

Erosive OA is a subset of primary OA, diagnosis is (Correct answer)
Infection associated with Contact primarily with dogs
Colonoscopy surveillence if you have IBD
When to get Coronary artery calcium score

Correct answer: Erosive OA is a subset of primary OA, diagnosis is

Erosive osteoarthritis (EOA) is indeed a subset of primary osteoarthritis (OA) that involves characteristic radiographic features. The diagnosis of erosive OA is primarily made based on the presence of central erosions and collapse of the subchondral bone in the affected joints. These radiographic findings help differentiate erosive OA from other forms of arthritis, such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA), which typically exhibit marginal erosions.

Question 192: A 55-year-old woman with idiopathic pulmonary fibrosis (IPF) has progressive dyspnea with a UIP pattern on HRCT. FVC is 68% predicted. Which medication is approved to slow disease progression?

Nintedanib or pirfenidone (Correct answer)
Prednisone
Azathioprine
N-acetylcysteine

Correct answer: Nintedanib or pirfenidone

Nintedanib and pirfenidone are the only FDA-approved antifibrotic agents for IPF and have been shown to slow the rate of FVC decline.

Question 193: A 40-year-old woman with nephrotic syndrome due to minimal change disease (MCD) fails to respond to two courses of prednisone. What is the next treatment?

Mycophenolate mofetil
Cyclophosphamide
Rituximab
Cyclosporine (Correct answer)

Correct answer: Cyclosporine

For frequently relapsing or steroid-dependent MCD, calcineurin inhibitors (cyclosporine or tacrolimus) are the next line of therapy after steroid failure.

Question 194: A patient with heart failure has an ejection fraction of 35%. Which medication class has been shown to reduce mortality in this population?

Beta-blockers (Correct answer)
Loop diuretics
Calcium channel blockers
Short-acting nitrates

Correct answer: Beta-blockers

Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) have a Class I indication for reducing mortality in HFrEF with EF ≤40%.

Question 195: A 62-year-old man with a 40 pack-year smoking history presents with a 2.5-cm solid pulmonary nodule. PET scan shows avid FDG uptake (SUV 6.8). He is a surgical candidate. What is the most appropriate next step?

Proceed directly to surgical resection (Correct answer)
Bronchoscopy with BAL
CT-guided biopsy then resection if malignant
Repeat CT in 3 months

Correct answer: Proceed directly to surgical resection

A solid nodule >8 mm with high pre-test probability and avid PET uptake in a surgical candidate warrants direct resection without prior biopsy per Fleischner Society guidelines.

Question 196: A 58-year-old man with known MEN2A syndrome undergoes genetic testing. The RET mutation is confirmed. He has a calcitonin level of 800 pg/mL. What malignancy must be ruled out first?

Parathyroid adenoma
Medullary thyroid carcinoma (Correct answer)
Pancreatic insulinoma
Adrenocortical carcinoma

Correct answer: Medullary thyroid carcinoma

Medullary thyroid carcinoma (MTC) arises from parafollicular C-cells and is the most common and life-threatening component of MEN2A, diagnosed by elevated calcitonin.

Question 197: Which antibody is characteristically associated with drug-induced lupus?

Anti-dsDNA
Anti-histone (Correct answer)
Anti-Ro/SSA
Anti-Smith

Correct answer: Anti-histone

Drug-induced lupus is characteristically associated with anti-histone antibodies; common culprits include hydralazine, procainamide, isoniazid, and minocycline.

Question 198: The COPD symptom that frequently develops several years before the onset of airflow restriction is:

Cyanosis
Cough
Dyspnea (Correct answer)
Chest pain

Correct answer: Dyspnea

Dyspnea (shortness of breath, especially on exertion) is the COPD symptom that commonly appears years before measurable airflow limitation and usually drives patients to seek care. Cough, cyanosis, and chest pain tend to occur later or are nonspecific, so dyspnea is the earliest hallmark.

Question 199: A 52-year-old woman with obesity and type 2 diabetes is found to have persistently elevated ALT (3× ULN) and AST (2× ULN) on two measurements 6 months apart. Liver biopsy shows macrovesicular steatosis, lobular inflammation, and ballooning hepatocyte degeneration. What pharmacologic agent has FDA approval for this condition?

Pioglitazone
Vitamin E
Obeticholic acid
Resmetirom (Rezdiffra) (Correct answer)

Correct answer: Resmetirom (Rezdiffra)

Resmetirom (Rezdiffra) received FDA approval in March 2024 as the first pharmacologic treatment specifically approved for metabolic dysfunction-associated steatohepatitis (MASH) with moderate-to-advanced fibrosis.

Question 200: A 70-year-old man with COPD (FEV₁ 45% predicted) is admitted with acute exacerbation. After 48 hours of bronchodilators and systemic corticosteroids, he remains hypercapnic (PaCO₂ 68 mmHg, pH 7.28). Which intervention has been shown to reduce mortality and need for intubation in this setting?

High-flow nasal cannula oxygen
Immediate intubation and mechanical ventilation
Noninvasive positive-pressure ventilation (NIPPV) (Correct answer)
Inhaled helium-oxygen mixture

Correct answer: Noninvasive positive-pressure ventilation (NIPPV)

NIPPV reduces intubation rates, ICU length of stay, and mortality in COPD exacerbations with hypercapnic respiratory failure.

Question 201: A 45-year-old woman is found to have a serum calcium of 11.2 mg/dL on routine labs. PTH is elevated at 92 pg/mL. She is asymptomatic with a creatinine of 1.0 mg/dL and a DEXA T-score of -1.8. What is the most appropriate management?

Bisphosphonate therapy
Observation with annual monitoring (Correct answer)
Parathyroidectomy
Cinacalcet therapy

Correct answer: Observation with annual monitoring

Asymptomatic primary hyperparathyroidism without meeting surgical criteria (T-score ≤ -2.5, age <50, serum Ca >1 mg/dL above normal, creatinine clearance <60) is managed with observation.

Question 202: A 70-year-old woman presents with sudden-onset severe headache rated 10/10, described as 'the worst headache of my life.' CT head is negative. What is the next most critical diagnostic step?

Lumbar puncture for xanthochromia (Correct answer)
Observation and analgesics
CT angiography of the head
MRI brain with contrast

Correct answer: Lumbar puncture for xanthochromia

A negative CT does not rule out subarachnoid hemorrhage; lumbar puncture demonstrating xanthochromia confirms the diagnosis when CT is non-diagnostic.

Question 203: A 78-year-old man with hypertension and prior stroke is started on apixaban for new atrial fibrillation. His creatinine is 1.8 mg/dL. What is the correct dose of apixaban?

10 mg twice daily
5 mg twice daily
2.5 mg twice daily (Correct answer)
20 mg once daily

Correct answer: 2.5 mg twice daily

Dose reduction to 2.5 mg twice daily is required when at least 2 of 3 criteria are met: age ≥80, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL; this patient meets age and creatinine criteria.

Question 204: A 52-year-old man presents with progressive dyspnea and bilateral lower extremity edema. Echo shows EF of 65% with E/e' ratio of 16 and left atrial enlargement. NT-proBNP is 1,200 pg/mL. What is the most likely diagnosis?

Restrictive cardiomyopathy
Heart failure with preserved ejection fraction (HFpEF) (Correct answer)
Cardiac tamponade
Hypertrophic cardiomyopathy

Correct answer: Heart failure with preserved ejection fraction (HFpEF)

Preserved EF with elevated filling pressures (elevated E/e' ratio), elevated natriuretic peptides, and left atrial enlargement in a symptomatic patient defines HFpEF.

Question 205: Which of the following is the most common cause of secondary hypertension in adults?

Pheochromocytoma
Renal artery stenosis
Cushing syndrome
Primary aldosteronism (Correct answer)

Correct answer: Primary aldosteronism

Primary aldosteronism (Conn syndrome) is the most common cause of secondary hypertension in adults, accounting for approximately 5–10% of all hypertension cases.

Question 206: A 35-year-old woman develops hypercalcemia with a PTH of 120 pg/mL (normal 10–65). She is asymptomatic. Which statement is correct about management?

Start bisphosphonate therapy
Only observation is appropriate for asymptomatic patients
Immediate parathyroidectomy is required
Surgery is indicated if age <50 or serum calcium >1 mg/dL above upper limit (Correct answer)

Correct answer: Surgery is indicated if age <50 or serum calcium >1 mg/dL above upper limit

According to guidelines, parathyroidectomy is indicated in asymptomatic primary hyperparathyroidism if age <50, calcium >1 mg/dL above normal, T-score <−2.5, or GFR <60 mL/min.

Question 207: A 30-year-old man with a piece of steak lodged in his throat arrives at the emergency room. He claims that this has now occurred twice. He claims that he just received a diagnosis of eosinophilic esophagitis. Which of the following statements is accurate for eosinophilic esophagitis (EOE)?

Besides diet elimination, there is no other treatment for EOE
We can determine which foods are causing EOE by patch testing
We can determine which foods are causing EOE by skin prick testing
One must rule out reflux-induced eosinophilia prior to diagnosis of EOE (Correct answer)

Correct answer: One must rule out reflux-induced eosinophilia prior to diagnosis of EOE

Before a diagnosis of EOE, reflux-induced eosinophilia must be ruled out. Elevated eosinophils are another side effect of reflux. Before an EOE diagnosis, one must take high-dosage PPI for eight weeks and have a repeat biopsy. As the precise pathophysiology of EOE is unclear, (A) there is no tested method to identify if or which foods cause EOE. (B) Since the precise pathophysiology of EOE is unclear, there is no tested method to identify if or which foods cause EOE. (D) EOE needs 15 eosinophils/hpf or more. (E) Treatment for EOE has included an elimination diet in addition to using steroids.

Question 208: A 61-year-old woman with a history of breast cancer treated 10 years ago presents with back pain and hypercalcemia (Ca 12.4 mg/dL). PTH is low (<5 pg/mL) and PTHrP is elevated. Bone scan shows multiple areas of increased uptake. What is the mechanism of her hypercalcemia?

Vitamin D-mediated granulomatous hypercalcemia
Osteolytic metastases releasing calcium
PTHrP-mediated humoral hypercalcemia of malignancy (Correct answer)
Primary hyperparathyroidism

Correct answer: PTHrP-mediated humoral hypercalcemia of malignancy

Elevated PTHrP with suppressed PTH confirms humoral hypercalcemia of malignancy; PTHrP mimics PTH action on osteoclasts, mobilizing calcium from bone.

Question 209: A patient with hypertrophic obstructive cardiomyopathy (HOCM) experiences syncope during exercise. Which medication is contraindicated?

Nitroglycerin (Correct answer)
Verapamil
Metoprolol
Disopyramide

Correct answer: Nitroglycerin

Nitroglycerin is contraindicated in HOCM because vasodilation reduces preload, worsening the dynamic outflow tract obstruction and potentially causing hemodynamic collapse.

Question 210: A 44-year-old woman presents with fatigue, constipation, and hypercalcemia (Ca 11.8 mg/dL). PTH is 98 pg/mL (elevated). Renal function is normal and she is asymptomatic. Which criterion would make parathyroidectomy indicated per current guidelines?

T-score of -1.8 at the femoral neck
Serum calcium >1 mg/dL above the upper limit of normal
24-hour urine calcium >350 mg/day
Age under 50 years (Correct answer)

Correct answer: Age under 50 years

Current AACE/AAES guidelines recommend parathyroidectomy for asymptomatic primary hyperparathyroidism in patients under 50 years of age.

Question 211: A 35-year-old woman presents with chronic diarrhea, bloating, and weight loss. Small bowel biopsy shows villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis. Serologic testing shows positive anti-tissue transglutaminase IgA. What is the diagnosis?

Celiac disease (Correct answer)
Microscopic colitis
Small intestinal bacterial overgrowth
Crohn disease

Correct answer: Celiac disease

Celiac disease is diagnosed by positive anti-tTG IgA antibodies combined with duodenal biopsy showing villous atrophy and intraepithelial lymphocytosis on a gluten-containing diet.

Question 212: A 59-year-old man presents with progressive symmetric distal lower extremity weakness, hyporeflexia, and a stocking-glove pattern of sensory loss. He was treated for lymphoma 6 months ago. Nerve conduction studies show axonal sensorimotor neuropathy. What is the most likely cause?

Vincristine-induced neuropathy (Correct answer)
Cisplatin-induced neuropathy
Paraneoplastic neuropathy
Guillain-Barré syndrome

Correct answer: Vincristine-induced neuropathy

Vincristine causes a length-dependent axonal sensorimotor polyneuropathy that typically manifests during or after chemotherapy for lymphoma.

Question 213: A 25-year-old man presents with low back pain and morning stiffness that improves with exercise, positive HLA-B27, and sacroiliitis on imaging. What is the most appropriate initial treatment?

Methotrexate
NSAIDs (Correct answer)
Hydroxychloroquine
Rituximab

Correct answer: NSAIDs

NSAIDs are the first-line treatment for ankylosing spondylitis (axial spondyloarthropathy); TNF inhibitors or IL-17 inhibitors are added if NSAIDs provide insufficient relief.

Question 214: A 32-year-old woman with type 1 diabetes presents with recurrent hypoglycemia, nausea, and weight loss. Morning cortisol is undetectable. What additional test should be performed?

Dexamethasone suppression test
24-hour urinary free cortisol
ACTH stimulation test (Correct answer)
Fasting glucose tolerance test

Correct answer: ACTH stimulation test

The ACTH (cosyntropin) stimulation test is the gold standard for diagnosing primary adrenal insufficiency (Addison disease) by assessing adrenal cortisol response.

Question 215: A patient develops hypocalcemia and low PTH after thyroid surgery. Signs of Chvostek and Trousseau are present. Which is the most appropriate immediate treatment?

Calcitonin spray
IV calcium gluconate (Correct answer)
Oral calcium carbonate only
Teriparatide injection

Correct answer: IV calcium gluconate

Symptomatic hypocalcemia (with neuromuscular signs) after parathyroid injury requires immediate IV calcium gluconate for rapid correction.

Question 216: A 50-year-old man with polycystic kidney disease asks about his prognosis. His father died from a ruptured cerebral aneurysm. What screening should be offered?

Genetic testing for PKD1 mutation
24-hour urine protein
Annual renal ultrasound
MRA of the cerebral vasculature (Correct answer)

Correct answer: MRA of the cerebral vasculature

Patients with ADPKD and a family history of intracranial aneurysm should undergo MRA screening for cerebral aneurysms due to the increased familial risk.

ABIM Internal Medicine Board Exam

The ABIM Internal Medicine Certification Exam assesses the clinical knowledge and judgment required for board certification in internal medicine, covering 18 content domains across all major organ systems.

240

Questions

600 min

Time Limit

46%

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