Internal Medicine Board Exam — Questions and Answers

Question 1: A 65-year-old man with CKD stage 4 has serum bicarbonate of 16 mEq/L. He has muscle wasting and accelerated bone disease. What is the most appropriate treatment for his metabolic acidosis?

Oral sodium bicarbonate supplementation (Correct answer)
Dietary protein restriction alone
Potassium citrate only
Urgent dialysis initiation

Correct answer: Oral sodium bicarbonate supplementation

Oral sodium bicarbonate supplementation slows CKD progression, preserves muscle mass, and reduces bone disease by correcting the acidosis-driven protein catabolism.

Question 2: A 45-year-old man with alcoholic cirrhosis develops tense ascites. Paracentesis reveals 4.5 L of fluid removed. Which intervention is most important to prevent post-paracentesis circulatory dysfunction?

Start oral midodrine immediately after procedure
Administer IV albumin 6-8 g per liter removed (Correct answer)
Administer IV normal saline 500 mL
Restrict sodium to less than 1 g per day

Correct answer: Administer IV albumin 6-8 g per liter removed

IV albumin (6-8 g/L of ascites removed) is the standard of care to prevent post-paracentesis circulatory dysfunction after large-volume paracentesis exceeding 5 L.

Question 3: A 48-year-old woman with known cirrhosis presents with confusion and asterixis after starting a new medication. Which drug is most likely responsible for precipitating hepatic encephalopathy?

Furosemide causing hypokalemia and alkalosis (Correct answer)
Lactulose
Rifaximin
Zinc supplementation

Correct answer: Furosemide causing hypokalemia and alkalosis

Excessive diuresis with furosemide causes hypokalemia and metabolic alkalosis, which increases ammonia production in the kidney and reduces ammonia excretion, precipitating hepatic encephalopathy.

Question 4: Which biomarker has the fastest rise-and-fall kinetics and was historically used for early diagnosis of re-infarction after STEMI?

CK-MB (creatine kinase-MB) (Correct answer)
Myoglobin
Troponin T
Troponin I

Correct answer: CK-MB (creatine kinase-MB)

CK-MB rises and falls more rapidly than troponin (peaks at 24h, normalizes by 48-72h), making it useful for detecting re-infarction when troponin remains elevated from the initial event.

Question 5: It was shown for patients with A. Rate control outperformed rhythm control.

What treatment is required for TOF
What is Churg-Strauss syndrome?
How does USA differ from NSTEMI?
What did the AFFIRM trial show? (Correct answer)

Correct answer: What did the AFFIRM trial show?

The provided text states, 'It was shown for patients with A. Rate control outperformed rhythm control.' This is a direct summary of a key finding from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial. The AFFIRM trial was a landmark study that compared rate control versus rhythm control strategies in patients with atrial fibrillation, concluding that a rate control strategy was not inferior to rhythm control.

Question 6: A 58-year-old male with NSTEMI undergoes successful PCI with the placement of a new-generation drug-eluting stent in the left anterior descending artery. He has no history of bleeding disorders and is considered at low bleeding risk. According to current ACC/AHA guidelines, what is the minimum recommended duration of dual antiplatelet therapy (DAPT) for this patient?

24 months
12 months (Correct answer)
3 months
6 months

Correct answer: 12 months

For patients presenting with an acute coronary syndrome (ACS), including NSTEMI, who are treated with a drug-eluting stent, the standard recommended duration of dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is at least 12 months. While shorter durations may be considered in patients with stable ischemic heart disease or those at high bleeding risk, the standard for ACS is 12 months to reduce the risk of subsequent ischemic events.

Question 7: An ER visit for a 46-year-old male with non-alcoholic cirrhosis and a history of splenectomy following a car accident five years prior reveals a 102 F fever, nausea, weakness, stomach discomfort, and myalgia. The patient and his dog had trekked on Cape Cod two weeks earlier. Temperatures upon arrival were 103°F, 108°F, RR 12, Sa02 98% in RA, and BP 90/70. During the examination, the patient appears sickly and is feeble, febrile, and tachycardic. WBC 14.6; Platelets 218000; Hb 10; Na 136; K 4.0; BUN 22; Cr 1.3; are the results of the lab tests. Additional labs are pending. The image below shows a blood smear. Intravenous fluids and supportive treatment are initiated for the patient after admission to the MICU. What specific therapy is being used?

Clindamycin
Clindamycin + Doxycycline
Clindamycin + Atovaquone
Atovaquone+ Doxycycline
Clindamycin + Quinine+ Doxycycline (Correct answer)

Correct answer: Clindamycin + Quinine+ Doxycycline

The patient's history of splenectomy, travel to an endemic area (Cape Cod), fever, anemia, and the presence of intraerythrocytic parasites on the blood smear (consistent with Babesia) strongly indicate severe babesiosis. For severe cases, especially in asplenic patients, the recommended treatment regimen is a combination of quinine and clindamycin, often with doxycycline for broader coverage.

Question 8: A 55-year-old woman with type 2 diabetes has persistently elevated liver enzymes. Liver biopsy shows hepatocyte ballooning, lobular inflammation, and pericellular fibrosis without significant alcohol use. What is the most likely diagnosis?

Autoimmune hepatitis
Drug-induced liver injury
Nonalcoholic steatohepatitis (NASH) (Correct answer)
Alcoholic hepatitis

Correct answer: Nonalcoholic steatohepatitis (NASH)

NASH is defined by steatohepatitis (ballooning + lobular inflammation + steatosis) in a patient without significant alcohol use and is strongly associated with metabolic syndrome and type 2 diabetes.

Question 9: Which antibiotic regimen is recommended for SBP prophylaxis in a cirrhotic patient with a prior episode of SBP?

Ceftriaxone 1 g IV weekly
Amoxicillin-clavulanate 875 mg daily
Metronidazole 500 mg twice daily
Norfloxacin 400 mg daily (or trimethoprim-sulfamethoxazole) (Correct answer)

Correct answer: Norfloxacin 400 mg daily (or trimethoprim-sulfamethoxazole)

Indefinite secondary prophylaxis with norfloxacin 400 mg/day or TMP-SMX is recommended after a first episode of SBP to prevent recurrence.

Question 10: Which of the following is the strongest independent risk factor for spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites?

Ascitic fluid protein <1.5 g/dL (Correct answer)
Serum albumin <2.5 g/dL
Platelet count <100,000/μL
Child-Pugh class B

Correct answer: Ascitic fluid protein <1.5 g/dL

Low ascitic fluid protein (<1.5 g/dL) reflects reduced opsonic activity and is the strongest independent risk factor for SBP in cirrhotic ascites.

Question 11: A 58-year-old female is being treated for DKA. After 12 hours of treatment, her anion gap has closed, her pH is 7.32, and her blood glucose is 175 mg/dL. She is awake, alert, and hungry. The decision is made to transition her to subcutaneous insulin. What is the correct procedure to ensure a safe transition?

Administer the first dose of subcutaneous rapid-acting insulin and stop the IV insulin infusion 30 minutes later.
Administer the first dose of subcutaneous long-acting insulin and continue the IV insulin infusion for 1-2 hours. (Correct answer)
Stop the IV insulin infusion for 4 hours, then begin the patient's home subcutaneous insulin regimen.
Stop the IV insulin infusion and immediately administer the first dose of subcutaneous long-acting insulin.

Correct answer: Administer the first dose of subcutaneous long-acting insulin and continue the IV insulin infusion for 1-2 hours.

To prevent rebound hyperglycemia and the recurrence of ketosis, there must be an overlap between the intravenous insulin and the newly administered subcutaneous basal insulin. Because long-acting insulins like glargine have an onset of action of 1-2 hours, the IV insulin infusion should be continued for this duration after the subcutaneous dose is given. Stopping the IV infusion before the subcutaneous insulin has taken effect will result in a period of insulin deficiency.

Question 12: A 55-year-old woman with type 2 diabetes has a GFR of 28 mL/min/1.73m² and serum phosphorus of 6.1 mg/dL despite dietary restriction. What is the most appropriate next step?

Increase dietary protein
Initiate dialysis
Start calcium carbonate with meals
Start sevelamer (non-calcium binder) (Correct answer)

Correct answer: Start sevelamer (non-calcium binder)

Sevelamer is preferred over calcium-based binders in dialysis-stage CKD to avoid calcium loading and vascular calcification risk.

Question 13: A 50-year-old diabetic man develops AKI after starting an ACE inhibitor. Renal artery duplex shows >70% stenosis bilaterally. What is the mechanism of AKI in this patient?

Loss of efferent arteriolar tone causing drop in glomerular perfusion pressure (Correct answer)
Afferent arteriolar vasoconstriction
Direct tubular toxicity from ACE inhibitor
Immune-mediated interstitial nephritis

Correct answer: Loss of efferent arteriolar tone causing drop in glomerular perfusion pressure

In bilateral renal artery stenosis, glomerular filtration depends on angiotensin II–mediated efferent vasoconstriction; ACE inhibitors remove this compensation, causing GFR to fall precipitously.

Question 14: A 55-year-old male with type 2 diabetes presents with a 2-day history of a warm, tender, erythematous rash on his left lower leg. The area is non-fluctuant and there is no purulent drainage or abscess. He is afebrile and hemodynamically stable. What is the most appropriate initial oral antibiotic therapy for this patient's non-purulent cellulitis?

Doxycycline
Clindamycin
Cephalexin (Correct answer)
Trimethoprim-sulfamethoxazole

Correct answer: Cephalexin

This patient presents with non-purulent cellulitis, which is most commonly caused by beta-hemolytic streptococci. Therefore, empiric treatment should primarily target this organism. Cephalexin is a first-generation cephalosporin with excellent activity against both streptococci and methicillin-susceptible Staphylococcus aureus (MSSA). Trimethoprim-sulfamethoxazole and doxycycline have poor activity against streptococci and are typically reserved for purulent infections where MRSA is a concern.

Question 15: Which antibiotic is first-line for treatment of Lyme disease presenting with erythema migrans in an adult?

Doxycycline 100mg orally twice daily for 10–21 days (Correct answer)
Azithromycin 500mg once daily for 7 days
Ceftriaxone 2g IV for 14 days
Amoxicillin IV for 28 days

Correct answer: Doxycycline 100mg orally twice daily for 10–21 days

Doxycycline orally for 10–21 days is first-line for early Lyme disease (erythema migrans) in adults; IV ceftriaxone is reserved for neurologic or cardiac involvement.

Question 16: A patient with known type 1 diabetes is NPO for surgery scheduled tomorrow morning. How should insulin be managed to prevent DKA?

Give 50% of total daily dose as regular insulin q6h
Switch to sliding scale only
Hold all insulin until after surgery
Continue basal insulin at full dose; hold prandial insulin (Correct answer)

Correct answer: Continue basal insulin at full dose; hold prandial insulin

Basal insulin should be continued (sometimes at 75–80% dose) during NPO periods to prevent DKA; prandial insulin is held when there is no oral intake.

Question 17: A 55-year-old man with multiple myeloma presents with AKI, hypercalcemia, and Bence Jones proteinuria. Which mechanism directly causes AKI in this condition?

Immune complex deposition in glomeruli
Light chain cast nephropathy obstructing tubular lumens (Correct answer)
Amyloid deposition causing nephrotic syndrome exclusively
NSAIDs used for bone pain

Correct answer: Light chain cast nephropathy obstructing tubular lumens

Myeloma cast nephropathy occurs when light chains (Bence Jones proteins) precipitate with Tamm-Horsfall protein in distal tubules, forming obstructing casts that cause AKI.

Question 18: A cirrhotic patient develops sudden onset of right-sided pleural effusion. Thoracentesis reveals transudative fluid with SAAG >1.1. No pulmonary pathology is identified. What is the diagnosis?

Malignant pleural effusion
Parapneumonic effusion
Chylothorax
Hepatic hydrothorax (Correct answer)

Correct answer: Hepatic hydrothorax

Hepatic hydrothorax is a transudative pleural effusion (usually right-sided) caused by passage of ascitic fluid through diaphragmatic defects in cirrhotic patients.

Question 19: A 65-year-old woman presents with worsening dyspnea and is found to have severe aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg). She has severe COPD with FEV1 40% predicted and is deemed high surgical risk. What is the preferred intervention?

Transcatheter aortic valve replacement (TAVR) (Correct answer)
Medical management with diuretics
Aortic balloon valvuloplasty
Surgical aortic valve replacement (SAVR)

Correct answer: Transcatheter aortic valve replacement (TAVR)

TAVR is preferred over SAVR in patients with severe symptomatic aortic stenosis who are at high or prohibitive surgical risk, as shown in the PARTNER trials.

Question 20: A 60-year-old man on allopurinol develops a severe desquamating rash with mucous membrane involvement. Which HLA allele is strongly associated with this severe drug reaction?

HLA-DR4
HLA-DQ2
HLA-B*58:01 (Correct answer)
HLA-B27

Correct answer: HLA-B*58:01

HLA-B*58:01 is strongly associated with allopurinol-induced Stevens-Johnson syndrome and toxic epidermal necrolysis, particularly in Asian populations.

Question 21: A 65-year-old male with decompensated cirrhosis due to alcohol use presents with moderate, new-onset ascites. His renal function is normal, and his serum potassium is 4.2 mEq/L. According to current guidelines, what is the most appropriate initial diuretic regimen?

Metolazone 5 mg daily
Spironolactone 100 mg and furosemide 40 mg daily (Correct answer)
Furosemide 40 mg daily
Spironolactone 25 mg daily

Correct answer: Spironolactone 100 mg and furosemide 40 mg daily

The standard and recommended initial management for ascites in cirrhosis is dual-diuretic therapy with an aldosterone antagonist and a loop diuretic. The typical starting doses are spironolactone 100 mg and furosemide 40 mg daily. This combination helps to counteract the hyperaldosteronism of cirrhosis and maintain normokalemia. Starting with spironolactone alone is an option, but combination therapy is often preferred for more effective and rapid natriuresis. Furosemide monotherapy is less effective and not recommended as initial treatment.

Question 22: A patient with rheumatoid arthritis on methotrexate develops a dry cough and progressive dyspnea. Chest CT shows interstitial infiltrates. What is the most likely diagnosis?

Bacterial pneumonia
Rheumatoid pleural effusion
Methotrexate-induced pneumonitis (Correct answer)
Pulmonary embolism

Correct answer: Methotrexate-induced pneumonitis

Methotrexate-induced pneumonitis is a serious hypersensitivity reaction presenting with cough, dyspnea, and interstitial infiltrates.

Question 23: A patient with chronic stable heart failure (EF 25%) develops a 3-second pause on Holter monitoring and near-syncope. What is the most appropriate next step?

Permanent pacemaker implantation only
Implantable cardioverter-defibrillator (ICD) evaluation (Correct answer)
Oral amiodarone
Observation and repeat Holter in 3 months

Correct answer: Implantable cardioverter-defibrillator (ICD) evaluation

Patients with HFrEF (EF ≤35%) and symptomatic arrhythmia should be evaluated for ICD, which treats both bradycardia (if combined with pacing) and sudden cardiac death risk.

Question 24: A 66-year-old woman presents with symmetric polyarthritis, bilateral parotid enlargement, hypercalcemia, and hilar lymphadenopathy on CXR. Serum ACE level is elevated. Which rheumatologic manifestation is most common in this condition?

Sacroiliitis
Acute migratory polyarthritis (Löfgren syndrome) (Correct answer)
Dactylitis
Erosive small joint arthritis

Correct answer: Acute migratory polyarthritis (Löfgren syndrome)

Löfgren syndrome (acute arthritis, erythema nodosum, bilateral hilar adenopathy) is the most common rheumatologic presentation of sarcoidosis and carries an excellent prognosis.

Question 25: A 72-year-old male with CKD stage 4, diabetes, and hypertension is brought to the emergency department with generalized weakness. His medications include lisinopril and spironolactone. An ECG shows peaked T-waves and a widened QRS complex. His serum potassium is 7.2 mEq/L. What is the most appropriate initial step in management?

Administer intravenous calcium gluconate (Correct answer)
Initiate emergent hemodialysis
Administer intravenous insulin and glucose
Administer an oral potassium-binding resin

Correct answer: Administer intravenous calcium gluconate

In a patient with severe hyperkalemia and ECG changes indicating cardiac membrane instability (peaked T-waves, widened QRS), the immediate priority is to stabilize the cardiac membrane to prevent life-threatening arrhythmias. Intravenous calcium gluconate directly antagonizes the membrane-depolarizing effects of hyperkalemia and works within minutes. While insulin/glucose, dialysis, and binding resins are all effective at lowering total body potassium, they take longer to act and do not provide immediate cardioprotection.

Question 26: A 35-year-old woman presents with bilateral knee pain and swelling, erythema nodosum on her shins, and bilateral hilar adenopathy on chest X-ray. Which rheumatologic diagnosis fits this picture?

Reactive arthritis
Behçet's disease
Löfgren's syndrome (acute sarcoidosis) (Correct answer)
Rheumatic fever

Correct answer: Löfgren's syndrome (acute sarcoidosis)

Löfgren's syndrome is an acute form of sarcoidosis presenting with the triad of erythema nodosum, bilateral hilar adenopathy, and periarthritis, typically carrying a good prognosis.

Question 27: A patient with alcoholic cirrhosis has a prolonged INR of 2.4 but no active bleeding. Surgery is required for cholecystitis. Which intervention is most appropriate to assess true bleeding risk?

Transfuse platelets to >100,000/μL
Administer fresh frozen plasma to correct INR to <1.5
Measure thromboelastography (TEG) or rotational thromboelastometry (ROTEM) (Correct answer)
Vitamin K infusion for 3 days

Correct answer: Measure thromboelastography (TEG) or rotational thromboelastometry (ROTEM)

INR in cirrhosis overestimates bleeding risk because it does not reflect the balanced reduction in both pro- and anticoagulant factors; viscoelastic testing (TEG/ROTEM) provides a more accurate assessment.

Question 28: Which antibiotic class is the treatment of choice for community-acquired pneumonia caused by atypical organisms such as Mycoplasma pneumoniae in an otherwise healthy outpatient adult?

Aminoglycosides
Macrolides (Correct answer)
Beta-lactams
Carbapenems

Correct answer: Macrolides

Macrolides (e.g., azithromycin) are first-line for atypical CAP in healthy outpatients because they cover Mycoplasma, Chlamydophila, and Legionella.

Question 29: A 55-year-old woman develops oliguric AKI after prolonged hypotension during cardiac surgery. Urine microscopy shows muddy-brown granular casts. Urine sodium is 55 mEq/L and FENa is 3.2%. What is the mechanism?

Glomerulonephritis from immune complex deposition
Pre-renal azotemia from volume depletion
Ischemic acute tubular necrosis (Correct answer)
Obstructive nephropathy from surgical ligation

Correct answer: Ischemic acute tubular necrosis

Ischemic ATN follows prolonged hypoperfusion, manifesting as muddy-brown granular casts, high urine sodium (>40 mEq/L), and FENa >1% due to tubular injury.

Question 30: A 35-year-old woman presents with recurrent watery diarrhea, bloating, and abdominal pain relieved by defecation. Colonoscopy and labs are normal. What is the most likely diagnosis?

Irritable bowel syndrome (IBS) (Correct answer)
Celiac disease
Microscopic colitis
Crohn's disease

Correct answer: Irritable bowel syndrome (IBS)

IBS is characterized by recurrent abdominal pain associated with defecation and altered stool frequency/form with no structural abnormalities.

Question 31: A 50-year-old with cirrhosis develops confusion, asterixis, and elevated ammonia. His medications include furosemide and spironolactone. What is the most appropriate immediate treatment for hepatic encephalopathy?

Neomycin IV
Lactulose titrated to 2-3 soft stools per day (Correct answer)
Fresh frozen plasma
Protein restriction to 0 g/day

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

Lactulose reduces ammonia production and absorption in the colon and is the first-line treatment for hepatic encephalopathy.

Question 32: A patient has a prolonged PT but normal aPTT. Deficiency of which coagulation factor is most likely responsible?

Factor VIII
Factor IX
Factor XII
Factor VII (Correct answer)

Correct answer: Factor VII

Factor VII is the only coagulation factor exclusive to the extrinsic pathway; its deficiency prolongs PT without affecting aPTT.

Question 33: A 70-year-old male was started on omeprazole and piperacillin-tazobactam one week ago for aspiration pneumonia. He now presents with a new-onset maculopapular rash, a temperature of 38.5°C (101.3°F), and a rise in his serum creatinine from a baseline of 1.1 mg/dL to 3.0 mg/dL. Urinalysis is most likely to show which of the following findings?

Muddy brown granular casts
Red blood cell casts and dysmorphic RBCs
White blood cell casts and sterile pyuria (Correct answer)
Hyaline casts and a fractional excretion of sodium <1%

Correct answer: White blood cell casts and sterile pyuria

The clinical triad of fever, rash, and rising creatinine after exposure to a new drug is highly suggestive of drug-induced acute interstitial nephritis (AIN). The characteristic urinalysis finding in AIN is sterile pyuria (white blood cells in the absence of bacteria) and white blood cell casts, indicating inflammation within the renal interstitium. While urine eosinophils are classic, they are not always present. The other options suggest ATN (A), pre-renal disease (C), or glomerulonephritis (D).

Question 34: Which of the following is the most significant contraindication to the use of teriparatide for the treatment of severe osteoporosis?

Creatinine clearance < 30 mL/min
Prior radiation therapy to the skeleton (Correct answer)
History of nephrolithiasis
Severe vitamin D deficiency

Correct answer: Prior radiation therapy to the skeleton

Teriparatide carries a warning regarding an increased risk of osteosarcoma, based on findings in rat studies. Therefore, it is contraindicated in patients with an increased baseline risk for osteosarcoma. This includes individuals with Paget's disease of the bone, unexplained elevations of alkaline phosphatase, and, significantly, a history of prior radiation therapy to the skeleton. While caution is advised in patients with renal impairment or a history of kidney stones, and vitamin D should be repleted before starting therapy, these are not absolute contraindications like prior skeletal radiation.

Question 35: A patient with ESRD on peritoneal dialysis develops fever, abdominal pain, and cloudy dialysate. Dialysate WBC count is 380 cells/µL (>50% neutrophils). Gram stain is negative. What is the most likely organism?

Pseudomonas aeruginosa
Staphylococcus epidermidis (Correct answer)
Candida albicans
Mycobacterium tuberculosis

Correct answer: Staphylococcus epidermidis

Coagulase-negative staphylococci (S. epidermidis) are the most common cause of peritoneal dialysis-associated peritonitis, typically from touch contamination.

Question 36: A 55-year-old man with long-standing rheumatoid arthritis develops new-onset wrist drop. Which extra-articular manifestation of RA is most likely responsible?

Mononeuritis multiplex due to rheumatoid vasculitis (Correct answer)
Carpal tunnel syndrome
Amyloid neuropathy
Felty syndrome

Correct answer: Mononeuritis multiplex due to rheumatoid vasculitis

Mononeuritis multiplex from rheumatoid vasculitis can cause focal nerve deficits such as wrist drop due to radial nerve involvement.

Question 37: A 43-year-old woman with RA is on methotrexate 20mg/week. She develops mouth sores, macrocytic anemia, and fatigue. What is the most appropriate management?

Add vitamin B12 supplementation only
Switch to leflunomide
Add folic acid 1mg daily and continue methotrexate (Correct answer)
Discontinue methotrexate permanently

Correct answer: Add folic acid 1mg daily and continue methotrexate

Methotrexate toxicity (mucositis, megaloblastic anemia) is reduced by supplemental folic acid 1-5mg daily without significantly impairing its efficacy.

Question 38: Sarcoidosis most commonly presents with which chest radiograph finding?

Cavitary upper lobe lesion
Unilateral pleural effusion
Bilateral hilar lymphadenopathy (Correct answer)
Diffuse ground-glass opacity

Correct answer: Bilateral hilar lymphadenopathy

Bilateral hilar lymphadenopathy (Stage I or II on the Scadding classification) is the most common chest X-ray finding in sarcoidosis.

Question 39: A patient with inferior STEMI is brought to the cath lab. Coronary angiography reveals 100% occlusion of a large dominant RCA. After successful PCI to the RCA, which hemodynamic complication is most likely to respond to IV fluids?

Ventricular free wall rupture
Right ventricular failure from RV infarction (Correct answer)
Cardiogenic shock from LV dysfunction
Flash pulmonary edema

Correct answer: Right ventricular failure from RV infarction

RV infarction causes preload-dependent hemodynamics; aggressive IV fluid resuscitation is the mainstay of treatment, as the failing RV needs adequate filling pressure to maintain forward output.

Question 40: A 60-year-old with a history of alcohol use presents with severe epigastric pain radiating to the back, elevated lipase (5x normal), and CT showing pancreatic edema without necrosis. What is the Ranson's criterion finding at admission most predictive of severity?

LDH > 350 IU/L
Blood glucose > 200 mg/dL
WBC > 16,000/µL
Age > 55 (Correct answer)

Correct answer: Age > 55

All listed findings are Ranson's criteria, but age > 55 is the admission criterion; however, any single criterion predicts severity, and WBC >16,000 is also an admission criterion.

Question 41: Which of the following medication classes has been shown in recent large clinical trials to reduce the composite risk of cardiovascular death or hospitalization for heart failure in patients with Heart Failure with preserved Ejection Fraction (HFpEF)?

Sodium-glucose cotransporter-2 (SGLT2) inhibitors (Correct answer)
Loop diuretics
Angiotensin-converting enzyme (ACE) inhibitors
Beta-blockers

Correct answer: Sodium-glucose cotransporter-2 (SGLT2) inhibitors

Recent major clinical trials, such as EMPEROR-Preserved (empagliflozin) and DELIVER (dapagliflozin), have demonstrated that SGLT2 inhibitors significantly reduce the primary composite outcome of cardiovascular death or hospitalization for heart failure in patients with HFpEF. While beta-blockers, ACE inhibitors, and ARBs are mainstays in HFrEF, they have not shown a clear mortality or hospitalization benefit in HFpEF. Loop diuretics are used for symptom management of congestion but do not modify the disease course.

Question 42: Hereditary spherocytosis is caused by a defect in which cellular component?

Spectrin or ankyrin proteins in the RBC membrane (Correct answer)
Hemoglobin beta-globin chains
Glucose-6-phosphate dehydrogenase
Pyruvate kinase enzyme

Correct answer: Spectrin or ankyrin proteins in the RBC membrane

Hereditary spherocytosis results from mutations in RBC membrane proteins (spectrin, ankyrin, band 3), leading to loss of membrane surface area, spherocyte formation, and hemolysis in the spleen.

Question 43: A 44-year-old woman presents with sudden onset of pulmonary edema. Echo reveals severe mitral regurgitation with a flail posterior leaflet. Her blood pressure is 85/60 mmHg. What is the most appropriate immediate intervention?

Intra-aortic balloon pump followed by urgent surgery (Correct answer)
High-dose furosemide IV bolus
ACE inhibitor titration
Coronary angiography first

Correct answer: Intra-aortic balloon pump followed by urgent surgery

Acute severe MR causing cardiogenic shock requires hemodynamic stabilization with an intra-aortic balloon pump (reduces afterload, increases coronary perfusion) as a bridge to urgent surgical repair.

Question 44: A 58-year-old man with NSTEMI has a TIMI risk score of 5. Which management strategy is most appropriate?

Emergent surgical revascularization without catheterization
Early invasive strategy (cardiac catheterization within 24-48 hours) (Correct answer)
Medical therapy alone with discharge in 24 hours
Immediate thrombolytic therapy

Correct answer: Early invasive strategy (cardiac catheterization within 24-48 hours)

A high TIMI score (≥3) in NSTEMI favors an early invasive strategy with catheterization within 24-48 hours due to higher risk of adverse outcomes.

Question 45: Which of the following best distinguishes cardiac pulmonary edema from ARDS on laboratory and physiologic testing?

PCWP >18 mmHg in cardiac edema but ≤18 mmHg in ARDS (Correct answer)
Bilateral infiltrates only in ARDS
PaO2/FiO2 ratio <200 in ARDS but not in cardiac edema
Elevated BNP found only in ARDS

Correct answer: PCWP >18 mmHg in cardiac edema but ≤18 mmHg in ARDS

The Berlin definition of ARDS requires PCWP ≤18 mmHg (or absence of heart failure) to exclude cardiogenic pulmonary edema.

Question 46: A 30-year-old patient with persistent asthma is using a low-dose inhaled corticosteroid (ICS) daily and a short-acting beta-agonist (SABA) for relief. She reports waking with cough 3 times per month and using her SABA reliever 4 days a week. According to the 2024 GINA guidelines' preferred pathway, what is the most appropriate next step in management?

Add montelukast and continue her current regimen.
Increase the dose of her current ICS to medium-dose and continue SABA for relief.
Add a long-acting muscarinic antagonist (LAMA) to her current regimen.
Switch to a low-dose ICS-formoterol combination for both maintenance and reliever therapy (MART). (Correct answer)

Correct answer: Switch to a low-dose ICS-formoterol combination for both maintenance and reliever therapy (MART).

The patient's symptoms indicate her asthma is not well-controlled, requiring a step-up in therapy from GINA Step 2. The preferred GINA strategy (Track 1) for Step 3 is to switch the patient to a low-dose inhaled corticosteroid-formoterol combination to be used for both daily maintenance and as a reliever (MART strategy). This approach is favored over simply increasing the ICS dose or adding other agents while continuing with a SABA-only reliever, as it reduces the risk of severe exacerbations.

Question 47: A 45-year-old woman undergoing coronary angiography receives iodinated contrast. Her baseline creatinine is 1.6 mg/dL. Which intervention has the strongest evidence for preventing contrast-induced AKI?

Sodium bicarbonate infusion
Isotonic saline hydration before and after the procedure (Correct answer)
N-acetylcysteine administration
Furosemide administration before contrast

Correct answer: Isotonic saline hydration before and after the procedure

Isotonic saline (0.9% NaCl) pre- and post-procedure hydration remains the best-established intervention for preventing contrast-induced nephropathy.

Question 48: A 65-year-old diabetic man develops a rapidly spreading, painful necrotizing infection of the perineum with crepitus on exam. What is the MOST critical initial intervention after resuscitation?

Emergency surgical debridement (Correct answer)
CT-guided drainage
Broad-spectrum antibiotics alone
Hyperbaric oxygen therapy

Correct answer: Emergency surgical debridement

Fournier's gangrene (necrotizing fasciitis) requires urgent surgical debridement as the cornerstone of treatment; antibiotics are adjunctive but cannot replace surgery.

Question 49: A 30-year-old African American woman presents with dyspnea, bilateral hilar lymphadenopathy on CXR, and elevated serum ACE. Transbronchial biopsy shows noncaseating granulomas. What is the diagnosis?

Sarcoidosis (Correct answer)
Berylliosis
Tuberculosis
Hypersensitivity pneumonitis

Correct answer: Sarcoidosis

Sarcoidosis classically presents with bilateral hilar adenopathy, elevated ACE, and noncaseating granulomas on biopsy, most commonly in young Black women.

Question 50: A patient with Sjögren's syndrome develops peripheral neuropathy and purpura. Serum protein electrophoresis shows a monoclonal spike. Which complication should be suspected?

Antiphospholipid syndrome
Secondary amyloidosis
Cryoglobulinemic vasculitis (Correct answer)
Interstitial nephritis

Correct answer: Cryoglobulinemic vasculitis

Sjögren's syndrome is associated with type II cryoglobulinemia, which can present with purpura, peripheral neuropathy, and a monoclonal protein.

Question 51: A 70-year-old man is found to have a 2 cm hepatic mass on ultrasound. He has a history of hepatitis C cirrhosis and AFP of 450 ng/mL. Dynamic CT shows arterial enhancement with venous washout. What is the most likely diagnosis?

Focal nodular hyperplasia
Hepatocellular carcinoma (Correct answer)
Hepatic hemangioma
Metastatic colorectal cancer

Correct answer: Hepatocellular carcinoma

Arterial enhancement with venous-phase washout on CT in a cirrhotic patient with elevated AFP is diagnostic of hepatocellular carcinoma per AASLD criteria.

Question 52: A 60-year-old man with diabetes develops unilateral facial pain, periorbital swelling, and black eschar on the nasal turbinate. CT shows bony destruction of the sinuses. What is the most appropriate treatment?

Oral itraconazole and close outpatient follow-up
Systemic corticosteroids to reduce inflammation
IV voriconazole plus surgical debridement
Liposomal amphotericin B plus urgent surgical debridement (Correct answer)

Correct answer: Liposomal amphotericin B plus urgent surgical debridement

Rhinocerebral mucormycosis requires immediate liposomal amphotericin B combined with aggressive surgical debridement; delay is associated with rapid mortality.

Question 53: A 40-year-old woman presents with progressive dyspnea. Echo shows a mean mitral valve gradient of 12 mmHg and mitral valve area of 1.0 cm². She is in sinus rhythm with no left atrial thrombus. What is the preferred intervention?

Mitral valve repair
Percutaneous mitral balloon commissurotomy (Correct answer)
Medical therapy with diuretics
Mitral valve replacement

Correct answer: Percutaneous mitral balloon commissurotomy

Percutaneous mitral balloon commissurotomy (PMBC) is the preferred treatment for symptomatic severe mitral stenosis with favorable valve morphology and no thrombus.

Question 54: A 30-year-old woman with autoimmune hepatitis is in remission on azathioprine monotherapy. She wishes to become pregnant. What is the most appropriate counseling regarding her medications?

Switch to mycophenolate mofetil for safer pregnancy use
Azathioprine can be continued during pregnancy as the risk of relapse outweighs fetal risk (Correct answer)
Discontinue all immunosuppression once pregnant
Azathioprine must be stopped immediately before conception

Correct answer: Azathioprine can be continued during pregnancy as the risk of relapse outweighs fetal risk

Azathioprine is considered relatively safe in pregnancy and should be continued to prevent AIH relapse, which poses greater risk to mother and fetus than the medication itself; mycophenolate is teratogenic.

Question 55: Which finding on ascitic fluid analysis most reliably distinguishes SBP from secondary bacterial peritonitis?

PMN count >250 cells/mm³ with single organism on culture
Ascitic fluid protein >1 g/dL with multiple organisms (Correct answer)
Ascitic fluid glucose <50 mg/dL
Lactate dehydrogenase elevated in ascitic fluid

Correct answer: Ascitic fluid protein >1 g/dL with multiple organisms

Secondary peritonitis typically shows multiple organisms on culture, high protein, high LDH, and low glucose in ascitic fluid, distinguishing it from SBP.

Question 56: Which of the following patients meets the 2021 USPSTF criteria for annual screening for lung cancer with low-dose computed tomography (LDCT)?

A 48-year-old with a 25 pack-year smoking history who currently smokes.
A 55-year-old with a 30 pack-year smoking history who quit smoking 18 years ago.
A 65-year-old with a 22 pack-year smoking history who quit smoking 10 years ago. (Correct answer)
A 70-year-old with a 15 pack-year smoking history who quit smoking 5 years ago.

Correct answer: A 65-year-old with a 22 pack-year smoking history who quit smoking 10 years ago.

The 2021 USPSTF guidelines recommend annual screening for lung cancer with LDCT in adults aged 50 to 80 years who have a 20 pack-year or greater smoking history and either currently smoke or have quit within the past 15 years. The patient in option B (age 65, 22 pack-years, quit 10 years ago) is the only one who meets all three criteria.

Question 57: A 65-year-old woman with rheumatoid arthritis develops bilateral interstitial infiltrates and restrictive pulmonary physiology. Biopsy shows usual interstitial pneumonia (UIP) pattern. Which medication is most appropriate?

Nintedanib or pirfenidone (Correct answer)
Cyclophosphamide
Methotrexate
High-dose oral prednisone

Correct answer: Nintedanib or pirfenidone

Antifibrotic agents (nintedanib, pirfenidone) slow progression in UIP-pattern fibrosis; steroids alone do not reverse established fibrosis and may cause harm.

Question 58: A 70-year-old woman with known osteoporosis sustains a vertebral compression fracture. She is unable to tolerate bisphosphonates. Which agent builds new bone rather than preventing its resorption?

Denosumab
Teriparatide (Correct answer)
Calcitonin
Raloxifene

Correct answer: Teriparatide

Teriparatide (PTH 1-34) is an anabolic agent that stimulates osteoblast activity to build new bone, unlike antiresorptive agents which prevent bone breakdown.

Question 59: A patient with DKA has a serum potassium of 3.2 mEq/L on arrival. What is the correct next step before starting insulin?

Give sodium bicarbonate to correct acidosis first
Replace potassium to ≥3.5 mEq/L before starting insulin (Correct answer)
Administer glucagon to stabilize glucose
Begin insulin infusion immediately

Correct answer: Replace potassium to ≥3.5 mEq/L before starting insulin

Insulin drives potassium intracellularly, so potassium must be ≥3.5 mEq/L before insulin is started to prevent life-threatening hypokalemia.

Question 60: A 35-year-old healthcare worker has a newly positive tuberculin skin test (12 mm induration) as part of an annual screening. A chest X-ray is normal, and she denies any symptoms such as cough, fever, or weight loss. Which of the following is a preferred short-course regimen for the treatment of latent tuberculosis infection (LTBI) in this patient?

Isoniazid and rifapentine weekly for 3 months (Correct answer)
Ethambutol and pyrazinamide daily for 2 months
Rifampin daily for 6 months
Isoniazid daily for 9 months

Correct answer: Isoniazid and rifapentine weekly for 3 months

The CDC and ATS currently recommend several rifamycin-based, short-course regimens for the treatment of LTBI due to their efficacy and higher rates of treatment completion. The 3-month regimen of once-weekly isoniazid plus rifapentine (3HP) is a preferred option. Other preferred short-course options include 4 months of daily rifampin (4R) or 3 months of daily isoniazid and rifampin (3HR). While 9 months of isoniazid is still an acceptable alternative, shorter courses are now favored. Ethambutol and pyrazinamide are used for active TB, not latent infection.

Question 61: A 45-year-old female is evaluated for a 1.5 cm thyroid nodule found incidentally. Her TSH is normal. A fine-needle aspiration (FNA) returns as 'Bethesda category III: Atypia of Undetermined Significance (AUS)'. What is the most appropriate next step in management?

Start suppressive levothyroxine therapy
Repeat FNA in 6-12 months
Immediate total thyroidectomy
Perform molecular testing on the FNA sample (Correct answer)

Correct answer: Perform molecular testing on the FNA sample

For thyroid nodules with indeterminate cytology, such as Bethesda category III (Atypia of Undetermined Significance or AUS), molecular testing is recommended to further stratify the risk of malignancy. Tests like Afirma Gene Expression Classifier or ThyroSeq can help differentiate benign from potentially malignant nodules, guiding the decision between observation and diagnostic surgery. Repeating the FNA is an alternative but offers less definitive risk stratification. Immediate thyroidectomy is overly aggressive for a Bethesda III nodule, and suppressive levothyroxine therapy is not indicated for euthyroid patients with benign or indeterminate nodules.

Question 62: A 55-year-old presents with CAP and a PSI score placing him in Risk Class IV. What is the recommended site of care?

Inpatient hospitalization (Correct answer)
Outpatient
Observation unit only
ICU admission

Correct answer: Inpatient hospitalization

PSI Risk Class IV (score 91–130) carries significant mortality risk (8.2%) and warrants inpatient hospitalization.

Question 63: Which statin regimen is recommended for all ACS patients regardless of baseline LDL level?

Moderate-intensity statin (e.g., atorvastatin 20 mg)
High-intensity statin (e.g., atorvastatin 40-80 mg or rosuvastatin 20-40 mg) (Correct answer)
Statin therapy only if LDL >130 mg/dL
Low-intensity statin (e.g., pravastatin 10 mg)

Correct answer: High-intensity statin (e.g., atorvastatin 40-80 mg or rosuvastatin 20-40 mg)

Guidelines recommend high-intensity statin therapy for all ACS patients to achieve LDL <70 mg/dL and reduce cardiovascular events, regardless of baseline LDL.

Question 64: A patient with severe sepsis is started on empiric broad-spectrum antibiotics. Blood cultures later grow Pseudomonas aeruginosa sensitive to piperacillin-tazobactam. At 72 hours the patient is clinically improving. What is the appropriate antibiotic de-escalation?

Switch to oral fluoroquinolone regardless of susceptibilities
Discontinue all antibiotics
Narrow to piperacillin-tazobactam alone (Correct answer)
Continue broad-spectrum regimen for full 14-day course

Correct answer: Narrow to piperacillin-tazobactam alone

Antibiotic stewardship mandates de-escalation to the narrowest effective agent once culture and sensitivity data are available, reducing resistance and adverse effects.

Question 65: A 66-year-old man with known HFrEF (EF 30%) develops worsening renal function after ACE inhibitor dose uptitration. Creatinine rose from 1.2 to 1.8 mg/dL. What is the most appropriate action?

Discontinue ACE inhibitor immediately
Add aldosterone antagonist to offset renal effects
Switch to ARB immediately
Continue ACE inhibitor if creatinine rise is ≤30% above baseline (Correct answer)

Correct answer: Continue ACE inhibitor if creatinine rise is ≤30% above baseline

A creatinine rise of up to 30-50% above baseline is acceptable when starting or uptitrating ACE inhibitors in HFrEF, as these agents provide mortality benefit that outweighs the modest GFR reduction.

Question 66: A patient with cirrhosis develops rapidly progressive renal failure. Terlipressin plus albumin is started. What is the proposed mechanism of terlipressin in hepatorenal syndrome?

Blocks aldosterone receptors in the distal tubule
Directly increases renal blood flow via vasodilation
Increases glomerular filtration via tubular dilation
Causes splanchnic vasoconstriction, reducing portal pressure and improving renal perfusion (Correct answer)

Correct answer: Causes splanchnic vasoconstriction, reducing portal pressure and improving renal perfusion

Terlipressin is a vasopressin analogue that constricts splanchnic vasculature, reduces portal hypertension-driven vasodilation, and improves systemic and renal perfusion.

Question 67: Heparin-induced thrombocytopenia (HIT) typically develops at what time point after heparin initiation?

Within 24 hours
Immediately upon re-exposure regardless of timing
5-10 days after starting heparin (Correct answer)
Only after 4 weeks of therapy

Correct answer: 5-10 days after starting heparin

Classic HIT (type II) develops 5-10 days after starting heparin due to the time required for antibody formation against platelet factor 4-heparin complexes.

Question 68: A 64-year-old woman is diagnosed with Takotsubo (stress) cardiomyopathy after an emotional stressor. Which angiographic finding distinguishes this from anterior STEMI?

Troponin elevation >10x upper limit of normal
Complete AV block
ST elevation in leads V1-V4
Apical ballooning with normal or non-obstructive coronary arteries (Correct answer)

Correct answer: Apical ballooning with normal or non-obstructive coronary arteries

Takotsubo cardiomyopathy shows apical LV ballooning with hypercontractile base on ventriculography, with absent or non-obstructive coronary artery disease on angiography, distinguishing it from anterior STEMI.

Question 69: Which Child-Pugh score component best correlates with the severity of synthetic liver dysfunction?

Presence of ascites
Prothrombin time/INR (Correct answer)
Degree of encephalopathy
Bilirubin level

Correct answer: Prothrombin time/INR

Prothrombin time/INR reflects hepatic synthesis of clotting factors and is the most direct measure of synthetic dysfunction in the Child-Pugh score.

Question 70: A 45-year-old with autoimmune hepatitis presents with elevated ALT/AST (10x normal) and positive anti-smooth muscle antibodies. What is the standard induction therapy?

Ursodeoxycholic acid
Mycophenolate mofetil alone
Prednisone with or without azathioprine (Correct answer)
Pegylated interferon

Correct answer: Prednisone with or without azathioprine

Autoimmune hepatitis is treated with prednisone alone or combined with azathioprine to induce remission.

Question 71: A 45-year-old man presents to the emergency department with the sudden onset of a severely painful, swollen, and warm right knee, making him unable to bear weight. He has a fever of 38.5°C (101.3°F). What is the most critical next step in the management of this patient?

Perform an arthrocentesis of the knee (Correct answer)
Initiate empiric intravenous antibiotics
Obtain a serum uric acid level
Order a plain radiograph of the knee

Correct answer: Perform an arthrocentesis of the knee

In a patient presenting with an acute, febrile monoarthritis, the most urgent diagnosis to exclude is septic arthritis, as it can lead to rapid joint destruction. Arthrocentesis with synovial fluid analysis (cell count, Gram stain, culture, and crystal analysis) is the single most important diagnostic test. While antibiotics will be needed if septic arthritis is confirmed, they should ideally be administered after the joint fluid is aspirated to maximize the diagnostic yield of the culture. Serum uric acid can be normal during an acute gout attack, and radiographs are often non-specific in the acute setting.

Question 72: A 28-year-old man with Crohn's disease on azathioprine develops fever, right lower quadrant pain, and a palpable mass. CT reveals a 4 cm periappendiceal abscess. What is the best initial management?

Immediate surgical resection
Increase azathioprine dose
IV antibiotics alone without drainage
Percutaneous CT-guided drainage and IV antibiotics (Correct answer)

Correct answer: Percutaneous CT-guided drainage and IV antibiotics

Abdominal abscesses in Crohn's disease are best managed initially with percutaneous drainage and antibiotics, allowing inflammation to resolve before elective surgery.

Question 73: A 72-year-old man with known diverticulosis presents with acute bright red blood per rectum that stops spontaneously. Colonoscopy shows diverticulosis throughout the colon without active bleeding. What is the most common site of diverticular bleeding?

Rectum
Transverse colon
Sigmoid colon
Right colon (cecum and ascending colon) (Correct answer)

Correct answer: Right colon (cecum and ascending colon)

Despite diverticula being most prevalent in the sigmoid colon, diverticular bleeding occurs most commonly from right-sided (cecal/ascending) diverticula due to their wider necks and exposed vasa recta.

Question 74: A 60-year-old man with ESRD on hemodialysis presents with acute onset sharp chest pain that improves when leaning forward. ECG shows diffuse ST elevation with PR depression. What is the most likely diagnosis?

Pulmonary embolism
Aortic dissection
STEMI
Acute pericarditis (Correct answer)

Correct answer: Acute pericarditis

Diffuse ST elevation with PR depression in a uremic patient with positional chest pain is classic for acute pericarditis, which is common in ESRD due to uremic toxin accumulation.

Question 75: A 48-year-old woman presents with dyspnea, peripheral edema, and a JVP that rises with inspiration (Kussmaul's sign). Echo shows preserved EF with septal bounce. What is the most likely diagnosis?

Restrictive cardiomyopathy
Constrictive pericarditis (Correct answer)
Pulmonary embolism
Cardiac tamponade

Correct answer: Constrictive pericarditis

Kussmaul's sign (JVP rise with inspiration) combined with septal bounce and preserved EF on echo points to constrictive pericarditis, where inspiration cannot augment RV filling.

Question 76: A 72-year-old former smoker presents with a 2-year history of progressive exertional dyspnea and a persistent dry cough. A high-resolution CT (HRCT) of the chest reveals bilateral, peripheral, and basilar predominant reticular abnormalities with definitive honeycombing. What is the most likely diagnosis based on this classic HRCT finding?

Usual Interstitial Pneumonia (UIP) pattern consistent with Idiopathic Pulmonary Fibrosis (IPF) (Correct answer)
Nonspecific Interstitial Pneumonia (NSIP)
Sarcoidosis
Hypersensitivity Pneumonitis

Correct answer: Usual Interstitial Pneumonia (UIP) pattern consistent with Idiopathic Pulmonary Fibrosis (IPF)

The HRCT findings described—bilateral, peripheral, basilar predominant fibrosis with honeycombing—are the classic features of a Usual Interstitial Pneumonia (UIP) pattern. In the appropriate clinical context (an older adult with progressive dyspnea and exclusion of other causes), a definitive UIP pattern on HRCT is diagnostic for Idiopathic Pulmonary Fibrosis (IPF) without the need for a surgical lung biopsy.

Question 77: A 70-year-old man with HFrEF (EF 28%) has persistent LBBB with QRS duration of 160 ms despite optimal medical therapy. His NYHA class is III. What device therapy is indicated?

Permanent pacemaker alone
Cardiac resynchronization therapy with defibrillator (CRT-D) (Correct answer)
No device therapy until EF <20%
ICD alone

Correct answer: Cardiac resynchronization therapy with defibrillator (CRT-D)

CRT-D is a Class I indication for HFrEF with LBBB morphology, QRS ≥150 ms, and NYHA class II–III on optimal medical therapy, reducing mortality and improving EF.

Question 78: A patient with Crohn's disease develops a new perianal fistula. Initial treatment with antibiotics (metronidazole) fails. What is the next best pharmacologic therapy?

Azathioprine monotherapy
Cyclosporine
Oral prednisone
Infliximab (anti-TNF) (Correct answer)

Correct answer: Infliximab (anti-TNF)

Infliximab is FDA-approved for fistulizing Crohn's disease and is the preferred biologic after antibiotic failure.

Question 79: Which clinical finding is characteristic of Kussmaul respirations in DKA?

Cheyne-Stokes pattern with apneic episodes
Rapid irregular breathing with pleuritic chest pain
Shallow, rapid breathing with accessory muscle use
Deep, slow, labored breathing as respiratory compensation for acidosis (Correct answer)

Correct answer: Deep, slow, labored breathing as respiratory compensation for acidosis

Kussmaul respirations are deep, slow, and labored — a compensatory response to metabolic acidosis that lowers PaCO2 to raise pH.

Question 80: According to the American Association for the Study of Liver Diseases (AASLD) guidelines, which of the following is the recommended surveillance strategy for hepatocellular carcinoma (HCC) in an adult patient with compensated cirrhosis?

Abdominal ultrasound with or without AFP every 6 months (Correct answer)
Serum alpha-fetoprotein (AFP) level every 3 months
Annual contrast-enhanced abdominal MRI
Flexible sigmoidoscopy every 5 years

Correct answer: Abdominal ultrasound with or without AFP every 6 months

Major society guidelines, including the AASLD, recommend surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis using an abdominal ultrasound every 6 months. The addition of serum alpha-fetoprotein (AFP) testing to ultrasound is also recommended as it may increase sensitivity. More frequent AFP testing alone or annual advanced imaging like MRI or CT are not the standard of care for routine surveillance. Flexible sigmoidoscopy is for colorectal cancer screening.

Question 81: A 62-year-old male with a history of hypertension and dyslipidemia presents to the emergency department with severe, substernal chest pain that started 2 hours ago. An ECG shows ST-segment elevation in the anterior leads. He undergoes successful percutaneous coronary intervention (PCI) with the placement of a drug-eluting stent in his left anterior descending artery. According to the most recent ACC/AHA guidelines, what is the recommended minimum duration of dual antiplatelet therapy (DAPT) for this patient?

24 months
6 months
12 months (Correct answer)
3 months

Correct answer: 12 months

For patients who have undergone PCI with a drug-eluting stent after an ST-elevation myocardial infarction (STEMI), which is a form of acute coronary syndrome (ACS), the standard recommendation is at least 12 months of DAPT (aspirin plus a P2Y12 inhibitor). This duration is proven to reduce the risk of stent thrombosis and major adverse cardiovascular events. Shorter durations may be considered in patients with a very high bleeding risk, while longer durations might be considered in those with low bleeding risk and high ischemic risk.

Question 82: A 65-year-old man with hypertension develops AKI with blood pressure of 240/130 mmHg. Urinalysis shows RBC casts and 3+ proteinuria. LDH is elevated and peripheral smear shows schistocytes. What diagnosis best explains his AKI?

IgA nephropathy
Thrombotic microangiopathy (malignant hypertension) (Correct answer)
Minimal change disease
Lupus nephritis

Correct answer: Thrombotic microangiopathy (malignant hypertension)

Malignant hypertension causes thrombotic microangiopathy with schistocytes on peripheral smear, hemolysis (elevated LDH), and glomerular injury (RBC casts, proteinuria).

Question 83: A 68-year-old male with a history of stable ischemic heart disease underwent percutaneous coronary intervention (PCI) with a drug-eluting stent to the left anterior descending artery one year ago. He has been asymptomatic on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. He has a high bleeding risk (PRECISE-DAPT score of 30). According to the most recent ACC/AHA guidelines, what is the most appropriate recommendation for his antiplatelet therapy at this time?

Discontinue clopidogrel and continue aspirin monotherapy. (Correct answer)
Discontinue aspirin and continue clopidogrel monotherapy.
Discontinue both aspirin and clopidogrel.
Continue DAPT for at least another 12 months.

Correct answer: Discontinue clopidogrel and continue aspirin monotherapy.

For a patient with stable ischemic heart disease (SIHD) who is at high risk for bleeding and has completed 12 months of DAPT after receiving a drug-eluting stent, guidelines support transitioning to single antiplatelet therapy. In patients with SIHD treated with a drug-eluting stent, DAPT for 6 months is generally recommended. For patients with a high bleeding risk, this duration can be shortened to 3 months. Since this patient has completed 12 months, discontinuing the P2Y12 inhibitor (clopidogrel) and continuing aspirin monotherapy is the standard of care.

Question 84: A 67-year-old male with a history of COPD and type 2 diabetes presents to an outpatient clinic with a 3-day history of productive cough, fever, and dyspnea. He has not taken antibiotics in the past year. According to the 2019 IDSA/ATS guidelines, which of the following is the most appropriate empiric antibiotic regimen for this patient?

Amoxicillin monotherapy
Azithromycin monotherapy
Ciprofloxacin
Amoxicillin-clavulanate plus doxycycline (Correct answer)

Correct answer: Amoxicillin-clavulanate plus doxycycline

According to the 2019 IDSA/ATS guidelines, outpatients with community-acquired pneumonia (CAP) who have comorbidities (such as chronic lung disease or diabetes) should be treated with either combination therapy or monotherapy with a respiratory fluoroquinolone. [15] Combination therapy consists of a beta-lactam (like amoxicillin-clavulanate) PLUS a macrolide or doxycycline. [11, 15] Macrolide monotherapy is not recommended due to high rates of pneumococcal resistance. Amoxicillin monotherapy is an option for patients without comorbidities. Ciprofloxacin is not a respiratory fluoroquinolone and lacks reliable activity against *Streptococcus pneumoniae*.

Question 85: A 70-year-old nursing home resident presents with altered mental status and dysuria. Urinalysis shows pyuria and bacteriuria. She is afebrile with stable vitals. What is the BEST management?

Obtain urine culture and treat based on sensitivities
Treat only if urine culture grows ≥10⁵ CFU/mL
Start empiric antibiotics immediately
No antibiotic treatment; reassess in 48 hours (Correct answer)

Correct answer: No antibiotic treatment; reassess in 48 hours

Asymptomatic bacteriuria in elderly women should not be treated with antibiotics, as treatment does not reduce morbidity and promotes resistance; altered mental status requires workup for other causes.

Question 86: A 55-year-old female is evaluated for an acute coronary syndrome. According to the TIMI risk score for UA/NSTEMI, which of the following patient characteristics is NOT considered a risk factor?

Aspirin use in the past 7 days
Age ≥ 65 years
Known coronary artery disease with >50% stenosis
Systolic blood pressure < 100 mmHg (Correct answer)

Correct answer: Systolic blood pressure < 100 mmHg

The TIMI risk score for unstable angina/non-ST elevation MI (UA/NSTEMI) includes seven variables: age ≥65 years, ≥3 risk factors for CAD (e.g., hypertension, diabetes, smoking), known CAD with ≥50% stenosis, aspirin use in the past 7 days, severe angina (≥2 episodes in 24 hours), ST deviation ≥0.5 mm, and positive cardiac markers. Systolic blood pressure is not a component of this specific risk score.

Question 87: In DKA, the serum potassium is initially high despite total body potassium depletion. What is the primary mechanism?

Reduced renal potassium excretion
Acidosis-driven transcellular shift of potassium out of cells (Correct answer)
Aldosterone deficiency causing potassium retention
Increased potassium absorption from the gut

Correct answer: Acidosis-driven transcellular shift of potassium out of cells

Metabolic acidosis causes H⁺ to shift into cells in exchange for K⁺ moving out, raising serum potassium despite total body depletion.

Question 88: A 55-year-old female has a long-standing history of Raynaud's phenomenon, telangiectasias, and skin thickening limited to her hands and face. She is positive for anti-centromere antibodies. She now presents with several months of progressive dyspnea on exertion. Echocardiogram reveals elevated right ventricular systolic pressure. Which of the following complications is the most likely cause of her symptoms?

Pulmonary arterial hypertension (Correct answer)
Progressive interstitial lung disease
Scleroderma renal crisis
Aspiration pneumonia due to esophageal dysmotility

Correct answer: Pulmonary arterial hypertension

This patient's clinical picture (long-standing Raynaud's, limited skin involvement, anti-centromere antibodies) is classic for limited cutaneous systemic sclerosis. Pulmonary arterial hypertension (PAH) is a major, and often late, complication of this subtype and a leading cause of mortality. [25] While interstitial lung disease can occur, it is more common and severe in the diffuse subtype (associated with anti-Scl-70 antibodies). Scleroderma renal crisis is also much more characteristic of early, diffuse disease. [24, 28]

Question 89: A 70-year-old man presents with steatorrhea, weight loss, and a fasting serum glucose of 160 mg/dL. CT shows diffuse pancreatic atrophy and calcifications. What is the most likely underlying diagnosis?

Chronic pancreatitis (Correct answer)
Pancreatic adenocarcinoma
Cystic fibrosis
Autoimmune pancreatitis

Correct answer: Chronic pancreatitis

Diffuse pancreatic calcifications with atrophy on CT are pathognomonic of chronic pancreatitis, which causes both exocrine insufficiency (steatorrhea) and endocrine dysfunction (diabetes).

Question 90: Spontaneous coronary artery dissection (SCAD) causing ACS most commonly occurs in which patient population?

Patients with prior cocaine use
Diabetic patients with multivessel CAD
Young women in the peripartum period or with fibromuscular dysplasia (Correct answer)
Elderly men with longstanding hypertension

Correct answer: Young women in the peripartum period or with fibromuscular dysplasia

SCAD predominantly affects young women, especially peripartum or those with fibromuscular dysplasia, and presents with ACS without typical atherosclerotic risk factors.

Question 91: A 62-year-old male presents to the emergency department with 3 hours of substernal chest pressure. His ECG shows ST-segment depression in the lateral leads. Initial troponin levels are elevated. He is diagnosed with NSTE-ACS (Non-ST-Elevation Acute Coronary Syndrome). In addition to aspirin, nitrates, and a high-intensity statin, which of the following is a critical component of initial medical management?

Administration of a P2Y12 inhibitor and an anticoagulant. (Correct answer)
Initiation of an ACE inhibitor within the first hour.
Immediate administration of a thrombolytic agent.
Urgent cardioversion.

Correct answer: Administration of a P2Y12 inhibitor and an anticoagulant.

The initial management of NSTE-ACS involves a combination of anti-ischemic and antithrombotic therapies. Antithrombotic therapy is crucial and consists of both an antiplatelet agent (aspirin plus a P2Y12 inhibitor like clopidogrel or ticagrelor) and an anticoagulant (such as unfractionated heparin, enoxaparin, or fondaparinux). Thrombolytics are contraindicated in NSTEMI. While ACE inhibitors are important for long-term management, their immediate initiation is not as critical as antithrombotic therapy. Cardioversion is not indicated unless there is a life-threatening arrhythmia.

Question 92: A 29-year-old male presents with DKA precipitated by an infection. His initial labs include a pH of 6.95, bicarbonate of 6 mEq/L, and potassium of 5.8 mEq/L. He is hemodynamically stable. In addition to IV fluids and insulin, which of the following interventions is most appropriate regarding his severe acidemia?

Routine use of sodium bicarbonate is not recommended. (Correct answer)
Administer 50 mEq of sodium bicarbonate IV over 30 minutes.
Withhold insulin until the pH is > 7.1.
Initiate continuous renal replacement therapy (CRRT).

Correct answer: Routine use of sodium bicarbonate is not recommended.

The routine use of sodium bicarbonate in DKA is not recommended and is generally reserved for cases of life-threatening hyperkalemia or severe acidemia (pH < 6.9) causing hemodynamic instability. Studies have not shown a benefit in the rate of recovery of acidosis and have suggested potential harm, including paradoxical CNS acidosis, worsened hypokalemia, and hypernatremia. The acidosis will typically resolve with appropriate fluid resuscitation and insulin therapy, which inhibits further ketone production.

Question 93: A 44-year-old woman presents with episodic diarrhea, flushing, and a new heart murmur. 24-hour urine shows markedly elevated 5-HIAA. CT reveals a 1.5 cm ileal mass and multiple hepatic lesions. What is the first-line therapy for symptom control?

Systemic chemotherapy with streptozocin
Octreotide LAR (long-acting somatostatin analog) (Correct answer)
Surgical resection of the primary tumor
High-dose corticosteroids

Correct answer: Octreotide LAR (long-acting somatostatin analog)

Somatostatin analogs (octreotide LAR or lanreotide) are first-line for controlling carcinoid syndrome symptoms and have also demonstrated anti-proliferative effects in well-differentiated neuroendocrine tumors.

Question 94: A patient with Wilson's disease presents with liver disease, Kayser-Fleischer rings, and neuropsychiatric symptoms. Serum ceruloplasmin is low. What is the first-line treatment for symptomatic Wilson's disease?

D-penicillamine or trientine (copper chelation) (Correct answer)
Liver transplantation immediately
Low-copper diet as sole management
Zinc supplementation alone as initial therapy

Correct answer: D-penicillamine or trientine (copper chelation)

Symptomatic Wilson's disease is treated with copper chelators (D-penicillamine or trientine) to remove excess copper.

Question 95: A 58-year-old male with a 15-year history of poorly controlled type 2 diabetes and CKD stage 3 is noted to have a persistent, non-anion gap metabolic acidosis and a serum potassium of 5.8 mEq/L despite dietary counseling. His urine pH is 5.0. Which of the following is the most likely diagnosis?

Type 1 (Distal) Renal Tubular Acidosis
Type 4 (Hyperkalemic) Renal Tubular Acidosis (Correct answer)
Type 2 (Proximal) Renal Tubular Acidosis
Diabetic Ketoacidosis

Correct answer: Type 4 (Hyperkalemic) Renal Tubular Acidosis

This patient's presentation of non-anion gap metabolic acidosis, persistent hyperkalemia, and an appropriately acidic urine pH (<5.5) in the setting of diabetic nephropathy is classic for Type 4 Renal Tubular Acidosis. This condition results from aldosterone deficiency or resistance, which impairs distal nephron secretion of both potassium and hydrogen ions. Type 1 RTA is associated with hypokalemia and an inability to acidify the urine. Type 2 RTA is also associated with hypokalemia. Diabetic ketoacidosis would present with a high anion gap.

Question 96: After successful kidney transplantation, a recipient develops AKI on day 3 with oliguria and a biopsy showing interstitial edema, lymphocytic infiltration, and tubulitis. What is the most likely cause?

Recurrent focal segmental glomerulosclerosis
BK virus nephropathy
Calcineurin inhibitor toxicity
Acute cellular rejection (T-cell mediated) (Correct answer)

Correct answer: Acute cellular rejection (T-cell mediated)

Acute cellular rejection occurring days to weeks post-transplant is characterized by tubulitis and lymphocytic interstitial infiltration on biopsy and requires augmented immunosuppression.

Question 97: A 58-year-old man with alcoholic cirrhosis (Child-Pugh C) develops a variceal bleed. After stabilization with octreotide and endoscopic band ligation, what is the most important next step to prevent recurrent bleeding?

Surgical portosystemic shunt
Non-selective beta-blocker plus repeat band ligation (Correct answer)
TIPS procedure immediately
Propranolol monotherapy only

Correct answer: Non-selective beta-blocker plus repeat band ligation

Secondary prophylaxis of variceal bleeding requires combination therapy with non-selective beta-blockers (nadolol or propranolol) plus endoscopic variceal ligation, which is superior to either alone.

Question 98: A 55-year-old woman presents with bilateral hand pain, Heberden's nodes at the DIP joints, and Bouchard's nodes at the PIP joints. X-ray shows joint space narrowing without erosions. What is the most likely diagnosis?

Psoriatic arthritis
Rheumatoid arthritis
Gout
Osteoarthritis (Correct answer)

Correct answer: Osteoarthritis

Osteoarthritis characteristically involves DIP joints with Heberden's nodes and PIP joints with Bouchard's nodes, with joint space narrowing but no erosions.

Question 99: A 48-year-old patient requires treatment for a newly diagnosed Helicobacter pylori infection. The local clarithromycin resistance rate is known to be over 20%. According to the latest ACG guidelines, which of the following is a recommended first-line therapy?

Dual therapy with a PPI and amoxicillin for 14 days
Clarithromycin-based triple therapy for 7 days
Bismuth quadruple therapy for 14 days (Correct answer)
Levofloxacin-based triple therapy for 10 days

Correct answer: Bismuth quadruple therapy for 14 days

In regions where clarithromycin resistance is high (>15%), standard clarithromycin-based triple therapy is no longer recommended as a first-line treatment due to low eradication rates. The updated 2024 ACG guidelines strongly recommend bismuth quadruple therapy (a PPI, bismuth, tetracycline, and a nitroimidazole) for 14 days as a preferred first-line option. Levofloxacin-based regimens are typically reserved for salvage therapy, and dual therapy has inferior efficacy.

Question 100: A cirrhotic patient develops confusion and asterixis after a high-protein meal. Serum ammonia is elevated. Which neurotransmitter system is most implicated in hepatic encephalopathy?

GABAergic system (Correct answer)
Serotonergic system
Cholinergic system
Dopaminergic system

Correct answer: GABAergic system

Elevated ammonia enhances GABAergic neurotransmission, promoting inhibitory tone and causing hepatic encephalopathy.

Question 101: Which of the following findings is an absolute indication for initiating urgent hemodialysis in a patient with acute kidney injury?

Serum creatinine of 8.0 mg/dL
Urine output of 300 mL in 24 hours
Uremic pericarditis with a friction rub (Correct answer)
Blood Urea Nitrogen (BUN) of 120 mg/dL

Correct answer: Uremic pericarditis with a friction rub

The development of uremic complications, such as pericarditis or encephalopathy, is an absolute indication for urgent hemodialysis, regardless of the specific BUN or creatinine values. While high creatinine and BUN levels are concerning and often accompany the need for dialysis, they are not, in themselves, absolute indications. The decision is based on life-threatening clinical manifestations, which also include refractory severe metabolic acidosis, severe hyperkalemia, or refractory fluid overload.

Question 102: A patient with G6PD deficiency develops acute hemolytic anemia after starting primaquine. What is the underlying mechanism?

Mechanical destruction of RBCs in small vessels
Complement-mediated intravascular lysis
Immune-mediated destruction of RBCs via antibodies
Oxidative stress causing Heinz body formation and hemolysis (Correct answer)

Correct answer: Oxidative stress causing Heinz body formation and hemolysis

G6PD deficiency impairs the pentose phosphate pathway, leaving RBCs unable to neutralize oxidative stress; oxidant drugs cause Heinz body formation and subsequent hemolysis.

Question 103: A patient with penicillin allergy (anaphylaxis) requires treatment for neurosyphilis. What is the recommended management?

Penicillin desensitization followed by IV penicillin G (Correct answer)
Ceftriaxone 2 g IV daily for 10–14 days
Doxycycline 100 mg BID for 28 days
Azithromycin 2 g single dose

Correct answer: Penicillin desensitization followed by IV penicillin G

Penicillin G remains the only proven therapy for neurosyphilis; patients with penicillin allergy should undergo desensitization and then receive IV penicillin G.

Question 104: A 65-year-old with CAP and no comorbidities is treated as an outpatient. Which antibiotic is appropriate as monotherapy?

Azithromycin (if low macrolide resistance) (Correct answer)
Levofloxacin plus amoxicillin
Ceftriaxone IV
Amoxicillin-clavulanate

Correct answer: Azithromycin (if low macrolide resistance)

Azithromycin monotherapy is appropriate for outpatient CAP in healthy patients without comorbidities in areas with low macrolide resistance (<25%).

Question 105: A patient with advanced cirrhosis has a prolonged INR of 2.5. Despite this, he develops a spontaneous portal vein thrombosis. Which of the following pathophysiologic changes best explains this prothrombotic tendency?

Thrombocytopenia secondary to splenomegaly
A severe deficiency of anticoagulant proteins C and S
Markedly elevated levels of Factor VIII and von Willebrand factor (Correct answer)
Decreased clearance of activated clotting factors

Correct answer: Markedly elevated levels of Factor VIII and von Willebrand factor

While patients with cirrhosis are deficient in many liver-synthesized pro-coagulant and anti-coagulant factors, they have markedly elevated levels of Factor VIII and von Willebrand factor, which are produced by endothelial cells. This increase in pro-thrombotic factors can disrupt the 'rebalanced hemostasis' and tip the patient into a hypercoagulable state, leading to thrombotic events like portal vein thrombosis despite a prolonged INR. While deficiency of proteins C and S and decreased factor clearance contribute to the complex picture, the significant elevation of FVIII/vWF is a key driver of this paradoxical thrombosis. Thrombocytopenia would favor bleeding, not clotting.

Question 106: A 62-year-old female with severe acute kidney injury (creatinine 6.8 mg/dL) secondary to sepsis is being managed in the ICU. Which of the following findings is the most urgent indication for initiating renal replacement therapy?

Blood urea nitrogen (BUN) of 110 mg/dL
Serum bicarbonate of 16 mEq/L
Pericardial friction rub on auscultation (Correct answer)
Serum potassium of 6.3 mEq/L, refractory to medical therapy

Correct answer: Pericardial friction rub on auscultation

The classic indications for urgent dialysis are remembered by the mnemonic AEIOU: Acidosis (severe), Electrolytes (refractory hyperkalemia), Intoxications, Overload (refractory), and Uremia (symptomatic). A pericardial friction rub is a sign of uremic pericarditis, a life-threatening complication of uremia, and is an absolute indication for immediate dialysis. While refractory hyperkalemia is also an urgent indication, uremic pericarditis represents severe end-organ toxicity requiring the most emergent intervention. An elevated BUN or moderate acidosis alone are not absolute indications.

Question 107: A 72-year-old man with BPH presents with AKI and bilateral hydronephrosis on ultrasound. Bladder scan shows 800 mL of residual urine. After Foley catheter placement, urine output is 400 mL/hour. What electrolyte complication is most expected?

Hypertonic hyponatremia
Hyperkalemia and metabolic alkalosis
Hypercalcemia
Post-obstructive diuresis causing hypokalemia and hyponatremia (Correct answer)

Correct answer: Post-obstructive diuresis causing hypokalemia and hyponatremia

Post-obstructive diuresis after relief of urinary obstruction commonly causes hypokalemia and hyponatremia due to loss of electrolytes in large urine volumes.

Question 108: A 55-year-old woman with HFpEF (EF 60%) presents with dyspnea and leg edema. Which intervention has the strongest evidence for improving outcomes in HFpEF?

Aldosterone antagonist
SGLT2 inhibitor (empagliflozin or dapagliflozin) (Correct answer)
ACE inhibitor
Beta-blocker

Correct answer: SGLT2 inhibitor (empagliflozin or dapagliflozin)

SGLT2 inhibitors have demonstrated significant reduction in heart failure hospitalizations and cardiovascular death in HFpEF in landmark trials (EMPEROR-Preserved, DELIVER).

Question 109: A 29-year-old man with IBD-associated arthritis has asymmetric oligoarthritis of large joints that parallels bowel disease activity. Which treatment is most appropriate for both his arthritis and bowel disease?

Infliximab (Correct answer)
Etanercept
Adalimumab only for joints
Methotrexate alone

Correct answer: Infliximab

Infliximab (anti-TNF chimeric antibody) is effective for both IBD and its associated peripheral arthritis, making it the preferred biologic in this setting.

Question 110: A 50-year-old with known esophageal varices presents with acute hematemesis. After resuscitation, what pharmacologic therapy should be started immediately before endoscopy?

IV octreotide (somatostatin analogue) (Correct answer)
IV vasopressin alone
IV pantoprazole
Oral propranolol

Correct answer: IV octreotide (somatostatin analogue)

Octreotide reduces portal pressure by inhibiting splanchnic vasodilation and should be initiated immediately in suspected variceal bleeding.

Question 111: A 48-year-old man is diagnosed with Wilson's disease presenting as acute liver failure. Which finding on labs would be most characteristic?

Elevated serum ferritin >1000 ng/mL
Low serum alkaline phosphatase with Coombs-negative hemolytic anemia (Correct answer)
Markedly elevated alkaline phosphatase
High serum ceruloplasmin

Correct answer: Low serum alkaline phosphatase with Coombs-negative hemolytic anemia

Wilson's disease presenting as acute liver failure characteristically shows paradoxically low alkaline phosphatase (released copper inhibits bone isoform) combined with Coombs-negative hemolytic anemia.

Question 112: A patient with STEMI undergoes primary PCI. Post-procedure, the culprit vessel is patent but the patient has no ST resolution and persistent symptoms. What phenomenon best explains this?

Stent thrombosis
Coronary vasospasm
No-reflow phenomenon (Correct answer)
Aortic dissection extension

Correct answer: No-reflow phenomenon

No-reflow occurs when myocardial perfusion is inadequate despite a patent epicardial artery, caused by microvascular obstruction from embolization of debris and reperfusion injury.

Question 113: A patient with known asthma presents with severe bronchospasm unresponsive to multiple doses of inhaled beta-agonist. What is the most appropriate next step?

Give oral montelukast
Administer IV magnesium sulfate (Correct answer)
Perform emergency intubation
Increase inhaled corticosteroid dose

Correct answer: Administer IV magnesium sulfate

IV magnesium sulfate causes bronchial smooth muscle relaxation and is indicated in severe asthma refractory to initial beta-agonist and steroid therapy.

Question 114: A 67-year-old male presents with a 3-month history of predictable, substernal chest discomfort that occurs when he walks uphill and resolves within 5 minutes of rest. He has a normal resting ECG and no history of myocardial infarction. Which of the following is the most appropriate initial non-invasive test to evaluate for coronary artery disease?

Coronary angiography
Coronary MRA (Magnetic Resonance Angiography)
Exercise stress echocardiography (Correct answer)
Resting 2D echocardiogram

Correct answer: Exercise stress echocardiography

For a patient with an intermediate pre-test probability of stable coronary artery disease who is able to exercise and has a normal baseline ECG, an exercise stress test is the recommended initial diagnostic step. An exercise stress echocardiogram provides both functional (ECG changes, symptoms) and imaging (wall motion abnormalities) data, which increases its diagnostic accuracy compared to an exercise ECG alone. A resting echo is not sufficient to diagnose ischemia, and coronary angiography is an invasive test reserved for high-risk patients or when non-invasive testing is inconclusive.

Question 115: A 55-year-old patient on prolonged broad-spectrum antibiotics develops profuse watery diarrhea. Stool toxin assay is positive for Clostridioides difficile. He has WBC 18,000 and serum creatinine 1.8 mg/dL. What is the appropriate initial treatment?

IV metronidazole plus oral vancomycin
Oral vancomycin 125 mg QID (Correct answer)
Oral metronidazole 500 mg TID
Fidaxomicin 200 mg BID

Correct answer: Oral vancomycin 125 mg QID

Fidaxomicin or oral vancomycin is preferred over metronidazole for non-severe C. difficile infection; elevated WBC and creatinine indicate non-fulminant disease still treated with oral vancomycin per current IDSA guidelines.

Question 116: Portal vein thrombosis (PVT) is found incidentally in a patient with cirrhosis. It is non-occlusive and asymptomatic. What is the most appropriate management?

Observation only without anticoagulation
Emergent TIPS placement
Anticoagulation with low-molecular-weight heparin or direct oral anticoagulants (Correct answer)
Surgical thrombectomy

Correct answer: Anticoagulation with low-molecular-weight heparin or direct oral anticoagulants

Anticoagulation is recommended for non-occlusive PVT in cirrhosis to prevent extension and promote recanalization, as the bleeding risk is generally outweighed by thrombosis risk.

Question 117: Which of the following urine microscopy findings is most specific for acute tubular necrosis?

White blood cell casts
Muddy brown granular casts (Correct answer)
Hyaline casts
Red blood cell casts

Correct answer: Muddy brown granular casts

Muddy brown granular casts (composed of sloughed tubular epithelial cells) are the hallmark finding of acute tubular necrosis.

Question 118: A 78-year-old man presents with syncope. ECG shows alternating left and right bundle branch block. What is the most appropriate management?

Holter monitoring for 30 days
Permanent pacemaker implantation (Correct answer)
Antiarrhythmic therapy
Electrophysiology study only

Correct answer: Permanent pacemaker implantation

Alternating bundle branch block indicates severe infranodal conduction disease with a high risk of complete heart block, and permanent pacemaker implantation is indicated.

Question 119: A 79-year-old male with known coronary artery disease, prior myocardial infarction, and systolic heart failure (LVEF 30%) presents with recurrent episodes of syncope. A 12-lead ECG shows sinus rhythm with a left bundle branch block and a QRS duration of 160 ms. He is on optimal guideline-directed medical therapy. Which of the following interventions is most likely to improve his symptoms and reduce mortality?

Ablation of the AV node and placement of a single-chamber pacemaker.
Coronary artery bypass grafting (CABG).
Implantation of a cardiac resynchronization therapy with defibrillator (CRT-D) device. (Correct answer)
Implantation of a subcutaneous implantable cardioverter-defibrillator (S-ICD).

Correct answer: Implantation of a cardiac resynchronization therapy with defibrillator (CRT-D) device.

This patient has symptomatic systolic heart failure (LVEF ≤35%) on optimal medical therapy with evidence of ventricular dyssynchrony (LBBB with QRS ≥150 ms). In this setting, a Cardiac Resynchronization Therapy with Defibrillator (CRT-D) device is indicated. CRT improves synchrony of ventricular contraction, which can improve LVEF, reduce heart failure symptoms, and decrease mortality. The defibrillator component is indicated for primary prevention of sudden cardiac death in patients with ischemic cardiomyopathy and LVEF ≤35%.

Question 120: A 40-year-old man with a history of intravenous drug use presents with fever and malaise. Blood cultures are drawn, and an echocardiogram is ordered. According to the modified Duke criteria for infective endocarditis, which of the following is considered a major criterion for diagnosis?

Vascular phenomena, such as Janeway lesions
Fever > 38.0°C (100.4°F)
Positive blood culture with a typical microorganism (Correct answer)
Immunologic phenomena, such as Osler nodes

Correct answer: Positive blood culture with a typical microorganism

The modified Duke criteria categorize clinical findings into major and minor criteria. The two major criteria are: (1) positive blood cultures with a microorganism typical for causing infective endocarditis (e.g., S. aureus, Viridans streptococci, Enterococcus), and (2) evidence of endocardial involvement, such as a new valvular regurgitation or a positive echocardiogram (vegetation, abscess). Fever, vascular phenomena (Janeway lesions), and immunologic phenomena (Osler nodes) are all considered minor criteria.

Question 121: A 55-year-old man presents with sharp, positional chest pain that worsens when lying flat and improves when leaning forward. Temperature is 38.4°C. ECG shows diffuse ST elevation with PR depression. What is the most likely diagnosis?

STEMI
Pleuritis
Aortic dissection
Acute pericarditis (Correct answer)

Correct answer: Acute pericarditis

Diffuse (saddle-shaped) ST elevation with PR depression, pleuritic positional pain, and low-grade fever are classic findings of acute pericarditis.

Question 122: A 52-year-old male is evaluated for resistant hypertension and is found to have a serum potassium of 3.2 mEq/L. Primary aldosteronism is suspected. What is the most appropriate initial screening test for this condition?

Morning plasma aldosterone concentration and plasma renin activity (Correct answer)
Low-dose dexamethasone suppression test
24-hour urine free cortisol
Abdominal CT scan with adrenal protocol

Correct answer: Morning plasma aldosterone concentration and plasma renin activity

The Endocrine Society recommends screening for primary aldosteronism in patients with resistant hypertension and hypokalemia by measuring the morning plasma aldosterone concentration (PAC) and plasma renin activity (PRA) to calculate the aldosterone-to-renin ratio (ARR). An elevated ARR is a positive screen, prompting further confirmatory testing. An abdominal CT scan is used for subtype localization (e.g., adenoma vs. hyperplasia) after the biochemical diagnosis is established. The other tests are used to screen for Cushing's syndrome.

Question 123: A patient with celiac disease continues to have diarrhea and weight loss despite strict gluten-free diet for 12 months. Repeat biopsy shows persistent villous atrophy. What is the most concerning complication to consider?

Small intestinal bacterial overgrowth
Enteropathy-associated T-cell lymphoma (EATL) (Correct answer)
Refractory celiac disease type I
Microscopic colitis

Correct answer: Enteropathy-associated T-cell lymphoma (EATL)

Refractory celiac disease unresponsive to strict gluten-free diet, particularly type II, carries a high risk of progression to enteropathy-associated T-cell lymphoma (EATL).

Question 124: Which combination of laboratory findings is most characteristic of disseminated intravascular coagulation (DIC)?

Isolated elevation of PT with normal platelet count
Elevated platelet count with isolated low fibrinogen
Elevated D-dimer, prolonged PT/aPTT, low fibrinogen, and thrombocytopenia (Correct answer)
Normal fibrinogen with elevated D-dimer only

Correct answer: Elevated D-dimer, prolonged PT/aPTT, low fibrinogen, and thrombocytopenia

DIC involves simultaneous widespread coagulation and fibrinolysis, consuming clotting factors and platelets, resulting in elevated D-dimer, prolonged PT/aPTT, low fibrinogen, and thrombocytopenia.

Question 125: Which mechanism best explains vancomycin resistance in Enterococcus faecium (VanA phenotype)?

Efflux pump overexpression
Substitution of D-Ala-D-Lac for D-Ala-D-Ala in peptidoglycan precursors (Correct answer)
Enzymatic beta-lactamase production
Altered penicillin-binding proteins

Correct answer: Substitution of D-Ala-D-Lac for D-Ala-D-Ala in peptidoglycan precursors

VanA resistance results from replacing the terminal D-Ala-D-Ala with D-Ala-D-Lac, dramatically reducing vancomycin binding affinity.

Question 126: A 62-year-old man develops new bundle branch block and cardiogenic shock 6 hours after anterior STEMI. Echocardiography shows a ventricular septal defect. What is the definitive treatment?

Emergency surgical repair or percutaneous closure with hemodynamic support (Correct answer)
IV dobutamine and watchful waiting
Intra-aortic balloon pump alone
Thrombolytic therapy

Correct answer: Emergency surgical repair or percutaneous closure with hemodynamic support

Post-MI ventricular septal rupture causing cardiogenic shock requires urgent mechanical repair (surgical or percutaneous) along with hemodynamic support; medical therapy alone has very high mortality.

Question 127: Five days after an extensive anterior wall myocardial infarction, a 70-year-old female becomes acutely hypotensive and develops respiratory distress. On examination, a new, loud, harsh holosystolic murmur is heard best at the left lower sternal border, accompanied by a palpable thrill. Which of the following is the most likely diagnosis?

Dressler syndrome
Ventricular septal rupture (Correct answer)
Papillary muscle rupture
Ventricular free wall rupture

Correct answer: Ventricular septal rupture

The clinical presentation of acute hemodynamic deterioration 3-5 days post-MI, coupled with a new, loud, harsh holosystolic murmur at the left lower sternal border and a palpable thrill, is classic for a post-infarction ventricular septal rupture (VSR). Papillary muscle rupture typically presents with a murmur of acute mitral regurgitation best heard at the apex. Ventricular free wall rupture leads to hemopericardium and rapid progression to pulseless electrical activity. Dressler syndrome is a post-MI pericarditis that occurs weeks to months later.

Question 128: A 34-year-old mother of three brings concerns of restlessness, agitation, palpitations, sweating, and a dramatic 8-pound weight loss to her primary care physician (without any dietary or exercise intervention). She also complains of fine trembling and heat sensitivity. She categorically denied using any form of tobacco, alcohol, or caffeine. Her vital signs are as follows: 37 °C (98.6 °F), 120 beats per minute for her heartbeat, 140/80 mmHg for her blood pressure, and 20 beats per minute for her breathing. During a physical examination, the doctor noted pre-tibial myxedema, lid lag, a distinctive gaze, and fine tremors. The thyroid gland is lobular and diffusely enlarged when palpated. On auscultation, a bruit is audible over the surface of the gland. According to lab tests, TSH levels are deficient, and radioactive iodine uptake is boosted. Graves disease is identified, and potential therapies are addressed. What long-term risks are there if a patient chooses radioactive iodine therapy?

Hypothyroidism (Correct answer)
Recurrent laryngeal nerve damage
Carcinoma of thyroid gland
Cholestasis
Granulocytopenia

Correct answer: Hypothyroidism

Radioactive iodine therapy (RAI) for Graves' disease works by destroying overactive thyroid cells, effectively treating hyperthyroidism. However, the most common and significant long-term risk of this treatment is the development of hypothyroidism, as the destruction of thyroid tissue can lead to insufficient hormone production, requiring lifelong thyroid hormone replacement.

Question 129: A 58-year-old male with type 2 diabetes, hypertension, and a history of heart failure with reduced ejection fraction (HFrEF) presents for a medication review. His A1c is 7.8% on metformin and glipizide. His eGFR is 50 mL/min/1.73m². Which of the following medications should be added to his regimen to improve glycemic control and provide a mortality benefit?

Empagliflozin (Correct answer)
Sitagliptin
Insulin glargine
Pioglitazone

Correct answer: Empagliflozin

Sodium-glucose cotransporter-2 (SGLT2) inhibitors, such as empagliflozin, have demonstrated significant cardiovascular benefits in patients with type 2 diabetes and established cardiovascular disease. Clinical trials like EMPA-REG OUTCOME have shown that empagliflozin reduces the risk of cardiovascular death, all-cause mortality, and hospitalization for heart failure. Pioglitazone is contraindicated in patients with heart failure as it can cause fluid retention and exacerbate the condition. Sitagliptin (a DPP-4 inhibitor) is considered cardiovascularly neutral. Insulin glargine effectively lowers glucose but does not provide the same cardiovascular mortality benefit seen with SGLT2 inhibitors in this patient population.

Question 130: Which of the following is a contraindication to lung transplantation evaluation?

Ongoing cigarette smoking within the past 6 months (Correct answer)
FEV1 of 20% predicted in IPF
Age 65 years with COPD
BMI of 32 kg/m²

Correct answer: Ongoing cigarette smoking within the past 6 months

Active smoking or substance use within 3-6 months is an absolute contraindication to lung transplant listing due to ongoing organ damage and nonadherence risk.

Question 131: Which of the following is the most common cause of massive hemoptysis (>300 mL/24h) in the United States?

Bronchiectasis (Correct answer)
Lung adenocarcinoma
Acute bronchitis
Pulmonary embolism

Correct answer: Bronchiectasis

Bronchiectasis, particularly from cystic fibrosis or prior infections, is the most common cause of massive hemoptysis due to erosion of hypertrophied bronchial arteries.

Question 132: A 25-year-old woman presents with intermittent episodes of wheezing, shortness of breath, and chest tightness. These symptoms occur 3-4 days a week and awaken her from sleep about twice a month. She uses an albuterol inhaler for symptom relief, which she needs several times a week. According to the most recent GINA guidelines, which of the following is the preferred initial controller therapy?

As-needed low-dose inhaled corticosteroid (ICS)-formoterol (Correct answer)
Daily leukotriene receptor antagonist (LTRA)
Short-acting beta-agonist (SABA) as needed
Daily low-dose inhaled corticosteroid (ICS) plus as-needed SABA

Correct answer: As-needed low-dose inhaled corticosteroid (ICS)-formoterol

The GINA 2022 and subsequent guidelines recommend as-needed low-dose ICS-formoterol as the preferred controller for patients with mild to moderate asthma (Step 1 and 2). This patient's symptoms (more than twice a week) place her in at least Step 2. This strategy reduces the risk of severe exacerbations associated with SABA-only treatment by ensuring an anti-inflammatory is taken whenever reliever medication is used. Daily low-dose ICS is an alternative but not the preferred initial approach.

Question 133: A 68-year-old woman with newly diagnosed atrial flutter undergoes successful cardioversion to sinus rhythm. How long should anticoagulation be continued after cardioversion?

48 hours only
At least 4 weeks post-cardioversion, then ongoing based on stroke risk score (Correct answer)
No anticoagulation is needed after successful cardioversion
Anticoagulation for 3 months then stop regardless of risk

Correct answer: At least 4 weeks post-cardioversion, then ongoing based on stroke risk score

Post-cardioversion anticoagulation for at least 4 weeks is mandatory (due to atrial stunning), followed by long-term anticoagulation guided by CHA₂DS₂-VASc score.

Question 134: A 34-year-old female is diagnosed with Graves' disease and is started on methimazole. Which of the following best describes the primary mechanism of action of this medication?

Blocking the peripheral conversion of T4 to T3
Inhibiting the release of pre-formed thyroid hormone
Destroying thyroid follicular cells via antibody-dependent cytotoxicity
Inhibiting the thyroid peroxidase enzyme, thus blocking hormone synthesis (Correct answer)

Correct answer: Inhibiting the thyroid peroxidase enzyme, thus blocking hormone synthesis

Thionamides, which include methimazole and propylthiouracil (PTU), work by inhibiting the thyroid peroxidase (TPO) enzyme. TPO is essential for catalyzing the organification of iodide and the coupling of iodotyrosines to form T4 and T3. By blocking this enzyme, thionamides effectively decrease the synthesis of new thyroid hormones. While PTU also weakly inhibits the peripheral conversion of T4 to T3, this is not the primary mechanism of action for methimazole.

Question 135: A 28-year-old woman with asthma is well controlled on low-dose ICS. She becomes pregnant. Which statement about asthma management in pregnancy is correct?

Oral corticosteroids should never be used even for acute severe asthma
All ICS should be discontinued in the first trimester
LABA are absolutely contraindicated throughout pregnancy
Budesonide is preferred ICS due to the most safety data in pregnancy (Correct answer)

Correct answer: Budesonide is preferred ICS due to the most safety data in pregnancy

Budesonide has the most reassuring safety data in pregnancy and is the preferred ICS, though other ICS are not contraindicated if already effective.

Question 136: Which lab finding best distinguishes iron deficiency anemia from anemia of chronic disease?

Low hemoglobin
Elevated serum ferritin with low TIBC
Low serum ferritin (Correct answer)
Elevated reticulocyte count

Correct answer: Low serum ferritin

A low serum ferritin is highly specific for iron deficiency anemia; in anemia of chronic disease, ferritin is normal or elevated because it is an acute-phase reactant.

Question 137: A 35-year-old athlete collapses during a basketball game. ECG shows asymmetric septal hypertrophy and dynamic LVOT obstruction of 50 mmHg. Which medication is most appropriate for symptom management?

Amlodipine
Metoprolol succinate (Correct answer)
Furosemide
Nitroglycerin

Correct answer: Metoprolol succinate

Beta-blockers like metoprolol are first-line therapy for symptomatic hypertrophic obstructive cardiomyopathy as they reduce heart rate, decrease LV contractility, and lessen dynamic outflow obstruction.

Question 138: Which spirometry pattern is consistent with a diagnosis of restrictive lung disease?

FEV1/FVC ≥ 0.70 with reduced TLC (Correct answer)
FEV1/FVC < 0.70 with normal TLC
FEV1/FVC ≥ 0.70 with normal TLC and reduced DLCO
FEV1/FVC < 0.70 with increased TLC and air trapping

Correct answer: FEV1/FVC ≥ 0.70 with reduced TLC

Restrictive lung disease is defined by reduced TLC (< 80% predicted) with a preserved or elevated FEV1/FVC ratio on spirometry.

Question 139: A patient with COPD exacerbation receives supplemental oxygen and develops worsening somnolence. ABG shows pH 7.28, PaCO2 72 mmHg, PaO2 68 mmHg. What is the best next intervention?

Administer IV sodium bicarbonate
Increase oxygen flow rate to achieve SpO2 >98%
Start noninvasive positive pressure ventilation (NIPPV) (Correct answer)
Perform immediate endotracheal intubation

Correct answer: Start noninvasive positive pressure ventilation (NIPPV)

NIPPV (BiPAP) is the first-line intervention for hypercapnic respiratory failure in COPD exacerbations, reducing the need for intubation and improving outcomes.

Question 140: A 68-year-old develops profuse, watery, non-bloody diarrhea after a 10-day course of clindamycin for a skin infection. Stool PCR is positive for C. difficile toxin. This is his first episode. What is the first-line treatment?

Oral metronidazole
IV metronidazole
Oral vancomycin or fidaxomicin (Correct answer)
Fecal microbiota transplant

Correct answer: Oral vancomycin or fidaxomicin

Updated guidelines (IDSA 2021) recommend oral vancomycin or fidaxomicin over metronidazole for initial C. difficile infection due to superior cure rates.

Question 141: A 25-year-old man presents with episodic gross hematuria 1-2 days after upper respiratory infections. Renal biopsy shows mesangial IgA deposits. What is the most likely diagnosis?

Henoch-Schönlein purpura nephritis
IgA nephropathy (Berger disease) (Correct answer)
Post-streptococcal GN
Thin basement membrane disease

Correct answer: IgA nephropathy (Berger disease)

Synpharyngitic hematuria (hematuria concurrent with URI, not 2-3 weeks later) with mesangial IgA deposits is the hallmark of IgA nephropathy.

Question 142: What is the appropriate duration of antibiotic therapy for uncomplicated, mild-to-moderate CAP that shows clinical improvement?

21 days
5 days (Correct answer)
3 days
10–14 days

Correct answer: 5 days

Current evidence supports 5-day courses for uncomplicated CAP in patients who show clinical stability by day 3.

Question 143: A 30-year-old man presents with urethral discharge and dysuria. Gram stain shows gram-negative intracellular diplococci. In addition to treating gonorrhea, empiric treatment for which co-infection is mandatory?

Trichomonas vaginalis
Syphilis
Herpes simplex virus
Chlamydia trachomatis (Correct answer)

Correct answer: Chlamydia trachomatis

Co-infection with Chlamydia trachomatis is so common with gonorrhea that dual therapy (ceftriaxone + doxycycline or azithromycin) is always recommended.

Question 144: A 28-year-old male presents with a 3-year history of chronic inflammatory back pain and stiffness that improves with exercise but not with rest. A plain radiograph of the pelvis is obtained. Which of the following radiographic findings in the sacroiliac joints would be most characteristic of ankylosing spondylitis?

Subchondral cysts and osteophyte formation
Bilateral symmetric sclerosis and joint space fusion (ankylosis) (Correct answer)
Juxta-articular osteopenia and marginal erosions
Punched-out erosions with sclerotic borders

Correct answer: Bilateral symmetric sclerosis and joint space fusion (ankylosis)

Ankylosing spondylitis is an inflammatory arthritis primarily affecting the axial skeleton. The hallmark radiographic finding is sacroiliitis, which characteristically presents as bilateral and symmetric erosions, subchondral sclerosis, and eventual bridging and fusion (ankylosis) of the sacroiliac joints. In advanced disease, syndesmophyte formation in the spine can lead to a 'bamboo spine' appearance.

Question 145: A patient with cirrhosis and grade 2 hepatic encephalopathy is precipitated by a GI bleed. After controlling the bleed, which intervention specifically targets ammonia reduction to treat the encephalopathy?

IV thiamine supplementation
Branched-chain amino acid infusion
Low-protein enteral nutrition
Lactulose titrated to 2–3 soft stools per day (Correct answer)

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

Lactulose is the first-line treatment for hepatic encephalopathy; it acidifies the colon, traps ammonia as ammonium, and accelerates its fecal excretion.

Question 146: Which electrocardiographic pattern is characteristic of Wolff-Parkinson-White (WPW) syndrome during sinus rhythm?

Prolonged QT interval with U waves
Short PR interval with delta wave and wide QRS (Correct answer)
Long PR interval with narrow QRS
Short PR interval with normal QRS

Correct answer: Short PR interval with delta wave and wide QRS

WPW syndrome manifests during sinus rhythm as a short PR interval (<120 ms), slurred upstroke (delta wave), and widened QRS due to ventricular pre-excitation via an accessory pathway.

Question 147: A 72-year-old woman receives IV contrast for a CT scan. Her baseline creatinine is 1.8 mg/dL. Creatinine rises to 2.6 mg/dL at 48 hours. Which finding best distinguishes contrast-induced nephropathy from pre-renal azotemia?

Response to IV fluids
Rapid recovery within 24 hours
BUN:creatinine ratio > 20
Urine sodium > 40 mEq/L (Correct answer)

Correct answer: Urine sodium > 40 mEq/L

A urine sodium >40 mEq/L indicates tubular dysfunction (FENa >1%), consistent with intrinsic AKI such as contrast nephropathy rather than pre-renal azotemia.

Question 148: A 65-year-old immunocompromised patient develops fever and a new pulmonary infiltrate with a halo sign on CT chest. What is the most likely diagnosis?

Bacterial lung abscess
Cytomegalovirus pneumonitis
Pneumocystis jirovecii pneumonia
Invasive pulmonary aspergillosis (Correct answer)

Correct answer: Invasive pulmonary aspergillosis

The halo sign (ground-glass opacity surrounding a nodule) on CT chest in an immunocompromised host is classic for invasive pulmonary aspergillosis.

Question 149: A patient presents with fever, cough, and bilateral hilar adenopathy on chest X-ray after exposure to bird droppings in the Ohio River Valley. What is the most likely diagnosis?

Aspergillosis
Blastomycosis
Histoplasmosis (Correct answer)
Coccidioidomycosis

Correct answer: Histoplasmosis

Histoplasma capsulatum is endemic to the Ohio and Mississippi River Valleys and is associated with exposure to bat and bird droppings.

Question 150: A 33-year-old man presents with recurrent oral ulcers, genital ulcers, and uveitis. He also reports bloody diarrhea. Which GI condition is most strongly associated with this systemic disorder?

Behçet's disease with GI involvement (Correct answer)
Ulcerative colitis
Celiac disease
Crohn's disease

Correct answer: Behçet's disease with GI involvement

The triad of oral ulcers, genital ulcers, and uveitis defines Behçet's disease, which can cause GI ulceration (most often in the ileocecal region) with bloody diarrhea.

Question 151: A 70-year-old man with BPH undergoes bilateral hydronephrosis relief by Foley catheter insertion. Over the next 24 hours he produces 8 liters of urine and his creatinine falls from 8.2 to 3.1 mg/dL. What electrolyte abnormality requires monitoring?

Hypokalemia and hyponatremia from post-obstructive diuresis (Correct answer)
Hyponatremia from free water retention
Hypocalcemia from hungry bone syndrome
Hyperkalemia from tubular injury

Correct answer: Hypokalemia and hyponatremia from post-obstructive diuresis

Post-obstructive diuresis causes massive urinary losses of sodium, potassium, and water; close monitoring and replacement are required to prevent dangerous electrolyte depletion.

Question 152: Which type of lung cancer is most strongly associated with hypercalcemia without bone metastases?

Large cell carcinoma
Squamous cell carcinoma (Correct answer)
Adenocarcinoma
Small cell lung cancer

Correct answer: Squamous cell carcinoma

Squamous cell carcinoma secretes PTHrP, causing hypercalcemia of malignancy independent of bone metastases.

Question 153: An HIV-positive patient with CD4 count of 150 cells/μL is started on antiretroviral therapy. Two weeks later he develops worsening cervical lymphadenopathy and fever. Lymph node biopsy shows non-caseating granulomas. What is the most likely diagnosis?

Drug-induced lymphadenopathy
New opportunistic infection
ART failure
Immune reconstitution inflammatory syndrome (IRIS) (Correct answer)

Correct answer: Immune reconstitution inflammatory syndrome (IRIS)

IRIS occurs when recovering immunity mounts an exaggerated response to a previously subclinical infection (here, likely mycobacterial), typically 2–8 weeks after ART initiation.

Question 154: A 30-year-old marathon runner collapses near the finish line. Labs show creatinine 4.2 mg/dL, CK 85,000 U/L, urine dipstick positive for blood but no RBCs on microscopy. What is the pathophysiology of AKI in this case?

Myoglobinuria causing tubular injury and cast obstruction (Correct answer)
Dehydration alone causing prerenal AKI
NSAIDs taken pre-race causing interstitial nephritis
Heat stroke causing glomerulonephritis

Correct answer: Myoglobinuria causing tubular injury and cast obstruction

Rhabdomyolysis releases myoglobin, which causes direct tubular toxicity, tubular obstruction by casts, and renal vasoconstriction, leading to AKI.

Question 155: A 58-year-old female with no significant past medical history is admitted to a general medical ward for community-acquired pneumonia. She is hemodynamically stable, with an oxygen saturation of 94% on room air. Which of the following antibiotic regimens is the most appropriate initial empiric therapy?

Levofloxacin monotherapy
Vancomycin plus piperacillin-tazobactam
Ceftriaxone plus azithromycin (Correct answer)
Doxycycline monotherapy

Correct answer: Ceftriaxone plus azithromycin

For an adult with non-severe community-acquired pneumonia admitted to an inpatient ward, standard empiric therapy should cover both typical and atypical pathogens. The recommended primary regimen is a beta-lactam (e.g., ceftriaxone, ampicillin-sulbactam) combined with a macrolide (e.g., azithromycin). [16, 22] Monotherapy with a respiratory fluoroquinolone (e.g., levofloxacin) is an alternative. Vancomycin and piperacillin-tazobactam provide overly broad coverage for MRSA and Pseudomonas, which is not indicated without specific risk factors. Doxycycline monotherapy is typically reserved for outpatient treatment.

Question 156: A 70-year-old man with known aortic stenosis presents with syncope on exertion. His echocardiogram shows a mean gradient of 48 mmHg and AVA of 0.7 cm². What is the next step?

Exercise stress testing to confirm severity
Balloon aortic valvuloplasty as definitive therapy
Medical management with diuretics
Aortic valve replacement (surgical or TAVR) (Correct answer)

Correct answer: Aortic valve replacement (surgical or TAVR)

Symptomatic severe aortic stenosis (syncope, angina, or HF) is a Class I indication for aortic valve replacement; exercise stress testing is contraindicated in symptomatic severe AS.

Question 157: A 68-year-old man with NYHA class III heart failure has a biventricular pacemaker (CRT). His EF was 25% six months ago. Repeat echo now shows EF of 42%. Which statement about his ICD is most accurate?

The ICD should be kept given his prior indication (Correct answer)
The ICD should be removed since EF has recovered
ICD should be upgraded to a subcutaneous device
ICD therapy is contraindicated with EF >35%

Correct answer: The ICD should be kept given his prior indication

Even with EF recovery, the ICD should be kept because patients retain ongoing risk of sudden cardiac death and the original indication for implantation remains valid.

Question 158: A 45-year-old woman presents with fatigue and pallor. Labs show Hgb 8.2 g/dL, MCV 72 fL, and low serum ferritin. What is the most likely diagnosis?

Anemia of chronic disease
Vitamin B12 deficiency anemia
Thalassemia trait
Iron deficiency anemia (Correct answer)

Correct answer: Iron deficiency anemia

Iron deficiency anemia classically presents with microcytic anemia (low MCV) and low serum ferritin, which is the most specific marker of depleted iron stores.

Question 159: Which of the following is an ABSOLUTE indication for emergent dialysis in AKI?

Uremic pericarditis with friction rub (Correct answer)
BUN >60 mg/dL
Urine output <0.5 mL/kg/h for 6 hours
Creatinine >4 mg/dL

Correct answer: Uremic pericarditis with friction rub

Uremic pericarditis is an absolute indication for urgent dialysis, as it indicates severe uremia that can progress to life-threatening pericardial effusion or tamponade.

Question 160: A 60-year-old woman presents with dysphagia to solids and liquids simultaneously from the onset. Barium swallow shows a 'bird-beak' appearance at the lower esophageal sphincter. What is the most likely diagnosis?

Esophageal carcinoma
Scleroderma esophagus
Achalasia (Correct answer)
Diffuse esophageal spasm

Correct answer: Achalasia

Achalasia classically presents with dysphagia to both solids and liquids simultaneously and shows a bird-beak deformity at the lower esophageal sphincter on barium swallow.

Question 161: A 68-year-old man who is a patient in the emergency room woke up with palpitations, chest pain, dyspnea, and vertigo. He claims his heart is "beating," but he has no history of heart disease or high blood pressure. His pulse is quick and erratic, his blood pressure is 85/60 mmHg, and crackles can be heard at the bases of his lungs. His standard laboratory tests, including a troponin level, are expected. His EKG reveals atrial fibrillation with a 130-beat-per-minute ventricular response. Which course of action is ideal?

Intravenous digoxin (Correct answer)
Immediate cardioversion
Intravenous beta-blocker
Delayed cardioversion after anticoagulation

Correct answer: Intravenous digoxin

The patient presents with atrial fibrillation, rapid ventricular response, and signs of hemodynamic instability including hypotension and crackles, indicating heart failure. Digoxin is a cardiac glycoside that slows the ventricular rate in atrial fibrillation by increasing vagal tone and slowing AV nodal conduction, while also improving cardiac contractility, making it a suitable choice for rate control in hemodynamically unstable patients with concomitant heart failure.

Question 162: The JAK2 V617F mutation is present in approximately what percentage of polycythemia vera cases?

30-40% of cases
Greater than 95% of cases (Correct answer)
50-60% of cases
10-20% of cases

Correct answer: Greater than 95% of cases

The JAK2 V617F point mutation is present in over 95% of polycythemia vera cases and is a major diagnostic criterion per WHO criteria.

Question 163: A 64-year-old man with cirrhosis due to non-alcoholic steatohepatitis presents with increasing confusion, lethargy, and asterixis. His family notes he has been more forgetful over the past week. He has no fever or abdominal pain. What is the most appropriate initial pharmacologic therapy for this patient's condition?

Lactulose (Correct answer)
Rifaximin
Intravenous albumin
Propranolol

Correct answer: Lactulose

The patient is presenting with signs of overt hepatic encephalopathy (HE). According to guidelines from the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL), lactulose is the first-line treatment for an episode of overt HE. It works by decreasing the intestinal production and absorption of ammonia. Rifaximin is an effective add-on therapy, particularly for preventing recurrence, but is not the initial monotherapy of choice. Intravenous albumin is used in specific complications like hepatorenal syndrome or SBP, and propranolol is used for portal hypertension and variceal prophylaxis.

Question 164: A 25-year-old man with ulcerative colitis has a colonoscopy showing continuous inflammation from the rectum to the splenic flexure. He has 6 bloody stools per day and a heart rate of 102 bpm. What is the most appropriate next step?

Emergency colectomy
Oral prednisone taper
IV corticosteroids (Correct answer)
Oral mesalamine

Correct answer: IV corticosteroids

Severe UC (Truelove-Witts criteria: >6 bloody stools/day plus systemic features) requires hospitalization and IV corticosteroids as first-line treatment.

Question 165: A patient with severe persistent asthma remains uncontrolled on high-dose ICS/LABA and tiotropium. Serum IgE is 850 IU/mL and blood eosinophils are 350 cells/μL. Which biologic therapy targets both IgE and is FDA-approved for this patient?

Mepolizumab (anti-IL-5)
Omalizumab (anti-IgE) (Correct answer)
Benralizumab (anti-IL-5Rα)
Dupilumab (anti-IL-4Rα)

Correct answer: Omalizumab (anti-IgE)

Omalizumab binds free IgE and is indicated for moderate-to-severe allergic asthma with elevated serum IgE (30-700 IU/mL) in patients ≥ 6 years; at 850 IU/mL it exceeds the labeled range but dupilumab or mepolizumab would be alternatives.

Question 166: A 30-year-old woman in her 28th week of pregnancy develops dyspnea, orthopnea, and an EF of 35% on echo. She has no prior cardiac history. What is the most likely diagnosis?

Pre-eclampsia with pulmonary edema
Amniotic fluid embolism
Pulmonary embolism
Peripartum cardiomyopathy (Correct answer)

Correct answer: Peripartum cardiomyopathy

Peripartum cardiomyopathy presents with new-onset heart failure with reduced EF in the last month of pregnancy or within 5 months postpartum without another identifiable cause.

Question 167: A 68-year-old woman with osteoporosis takes high-dose vitamin D supplements. She now has polyuria, polydipsia, constipation, confusion, and serum calcium of 13.2 mg/dL. Her PTH is suppressed. The most likely mechanism of hypercalcemia is:

Malignancy-associated PTHrP release
Primary hyperparathyroidism
Milk-alkali syndrome
Vitamin D toxicity causing excess intestinal calcium absorption (Correct answer)

Correct answer: Vitamin D toxicity causing excess intestinal calcium absorption

Vitamin D toxicity increases intestinal calcium absorption via 1,25(OH)2D, causing hypercalcemia with suppressed PTH.

Question 168: A 35-year-old woman presents with a malar rash, arthralgias, and positive ANA with anti-dsDNA antibodies. Urinalysis shows proteinuria and RBC casts. Which class of lupus nephritis carries the worst prognosis if untreated?

Class IV (diffuse proliferative) (Correct answer)
Class V (membranous)
Class I (minimal mesangial)
Class III (focal proliferative)

Correct answer: Class IV (diffuse proliferative)

Class IV (diffuse proliferative) lupus nephritis is the most severe form and carries the worst renal prognosis without aggressive immunosuppressive therapy.

Question 169: A patient with psoriatic arthritis has predominantly distal interphalangeal joint involvement with nail pitting and 'sausage digit.' Which HLA type is most strongly associated with this condition?

HLA-B27 (Correct answer)
HLA-DR4
HLA-B13
HLA-Cw6

Correct answer: HLA-B27

HLA-B27 is the most strongly associated HLA antigen in psoriatic arthritis, particularly in patients with axial involvement.

Question 170: Which radiographic pattern is MOST characteristic of Pneumocystis jirovecii pneumonia (PCP) in an immunocompromised host?

Bilateral interstitial/perihilar infiltrates (Correct answer)
Dense lobar consolidation
Cavitary lesion with air-fluid level
Pleural effusion with atelectasis

Correct answer: Bilateral interstitial/perihilar infiltrates

PCP classically presents with bilateral perihilar interstitial infiltrates on CXR, often with a ground-glass pattern on CT.

Question 171: A 66-year-old man presents with melena and hemodynamic instability. Upper endoscopy reveals a 1 cm duodenal ulcer with a visible vessel. After endoscopic hemostasis, which pharmacologic regimen best reduces rebleeding risk?

Sucralfate suspension every 6 hours
Oral omeprazole 20 mg daily
IV ranitidine 50 mg every 8 hours
High-dose IV pantoprazole infusion (80 mg bolus then 8 mg/hr for 72 hours) (Correct answer)

Correct answer: High-dose IV pantoprazole infusion (80 mg bolus then 8 mg/hr for 72 hours)

High-dose IV PPI infusion (bolus followed by continuous infusion for 72 hours) significantly reduces rebleeding, need for surgery, and mortality after endoscopic hemostasis of high-risk stigmata.

Question 172: A 68-year-old male from a nursing home with a long-term indwelling urinary catheter presents with fever and flank pain. He was treated with levofloxacin for a UTI two months ago. He is admitted for pyelonephritis. Which of the following is the most appropriate empiric intravenous antibiotic while awaiting urine culture results?

Ciprofloxacin
Ceftriaxone
Piperacillin-tazobactam (Correct answer)
Ampicillin-sulbactam

Correct answer: Piperacillin-tazobactam

This patient has a complicated UTI (pyelonephritis with an indwelling catheter) and several risk factors for a multidrug-resistant organism: nursing home residence, indwelling hardware, and recent fluoroquinolone use. Empiric therapy should cover common uropathogens as well as *Pseudomonas aeruginosa*. Piperacillin-tazobactam provides this broad-spectrum coverage. Ceftriaxone lacks reliable Pseudomonas coverage. Ciprofloxacin is a poor choice due to recent use and high resistance rates. Ampicillin-sulbactam has limited activity against many common gram-negative uropathogens in this setting.

Question 173: A 59-year-old patient on treatment for latent tuberculosis with isoniazid develops fatigue, nausea, and right upper quadrant discomfort. Laboratory tests reveal an AST of 350 U/L and an ALT of 410 U/L (baseline was normal). Which of the following patterns of liver injury is most characteristically associated with isoniazid toxicity?

Granulomatous hepatitis
Nodular regenerative hyperplasia
Cholestatic injury
Hepatocellular injury (Correct answer)

Correct answer: Hepatocellular injury

Isoniazid (INH) is a well-known cause of drug-induced liver injury (DILI). The classic presentation is a hepatocellular pattern of injury, which mimics acute viral hepatitis. This is characterized by a significant elevation in aminotransferases (AST and ALT), often more than 10 times the upper limit of normal, as seen in this patient. A cholestatic pattern would involve a predominant rise in alkaline phosphatase and bilirubin. While other patterns can occur, hepatocellular injury is the most common and characteristic form of INH hepatotoxicity.

Question 174: A 70-year-old female with a history of heart failure and hypertension presents to the emergency department with acute-onset severe dyspnea, orthopnea, and a cough producing pink, frothy sputum. On examination, her blood pressure is 180/100 mmHg, heart rate is 110 bpm, and respiratory rate is 30/min. Auscultation reveals diffuse crackles throughout both lung fields. Oxygen saturation is 88% on room air. After applying oxygen, what is the most critical next step in management?

Administer a high-dose intravenous loop diuretic
Administer intravenous nitroglycerin (Correct answer)
Obtain a B-type natriuretic peptide (BNP) level
Administer intravenous dobutamine

Correct answer: Administer intravenous nitroglycerin

This patient is presenting with hypertensive acute decompensated heart failure, specifically flash pulmonary edema. The immediate priority is to reduce both preload and afterload. Intravenous vasodilators, such as nitroglycerin, are the key component of care in this scenario. They rapidly decrease afterload, leading to improved cardiac output and resolution of pulmonary congestion. While diuretics are important, their onset is slower, and afterload reduction is the most urgent priority in a hypertensive crisis. Dobutamine is an inotrope and is not indicated in a hypertensive patient. A BNP level can confirm the diagnosis but should not delay critical treatment.

Question 175: Which set of clinical features best describes the CRAB criteria used to diagnose symptomatic multiple myeloma?

HyperCalcemia, Renal failure, Anemia, and Bone lesions (Correct answer)
Confusion, Renal stones, Abdominal pain, and Bone pain
Cytopenias, Rash, Arthritis, and Bone pain
Cachexia, Recurrent infections, Adenopathy, and Bleeding

Correct answer: HyperCalcemia, Renal failure, Anemia, and Bone lesions

CRAB criteria for multiple myeloma are: hyperCalcemia, Renal failure, Anemia, and Bone lytic lesions—end-organ damage that indicates symptomatic disease requiring treatment.

Question 176: A 30-year-old male presents with bilateral sacroiliitis, uveitis, and limited lumbar flexion. Schober test measures 2 cm expansion. Which finding on MRI would confirm active sacroiliitis?

Periarticular soft tissue calcification
Osteophyte formation
Bone marrow edema (subchondral) (Correct answer)
Joint space narrowing

Correct answer: Bone marrow edema (subchondral)

Bone marrow edema on MRI (T2/STIR sequences) is the hallmark of active inflammatory sacroiliitis in ankylosing spondylitis.

Question 177: A 25-year-old woman presents with recurrent miscarriages, livedo reticularis, and a prolonged aPTT that does not correct with mixing study. Which antibody panel should be ordered?

Anticardiolipin and anti-beta-2 glycoprotein I (Correct answer)
Anti-SCL-70 and anti-centromere
Anti-dsDNA and anti-Smith
Anti-Ro/SSA and anti-La/SSB

Correct answer: Anticardiolipin and anti-beta-2 glycoprotein I

Antiphospholipid syndrome presents with thrombosis and/or recurrent pregnancy loss with positive anticardiolipin or anti-beta-2 glycoprotein I antibodies and lupus anticoagulant.

Question 178: Which anticoagulant requires NO dose adjustment in patients with severe renal failure?

Enoxaparin (LMWH)
Warfarin (Correct answer)
Dabigatran
Rivaroxaban

Correct answer: Warfarin

Warfarin is hepatically metabolized and has no significant renal excretion, making it the anticoagulant that does not require dose adjustment in renal failure.

Question 179: A 62-year-old man presents with sudden-onset tearing chest pain radiating to the back. CT angiography shows an intimal flap in the descending aorta without involvement of the ascending aorta. What is the first-line management?

Endovascular stent grafting
Medical therapy with heart rate and blood pressure control (Correct answer)
Thrombolysis
Emergency surgery

Correct answer: Medical therapy with heart rate and blood pressure control

Uncomplicated Type B aortic dissection (involving only the descending aorta) is managed medically with IV beta-blockers to achieve heart rate <60 bpm and SBP 100-120 mmHg.

Question 180: A 55-year-old man is newly diagnosed with Stage 1 Hypertension with a blood pressure of 136/88 mmHg on multiple readings. He has no other medical problems, and his 10-year atherosclerotic cardiovascular disease (ASCVD) risk is calculated to be 6%. According to the 2025 ACC/AHA guidelines, what is the most appropriate initial management step?

Recommend a 3- to 6-month trial of lifestyle modifications. (Correct answer)
Initiate therapy with a thiazide diuretic.
Start treatment with an ACE inhibitor.
Initiate combination therapy with an ARB and a calcium channel blocker.

Correct answer: Recommend a 3- to 6-month trial of lifestyle modifications.

According to the 2025 ACC/AHA hypertension guidelines, for adults with Stage 1 hypertension (130-139/80-89 mmHg) and a low 10-year ASCVD risk (<7.5% using the PREVENT calculator), the initial recommendation is a trial of lifestyle modifications for 3 to 6 months. Pharmacologic therapy is recommended if blood pressure remains elevated after this trial. For those with Stage 1 hypertension and a high ASCVD risk (≥7.5%) or with clinical CVD, diabetes, or CKD, both lifestyle changes and antihypertensive medication are recommended from the start.

Question 181: A patient with nephrotic syndrome develops sudden flank pain and hematuria. CT shows right renal vein thrombosis. Which underlying condition most predisposes to renal vein thrombosis in nephrotic syndrome?

Minimal change disease
IgA nephropathy
Membranous nephropathy (Correct answer)
FSGS

Correct answer: Membranous nephropathy

Membranous nephropathy has the highest risk of renal vein thrombosis among nephrotic syndromes due to urinary loss of anticoagulant proteins (antithrombin III, protein C/S).

Question 182: A 22-year-old college student presents with fever, pharyngitis, and splenomegaly. Monospot test is positive. Which complication warrants restriction from contact sports?

Splenic rupture (Correct answer)
Hepatitis
Hemolytic anemia
Airway obstruction

Correct answer: Splenic rupture

Splenic rupture is the most feared complication of infectious mononucleosis, and patients should avoid contact sports for at least 3–4 weeks.

Question 183: A 28-year-old woman presents with chronic diarrhea, bloating, and newly diagnosed iron deficiency anemia. Celiac disease is suspected. Which of the following is the most appropriate initial serologic test for this condition in an adult who is not IgA deficient?

Tissue transglutaminase (tTG)-IgA antibody (Correct answer)
Genetic testing for HLA-DQ2/DQ8
Anti-gliadin antibodies (AGA), IgG and IgA
Anti-endomysial antibodies (EMA), IgA

Correct answer: Tissue transglutaminase (tTG)-IgA antibody

The tissue transglutaminase (tTG)-IgA antibody test is the preferred single test for detecting celiac disease in adults and children over the age of two, due to its high sensitivity and specificity. Anti-endomysial (EMA) antibodies are highly specific but less sensitive and more operator-dependent. Anti-gliadin antibodies are no longer recommended for primary screening. Genetic testing is useful to rule out celiac disease but does not confirm a diagnosis.

Question 184: Legionella urinary antigen testing detects which serogroup of Legionella pneumophila?

Serogroup 1 only (Correct answer)
All serogroups equally
Serogroups 1 and 2
Serogroup 6 only

Correct answer: Serogroup 1 only

The Legionella urinary antigen test detects only serogroup 1, which causes approximately 70–80% of Legionella pneumonia cases.

Question 185: A patient with ankylosing spondylitis has failed two NSAIDs over 4 weeks each. Which biologic class is first-line for axial spondyloarthropathy?

CTLA4-Ig (abatacept)
Anti-IL-6 agents (tocilizumab)
Anti-IL-12/23 agents (ustekinumab)
TNF inhibitors or IL-17 inhibitors (Correct answer)

Correct answer: TNF inhibitors or IL-17 inhibitors

TNF inhibitors (etanercept, adalimumab, infliximab) and IL-17 inhibitors (secukinumab, ixekizumab) are the approved first-line biologics for NSAID-refractory axial spondyloarthropathy.

Question 186: Which of the following is the MOST important measure to prevent catheter-associated urinary tract infections (CAUTIs) in hospitalized patients?

Prompt removal of urinary catheters when no longer needed (Correct answer)
Daily antimicrobial bladder washouts
Routine prophylactic antibiotics in catheterized patients
Silver-coated catheters in all ICU patients

Correct answer: Prompt removal of urinary catheters when no longer needed

The most effective CAUTI prevention strategy is daily reassessment and prompt catheter removal, as infection risk increases with each catheter-day.

Question 187: A 72-year-old male recently treated with clindamycin presents with 5-6 watery, non-bloody stools per day for three days. He has lower abdominal cramping but no fever. His WBC count is 10,500/μL and serum creatinine is 1.0 mg/dL. A stool test is positive for Clostridioides difficile toxin. According to the most recent IDSA guidelines, which of the following is the most appropriate initial treatment for this patient's non-severe C. difficile infection?

Oral Vancomycin 125 mg four times daily for 10 days
Oral Fidaxomicin 200 mg twice daily for 10 days (Correct answer)
Oral Rifaximin 400 mg three times daily for 10 days
Oral Metronidazole 500 mg three times daily for 10 days

Correct answer: Oral Fidaxomicin 200 mg twice daily for 10 days

The 2021 IDSA guidelines recommend fidaxomicin as the preferred therapy for an initial episode of non-severe C. difficile infection based on superior sustained response rates. Oral vancomycin is an acceptable alternative. Metronidazole is no longer recommended for initial treatment of even mild-to-moderate CDI due to inferior efficacy compared to vancomycin and fidaxomicin.

Question 188: A patient with DKA has serum phosphate of 0.8 mg/dL. In which clinical scenario would phosphate replacement be most strongly indicated?

Symptomatic hypophosphatemia with cardiac dysfunction or respiratory failure (Correct answer)
All DKA patients as part of routine repletion
Any DKA patient with detectable ketonuria
Serum phosphate < 2.0 mg/dL in all patients

Correct answer: Symptomatic hypophosphatemia with cardiac dysfunction or respiratory failure

Phosphate replacement is indicated in DKA when hypophosphatemia is symptomatic or associated with cardiac/respiratory dysfunction.

Question 189: A 60-year-old with alcoholic cirrhosis develops increasing abdominal girth. Ultrasound confirms ascites. Serum-ascites albumin gradient (SAAG) is 1.5 g/dL. What does this SAAG indicate?

Tuberculous peritonitis
Portal hypertension-related ascites (Correct answer)
Nephrotic syndrome
Malignant ascites

Correct answer: Portal hypertension-related ascites

SAAG ≥ 1.1 g/dL indicates portal hypertension as the cause of ascites with 97% accuracy.

Question 190: A 28-year-old man presents with hematuria and deafness since childhood. Electron microscopy of his renal biopsy shows thinning and splitting of the glomerular basement membrane in a 'basket-weave' pattern. What is the inheritance pattern of this condition?

Autosomal dominant
X-linked (most common form) (Correct answer)
Autosomal recessive
Mitochondrial

Correct answer: X-linked (most common form)

Alport syndrome most commonly results from X-linked mutations in COL4A5 encoding type IV collagen, causing nephritis, sensorineural deafness, and ocular abnormalities.

Question 191: A 35-year-old woman presents with recurrent episodes of right upper quadrant pain after fatty meals. HIDA scan shows a gallbladder ejection fraction of 20%. What is the most appropriate management?

Ursodeoxycholic acid therapy
Endoscopic sphincterotomy
Low-fat diet alone
Laparoscopic cholecystectomy (Correct answer)

Correct answer: Laparoscopic cholecystectomy

Biliary dyskinesia with an ejection fraction below 35-40% and typical biliary symptoms is best treated with laparoscopic cholecystectomy.

Question 192: A 55-year-old African American male is diagnosed with Stage 1 Hypertension with an average blood pressure of 138/88 mmHg on multiple readings. He has no other comorbidities. His 10-year ASCVD risk score is calculated to be 12%. According to the 2025 ACC/AHA guidelines, what is the most appropriate initial monotherapy?

Metoprolol
Spironolactone
Amlodipine (Correct answer)
Lisinopril

Correct answer: Amlodipine

For African American adults with hypertension but without heart failure or chronic kidney disease, the ACC/AHA guidelines recommend either a thiazide-type diuretic or a calcium channel blocker (CCB) as first-line therapy. ACE inhibitors or ARBs are less effective as monotherapy in this population for blood pressure control, although they may be used in combination. Beta-blockers are not considered first-line agents for uncomplicated hypertension.

Question 193: An intermittent, mid-sternal chest ache that typically lasts 5 to 10 minutes affects a 57-year-old male. Both when we are working and when we are not. His throat also feels sore, which occasionally gets better with antacids. He stopped smoking around the age of 50. He denies having other serious medical issues. His type 2 diabetes and hypertension run in the family. His height is 70 inches, weight is 210 pounds, blood pressure is 135/85 mmHg, and pulse is regular at 76. Auscultation reveals his chest is clean and free of cardiac rubs or murmurs. The overall evaluation is unfavorable. He has a normal electrocardiogram. What logical step would result in the best chance of a diagnosis?

Troponin Level
Coronary Angiography
EGD Endoscopy
Technetium Tc99m Sestamibi stress test (Correct answer)

Correct answer: Technetium Tc99m Sestamibi stress test

The patient's intermittent chest pain, combined with multiple risk factors for coronary artery disease (type 2 diabetes, hypertension, obesity, family history) and a normal resting EKG, warrants further investigation for inducible ischemia. A Technetium Tc99m Sestamibi stress test is an excellent non-invasive diagnostic step to evaluate for perfusion abnormalities that might not be evident at rest, providing the best chance of diagnosing coronary artery disease.

Question 194: A 55-year-old diabetic patient develops painless black eschar on the nasal turbinates with orbital swelling and vision changes after DKA. Which organism is responsible?

Mucor/Rhizopus species (Correct answer)
Aspergillus fumigatus
Candida albicans
Cryptococcus neoformans

Correct answer: Mucor/Rhizopus species

Rhinocerebral mucormycosis is caused by Mucor/Rhizopus species and classically presents in diabetics during DKA, causing angioinvasion with characteristic black necrotic eschar.

Question 195: A 33-year-old patient with type 1 diabetes is admitted with severe DKA. Initial management includes aggressive IV fluid resuscitation and a continuous regular insulin infusion. According to current guidelines, what is the recommended initial rate for the insulin infusion in most adult patients?

0.2 units/kg/hour without a bolus
0.05 units/kg/hour without a bolus
0.1 units/kg/hour, with or without an initial bolus (Correct answer)
A fixed rate of 20 units/hour until blood glucose is <300 mg/dL

Correct answer: 0.1 units/kg/hour, with or without an initial bolus

The standard and widely recommended initial dose for a continuous intravenous insulin infusion in adult DKA is 0.1 units/kg/hour. An initial IV bolus of 0.1 units/kg is sometimes given, but studies have shown that starting with an infusion of 0.14 units/kg/hr without a bolus is also effective. A lower rate may not be sufficient to suppress ketogenesis, while a higher rate increases the risk of hypoglycemia and hypokalemia without proven benefit. Fixed-rate infusions that are not weight-based are not standard practice.

Question 196: What is the most common cause of secondary hypertension in adults under 40 years of age?

Pheochromocytoma
Primary aldosteronism
Renal artery stenosis due to fibromuscular dysplasia (Correct answer)
Obstructive sleep apnea

Correct answer: Renal artery stenosis due to fibromuscular dysplasia

Fibromuscular dysplasia causing renal artery stenosis is the most common cause of renovascular hypertension in young women and secondary hypertension in adults under 40.

Question 197: A 75-year-old woman presents with a 2-month history of severe stiffness and aching in her shoulders, neck, and pelvic girdle. The stiffness is most pronounced in the morning, making it difficult for her to get out of bed. She also reports malaise and a low-grade fever. Laboratory tests show a markedly elevated ESR of 90 mm/hr. What is the most appropriate initial therapy?

High-dose prednisone (60 mg daily)
Naproxen 500 mg twice daily
Methotrexate 15 mg weekly
Low-dose prednisone (15 mg daily) (Correct answer)

Correct answer: Low-dose prednisone (15 mg daily)

The patient's age, symmetric proximal girdle pain and stiffness, morning stiffness, and markedly elevated inflammatory markers are classic for polymyalgia rheumatica (PMR). The standard and most effective first-line treatment for PMR is low-dose oral prednisone, typically in the range of 12.5-25 mg daily, which usually produces a rapid and dramatic clinical response. High-dose prednisone is reserved for suspected concurrent giant cell arteritis (GCA). Methotrexate is a steroid-sparing agent used later if needed, and NSAIDs are generally ineffective.

Question 198: A post-STEMI patient is started on an ACE inhibitor. What is the PRIMARY evidence-based indication for this therapy?

Prevention of ventricular arrhythmias
Reduction of LV remodeling and mortality, especially with reduced EF (Correct answer)
Prevention of in-stent thrombosis
Lowering LDL cholesterol

Correct answer: Reduction of LV remodeling and mortality, especially with reduced EF

ACE inhibitors reduce LV remodeling, HF, and mortality after MI, with greatest benefit in patients with anterior STEMI or reduced ejection fraction (EF ≤40%).

Question 199: A 50-year-old patient with cirrhosis presents with fever, abdominal pain, and ascites with PMN count > 250 cells/μL on paracentesis. What is the empiric treatment of choice?

Oral amoxicillin-clavulanate
Piperacillin-tazobactam plus vancomycin
IV cefotaxime (or ceftriaxone) (Correct answer)
Metronidazole plus ciprofloxacin

Correct answer: IV cefotaxime (or ceftriaxone)

IV third-generation cephalosporins (cefotaxime or ceftriaxone) are the standard empiric therapy for spontaneous bacterial peritonitis.

Question 200: A patient with idiopathic pulmonary fibrosis has a 6-minute walk distance of 280 meters and SpO2 nadir of 84%. Which therapy is indicated?

Pirfenidone or nintedanib to slow fibrosis progression (Correct answer)
Azathioprine plus N-acetylcysteine triple therapy
Prophylactic trimethoprim-sulfamethoxazole only
High-dose prednisone taper for 12 weeks

Correct answer: Pirfenidone or nintedanib to slow fibrosis progression

Pirfenidone and nintedanib are the two antifibrotic agents with proven benefit in slowing FVC decline in IPF and are the standard of care.

Internal Medicine Board Exam

The Internal Medicine Board Exam exam validates essential knowledge and skills required for certification or licensure in this field.

200

Questions

240 min

Time Limit

70%

To Pass

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds