ABIM Internal Medicine Board Exam — Questions and Answers

Question 1: A patient has fatigue, hypotension, and a low morning cortisol. Which finding best supports primary adrenal insufficiency rather than secondary (pituitary) adrenal insufficiency?

Low cortisol response to cosyntropin
Hyperkalemia with hyperpigmentation (Correct answer)
Hypoglycemia
Hyponatremia

Correct answer: Hyperkalemia with hyperpigmentation

Primary adrenal failure causes mineralocorticoid deficiency (hyperkalemia) and high ACTH (hyperpigmentation), while the renin-angiotensin-aldosterone axis stays intact in secondary disease.

Question 2: 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?

Hydroxychloroquine
Rituximab
NSAIDs (Correct answer)
Methotrexate

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 3: 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?

IV methylprednisolone only
Non-invasive positive pressure ventilation (BiPAP) (Correct answer)
Immediate intubation
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 4: A patient with severe obstructive sleep apnea (AHI 42) and daytime sleepiness should first receive which treatment?

Continuous positive airway pressure (CPAP) (Correct answer)
Hypoglossal nerve stimulation
Modafinil
Uvulopalatopharyngoplasty

Correct answer: Continuous positive airway pressure (CPAP)

CPAP is first-line therapy for moderate-to-severe OSA; surgery and nerve stimulation are reserved for patients who cannot tolerate CPAP.

Question 5: A patient develops a DVT 2 weeks after knee replacement. What is the recommended duration of anticoagulation?

3 months (Correct answer)
6 weeks
Indefinite
12 months

Correct answer: 3 months

VTE provoked by a major transient risk factor such as surgery is treated for 3 months.

Question 6: What is the recommended treatment for a man with newly diagnosed metastatic castration-sensitive prostate cancer and good performance status?

Radical prostatectomy alone
Androgen deprivation therapy alone
Androgen deprivation therapy plus an androgen receptor pathway inhibitor (Correct answer)
Active surveillance

Correct answer: Androgen deprivation therapy plus an androgen receptor pathway inhibitor

Adding abiraterone, enzalutamide, or apalutamide to ADT improves overall survival in metastatic castration-sensitive disease.

Question 7: A patient has acute right facial weakness that includes the forehead, with no other deficits, and presents within 48 hours. What is the most appropriate treatment?

IV acyclovir alone
Observation only; steroids are contraindicated
Emergent thrombolysis
Oral prednisone (Correct answer)

Correct answer: Oral prednisone

Weakness that involves the forehead indicates a peripheral (lower motor neuron) lesion consistent with Bell palsy. Corticosteroids started within 72 hours improve recovery. Antivirals alone are not effective, and a central lesion such as stroke typically spares the forehead.

Question 8: 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?

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

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 9: A 38-year-old who has never smoked has panlobular emphysema mainly in the lung bases. Which test is most appropriate?

Serum ACE level
Serum alpha-1 antitrypsin level (Correct answer)
Sweat chloride test
Anti-GBM antibody

Correct answer: Serum alpha-1 antitrypsin level

Early-onset basilar panacinar emphysema suggests alpha-1 antitrypsin deficiency.

Question 10: 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
Cyclosporine
Corticosteroids (Correct answer)
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 11: 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?

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

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 12: 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?

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

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 13: A 40-year-old woman with poorly controlled hypertension has 6 migraine days per month. Which preventive agent is most suitable?

Topiramate
Valproate
Propranolol (Correct answer)
Amitriptyline

Correct answer: Propranolol

Propranolol is an evidence-based migraine preventive that also treats her hypertension.

Question 14: 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?

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

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 15: Which appetite stimulant does the Beers Criteria recommend avoiding in older adults because of thrombosis risk and minimal effect on weight?

Dronabinol
Megestrol acetate (Correct answer)
Oral nutritional supplements
Mirtazapine

Correct answer: Megestrol acetate

Megestrol increases thrombotic events and possibly death while producing little weight gain in older adults.

Question 16: A patient with HIV and newly diagnosed pulmonary tuberculosis (CD4 count 120 cells/µL) is started on rifampin-based TB therapy. Which ART component requires dose adjustment due to rifampin interaction?

Lamivudine given twice daily
Dolutegravir given twice daily (Correct answer)
Emtricitabine dose doubled
Tenofovir disoproxil dose doubled

Correct answer: Dolutegravir given twice daily

Rifampin induces UGT1A1 and CYP3A, so dolutegravir must be increased to 50 mg twice daily.

Question 17: A 52-year-old woman with type 2 diabetes on empagliflozin has nausea, vomiting, and malaise after laparoscopic cholecystectomy. Glucose is 180 mg/dL, bicarbonate 12 mEq/L, anion gap 22, and serum beta-hydroxybutyrate is elevated. What is the diagnosis?

Euglycemic diabetic ketoacidosis (Correct answer)
Starvation ketosis
Lactic acidosis from metformin
Hyperosmolar hyperglycemic state

Correct answer: Euglycemic diabetic ketoacidosis

SGLT2 inhibitors can cause DKA with near-normal glucose, especially around surgery or reduced oral intake, and it is treated with insulin and dextrose.

Question 18: 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
Heparin infusion only
Oral anticoagulation with a DOAC (Correct answer)
Aspirin alone

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 19: 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 circumflex artery
Left main coronary artery
Right coronary artery (Correct answer)
Left anterior descending 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 20: A 47-year-old woman has a 2-cm thyroid nodule on ultrasound. Her TSH is 0.05 mIU/L with a normal free T4. What is the next best step?

Radionuclide thyroid scan (I-123 or Tc-99m) (Correct answer)
Total thyroidectomy
Ultrasound-guided fine-needle aspiration
Repeat ultrasound in 12 months

Correct answer: Radionuclide thyroid scan (I-123 or Tc-99m)

With a suppressed TSH, a scan should be done first, and a hyperfunctioning ('hot') nodule is almost never malignant, so it usually does not need FNA.

Question 21: A 58-year-old nondiabetic man with HFrEF (EF 30%) is on sacubitril-valsartan, carvedilol, and spironolactone, with an eGFR of 45. What should be added next?

Amlodipine
Dapagliflozin (Correct answer)
Digoxin
Ivabradine

Correct answer: Dapagliflozin

SGLT2 inhibitors are a pillar of guideline-directed therapy and reduce HF hospitalization and death whether or not the patient has diabetes.

Question 22: A patient with myasthenia gravis is admitted with worsening dysphagia and dyspnea. Which measure best guides the decision to intubate?

Chest x-ray
Arterial PaO2
Forced vital capacity and negative inspiratory force (Correct answer)
Pulse oximetry

Correct answer: Forced vital capacity and negative inspiratory force

Neuromuscular respiratory failure is tracked with FVC (under about 20 mL/kg is concerning) and NIF; oxygen saturation drops late.

Question 23: 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?

Toxic multinodular goiter
Toxic adenoma
Graves disease (Correct answer)
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 24: 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
Bone marrow examination
Therapeutic trial of vitamin B12
Serum methylmalonic acid and homocysteine levels (Correct answer)
Electromyelography and nerve conduction studies

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 25: Which antibiotic is associated with QT prolongation, tendon rupture, aortic aneurysm risk, and dysglycemia?

Clindamycin
Doxycycline
Cefuroxime
Levofloxacin (Correct answer)

Correct answer: Levofloxacin

Fluoroquinolones such as levofloxacin carry FDA warnings for tendinopathy, aortic aneurysm, QT prolongation, and hypo/hyperglycemia.

Question 26: After starting dapsone, a patient develops hemolysis with bite cells and Heinz bodies. What is the most likely underlying condition?

G6PD deficiency (Correct answer)
Pyruvate kinase deficiency
Hereditary spherocytosis
Paroxysmal nocturnal hemoglobinuria

Correct answer: G6PD deficiency

Oxidant drugs trigger hemolysis in G6PD deficiency, producing Heinz bodies and bite cells.

Question 27: What is the preferred treatment for a hemodynamically stable patient with new-onset atrial flutter with a ventricular rate of 140 bpm?

Immediate electrical cardioversion
Digoxin loading
Adenosine IV push
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 28: A 45-year-old nurse has recurrent fasting hypoglycemia. During a symptomatic episode, glucose is 38 mg/dL, insulin is markedly elevated, and C-peptide is undetectable. What is the most likely cause?

Insulinoma
Insulin autoimmune syndrome
Surreptitious sulfonylurea use
Exogenous insulin administration (Correct answer)

Correct answer: Exogenous insulin administration

High insulin with suppressed C-peptide means the insulin came from outside the body, because pancreatic insulin is released together with C-peptide.

Question 29: A patient with metastatic prostate cancer has new back pain, leg weakness, and urinary retention. Which step should come first?

Start NSAIDs and reassess
High-dose IV dexamethasone and emergent whole-spine MRI (Correct answer)
Bone scan
Outpatient MRI within 2 weeks

Correct answer: High-dose IV dexamethasone and emergent whole-spine MRI

Suspected malignant spinal cord compression is an emergency. Glucocorticoids should be given promptly and an urgent MRI of the entire spine obtained, followed by radiation and/or surgery. Neurologic status at treatment strongly predicts outcome.

Question 30: A 35-year-old man with syncope during sleep has spontaneous coved ST elevation in V1-V2 (type 1 Brugada pattern). What is the most appropriate management?

Observation with annual ECG
Implantable cardioverter-defibrillator (Correct answer)
Flecainide
Metoprolol

Correct answer: Implantable cardioverter-defibrillator

A spontaneous type 1 Brugada pattern with arrhythmic syncope is a class I indication for ICD placement.

Question 31: A 40-year-old man with no comorbidities and no recent antibiotic use has outpatient community-acquired pneumonia. Per the 2019 ATS/IDSA guideline, which is a recommended empiric regimen?

Amoxicillin (Correct answer)
Ceftriaxone IV
Vancomycin plus piperacillin-tazobactam
Levofloxacin plus azithromycin

Correct answer: Amoxicillin

For healthy outpatients without comorbidities, the 2019 ATS/IDSA guideline recommends high-dose amoxicillin, with doxycycline or a macrolide as alternatives where local resistance allows. Broad-spectrum or IV regimens are for patients with comorbidities or those who are hospitalized.

Question 32: A patient with neutropenia after induction chemotherapy has fever and new pulmonary nodules with a halo sign on CT; serum galactomannan is positive. What is first-line therapy?

Caspofungin
Fluconazole
Amphotericin B deoxycholate
Voriconazole (Correct answer)

Correct answer: Voriconazole

Voriconazole (or isavuconazole) is first-line for invasive aspergillosis.

Question 33: Which mechanism accounts for most cases of hypercalcemia in patients with squamous cell carcinoma of the lung?

Osteolytic bone metastases
Ectopic parathyroid hormone secretion
Ectopic 1,25-dihydroxyvitamin D production
Secretion of PTH-related protein (Correct answer)

Correct answer: Secretion of PTH-related protein

Humoral hypercalcemia of malignancy from PTHrP is the most common mechanism, especially with squamous cell cancers.

Question 34: 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
Acute fatty liver of pregnancy
HELLP syndrome (Correct answer)
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 35: 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?

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

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 36: 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?

Prerenal azotemia (Correct answer)
Acute tubular necrosis
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 37: 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?

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

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 38: An 82-year-old hospitalized patient develops hyperactive delirium but is not a danger to self or others. What is the first-line management?

Lorazepam at night
Physical restraints
Non-pharmacologic measures: reorientation, sleep hygiene, mobilization, hearing and vision aids (Correct answer)
Scheduled haloperidol

Correct answer: Non-pharmacologic measures: reorientation, sleep hygiene, mobilization, hearing and vision aids

Non-pharmacologic, multicomponent interventions are first-line for both preventing and managing delirium, along with treating the underlying cause. Benzodiazepines can worsen delirium (except in alcohol withdrawal). Restraints and routine antipsychotics should be avoided.

Question 39: A 68-year-old man with painless obstructive jaundice has a diffusely enlarged 'sausage-shaped' pancreas with a capsule-like rim and elevated serum IgG4. What is the most appropriate treatment?

Whipple procedure
Oral glucocorticoids (Correct answer)
ERCP with sphincterotomy only
Pancreatic enzyme replacement alone

Correct answer: Oral glucocorticoids

Type 1 autoimmune pancreatitis (IgG4-related disease) responds rapidly to glucocorticoids.

Question 40: A 46-year-old man has blood pressure of 168/100 mmHg on three agents including a diuretic, plus spontaneous hypokalemia. What is the best initial screening test?

Overnight dexamethasone suppression test
Renal artery duplex ultrasonography
Plasma aldosterone-to-renin ratio (Correct answer)
24-hour urine metanephrines

Correct answer: Plasma aldosterone-to-renin ratio

Resistant hypertension with hypokalemia strongly suggests primary aldosteronism, which is screened with the aldosterone-renin ratio.

Question 41: What is the specific reversal agent for dabigatran?

Protamine sulfate
Vitamin K
Andexanet alfa
Idarucizumab (Correct answer)

Correct answer: Idarucizumab

Idarucizumab is a monoclonal antibody fragment that binds dabigatran.

Question 42: Before starting allopurinol in a patient of Han Chinese, Korean, or Thai descent, which test is recommended to reduce the risk of severe cutaneous adverse reactions?

G6PD level
TPMT enzyme activity
HLA-B*57:01 genotyping
HLA-B*58:01 genotyping (Correct answer)

Correct answer: HLA-B*58:01 genotyping

HLA-B*58:01 carriage strongly predicts allopurinol hypersensitivity syndrome (SJS/TEN/DRESS) and screening is advised in high-prevalence groups, including Southeast Asian and African American patients.

Question 43: To make the diagnosis, imaging using an MRI is required for early-stage diseases, whereas simple radiographs are required for late-stage diseases.

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

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

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

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 45: A patient with a reported penicillin allergy consisting of a remote childhood rash needs treatment for syphilis in pregnancy. What is the best approach?

Doxycycline for 14 days
Ceftriaxone for 10 days
Azithromycin 2 g once
Penicillin allergy evaluation and desensitization if confirmed, then penicillin (Correct answer)

Correct answer: Penicillin allergy evaluation and desensitization if confirmed, then penicillin

Penicillin is the only reliably effective treatment for syphilis in pregnancy, so allergic patients should be desensitized.

Question 46: Which malignancy is the most common cause of superior vena cava syndrome?

Thymoma
Non-Hodgkin lymphoma
Metastatic breast cancer
Lung cancer (Correct answer)

Correct answer: Lung cancer

Lung cancer, especially small cell, causes most cases of malignant SVC syndrome.

Question 47: 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?

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

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 48: 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 1: Intermittent asthma
Step 4: Severe persistent asthma
Step 3: Moderate persistent asthma
Step 2: Mild persistent asthma (Correct answer)

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 49: A patient has ascending symmetric leg weakness and absent reflexes 2 weeks after a diarrheal illness. Which CSF finding supports the diagnosis?

Xanthochromia
Oligoclonal bands with lymphocytosis
Elevated protein with a normal cell count (Correct answer)
Elevated WBC with low glucose

Correct answer: Elevated protein with a normal cell count

Guillain-Barré syndrome classically shows albuminocytologic dissociation: high CSF protein with a normal white cell count. Serial vital capacity (FVC) monitoring is essential because of the risk of respiratory failure.

Question 50: How does hydroxyurea reduce painful crises in sickle cell disease?

It inhibits P-selectin directly
It decreases HbS polymer solubility
It increases red cell 2,3-BPG
It increases fetal hemoglobin (Correct answer)

Correct answer: It increases fetal hemoglobin

Hydroxyurea induces HbF, which inhibits HbS polymerization.

Question 51: A patient with granulomatosis with polyangiitis on allopurinol for gout is about to start azathioprine for maintenance. What is the main concern with this combination?

Hepatic veno-occlusive disease from allopurinol alone
Severe myelosuppression from accumulation of 6-mercaptopurine (Correct answer)
Hyperuricemia rebound
Loss of azathioprine efficacy

Correct answer: Severe myelosuppression from accumulation of 6-mercaptopurine

Xanthine oxidase inhibition blocks 6-mercaptopurine metabolism, raising active thiopurine levels and causing life-threatening bone marrow suppression unless the azathioprine dose is markedly reduced or the combination avoided.

Question 52: A 70-year-old asks about shingles prevention; they had zoster 3 years ago. What is recommended?

Recombinant zoster vaccine, 2 doses (Correct answer)
Live zoster vaccine once
Recombinant zoster vaccine only if immunocompromised
No vaccine, prior infection confers immunity

Correct answer: Recombinant zoster vaccine, 2 doses

Recombinant zoster vaccine (2 doses) is recommended for adults 50 and older regardless of prior zoster history.

Question 53: Using Light's criteria, which pleural fluid-to-serum protein ratio classifies an effusion as an exudate?

Greater than 0.3
Greater than 0.6
Greater than 0.5 (Correct answer)
Greater than 0.8

Correct answer: Greater than 0.5

A pleural/serum protein ratio >0.5 meets one of Light's criteria for an exudate (the LDH ratio cutoff is >0.6).

Question 54: Three weeks after starting sertraline, a euvolemic 80-year-old woman has a serum sodium of 124 mEq/L and urine osmolality of 450 mOsm/kg. What is the most likely cause?

SIADH due to the SSRI (Correct answer)
Primary polydipsia
Beer potomania
Adrenal insufficiency

Correct answer: SIADH due to the SSRI

SSRIs commonly cause SIADH in older adults, presenting as euvolemic hyponatremia with inappropriately concentrated urine.

Question 55: A 50-year-old without cancer has an acute proximal DVT and normal renal function. Which anticoagulant class do CHEST guidelines suggest over warfarin?

Unfractionated heparin long-term
No anticoagulation; compression stockings only
Direct oral anticoagulant (e.g., apixaban) (Correct answer)
Aspirin

Correct answer: Direct oral anticoagulant (e.g., apixaban)

For VTE without cancer, CHEST guidelines suggest a direct oral anticoagulant (apixaban, rivaroxaban, dabigatran, or edoxaban) over a vitamin K antagonist. DOACs have similar efficacy, less major bleeding, and do not need INR monitoring. Treatment lasts at least 3 months.

Question 56: 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?

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

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 57: Before starting abacavir in a patient with HIV, which test must be performed?

Tropism assay
HLA-B*1502
HLA-B*5701 (Correct answer)
G6PD level

Correct answer: HLA-B*5701

HLA-B*5701 positivity predicts abacavir hypersensitivity, so abacavir must be avoided in carriers.

Question 58: 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?

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

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 59: A patient with ventilator-associated pneumonia grows Klebsiella pneumoniae producing a KPC carbapenemase. Which agent is most appropriate?

Ceftazidime-avibactam (Correct answer)
Meropenem
Cefepime
Piperacillin-tazobactam

Correct answer: Ceftazidime-avibactam

Avibactam inhibits KPC (class A) carbapenemases, making ceftazidime-avibactam a preferred option for KPC-producing Enterobacterales.

Question 60: A 24-year-old athlete has a systolic murmur at the left sternal border that gets louder with Valsalva. Which maneuver would most likely decrease the murmur's intensity?

Valsalva strain phase
Amyl nitrite inhalation
Squatting from a standing position (Correct answer)
Standing up quickly from a squat

Correct answer: Squatting from a standing position

Squatting increases venous return and afterload, which enlarges the LV cavity and reduces the dynamic outflow obstruction in hypertrophic cardiomyopathy.

Question 61: A patient from Arizona develops fever, erythema nodosum, and arthralgias 2 weeks after a dust storm. Chest x-ray shows hilar adenopathy. What is the most likely diagnosis?

Histoplasmosis
Coccidioidomycosis (Correct answer)
Blastomycosis
Sarcoidosis

Correct answer: Coccidioidomycosis

Primary coccidioidomycosis ('valley fever') in the Southwest often presents with erythema nodosum and arthralgias.

Question 62: 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 63: A patient has resected stage III (node-positive) colon adenocarcinoma. What is the standard adjuvant treatment?

Adjuvant pelvic radiation
Observation only
Single-agent irinotecan
Oxaliplatin-based chemotherapy (FOLFOX or CAPOX) (Correct answer)

Correct answer: Oxaliplatin-based chemotherapy (FOLFOX or CAPOX)

Fluoropyrimidine plus oxaliplatin is standard adjuvant therapy for stage III colon cancer.

Question 64: 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?

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

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 65: 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?

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

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 66: 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 67: For an uncomplicated gram-negative bacteremia from a urinary source with clinical improvement, what is the recommended treatment duration?

21 days
7 days (Correct answer)
5 days
3 days

Correct answer: 7 days

Randomized trials show 7 days is noninferior to 14 days for uncomplicated gram-negative bacteremia with source control and clinical response.

Question 68: A 55-year-old woman with Cushing disease undergoes transsphenoidal surgery but has persistent hypercortisolism. What is the next treatment option?

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

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 69: A 62-year-old smoker has proximal leg weakness, dry mouth, and absent reflexes, and strength briefly improves after sustained contraction. Which antibody is most likely present?

P/Q-type voltage-gated calcium channel (Correct answer)
Anti-GQ1b
Anti-MuSK
Acetylcholine receptor

Correct answer: P/Q-type voltage-gated calcium channel

Lambert-Eaton myasthenic syndrome comes from antibodies to presynaptic P/Q-type VGCCs and is often paraneoplastic from small cell lung cancer.

Question 70: A healthy 67-year-old has never received a pneumococcal vaccine. What is the appropriate recommendation?

PPSV23 followed by PCV13 in 1 year
PPSV23 alone
A single dose of PCV20 or PCV21 (Correct answer)
PCV15 alone

Correct answer: A single dose of PCV20 or PCV21

Current ACIP guidance allows a single dose of PCV20 or PCV21 to complete pneumococcal vaccination in adults 65 and older.

Question 71: In the Confusion Assessment Method (CAM), which feature must be present, along with acute onset or fluctuating course, to diagnose delirium?

Sleep-wake reversal
Inattention (Correct answer)
Visual hallucinations
Psychomotor agitation

Correct answer: Inattention

CAM requires acute onset/fluctuating course plus inattention, plus either disorganized thinking or altered level of consciousness.

Question 72: A 68-year-old woman with osteoporosis has taken denosumab every 6 months for 5 years and wants to stop. What is the most appropriate recommendation?

Stop denosumab with no further therapy
Extend the dosing interval to every 12 months
Switch to calcium and vitamin D supplements alone
Transition to a bisphosphonate such as zoledronic acid or alendronate (Correct answer)

Correct answer: Transition to a bisphosphonate such as zoledronic acid or alendronate

Stopping denosumab causes rebound bone turnover and a higher risk of multiple vertebral fractures, so sequential bisphosphonate therapy is recommended.

Question 73: After high-dose methotrexate, a patient has delayed clearance with acute kidney injury and toxic methotrexate levels. Which agent rapidly lowers plasma methotrexate?

Allopurinol
Glucarpidase (Correct answer)
Sodium bicarbonate alone
Folic acid

Correct answer: Glucarpidase

Glucarpidase enzymatically cleaves methotrexate into inactive metabolites, rapidly reducing plasma levels.

Question 74: 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?

Histoplasmosis
Lymphoma
Sarcoidosis (Correct answer)
Tuberculosis

Correct answer: Sarcoidosis

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

Question 75: Which lab pattern is most consistent with iron deficiency anemia?

Normal ferritin, high MCV
High ferritin, high transferrin saturation
Low ferritin, high TIBC (Correct answer)
High ferritin, low TIBC

Correct answer: Low ferritin, high TIBC

Iron deficiency causes low ferritin (low iron stores) and a high TIBC (more transferrin). Transferrin saturation is low and MCV is usually low. High ferritin with low TIBC suggests anemia of inflammation.

Question 76: A woman with rheumatoid arthritis plans pregnancy within the next year. Which DMARD can be continued safely throughout pregnancy?

Methotrexate
Hydroxychloroquine (Correct answer)
Leflunomide
Mycophenolate mofetil

Correct answer: Hydroxychloroquine

Hydroxychloroquine (and sulfasalazine) are compatible with pregnancy, whereas methotrexate, leflunomide, and mycophenolate are teratogenic.

Question 77: A 50-year-old woman with resistant hypertension and hypokalemia has a high aldosterone-to-renin ratio and a positive saline suppression test. CT shows a 1-cm left adrenal nodule. She wants surgical treatment if appropriate. What is the next best step?

Start spironolactone and repeat CT in 1 year
Adrenal vein sampling (Correct answer)
Dexamethasone suppression test for glucocorticoid-remediable aldosteronism
Left laparoscopic adrenalectomy

Correct answer: Adrenal vein sampling

Adrenal vein sampling is needed before surgery in most patients over 35 to tell unilateral from bilateral aldosterone excess, because small nodules seen on CT are often nonfunctional incidentalomas.

Question 78: In diffuse cutaneous systemic sclerosis, which autoantibody is most strongly associated with scleroderma renal crisis?

Anti-U1 RNP
Anti-centromere
Anti-RNA polymerase III (Correct answer)
Anti-PM/Scl

Correct answer: Anti-RNA polymerase III

Anti-RNA polymerase III antibodies mark rapidly progressive diffuse skin disease and the highest risk of scleroderma renal crisis.

Question 79: A 70-year-old man has slowly progressive weakness of the finger flexors and quadriceps over 5 years that did not respond to prednisone. What is the most likely diagnosis?

Myasthenia gravis
Polymyositis
Inclusion body myositis (Correct answer)
Dermatomyositis

Correct answer: Inclusion body myositis

Inclusion body myositis causes asymmetric finger flexor and quadriceps weakness in older men and does not respond to immunosuppression.

Question 80: A 42-year-old man has calcium pyrophosphate deposition disease with chondrocalcinosis of the second and third MCP joints. Which screening test is most important?

Serum uric acid
Serum ACE level
Anti-CCP antibody
Iron studies (ferritin and transferrin saturation) (Correct answer)

Correct answer: Iron studies (ferritin and transferrin saturation)

Early-onset CPPD, especially with MCP involvement, warrants screening for hemochromatosis, along with hyperparathyroidism and hypomagnesemia.

Question 81: 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?

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

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 82: A patient with cirrhosis and ascites develops a rising creatinine that does not improve after 48 hours of diuretic withdrawal and albumin; urine sediment is bland. What is the preferred treatment?

Terlipressin plus albumin (Correct answer)
Furosemide infusion
Large-volume paracentesis without albumin
Hemodialysis

Correct answer: Terlipressin plus albumin

Terlipressin with albumin is the FDA-approved first-line therapy for hepatorenal syndrome-acute kidney injury.

Question 83: A patient with relapsing MS on natalizumab for 3 years develops progressive aphasia and hemiparesis, with nonenhancing subcortical white matter lesions on MRI. What test confirms the diagnosis?

Serum aquaporin-4 antibody
CSF JC virus PCR (Correct answer)
Visual evoked potentials
CSF oligoclonal bands

Correct answer: CSF JC virus PCR

Natalizumab carries a risk of progressive multifocal leukoencephalopathy, which is diagnosed by JC virus DNA in CSF.

Question 84: 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?

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

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 85: A 42-year-old man with confirmed pheochromocytoma is scheduled for adrenalectomy in 2 weeks. Which preoperative regimen is most appropriate?

Start metoprolol, then add phenoxybenzamine
No medication is needed if blood pressure is normal at the visit
Start phenoxybenzamine or doxazosin first, adding a beta-blocker only after adequate alpha blockade (Correct answer)
Start labetalol alone

Correct answer: Start phenoxybenzamine or doxazosin first, adding a beta-blocker only after adequate alpha blockade

Alpha blockade must come first, because a beta-blocker given alone leaves alpha-mediated vasoconstriction unopposed and can trigger a hypertensive crisis.

Question 86: Using the CDC STEADI approach, a Timed Up and Go test result of what duration indicates increased fall risk in an older adult?

8 seconds or more
12 seconds or more (Correct answer)
6 seconds or more
20 seconds or more

Correct answer: 12 seconds or more

STEADI uses a TUG time of 12 seconds or longer as a marker of increased fall risk.

Question 87: 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?

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

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 88: 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?

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

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 89: An HIV-negative man has condomless sex with a partner of unknown status 36 hours ago. What is the best management?

Start a 28-day 3-drug PEP regimen now (Correct answer)
Start daily PrEP with tenofovir-emtricitabine only
Test in 6 weeks and treat if positive
PEP is not indicated beyond 24 hours

Correct answer: Start a 28-day 3-drug PEP regimen now

Post-exposure prophylaxis should start within 72 hours as a 28-day three-drug regimen, such as bictegravir/emtricitabine/tenofovir alafenamide.

Question 90: A 45-year-old woman with primary biliary cholangitis has an alkaline phosphatase of 4x normal and pruritus. Which medication is first-line?

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

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 91: 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)
Reactive arthritis
Sarcoidosis
Crohn's disease

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 92: A 55-year-old has a first episode of non-severe Clostridioides difficile infection. According to the 2021 IDSA/SHEA update, which treatment is preferred?

Oral metronidazole as preferred therapy
Oral clindamycin
IV vancomycin
Oral fidaxomicin (Correct answer)

Correct answer: Oral fidaxomicin

The 2021 IDSA/SHEA update prefers fidaxomicin for an initial episode because it lowers the recurrence rate. Oral vancomycin is an acceptable alternative. IV vancomycin does not reach the colon, and metronidazole is reserved for when the other options are unavailable.

Question 93: A 68-year-old woman with Takotsubo cardiomyopathy becomes hypotensive, and echo shows a new LV outflow tract obstruction. What is the most appropriate treatment?

Dobutamine infusion
IV fluids and a beta-blocker (Correct answer)
IV nitroglycerin
Intra-aortic balloon pump as first-line

Correct answer: IV fluids and a beta-blocker

Dynamic LVOT obstruction gets worse with inotropes and vasodilators, so volume and beta-blockade are used to relieve it.

Question 94: Per USPSTF (2021), at what age should average-risk adults begin colorectal cancer screening?

45 (Correct answer)
40
50
55

Correct answer: 45

In 2021 the USPSTF lowered the starting age for average-risk colorectal cancer screening from 50 to 45 because incidence is rising in younger adults.

Question 95: Which intervention does the USPSTF recommend to prevent falls in community-dwelling adults 65 and older at increased fall risk?

Vitamin D supplementation
Exercise interventions (Correct answer)
Routine hip protectors
Benzodiazepine taper only

Correct answer: Exercise interventions

The USPSTF gives a B recommendation to exercise interventions, such as gait, balance, and strength training, for fall prevention. It recommends against vitamin D supplementation to prevent falls in community-dwelling older adults.

Question 96: A 68-year-old with MRSA bacteremia has persistently positive blood cultures after 7 days of vancomycin despite a trough of 18 mcg/mL and no drainable focus. Vancomycin MIC is 2 mcg/mL. What is the best next antibiotic step?

Add rifampin to vancomycin
Add gentamicin to vancomycin
Switch to linezolid monotherapy
Switch to high-dose daptomycin (Correct answer)

Correct answer: Switch to high-dose daptomycin

Persistent MRSA bacteremia with vancomycin MIC ≥2 warrants switching to high-dose daptomycin (8-10 mg/kg), often with a beta-lactam, rather than adding rifampin or gentamicin.

Question 97: A 28-year-old obese woman has daily headaches, transient visual obscurations, and bilateral papilledema. MRI/MRV is normal, and LP opening pressure is 34 cm H2O with normal CSF. What is first-line therapy along with weight loss?

Acetazolamide (Correct answer)
Sumatriptan
Ventriculoperitoneal shunt
Prednisone

Correct answer: Acetazolamide

Acetazolamide plus weight loss is first-line for idiopathic intracranial hypertension.

Question 98: Which feature best distinguishes delirium from dementia?

Gradual progression over years
Memory impairment
Acute onset with fluctuating inattention (Correct answer)
Older age

Correct answer: Acute onset with fluctuating inattention

Delirium has an acute onset and a fluctuating course, and inattention is its core feature (as in the Confusion Assessment Method). Dementia is usually gradual and progressive, with attention relatively preserved early on.

Question 99: A man homozygous for HFE C282Y has a transferrin saturation of 70% and ferritin of 1,200 ng/mL with normal liver enzymes. What is the treatment of choice?

Liver transplantation
Iron-restricted diet alone
Therapeutic phlebotomy to a ferritin of 50-100 ng/mL (Correct answer)
Deferoxamine infusions

Correct answer: Therapeutic phlebotomy to a ferritin of 50-100 ng/mL

Weekly phlebotomy targeting ferritin 50-100 ng/mL is first-line therapy for hereditary hemochromatosis.

Question 100: 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
Angioedema
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 101: A patient has macrocytic anemia. Which lab result best distinguishes vitamin B12 deficiency from folate deficiency?

Elevated methylmalonic acid (Correct answer)
Elevated homocysteine
Elevated MCV
Hypersegmented neutrophils

Correct answer: Elevated methylmalonic acid

Both deficiencies raise homocysteine and cause hypersegmented neutrophils and macrocytosis. Only B12 deficiency raises methylmalonic acid, because B12 is the cofactor for methylmalonyl-CoA mutase.

Question 102: An adult with newly diagnosed ITP has a platelet count of 15,000/µL and only mild petechiae. What is the preferred initial therapy?

Rituximab
Splenectomy
Glucocorticoids (Correct answer)
A thrombopoietin receptor agonist

Correct answer: Glucocorticoids

Glucocorticoids are first-line for newly diagnosed adult ITP with platelets below 30,000/µL.

Question 103: 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?

Sulfasalazine
Methotrexate (Correct answer)
Leflunomide
Hydroxychloroquine

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 104: Which agent is preferred first-line for metastatic NSCLC with an ALK rearrangement?

Erlotinib
Alectinib (Correct answer)
Docetaxel
Nivolumab

Correct answer: Alectinib

Second-generation ALK inhibitors such as alectinib beat crizotinib and have strong CNS activity.

Question 105: A 50-year-old man has a hematocrit of 58% and a JAK2 V617F mutation, with no thrombosis history. Besides low-dose aspirin, what is the initial management?

Hydroxyurea
Ruxolitinib
Observation only
Phlebotomy to keep hematocrit below 45% (Correct answer)

Correct answer: Phlebotomy to keep hematocrit below 45%

Low-risk polycythemia vera is managed with phlebotomy to a hematocrit below 45% plus aspirin.

Question 106: 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?

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

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 107: Febuxostat carries an FDA boxed warning for which adverse outcome in patients with established cardiovascular disease?

Interstitial lung disease
Increased cardiovascular death (Correct answer)
Fulminant hepatic failure
Agranulocytosis

Correct answer: Increased cardiovascular death

The CARES trial showed higher cardiovascular and all-cause mortality with febuxostat versus allopurinol, prompting a boxed warning.

Question 108: A patient receiving ipilimumab develops headache, fatigue, and hypotension, with low ACTH and low cortisol. What is the most likely diagnosis?

Hypophysitis (Correct answer)
Thyroid storm
Brain metastasis
Primary adrenal insufficiency

Correct answer: Hypophysitis

Anti-CTLA-4 therapy commonly causes hypophysitis, leading to central (secondary) adrenal insufficiency.

Question 109: A patient with a central venous catheter has Candida albicans in blood cultures. Besides starting an echinocandin, which action is required?

Remove the catheter and perform a dilated ophthalmologic exam (Correct answer)
Continue the catheter and repeat cultures in 1 week
Begin amphotericin B bladder irrigation
Add fluconazole for synergy

Correct answer: Remove the catheter and perform a dilated ophthalmologic exam

Candidemia management includes catheter removal and ophthalmologic exam to exclude endophthalmitis, with therapy for 14 days after clearance.

Question 110: Minutes after starting a red cell transfusion, a patient develops anaphylaxis. She is later found to have IgA deficiency. How should future transfusions be given?

Irradiated products
Premedication with acetaminophen only
Leukoreduced products only
Washed or IgA-deficient donor products (Correct answer)

Correct answer: Washed or IgA-deficient donor products

Anti-IgA antibodies cause anaphylaxis, so future products should be washed or from IgA-deficient donors.

Question 111: 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?

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

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 112: A 35-year-old woman has ptosis and diplopia that worsen through the day, along with fatigable proximal weakness. Which test is most specific for the likely diagnosis?

Acetylcholine receptor antibodies (Correct answer)
Serum CK
MRI brain
Anti-GQ1b antibody

Correct answer: Acetylcholine receptor antibodies

Fatigable ocular and limb weakness suggests myasthenia gravis. Acetylcholine receptor antibodies are positive in about 85% of generalized cases and are highly specific.

Question 113: A patient has a generalized convulsive seizure lasting 7 minutes and has IV access. What is the first-line treatment?

IV levetiracetam
IV lorazepam (Correct answer)
Propofol infusion
IV phenytoin

Correct answer: IV lorazepam

A benzodiazepine is first-line for status epilepticus, with IV lorazepam preferred when IV access exists. Levetiracetam, fosphenytoin, or valproate are second-line if seizures continue. Anesthetic infusions are for refractory status.

Question 114: Per AAO guidance, a patient starting hydroxychloroquine at ≤5 mg/kg real body weight without major risk factors should have retinal screening on what schedule?

Annually starting after 10 years of use
Only if visual symptoms develop
Every 6 months from the start
Baseline exam, then annually starting after 5 years of use (Correct answer)

Correct answer: Baseline exam, then annually starting after 5 years of use

Guidelines recommend a baseline fundus exam and annual screening (SD-OCT and visual fields) beginning after 5 years in low-risk patients.

Question 115: Severe, life-threatening mucositis, diarrhea, and myelosuppression after the first dose of 5-fluorouracil suggest deficiency of which enzyme?

Thiopurine methyltransferase
Dihydropyrimidine dehydrogenase (Correct answer)
Cytochrome P450 2D6
Glucose-6-phosphate dehydrogenase

Correct answer: Dihydropyrimidine dehydrogenase

DPD catabolizes most 5-FU, and deficiency causes drug accumulation and severe toxicity.

Question 116: What is the preferred first-line therapy for metastatic colorectal cancer that is microsatellite instability-high (dMMR)?

Regorafenib
Capecitabine monotherapy
FOLFIRI plus cetuximab
Pembrolizumab (Correct answer)

Correct answer: Pembrolizumab

First-line pembrolizumab improved progression-free survival over chemotherapy in MSI-H/dMMR metastatic colorectal cancer.

Question 117: 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?

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

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

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 119: 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)
Antifungals (fluconazole)
Antibiotics (ciprofloxacin)
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 120: A 72-year-old man presents 2 hours after onset of acute ischemic stroke and is otherwise eligible for IV thrombolysis. His BP is 196/108 mm Hg. What BP must be achieved before thrombolysis is given?

<220/120 mm Hg
<185/110 mm Hg (Correct answer)
<160/90 mm Hg
<140/90 mm Hg

Correct answer: <185/110 mm Hg

BP must be lowered to below 185/110 mm Hg before thrombolysis and kept below 180/105 mm Hg for 24 hours afterward.

Question 121: 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
Sitagliptin
Glipizide
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 122: 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
Immediate parathyroidectomy is required
Only observation is appropriate for asymptomatic patients
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 123: A sickle cell patient with acute chest syndrome has worsening hypoxemia despite simple transfusion, with Hb 10 g/dL. What is the best next step?

Start hydroxyurea
An additional simple transfusion
Hematopoietic stem cell transplant
Exchange transfusion (Correct answer)

Correct answer: Exchange transfusion

Severe or progressive acute chest syndrome calls for exchange transfusion, which lowers HbS without causing hyperviscosity.

Question 124: A patient receiving cisplatin develops muscle cramps and tetany. Which electrolyte abnormality is most likely responsible?

Hypernatremia
Hyperkalemia
Hypomagnesemia (Correct answer)
Hypophosphatemia

Correct answer: Hypomagnesemia

Cisplatin causes renal magnesium wasting, and the resulting hypomagnesemia can cause hypocalcemia and tetany.

Question 125: 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?

Contrast nephropathy
Minimal change disease
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 126: A patient with an LVEF of 30% has an aortic valve area of 0.8 cm² and a mean gradient of 25 mmHg. Which test best distinguishes true severe aortic stenosis from pseudo-severe stenosis?

Low-dose dobutamine stress echocardiography (Correct answer)
Cardiac MRI with late gadolinium enhancement
Exercise treadmill testing
Coronary CT angiography

Correct answer: Low-dose dobutamine stress echocardiography

With dobutamine, true severe AS keeps a small valve area as the gradient rises, while in pseudo-severe AS the valve area increases.

Question 127: A 50-year-old woman with diffuse cutaneous systemic sclerosis presents with blood pressure 210/120 mm Hg, headache, and creatinine rising from 0.9 to 2.4 mg/dL. Which antihypertensive should be started first?

Captopril (Correct answer)
Amlodipine
Labetalol
Hydralazine

Correct answer: Captopril

ACE inhibitors are first-line for scleroderma renal crisis and should be continued even if dialysis is needed.

Question 128: 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?

Febuxostat
Colchicine (Correct answer)
Allopurinol
Probenecid

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 129: A man who is homozygous for HFE C282Y has a ferritin of 1,200 ng/mL. What is the first-line treatment?

A low-iron diet alone
Deferasirox
Deferoxamine
Serial phlebotomy (Correct answer)

Correct answer: Serial phlebotomy

Therapeutic phlebotomy is first-line for hereditary hemochromatosis, targeting a ferritin of about 50-100 ng/mL.

Question 130: 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?

Percutaneous mitral balloon commissurotomy (PMBC) (Correct answer)
Medical management with diuretics only
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 131: A bird breeder has subacute dyspnea and ground-glass centrilobular nodules on CT. Which bronchoalveolar lavage finding is most typical?

Lymphocytosis with a high CD4:CD8 ratio
Lymphocytosis with a low CD4:CD8 ratio (Correct answer)
Neutrophilia with a high CD4:CD8 ratio
Eosinophils above 25%

Correct answer: Lymphocytosis with a low CD4:CD8 ratio

Hypersensitivity pneumonitis typically causes marked BAL lymphocytosis, usually with a low CD4:CD8 ratio, whereas sarcoidosis classically raises the ratio.

Question 132: A 24-year-old has a confirmed pathogenic MLH1 mutation (Lynch syndrome). What is the recommended colorectal cancer screening?

CT colonography every 5 years starting at age 40
Annual FIT starting at age 30
Colonoscopy every 5 years starting at age 45
Colonoscopy every 1-2 years starting at age 20-25 (Correct answer)

Correct answer: Colonoscopy every 1-2 years starting at age 20-25

Lynch syndrome carriers (MLH1/MSH2) need colonoscopy every 1-2 years beginning at age 20-25 due to accelerated adenoma-carcinoma progression.

Question 133: A 64-year-old man in the ICU with septic shock has a low free T3, normal TSH, low-normal free T4, and elevated reverse T3. He has no history of thyroid disease. What is the most appropriate management?

Start levothyroxine 1.6 mcg/kg daily
No thyroid treatment; repeat thyroid tests after recovery (Correct answer)
Order a thyroid radioactive iodine uptake scan
Start liothyronine (T3) replacement

Correct answer: No thyroid treatment; repeat thyroid tests after recovery

This is nonthyroidal illness (euthyroid sick) syndrome, which does not benefit from thyroid hormone and should be reassessed after the acute illness resolves.

Question 134: 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-Scl-70 (anti-topoisomerase I)
Anti-Jo-1
Anti-centromere (Correct answer)
Anti-dsDNA

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 135: A 35-year-old man has nightly 45-minute attacks of severe unilateral periorbital pain with ipsilateral tearing and rhinorrhea. Which acute treatment works best?

Oral sumatriptan
High-flow 100% oxygen by non-rebreather mask (Correct answer)
Oral naproxen
IV dihydroergotamine as first-line

Correct answer: High-flow 100% oxygen by non-rebreather mask

High-flow oxygen at 12-15 L/min and subcutaneous sumatriptan are first-line abortive treatments for cluster headache.

Question 136: 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
Start phenoxybenzamine immediately
Surgical adrenalectomy without imaging
CT or MRI of the adrenal glands (Correct answer)

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 137: For community-dwelling adults 65 and older at increased fall risk, which intervention does the USPSTF recommend to prevent falls?

Exercise interventions (Correct answer)
Routine bone density testing
Hip protectors for all patients
Vitamin D supplementation in non-deficient adults

Correct answer: Exercise interventions

The USPSTF gives a B recommendation for exercise and recommends against vitamin D supplementation for fall prevention in community-dwelling adults.

Question 138: 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?

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

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 139: At what CD4 count should Pneumocystis jirovecii prophylaxis be started in a person with HIV?

Below 100 cells/µL
Below 350 cells/µL
Below 200 cells/µL (Correct answer)
Below 50 cells/µL

Correct answer: Below 200 cells/µL

PJP prophylaxis, typically TMP-SMX, is indicated when CD4 is below 200 cells/µL or with oropharyngeal candidiasis.

Question 140: 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?

Replete iron first, then reassess for ESA therapy (Correct answer)
Start erythropoiesis-stimulating agent (ESA) immediately
Start folic acid supplementation
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 141: A patient has fever, confusion, thrombocytopenia, schistocytes on smear, and elevated LDH. Which underlying deficiency is most likely?

Protein C
Antithrombin III
Factor VIII
ADAMTS13 activity (Correct answer)

Correct answer: ADAMTS13 activity

Thrombotic thrombocytopenic purpura (TTP) results from severely reduced ADAMTS13 activity, usually from an autoantibody. Ultra-large von Willebrand multimers build up and cause microangiopathic hemolytic anemia. Urgent plasma exchange is the mainstay of treatment.

Question 142: Angiography, since it allows for therapeutic intervention by embolization and can detect bleeding.

Patients with chronic liver disease and portosystemic shunting can develop a form of PAH referred to as
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)

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 143: A man treated with BEP for a germ cell tumor develops progressive dyspnea and bibasilar crackles. Which drug is most likely responsible?

Etoposide
Cisplatin
Bleomycin (Correct answer)
Vincristine

Correct answer: Bleomycin

Bleomycin causes dose-related pulmonary toxicity that can progress to fibrosis.

Question 144: Which patient meets USPSTF (2021) criteria for annual low-dose CT lung cancer screening?

A 75-year-old with a 40 pack-year history who quit 20 years ago
A 45-year-old current smoker with a 30 pack-year history
A 62-year-old with a 25 pack-year history who quit 5 years ago (Correct answer)
A 70-year-old with a 10 pack-year history who smokes currently

Correct answer: A 62-year-old with a 25 pack-year history who quit 5 years ago

USPSTF recommends annual LDCT for adults aged 50–80 with at least a 20 pack-year history who currently smoke or quit within the past 15 years. Only the 62-year-old meets all three criteria.

Question 145: Which antidepressant is most appropriate as first-line therapy for major depression in a 79-year-old man?

Imipramine
Amitriptyline
Sertraline (Correct answer)
Doxepin 75 mg

Correct answer: Sertraline

SSRIs such as sertraline are first-line in older adults, while tertiary amine tricyclics are avoided per Beers due to anticholinergic and cardiac effects.

Question 146: A patient with small cell lung cancer has a serum sodium of 121 mEq/L, euvolemia, and inappropriately concentrated urine. Which paraneoplastic process is most likely?

Primary adrenal insufficiency
Cerebral salt wasting
SIADH from ectopic ADH secretion (Correct answer)
Ectopic ACTH secretion

Correct answer: SIADH from ectopic ADH secretion

Small cell lung cancer commonly secretes ADH ectopically, causing euvolemic hypotonic hyponatremia.

Question 147: A previously healthy 55-year-old with community-acquired pneumonia is admitted to a general ward without MRSA or Pseudomonas risk factors. What is the recommended empiric regimen?

Ceftriaxone plus azithromycin (Correct answer)
Meropenem plus linezolid
Doxycycline alone
Vancomycin plus piperacillin-tazobactam

Correct answer: Ceftriaxone plus azithromycin

Non-severe inpatient CAP is treated with a beta-lactam plus macrolide or a respiratory fluoroquinolone alone.

Question 148: A 27-year-old has daily spiking fevers to 39.5°C, an evanescent salmon-colored rash during fevers, arthralgias, and leukocytosis. Which lab finding most supports the likely diagnosis?

Positive ANA in high titer
Markedly elevated serum ferritin (Correct answer)
Low complement C3 and C4
Positive rheumatoid factor

Correct answer: Markedly elevated serum ferritin

Adult-onset Still disease characteristically shows extreme hyperferritinemia with a low glycosylated ferritin fraction, while ANA and RF are typically negative.

Question 149: A nursing home resident has a sacral wound with full-thickness skin loss and visible subcutaneous fat, but no exposed bone, tendon, or muscle. What is the pressure injury stage?

Stage 2
Stage 4
Stage 3 (Correct answer)
Stage 1

Correct answer: Stage 3

Stage 3 involves full-thickness skin loss into adipose tissue without exposure of fascia, muscle, tendon, ligament, cartilage, or bone.

Question 150: 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?

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

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 151: 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?

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

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

Positive rheumatoid factor
Dactylitis (sausage digits) (Correct answer)
Morning stiffness lasting more than 1 hour
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 153: A patient on warfarin has an INR of 12 and no bleeding. What is the most appropriate management?

Hold warfarin and give oral vitamin K (Correct answer)
Continue warfarin at a lower dose
Give fresh frozen plasma
Give 4-factor PCC

Correct answer: Hold warfarin and give oral vitamin K

For an INR above 10 without bleeding, hold warfarin and give oral vitamin K; PCC is reserved for major bleeding.

Question 154: What is the core eligibility requirement for the Medicare hospice benefit?

Prognosis of 6 months or less if the disease runs its usual course (Correct answer)
Homebound status
A completed POLST form
Prognosis of 12 months or less

Correct answer: Prognosis of 6 months or less if the disease runs its usual course

Two physicians must certify a terminal prognosis of 6 months or less if the illness follows its expected course.

Question 155: A 50-year-old has a first unprovoked PE and low bleeding risk, and has finished 3 months of anticoagulation. What is the recommended next step?

Switch to aspirin only and stop anticoagulation
Place a permanent IVC filter and stop anticoagulation
Continue anticoagulation indefinitely (extended therapy) (Correct answer)
Stop anticoagulation

Correct answer: Continue anticoagulation indefinitely (extended therapy)

After unprovoked VTE with low bleeding risk, guidelines favor extended anticoagulation because recurrence risk is high.

Question 156: 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?

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

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 157: A patient with macrocytic anemia, low B12, and atrophic gastritis most likely has which antibody?

Anti-tissue transglutaminase antibody
Anti-smooth muscle antibody
Anti-intrinsic factor antibody (Correct answer)
Antimitochondrial antibody

Correct answer: Anti-intrinsic factor antibody

Anti-intrinsic factor antibodies are highly specific for pernicious anemia.

Question 158: A traveler returning from sub-Saharan Africa has fever, confusion, and 6% parasitemia with Plasmodium falciparum. What is the treatment of choice?

Oral atovaquone-proguanil
Oral primaquine
Oral chloroquine
Intravenous artesunate (Correct answer)

Correct answer: Intravenous artesunate

Severe malaria (cerebral involvement or parasitemia ≥5%) requires IV artesunate, now available in the US.

Question 159: A patient with idiopathic pulmonary arterial hypertension has a positive acute vasoreactivity test on right heart catheterization. What is the preferred initial therapy?

Bosentan monotherapy
Beta-blocker
Inhaled nitric oxide long-term
High-dose calcium channel blocker (Correct answer)

Correct answer: High-dose calcium channel blocker

Vasoreactive IPAH patients may respond durably to high-dose calcium channel blockers such as nifedipine or diltiazem.

Question 160: 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?

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

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 161: A 55-year-old man whose chest pain has resolved has deep symmetric T-wave inversions in V2-V3 and normal troponin. What is the most appropriate next step?

Pharmacologic nuclear stress test
Coronary angiography (Correct answer)
Exercise treadmill stress test
Discharge with outpatient follow-up

Correct answer: Coronary angiography

Wellens pattern indicates critical proximal LAD stenosis, so stress testing is contraindicated and angiography is indicated.

Question 162: In a stable patient with COPD at rest, which finding is an indication for long-term oxygen therapy?

PaO2 of 62 mm Hg with exertional dyspnea
PaCO2 of 48 mm Hg alone
SpO2 of 91% at rest
PaO2 ≤55 mm Hg (Correct answer)

Correct answer: PaO2 ≤55 mm Hg

Long-term oxygen improves survival when resting PaO2 is ≤55 mm Hg or SpO2 is ≤88%, or when PaO2 is 56–59 mm Hg with cor pulmonale or erythrocytosis.

Question 163: 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
Immediate adrenalectomy
Repeat CT in 5 years
Biochemical evaluation for hormonal hypersecretion (Correct answer)

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

High anion gap metabolic acidosis
Non-anion gap metabolic acidosis (Correct answer)
Metabolic alkalosis
Respiratory 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 165: 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
Biopsy the ulcer edges to exclude malignancy (Correct answer)
Immediate gastrectomy

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

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

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 167: A patient on pembrolizumab has 8 watery stools daily, and stool infection testing is negative. Besides holding the drug, what is the most appropriate management?

Continue pembrolizumab at a reduced dose
Oral budesonide only
Prednisone 1-2 mg/kg/day, adding infliximab if refractory (Correct answer)
Loperamide alone

Correct answer: Prednisone 1-2 mg/kg/day, adding infliximab if refractory

Grade 3 immune-mediated colitis requires systemic corticosteroids, with infliximab or vedolizumab for steroid-refractory cases.

Question 168: 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?

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

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 169: A 24-year-old man has a confirmed MLH1 pathogenic variant (Lynch syndrome). What colorectal screening is recommended?

Annual fecal immunochemical testing
CT colonography every 5 years
Colonoscopy every 1-2 years starting at age 20-25 (Correct answer)
Colonoscopy every 10 years starting at 45

Correct answer: Colonoscopy every 1-2 years starting at age 20-25

Adenomas progress quickly in Lynch syndrome, so colonoscopy every 1-2 years starting at age 20-25 is recommended.

Question 170: The COPD symptom that frequently develops several years before the onset of airflow restriction is:

Cyanosis
Chest pain
Dyspnea (Correct answer)
Cough

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 171: 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?

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

Correct answer: Levothyroxine (T4)

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

Question 172: Which finding best distinguishes acute tubular necrosis (ATN) from prerenal azotemia?

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

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 173: Which finding defines multiple myeloma even without CRAB features?

Involved/uninvolved serum free light chain ratio ≥100 (Correct answer)
A single lytic lesion under 5 mm on MRI
M-protein of 2 g/dL
Bone marrow plasma cells of 15%

Correct answer: Involved/uninvolved serum free light chain ratio ≥100

SLiM criteria include clonal plasma cells ≥60%, an FLC ratio ≥100, or more than one MRI focal lesion.

Question 174: A 72-year-old woman has morning stiffness in the shoulders and hips lasting over an hour, an elevated ESR, and no headache or visual symptoms. What is the most appropriate initial treatment?

Prednisone 12.5 to 25 mg daily (Correct answer)
High-dose naproxen indefinitely
Methotrexate monotherapy
Prednisone 60 mg daily

Correct answer: Prednisone 12.5 to 25 mg daily

Polymyalgia rheumatica typically responds dramatically to low-dose prednisone, whereas high doses are reserved for giant cell arteritis.

Question 175: A 45-year-old man has ascending weakness and areflexia 2 weeks after a diarrheal illness, and can no longer walk unaided. CSF shows protein 180 mg/dL and 2 WBC/µL. Which treatment is NOT effective?

Plasma exchange
Supportive care with respiratory monitoring
IV immunoglobulin
IV methylprednisolone (Correct answer)

Correct answer: IV methylprednisolone

Corticosteroids do not help Guillain-Barré syndrome, while IVIG and plasma exchange both hasten recovery.

Question 176: 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?

Ventricular tachycardia
Atrial flutter with 2:1 block
AV nodal reentrant tachycardia (AVNRT) (Correct answer)
Multifocal atrial 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 177: Which therapy slows the decline in FVC in idiopathic pulmonary fibrosis?

Cyclophosphamide
Nintedanib (Correct answer)
N-acetylcysteine monotherapy
Prednisone plus azathioprine

Correct answer: Nintedanib

Antifibrotics (nintedanib or pirfenidone) slow FVC decline in IPF, while combined immunosuppression causes harm.

Question 178: A 38-year-old woman with triple-positive antiphospholipid syndrome has an ischemic stroke. Which long-term anticoagulant is preferred?

Warfarin (Correct answer)
Apixaban
Aspirin alone
Rivaroxaban

Correct answer: Warfarin

Direct oral anticoagulants are associated with more arterial thromboses than warfarin in high-risk (triple-positive or arterial) APS, so a vitamin K antagonist is preferred.

Question 179: A patient with HIV and CD4 count 40 cells/µL has floaters and fluffy white retinal lesions with hemorrhage. What is the most likely diagnosis?

CMV retinitis (Correct answer)
Toxoplasma chorioretinitis
HIV retinopathy
Candida endophthalmitis

Correct answer: CMV retinitis

CMV retinitis classically shows 'pizza pie' white granular lesions with hemorrhage at CD4 below 50.

Question 180: 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?

Partial response requiring retreatment
Virological response (VR) at 12 weeks of treatment
End-of-treatment response only
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 181: A 30-year-old man has a single generalized tonic-clonic seizure. Exam, EEG, and MRI are normal, and there were no provoking factors. What is the most appropriate management?

Repeat MRI with contrast in 1 week
Start levetiracetam indefinitely
No antiseizure medication; counsel on recurrence risk and driving restrictions (Correct answer)
Start phenytoin for 2 years

Correct answer: No antiseizure medication; counsel on recurrence risk and driving restrictions

After a first unprovoked seizure with normal EEG and MRI, recurrence risk is low enough that treatment is usually deferred.

Question 182: For an eligible patient with acute ischemic stroke, what is the standard time window from last known well for IV thrombolysis (alteplase or tenecteplase)?

1 hour
12 hours
4.5 hours (Correct answer)
24 hours

Correct answer: 4.5 hours

IV thrombolysis is indicated within 4.5 hours of last known well in eligible patients. Mechanical thrombectomy for large-vessel occlusion can extend to 24 hours in selected patients.

Question 183: A patient presents with a spontaneous pneumothorax. CXR shows 30% lung collapse. He is hemodynamically stable with mild dyspnea. What is the appropriate management?

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

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 184: A 76-year-old man has fluctuating cognition, recurrent well-formed visual hallucinations, and mild parkinsonism. Which medication is most important to avoid?

Donepezil
Haloperidol (Correct answer)
Rivastigmine
Pimavanserin

Correct answer: Haloperidol

Patients with dementia with Lewy bodies have severe sensitivity to typical antipsychotics, which can cause rigidity, falls, and neuroleptic malignant syndrome.

Question 185: 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?

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

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 186: 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?

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

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

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

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

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

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 189: 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)?

We can determine which foods are causing EOE by skin prick testing
We can determine which foods are causing EOE by patch testing
Besides diet elimination, there is no other treatment for EOE
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 190: A 30-year-old asymptomatic man has mild hypercalcemia (10.8 mg/dL) and a mildly elevated PTH. His father had 'high calcium' and a neck surgery that did not fix it. His 24-hour urine calcium-to-creatinine clearance ratio is 0.005. What is the best next step?

Reassure; this is likely familial hypocalciuric hypercalcemia, and CASR genetic testing can confirm it (Correct answer)
Refer for parathyroidectomy
Start cinacalcet
Order a sestamibi scan to localize an adenoma

Correct answer: Reassure; this is likely familial hypocalciuric hypercalcemia, and CASR genetic testing can confirm it

A calcium-to-creatinine clearance ratio below 0.01 with a family history strongly suggests FHH, a benign condition that does not improve with parathyroidectomy.

Question 191: Within 2 hours of a plasma transfusion, a patient develops hypoxemia, bilateral infiltrates, fever, and hypotension, with a normal BNP and no volume overload. What is the most likely diagnosis?

TACO
TRALI (Correct answer)
Febrile nonhemolytic reaction
Acute hemolytic reaction

Correct answer: TRALI

TRALI causes noncardiogenic pulmonary edema within 6 hours, often with hypotension, and without volume overload.

Question 192: A patient has Na 140, Cl 98, and HCO3 20 mEq/L (anion gap 22; normal 12). What acid-base disorder is present?

Anion gap plus non-anion gap metabolic acidosis
Primary respiratory alkalosis only
Pure anion gap metabolic acidosis
Anion gap metabolic acidosis with a concurrent metabolic alkalosis (Correct answer)

Correct answer: Anion gap metabolic acidosis with a concurrent metabolic alkalosis

The anion gap rose by 10 while bicarbonate fell by only 4 (delta ratio >2), indicating an additional metabolic alkalosis.

Question 193: A patient from New England presents with fever, hemolytic anemia, and thrombocytopenia; blood smear shows intraerythrocytic ring forms and tetrads. What is the treatment for mild-moderate disease?

Chloroquine
Ceftriaxone
Atovaquone plus azithromycin (Correct answer)
Doxycycline alone

Correct answer: Atovaquone plus azithromycin

Babesiosis, transmitted by Ixodes ticks, is treated with atovaquone plus azithromycin; severe cases use clindamycin plus quinine or exchange transfusion.

Question 194: A patient on unfractionated heparin for 7 days after CABG has a 60% platelet drop and a new DVT. What is the most appropriate next step?

Stop heparin and start argatroban (Correct answer)
Continue heparin and add warfarin
Switch to enoxaparin
Transfuse platelets

Correct answer: Stop heparin and start argatroban

Suspected HIT with thrombosis requires stopping all heparin and starting a non-heparin anticoagulant such as argatroban.

Question 195: 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?

Abstinence alone
Prednisolone 40 mg/day for 28 days (Correct answer)
Pentoxifylline
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 196: 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?

Microscopic colitis
Small intestinal bacterial overgrowth
Celiac disease (Correct answer)
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 197: Which ANCA pattern and target antigen is most specific for granulomatosis with polyangiitis (formerly Wegener's granulomatosis)?

Anti-glomerular basement membrane (anti-GBM) antibody
Antinuclear antibody (ANA)
c-ANCA directed against proteinase 3 (PR3) (Correct answer)
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 198: A patient with newly diagnosed HIV has a CD4 count of 45 cells/µL and cryptococcal meningitis. When should antiretroviral therapy be started?

After 4-6 weeks of antifungal therapy (Correct answer)
Immediately, within 48 hours
After completing 1 year of fluconazole
After the CD4 count rises above 200

Correct answer: After 4-6 weeks of antifungal therapy

Early ART in cryptococcal meningitis increases mortality from IRIS, so ART is deferred 4-6 weeks after starting antifungals.

Question 199: A healthy 28-year-old non-pregnant woman has dysuria and urinary frequency with no fever or flank pain. Which is an appropriate first-line treatment for her uncomplicated cystitis?

Nitrofurantoin for 5 days (Correct answer)
Ciprofloxacin for 14 days
IV ceftriaxone for 7 days
Amoxicillin for 3 days

Correct answer: Nitrofurantoin for 5 days

IDSA guidelines list nitrofurantoin for 5 days as a first-line choice for acute uncomplicated cystitis. Fluoroquinolones are saved for other uses because of resistance and adverse effects. Amoxicillin alone works poorly because of high resistance rates, and IV therapy is not needed.

Question 200: A 70-year-old has an asymptomatic lymphocytosis with smudge cells, no cytopenias, and no lymphadenopathy. What is the best management?

Splenectomy
Ibrutinib
Observation (Correct answer)
FCR chemoimmunotherapy

Correct answer: Observation

Early-stage, asymptomatic CLL is managed by watch-and-wait.

Question 201: A 32-year-old woman has new resistant hypertension and an epigastric bruit. CT angiography shows a 'string-of-beads' appearance of the mid renal artery. What is the preferred treatment if blood pressure remains uncontrolled?

Lifelong anticoagulation
Surgical nephrectomy
Angioplasty with routine stent placement
Percutaneous transluminal angioplasty without stenting (Correct answer)

Correct answer: Percutaneous transluminal angioplasty without stenting

Fibromuscular dysplasia responds well to balloon angioplasty alone, and routine stenting is generally not needed.

Question 202: A 50-year-old man with Barrett esophagus (non-dysplastic, confirmed on two endoscopies) asks about surveillance. What is the recommended surveillance interval?

Every 1 year
No further surveillance needed
Every 3–5 years (Correct answer)
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 203: 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?

Diarrhea (Correct answer)
Renal failure
Diabetic ketoacidosis
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 204: A 70-year-old man on amiodarone for 3 years develops thyrotoxicosis. Thyroid Doppler shows absent vascularity, radioactive iodine uptake is very low, and TRAb is negative. What is the preferred treatment?

Prednisone (Correct answer)
Propranolol alone and observation
Radioactive iodine ablation
Methimazole

Correct answer: Prednisone

Type 2 amiodarone-induced thyrotoxicosis is a destructive thyroiditis that responds to glucocorticoids, while thionamides work best in type 1.

Question 205: In patients with limited cutaneous systemic sclerosis, which complication is the leading cause of morbidity and mortality?

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

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

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

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 207: A patient homozygous for UGT1A1*28 is at increased risk of severe neutropenia and diarrhea from which drug?

Capecitabine
Paclitaxel
Oxaliplatin
Irinotecan (Correct answer)

Correct answer: Irinotecan

UGT1A1 glucuronidates SN-38, the active metabolite of irinotecan, so reduced activity increases toxicity.

Question 208: A patient has marked leukocytosis with basophilia, and the BCR-ABL1 fusion is detected. What is the preferred first-line therapy for chronic phase?

A tyrosine kinase inhibitor such as imatinib (Correct answer)
Hydroxyurea alone
Interferon alfa
Allogeneic stem cell transplant

Correct answer: A tyrosine kinase inhibitor such as imatinib

TKIs are standard first-line therapy for chronic-phase CML.

Question 209: Which of the following is the most common cause of secondary hypertension in adults?

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

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 210: 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?

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

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 211: An 88-year-old with advanced Alzheimer disease has recurrent aspiration and weight loss. What does the American Geriatrics Society recommend?

Nasogastric tube feeding
Percutaneous gastrostomy tube placement
Total parenteral nutrition
Careful hand feeding (Correct answer)

Correct answer: Careful hand feeding

Tube feeding in advanced dementia does not prolong survival, prevent aspiration, or heal pressure injuries, so careful hand feeding is recommended.

Question 212: A patient with Gottron papules, palmar ulcerations, minimal muscle weakness, and rapidly progressive interstitial lung disease most likely has which antibody?

Anti-HMGCR
Anti-MDA5 (Correct answer)
Anti-TIF1-gamma
Anti-Mi-2

Correct answer: Anti-MDA5

Anti-MDA5 dermatomyositis is often clinically amyopathic with cutaneous ulcers and carries a high risk of rapidly progressive ILD.

Question 213: An HIV-positive patient with CD4 count 30 cells/µL presents with fever, ring-enhancing brain lesions, and positive Toxoplasma IgG. What is the preferred treatment?

Pyrimethamine, sulfadiazine, and leucovorin (Correct answer)
Ganciclovir
Amphotericin B and flucytosine
Albendazole

Correct answer: Pyrimethamine, sulfadiazine, and leucovorin

Pyrimethamine plus sulfadiazine with leucovorin is first-line for toxoplasmic encephalitis.

Question 214: Which adverse effect is associated with tamoxifen but NOT with aromatase inhibitors?

Hot flashes
Endometrial carcinoma (Correct answer)
Osteoporosis
Arthralgias

Correct answer: Endometrial carcinoma

Tamoxifen has partial estrogen agonist activity on the endometrium, which raises the risk of endometrial cancer.

Question 215: A patient with a prosthetic knee replaced 4 years ago develops chronic pain and a sinus tract; cultures grow Staphylococcus epidermidis. What is the most definitive management?

Oral antibiotics alone for 6 weeks
Two-stage exchange arthroplasty (Correct answer)
Arthrocentesis and observation
Debridement, antibiotics, and implant retention

Correct answer: Two-stage exchange arthroplasty

Chronic prosthetic joint infection with a sinus tract generally requires two-stage exchange, as implant retention is reserved for early or acute hematogenous infection.

Question 216: A patient in Tennessee develops fever, headache, leukopenia, thrombocytopenia, and elevated transaminases 10 days after a tick bite, without rash. What is the best management?

Start amoxicillin
Await serology before treatment
Start ciprofloxacin
Start doxycycline immediately (Correct answer)

Correct answer: Start doxycycline immediately

Suspected ehrlichiosis should be treated empirically with doxycycline without waiting for confirmatory tests.

Question 217: A patient presents 6 hours after a single acetaminophen ingestion with a serum level above the treatment line on the Rumack-Matthew nomogram. What is the next step?

Urgent liver transplant evaluation
Activated charcoal only and observe
Repeat the level in 4 hours before treating
Start N-acetylcysteine (Correct answer)

Correct answer: Start N-acetylcysteine

NAC should be started immediately when the 4-24 hour level falls above the treatment line.

Question 218: A 74-year-old man has a magnetic gait, urinary incontinence, and cognitive slowing, and MRI shows ventriculomegaly out of proportion to atrophy. Which test best predicts response to shunting?

EEG
Serum B12 level
Amyloid PET
High-volume lumbar tap test (Correct answer)

Correct answer: High-volume lumbar tap test

Gait improvement after removing about 30-50 mL of CSF predicts benefit from VP shunting in normal pressure hydrocephalus.

Question 219: A 34-year-old woman with autosomal dominant polycystic kidney disease has eGFR 65 mL/min/1.73 m2, total kidney volume showing rapid progression, and well-controlled blood pressure. Which therapy can slow cyst growth and eGFR decline?

Sirolimus
Tolvaptan (Correct answer)
Spironolactone
Hydrochlorothiazide

Correct answer: Tolvaptan

Tolvaptan, a vasopressin V2 receptor antagonist, slows kidney growth and eGFR decline in rapidly progressing ADPKD, with liver function monitoring required.

Question 220: 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)
Chronic thromboembolic PH (Group 4)
Pulmonary arterial hypertension (Group 1) (Correct answer)
Pulmonary venous hypertension (Group 2)

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 221: A malnourished patient with alcohol use disorder arrives confused, ataxic, and with nystagmus. What should be given first?

IV dextrose before anything else
IV thiamine before or with glucose (Correct answer)
Oral folate
IV naloxone

Correct answer: IV thiamine before or with glucose

Giving glucose without thiamine can trigger or worsen Wernicke encephalopathy.

Question 222: 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
Cyclosporine (Correct answer)
Rituximab

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 223: 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?

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

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 224: 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 4 (very severe)
GOLD 1 (mild)
GOLD 3 (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 225: A 78-year-old man with HFpEF and bilateral carpal tunnel syndrome has grade 3 myocardial uptake on Tc-99m pyrophosphate scintigraphy, with normal serum free light chains and no monoclonal protein on immunofixation. What is the most appropriate therapy?

Tafamidis (Correct answer)
Bortezomib-based chemotherapy
Digoxin
Verapamil

Correct answer: Tafamidis

Strong PYP uptake without a monoclonal protein confirms ATTR cardiac amyloidosis, and the transthyretin stabilizer tafamidis reduces mortality and hospitalizations.

Question 226: Which statement about DDAVP (desmopressin) is accurate?

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

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 227: Which lung cancer is most associated with hypercalcemia caused by PTH-related peptide?

Squamous cell carcinoma (Correct answer)
Carcinoid tumor
Small cell carcinoma
Adenocarcinoma

Correct answer: Squamous cell carcinoma

Squamous cell lung carcinoma classically secretes PTHrP, whereas small cell carcinoma is linked to SIADH and ectopic ACTH.

Question 228: 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?

Amiloride
Triamterene
Oral potassium chloride supplementation
Spironolactone (Correct answer)

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

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

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

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 230: 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?

24-hour urinary free cortisol
Dexamethasone suppression test
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 231: A man with a testicular mass has a pathology report of pure seminoma, but his serum AFP is markedly elevated. How should the tumor be managed?

As testicular lymphoma
As a nonseminomatous germ cell tumor (Correct answer)
As a sex cord-stromal tumor
As pure seminoma

Correct answer: As a nonseminomatous germ cell tumor

Pure seminoma does not make AFP, so an elevated AFP means nonseminomatous elements are present.

Question 232: 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?

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

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 233: A patient with Child-Pugh C cirrhosis is admitted with acute variceal hemorrhage. Besides octreotide and endoscopic band ligation, which therapy reduces mortality?

Oral norfloxacin for 30 days
Ceftriaxone 1 g daily for up to 7 days (Correct answer)
Prophylactic transfusion to hemoglobin >10 g/dL
IV pantoprazole for 72 hours

Correct answer: Ceftriaxone 1 g daily for up to 7 days

Short-term antibiotic prophylaxis, preferably ceftriaxone in advanced cirrhosis, reduces infections, rebleeding, and mortality in variceal bleeding.

Question 234: A hunter from Arkansas develops fever and a painful ulcer with tender regional lymphadenopathy after skinning a rabbit. What is the most likely organism?

Yersinia pestis
Francisella tularensis (Correct answer)
Pasteurella multocida
Bartonella henselae

Correct answer: Francisella tularensis

Ulceroglandular tularemia follows contact with infected rabbits and is treated with streptomycin or gentamicin.

Question 235: 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?

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

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 236: A patient with acute pancreatitis is hemodynamically stable without fluid overload. Which IV fluid strategy is preferred?

5% albumin boluses
Moderate goal-directed lactated Ringer's (Correct answer)
Aggressive normal saline at 500 mL/hour for 48 hours
Fluid restriction to avoid ARDS

Correct answer: Moderate goal-directed lactated Ringer's

Lactated Ringer's may reduce SIRS, and the WATERFALL trial showed moderate resuscitation is safer than aggressive fluids.

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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