Internal Medicine Board Exam — Questions and Answers

Question 1: A 30-year-old with bloody diarrhea, tenesmus, and diffuse colitis on colonoscopy is diagnosed with ulcerative colitis. After failing oral mesalamine, what is the next escalation?

Oral corticosteroids (Correct answer)
Colectomy
Infliximab immediately
Azathioprine as monotherapy

Correct answer: Oral corticosteroids

Moderate UC failing aminosalicylates is treated with corticosteroids before escalating to biologics or immunomodulators.

Question 2: A 45-year-old woman with Sjögren syndrome presents with purpura, peripheral neuropathy, and elevated serum cryoglobulins. Which complication is she at highest risk for?

Cervical carcinoma
Thyroid lymphoma
Renal cell carcinoma
Non-Hodgkin's lymphoma (Correct answer)

Correct answer: Non-Hodgkin's lymphoma

Sjögren syndrome carries a 44-fold increased risk of non-Hodgkin's lymphoma, particularly MALT lymphoma of the parotid gland.

Question 3: When symptoms persist despite receiving the best care possible from b-blockers, ACEI, diuretics, and aldosterone antagonists in patients with EF 40%, digoxin should be given.

When is surgery indicated for AAA?
What is the treatment for cholangitis?
What are the two pathological types of HCC?
When should digoxin be used in CHF patients (Correct answer)

Correct answer: When should digoxin be used in CHF patients

The provided text directly states the indication for digoxin use in CHF patients: 'When symptoms persist despite receiving the best care possible from b-blockers, ACEI, diuretics, and aldosterone antagonists in patients with EF 40%, digoxin should be given.' This clearly outlines that digoxin is reserved for symptomatic patients with reduced ejection fraction who remain symptomatic despite optimal guideline-directed medical therapy.

Question 4: Which troponin characteristic best distinguishes Type 2 MI (supply-demand mismatch) from Type 1 MI (plaque rupture)?

Higher absolute troponin level in Type 2 MI
Clinical context and absence of obstructive coronary disease on angiography in Type 2 MI (Correct answer)
Troponin I elevation only in Type 1 MI
Faster troponin rise in Type 2 MI

Correct answer: Clinical context and absence of obstructive coronary disease on angiography in Type 2 MI

Type 2 MI is distinguished by clinical context (e.g., sepsis, tachyarrhythmia, anemia) causing supply-demand mismatch, often without obstructive CAD on angiography, rather than by troponin kinetics.

Question 5: A 45-year-old man is hospitalized for community-acquired pneumonia and treated with intravenous piperacillin-tazobactam. Ten days later, his serum creatinine rises from a baseline of 1.0 mg/dL to 3.5 mg/dL. Urinalysis reveals white blood cells, red blood cells, and white blood cell casts. A peripheral blood smear shows eosinophilia. Which of the following is the most likely cause of his acute kidney injury?

Prerenal Azotemia
Acute Interstitial Nephritis (AIN) (Correct answer)
Acute Tubular Necrosis (ATN)
Postrenal Obstruction

Correct answer: Acute Interstitial Nephritis (AIN)

The clinical picture of a delayed rise in creatinine following exposure to a new drug (especially an antibiotic), along with urinalysis findings of sterile pyuria (WBCs) and WBC casts, and peripheral eosinophilia, is highly characteristic of drug-induced Acute Interstitial Nephritis (AIN). AIN is a hypersensitivity reaction in the renal interstitium. ATN typically presents with muddy brown casts, prerenal azotemia would show a bland sediment, and postrenal obstruction is unlikely without corresponding symptoms or imaging findings.

Question 6: A 68-year-old male with a history of hypertension and hyperlipidemia presents with 2 hours of substernal chest pain. An ECG shows ST-segment elevation in leads II, III, and aVF. His blood pressure is 85/50 mmHg, heart rate is 50 bpm, and lungs are clear to auscultation. Jugular venous pressure is elevated. Which of the following is the most appropriate initial management step?

Place an intra-aortic balloon pump
Administer a 500 mL bolus of normal saline (Correct answer)
Administer intravenous nitroglycerin
Administer intravenous metoprolol

Correct answer: Administer a 500 mL bolus of normal saline

This patient's presentation with an inferior STEMI (ST elevation in II, III, aVF), hypotension, bradycardia, and elevated JVP with clear lungs is highly suggestive of acute right ventricular (RV) infarction. In RV infarction, the right ventricle is stiff and preload-dependent. The primary goal of management is to maintain adequate RV preload to ensure sufficient left ventricular filling and cardiac output. Therefore, the most appropriate initial step is intravenous fluid administration with normal saline. Nitroglycerin and other preload-reducing agents are contraindicated as they can cause profound hypotension. Beta-blockers should be used with caution due to the risk of worsening bradycardia and hypotension. An IABP is not a first-line therapy and is considered for refractory cardiogenic shock.

Question 7: 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
Immediate thrombolytic therapy
Medical therapy alone with discharge in 24 hours
Early invasive strategy (cardiac catheterization within 24-48 hours) (Correct answer)

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 8: 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 9: Which finding on serum protein electrophoresis (SPEP) is characteristic of multiple myeloma?

M-spike representing a monoclonal protein (Correct answer)
Isolated beta-2 microglobulin elevation
Hypoalbuminemia with diffusely low globulins
Polyclonal hypergammaglobulinemia

Correct answer: M-spike representing a monoclonal protein

Multiple myeloma produces a single clone of plasma cells secreting identical immunoglobulin, creating a sharp M-spike (monoclonal protein) on SPEP.

Question 10: A 68-year-old man with chronic heart failure presents with worsening dyspnea and oliguria. Creatinine has risen from 1.2 to 2.8 mg/dL after aggressive diuresis. Urine sodium is 8 mEq/L and BUN/Cr ratio is 28. What is the most likely mechanism of AKI?

Intrinsic tubular necrosis
Cardiorenal syndrome type 1 (Correct answer)
Contrast nephropathy
Obstructive uropathy

Correct answer: Cardiorenal syndrome type 1

Cardiorenal syndrome type 1 occurs when acute cardiac decompensation causes AKI, with low urine sodium reflecting avid sodium retention due to reduced renal perfusion.

Question 11: A 28-year-old male presents with an episode of gross hematuria that occurred two days after the onset of an upper respiratory tract infection. He has had similar episodes in the past. His blood pressure is 135/85 mmHg, and serum creatinine is 1.1 mg/dL. Urinalysis confirms hematuria and shows 1+ proteinuria. Which of the following is the most likely diagnosis?

Post-streptococcal glomerulonephritis
IgA Nephropathy (Berger's Disease) (Correct answer)
Henoch-Schönlein Purpura (HSP)
Minimal Change Disease

Correct answer: IgA Nephropathy (Berger's Disease)

IgA Nephropathy is the most common cause of primary glomerulonephritis worldwide and classically presents as recurrent episodes of macroscopic hematuria that occur concurrently with or within a few days of a mucosal infection (synpharyngitic hematuria). Post-streptococcal glomerulonephritis typically has a latent period of 1-3 weeks after the infection. HSP (now called IgA vasculitis) is histologically similar but is a systemic vasculitis that would also involve purpura, arthralgias, or abdominal pain. Minimal Change Disease presents with nephrotic syndrome, not gross hematuria.

Question 12: Which finding best distinguishes bacterial meningitis from viral meningitis on CSF analysis?

Elevated opening pressure
Lymphocytic pleocytosis
Xanthochromia
Glucose less than 45 mg/dL with high protein (Correct answer)

Correct answer: Glucose less than 45 mg/dL with high protein

Low CSF glucose (<45 mg/dL) combined with markedly elevated protein is characteristic of bacterial meningitis, reflecting bacterial consumption of glucose.

Question 13: Which set of clinical features best describes the CRAB criteria used to diagnose symptomatic multiple myeloma?

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

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 14: 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?

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

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 15: A 72-year-old man presents with a blood pressure of 185/110 mmHg and acute pulmonary edema. What is the immediate pharmacologic priority?

IV hydralazine alone
IV labetalol alone
Oral amlodipine
IV nitrates and IV furosemide (Correct answer)

Correct answer: IV nitrates and IV furosemide

Hypertensive emergency with pulmonary edema requires rapid BP reduction with IV nitrates (venodilators) and diuresis with IV furosemide to reduce preload and congestion.

Question 16: A patient is being treated for PCP with TMP-SMX. She has room air PaO2 of 62 mmHg. What adjunctive therapy should be added within 72 hours of starting antibiotics?

Granulocyte colony-stimulating factor (G-CSF)
Inhaled pentamidine
Systemic corticosteroids (prednisone) (Correct answer)
IV immunoglobulin

Correct answer: Systemic corticosteroids (prednisone)

Adjunctive corticosteroids reduce mortality in moderate-to-severe PCP (PaO2 <70 mmHg or A-a gradient >35 mmHg) by blunting the inflammatory response triggered when organisms are killed.

Question 17: A diagnostic thoracentesis is performed on a patient with a new pleural effusion. The results are: pleural fluid protein 2.5 g/dL and LDH 120 IU/L. The concurrent serum protein is 7.5 g/dL and serum LDH is 300 IU/L (upper limit of normal is 200 IU/L). According to Light's criteria, how should this effusion be classified?

Chylous
Transudative (Correct answer)
Exudative
Hemorrhagic

Correct answer: Transudative

To be classified as an exudate by Light's criteria, a pleural effusion must meet at least one of the following: 1) Pleural fluid protein/serum protein ratio > 0.5; 2) Pleural fluid LDH/serum LDH ratio > 0.6; or 3) Pleural fluid LDH > 2/3 the upper limit of normal for serum LDH. In this case: 1) Protein ratio is 2.5/7.5 = 0.33 (<0.5). 2) LDH ratio is 120/300 = 0.4 (<0.6). 3) Pleural LDH (120) is less than 2/3 of the ULN for serum LDH (2/3 * 200 = 133 IU/L). Since none of the criteria are met, the fluid is classified as a transudate.

Question 18: 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?

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

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 19: A 42-year-old man with HIV (CD4 50 cells/μL, not on ART) develops progressive dyspnea. Chest CT shows bilateral ground-glass opacities. LDH is elevated. Which prophylaxis failure does this presentation most likely represent?

Mycobacterium avium complex prophylaxis failure
Cytomegalovirus retinitis prophylaxis failure
Pneumocystis jirovecii pneumonia (PCP) prophylaxis failure (Correct answer)
Toxoplasma gondii encephalitis prophylaxis failure

Correct answer: Pneumocystis jirovecii pneumonia (PCP) prophylaxis failure

Bilateral ground-glass opacities with elevated LDH in a severely immunocompromised HIV patient is classic for PCP; prophylaxis with TMP-SMX is indicated when CD4 <200 cells/μL.

Question 20: A 46-year-old asymptomatic woman presents for a health maintenance visit. She reports that her father was diagnosed with colon cancer at age 54. According to current USPSTF and ACG guidelines, what is the most appropriate screening recommendation for this patient?

Begin screening at age 50 with colonoscopy
Begin screening now with a colonoscopy (Correct answer)
Begin screening at age 44 with an annual fecal immunochemical test (FIT)
Begin screening now with a multi-target stool DNA test every 3 years

Correct answer: Begin screening now with a colonoscopy

For individuals with a first-degree relative diagnosed with colorectal cancer before the age of 60, screening should begin at age 40, or 10 years younger than the age at diagnosis of the affected relative, whichever is earlier. In this case, 10 years before her father's diagnosis at age 54 would be age 44. Since the patient is 46, she is past the recommended start age and should begin screening now. Colonoscopy is the preferred screening modality in this higher-risk scenario.

Question 21: A 55-year-old man with cirrhosis presents after eating raw oysters with rapidly progressive bullous skin lesions and septic shock. Blood cultures are pending. What pathogen is most likely?

Aeromonas hydrophila
Vibrio vulnificus (Correct answer)
Clostridium perfringens
Listeria monocytogenes

Correct answer: Vibrio vulnificus

Vibrio vulnificus causes fulminant primary septicemia after raw shellfish ingestion, particularly in patients with liver disease; characteristic bullous skin lesions develop rapidly.

Question 22: A 55-year-old woman with hypertension presents with a blood pressure of 220/120 mmHg and new-onset confusion. Creatinine is 2.8 mg/dL (baseline 1.0). What is the target blood pressure reduction in the first hour?

Normalize blood pressure immediately
Reduce systolic to below 140 mmHg
Reduce diastolic to below 80 mmHg immediately
Reduce mean arterial pressure by no more than 25% (Correct answer)

Correct answer: Reduce mean arterial pressure by no more than 25%

In hypertensive emergency, the MAP should be reduced by no more than 25% in the first hour to avoid ischemia from loss of cerebral autoregulation.

Question 23: 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 metronidazole 500 mg TID
Fidaxomicin 200 mg BID
Oral vancomycin 125 mg QID (Correct answer)

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 24: A 50-year-old woman with osteoporosis and a T-score of -2.8 has been on oral bisphosphonate therapy for 5 years. Which rare adverse effect should be discussed at this point?

Atypical femur fracture (Correct answer)
Avascular necrosis of the hip
Hypercalcemia
Osteosarcoma

Correct answer: Atypical femur fracture

Atypical subtrochanteric femur fractures are a recognized rare complication of prolonged bisphosphonate therapy, typically after 5+ years.

Question 25: 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?

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

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

Factor VIII
Factor XII
Factor IX
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 27: 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?

Administer 50 mEq of sodium bicarbonate IV over 30 minutes.
Withhold insulin until the pH is > 7.1.
Routine use of sodium bicarbonate is not recommended. (Correct answer)
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 28: 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?

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

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 29: Which complication of STEMI typically presents 5-10 days after the initial event with new holosystolic murmur and hemodynamic deterioration?

Ventricular septal defect (VSD) (Correct answer)
Free wall rupture
Papillary muscle rupture causing acute mitral regurgitation
Pericarditis (Dressler syndrome)

Correct answer: Ventricular septal defect (VSD)

Post-infarction VSD presents 3-7 days after STEMI with a new harsh holosystolic murmur at the left sternal border, step-up in O2 saturation from right atrium to pulmonary artery, and cardiogenic shock.

Question 30: A 75-year-old man with heart failure is admitted with decompensation and treated aggressively with intravenous furosemide. His baseline creatinine was 1.2 mg/dL. On day 3, his creatinine is 2.5 mg/dL and his urine output is low. His blood pressure is 105/65 mmHg. Which set of urine findings is most consistent with pre-renal azotemia from over-diuresis?

Urine Sodium > 40 mEq/L, FeNa > 2%, muddy brown casts
Urine Sodium < 20 mEq/L, FeNa < 1%, bland sediment (Correct answer)
Red blood cell casts, proteinuria > 1 g/day
White blood cell casts, urine eosinophils > 5%

Correct answer: Urine Sodium < 20 mEq/L, FeNa < 1%, bland sediment

Pre-renal azotemia is caused by decreased renal perfusion. In response, the healthy tubules avidly reabsorb sodium and water to conserve volume. This leads to concentrated urine with a low urine sodium (<20 mEq/L) and a fractional excretion of sodium (FeNa) less than 1%. The sediment is typically bland or may show hyaline casts. Muddy brown casts are pathognomonic for Acute Tubular Necrosis (ATN). RBC casts suggest glomerulonephritis. WBC casts and eosinophils suggest Acute Interstitial Nephritis (AIN).

Question 31: Which of the following is the defining spirometric criterion for establishing a diagnosis of Chronic Obstructive Pulmonary Disease (COPD)?

Forced Expiratory Volume in 1 second (FEV1) less than 80% of predicted
A post-bronchodilator Forced Expiratory Volume in 1 second (FEV1) to Forced Vital Capacity (FVC) ratio of less than 0.70 (Correct answer)
Total Lung Capacity (TLC) greater than 120% of predicted
A greater than 12% and 200 mL increase in FEV1 after bronchodilator administration

Correct answer: A post-bronchodilator Forced Expiratory Volume in 1 second (FEV1) to Forced Vital Capacity (FVC) ratio of less than 0.70

The diagnosis of COPD is confirmed by the presence of a post-bronchodilator FEV1/FVC ratio of less than 0.70 in a patient with appropriate symptoms and exposure history. This indicates persistent airflow limitation that is not fully reversible, which is the hallmark of COPD. While a low FEV1 indicates severity, it is not the diagnostic criterion itself. A significant response to a bronchodilator is characteristic of asthma, and an increased TLC suggests hyperinflation but is not the primary diagnostic measure.

Question 32: A 28-year-old man presents with urethral discharge. Gram stain shows intracellular gram-negative diplococci. Which treatment regimen addresses both gonorrhea and likely co-infection?

Penicillin G IM single dose
Ciprofloxacin 500 mg single oral dose
Metronidazole plus azithromycin
Ceftriaxone 500 mg IM plus doxycycline 100 mg BID × 7 days (Correct answer)

Correct answer: Ceftriaxone 500 mg IM plus doxycycline 100 mg BID × 7 days

CDC guidelines recommend ceftriaxone for gonorrhea plus doxycycline (or azithromycin) to treat concurrent Chlamydia trachomatis co-infection.

Question 33: 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?

Increase oxygen flow rate to achieve SpO2 >98%
Start noninvasive positive pressure ventilation (NIPPV) (Correct answer)
Administer IV sodium bicarbonate
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 34: A 65-year-old woman with HFrEF (EF 30%) is already on maximally tolerated ACE inhibitor and beta-blocker. Her NT-proBNP remains elevated. Which medication should be added next?

Spironolactone
Hydralazine
Digoxin
Sacubitril/valsartan replacing the ACE inhibitor (Correct answer)

Correct answer: Sacubitril/valsartan replacing the ACE inhibitor

Sacubitril/valsartan (ARNI) reduces mortality and hospitalization in HFrEF and should replace ACE inhibitor therapy in eligible patients with persistently symptomatic disease.

Question 35: A 72-year-old male with a new diagnosis of idiopathic pulmonary fibrosis (IPF) presents for management. His FVC is 75% of predicted. He complains of a persistent dry cough and exertional dyspnea. Which of the following treatments has been shown to slow the rate of FVC decline in patients with IPF?

N-acetylcysteine
Pirfenidone (Correct answer)
Azathioprine
Prednisone

Correct answer: Pirfenidone

Pirfenidone and nintedanib are the two FDA-approved antifibrotic medications that have been demonstrated in clinical trials to slow the progressive decline in forced vital capacity (FVC) in patients with IPF. Previous therapies, including corticosteroids (prednisone) and immunosuppressants like azathioprine, have not shown benefit and may be harmful.

Question 36: 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?

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

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 37: 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?

Spironolactone 100 mg and furosemide 40 mg daily (Correct answer)
Spironolactone 25 mg daily
Metolazone 5 mg daily
Furosemide 40 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 38: A hospitalized patient develops fever 5 days after a central venous catheter insertion. Blood cultures from the line and periphery both grow Candida albicans. What is the FIRST management step?

Start topical antifungal and reassess in 24 hours
Obtain repeat cultures and wait for sensitivity results
Start fluconazole and leave the catheter in place
Remove the central venous catheter and start echinocandin therapy (Correct answer)

Correct answer: Remove the central venous catheter and start echinocandin therapy

Candidemia requires prompt catheter removal (source control) and initiation of an echinocandin, which is preferred over fluconazole for empiric treatment pending species identification.

Question 39: A 28-year-old surgical resident sustains a deep needlestick injury from a hollow-bore needle used on a patient with a known high HIV viral load and no documented drug resistance. According to current CDC guidelines, what is the most appropriate regimen for post-exposure prophylaxis (PEP) that should be initiated as soon as possible?

A two-drug regimen with tenofovir and emtricitabine for 28 days.
No prophylaxis is needed if the resident's baseline rapid HIV test is negative.
Zidovudine (AZT) monotherapy for 28 days.
A three-drug regimen with tenofovir, emtricitabine, and an integrase inhibitor (e.g., raltegravir or dolutegravir) for 28 days. (Correct answer)

Correct answer: A three-drug regimen with tenofovir, emtricitabine, and an integrase inhibitor (e.g., raltegravir or dolutegravir) for 28 days.

For a high-risk occupational exposure to HIV (e.g., deep injury, hollow-bore needle, high viral load source), a three-drug PEP regimen is the standard of care. The preferred regimen for adults typically includes two nucleoside reverse transcriptase inhibitors (like tenofovir and emtricitabine) plus an integrase inhibitor (like raltegravir or dolutegravir). Two-drug regimens are no longer preferred for most exposures, and monotherapy is outdated. PEP should be initiated as soon as possible, ideally within 2 hours of exposure, and should not be delayed pending the results of the healthcare worker's baseline tests.

Question 40: A 68-year-old male with a 40-pack-year smoking history presents with chronic dyspnea and cough. Spirometry reveals a post-bronchodilator FEV1/FVC ratio of 0.65 and an FEV1 of 45% predicted. He has had three exacerbations in the past year, one requiring hospitalization. His blood eosinophil count is 350 cells/µL. According to the 2024 GOLD guidelines, what is the most appropriate initial pharmacologic management?

Long-acting muscarinic antagonist (LAMA) monotherapy
Long-acting beta-agonist (LABA) + LAMA combination therapy
Short-acting beta-agonist (SABA) as needed only
LAMA + LABA + Inhaled corticosteroid (ICS) combination therapy (Correct answer)

Correct answer: LAMA + LABA + Inhaled corticosteroid (ICS) combination therapy

According to the 2023-2024 GOLD report, this patient falls into Group E due to his history of frequent exacerbations (≥2 moderate or ≥1 leading to hospitalization). For patients in Group E with a blood eosinophil count ≥300 cells/µL, initial therapy with a LAMA+LABA+ICS combination is recommended. This approach addresses both bronchodilation and the underlying eosinophilic inflammation contributing to exacerbation risk.

Question 41: The JAK2 V617F mutation is present in approximately what percentage of polycythemia vera cases?

30-40% of cases
50-60% of cases
Greater than 95% of cases (Correct answer)
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 42: A 35-year-old woman presents with a 4-month history of symmetric pain and swelling in her metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, accompanied by morning stiffness lasting over an hour. Physical examination reveals soft, boggy swelling of the affected joints. Which of the following sets of laboratory findings would be most specific for diagnosing her condition?

Elevated erythrocyte sedimentation rate (ESR) and hyperuricemia.
Elevated C-reactive protein (CRP) and a positive antinuclear antibody (ANA) test.
Normal inflammatory markers and a positive human leukocyte antigen B27 (HLA-B27) test.
Positive anti-cyclic citrullinated peptide (anti-CCP) antibodies and a positive rheumatoid factor (RF). (Correct answer)

Correct answer: Positive anti-cyclic citrullinated peptide (anti-CCP) antibodies and a positive rheumatoid factor (RF).

The patient's presentation of symmetric inflammatory polyarthritis affecting small joints with prolonged morning stiffness is classic for rheumatoid arthritis (RA). While rheumatoid factor (RF) is commonly associated with RA, it can be present in other conditions. Anti-CCP antibodies, however, are highly specific for RA and are a key component of the diagnostic criteria. The combination of positive anti-CCP and RF provides the highest specificity for diagnosis.

Question 43: Which organism is the most common cause of community-acquired pneumonia in otherwise healthy adults under 60?

Klebsiella pneumoniae
Streptococcus pneumoniae (Correct answer)
Mycoplasma pneumoniae
Haemophilus influenzae

Correct answer: Streptococcus pneumoniae

Streptococcus pneumoniae is the most common bacterial cause of community-acquired pneumonia across all age groups.

Question 44: A 35-year-old asymptomatic healthcare worker undergoes routine annual screening and has a positive Interferon-Gamma Release Assay (IGRA) test. A subsequent chest X-ray is normal. What is the most appropriate next step in the management of this patient?

Offer a recommended treatment regimen for latent TB infection (LTBI). (Correct answer)
Reassure the patient that this is likely a false positive and repeat the test in 6 months.
Start a four-drug regimen for active tuberculosis.
Obtain three morning sputum samples for AFB smear and culture.

Correct answer: Offer a recommended treatment regimen for latent TB infection (LTBI).

A positive IGRA in the context of a normal chest X-ray is diagnostic for latent TB infection (LTBI). For individuals like healthcare workers who are at increased risk of exposure, treatment for LTBI is recommended to prevent progression to active disease. Sputum samples and active TB treatment are only indicated if active disease is suspected based on symptoms or radiographic findings. Assuming a false positive is not appropriate without further evaluation.

Question 45: A 65-year-old male with diabetes presents to the emergency department with fever, confusion, and a blood pressure of 85/50 mmHg. He is diagnosed with septic shock from a urinary source. After an initial 30 mL/kg crystalloid fluid bolus, his mean arterial pressure (MAP) remains 55 mmHg. According to the Surviving Sepsis Campaign guidelines, what is the most appropriate next step?

Administer an additional 1-liter fluid bolus before considering other therapies.
Add vasopressin to the current regimen.
Obtain a central venous oxygen saturation (ScvO2) measurement to guide resuscitation.
Initiate a norepinephrine infusion. (Correct answer)

Correct answer: Initiate a norepinephrine infusion.

The Surviving Sepsis Campaign guidelines recommend initiating vasopressors if hypotension persists after initial fluid resuscitation to maintain a MAP of ≥65 mmHg. Norepinephrine is the first-line vasopressor of choice. While further fluid administration may be considered, vasopressor therapy should not be delayed in patients with persistent shock. Vasopressin is typically added as a second-line agent if the patient is refractory to norepinephrine. Routine monitoring of ScvO2 is no longer a primary resuscitation target.

Question 46: A 70-year-old presents with painless jaundice, weight loss, and a palpable, non-tender gallbladder (Courvoisier's sign). CT shows a mass at the head of the pancreas. Which statement is most accurate?

ERCP is the definitive diagnostic test
The gallbladder is typically tender in pancreatic head cancer
This presentation is classic for choledocholithiasis
Courvoisier's sign suggests malignant biliary obstruction rather than gallstones (Correct answer)

Correct answer: Courvoisier's sign suggests malignant biliary obstruction rather than gallstones

Courvoisier's law states that a palpable, non-tender gallbladder with jaundice suggests malignant obstruction, as chronic gallstone disease causes a fibrotic, non-distensible gallbladder.

Question 47: 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)
Lowering LDL cholesterol
Prevention of in-stent thrombosis

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 48: A 52-year-old woman presents with proximal muscle weakness, heliotrope rash, and Gottron's papules. CK is 4,500 U/L. Which malignancy screening is most important within the first year of diagnosis?

Chest X-ray only
Colonoscopy only
Ovarian cancer screening with CA-125 and transvaginal ultrasound (Correct answer)
Brain MRI

Correct answer: Ovarian cancer screening with CA-125 and transvaginal ultrasound

Dermatomyositis has the strongest cancer association, and ovarian cancer is one of the most commonly linked malignancies requiring active screening.

Question 49: A 45-year-old presents with episodic right upper quadrant pain after fatty meals, nausea, and Murphy's sign on exam. Ultrasound shows gallstones with a thickened gallbladder wall. What is the most appropriate next step?

Laparoscopic cholecystectomy (Correct answer)
IV antibiotics and watchful waiting
Ursodeoxycholic acid therapy
ERCP with sphincterotomy

Correct answer: Laparoscopic cholecystectomy

Symptomatic cholelithiasis with cholecystitis is best treated with laparoscopic cholecystectomy.

Question 50: 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
Uremic pericarditis with a friction rub (Correct answer)
Urine output of 300 mL in 24 hours
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 51: A 62-year-old man with myeloma presents with AKI, hypercalcemia, and anemia. Urinalysis shows no blood or protein by dipstick but urine protein electrophoresis reveals a spike. Which cast type is pathognomonic on renal biopsy?

Red blood cell casts
Myeloma (Bence Jones) casts (Correct answer)
Waxy broad casts
Granular casts

Correct answer: Myeloma (Bence Jones) casts

Myeloma kidney shows large, fractured eosinophilic casts composed of light chains (Bence Jones protein) surrounded by giant cells in tubular lumina.

Question 52: Which ECG finding in a patient with chest pain represents a 'STEMI equivalent' requiring immediate reperfusion?

T-wave inversions in leads III and aVF
Diffuse ST depression in leads V1-V6
PR interval prolongation with ST changes
New left bundle branch block (LBBB) with typical ischemic symptoms (Correct answer)

Correct answer: New left bundle branch block (LBBB) with typical ischemic symptoms

New LBBB in the context of ischemic symptoms is considered a STEMI equivalent because it obscures ST-segment analysis and warrants immediate reperfusion therapy.

Question 53: Spontaneous coronary artery dissection (SCAD) causing ACS most commonly occurs in which patient population?

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

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 54: A 76-year-old female with a history of hypertension and type 2 diabetes mellitus is diagnosed with non-valvular atrial fibrillation. Her CHA2DS2-VASc score is calculated to be 4. Which of the following is the most appropriate management for stroke prevention in this patient?

Aspirin 81 mg daily.
Aspirin 325 mg and clopidogrel 75 mg daily.
Oral anticoagulation with a direct oral anticoagulant (DOAC) or warfarin. (Correct answer)
No antithrombotic therapy is needed.

Correct answer: Oral anticoagulation with a direct oral anticoagulant (DOAC) or warfarin.

A CHA2DS2-VASc score of 2 or greater in males, or 3 or greater in females, indicates a high risk of stroke, and oral anticoagulation is recommended. This patient's score is 4 (1 for hypertension, 1 for age 65-74, 1 for diabetes, 1 for female sex), placing her at high risk for thromboembolic events. Therefore, oral anticoagulation is the indicated therapy. Aspirin alone or dual antiplatelet therapy is not considered sufficient for stroke prevention in this risk category.

Question 55: 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)
Observation and repeat Holter in 3 months
Oral amiodarone

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 56: 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)
Begin insulin infusion immediately
Administer glucagon to stabilize glucose

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

A 65-year-old with a 22 pack-year smoking history who quit smoking 10 years ago. (Correct answer)
A 48-year-old with a 25 pack-year smoking history who currently smokes.
A 70-year-old with a 15 pack-year smoking history who quit smoking 5 years ago.
A 55-year-old with a 30 pack-year smoking history who quit smoking 18 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 58: A 70-year-old man with anterior STEMI develops cardiogenic shock. His BP is 75/50 mmHg and he is on maximum vasopressors. What is the most appropriate next step?

Insert an intra-aortic balloon pump (IABP) and proceed to PCI (Correct answer)
Add IV diuretics to reduce preload
Transfer for emergent surgical revascularization without PCI
Administer thrombolytics given inability to reach cath lab

Correct answer: Insert an intra-aortic balloon pump (IABP) and proceed to PCI

Cardiogenic shock complicating STEMI requires mechanical circulatory support (IABP or more advanced devices) along with emergent PCI, which is the definitive treatment to restore perfusion.

Question 59: Which of the following statements about a ventilator with volume control is false?

Pressure is controlled (Correct answer)
Tidal volume is preset and fixed
Minute ventilation volume can be preset
lung injury may occur at high pressures

Correct answer: Pressure is controlled

In volume-controlled ventilation, the tidal volume (the amount of air delivered with each breath) is preset and fixed, ensuring a consistent minute ventilation. The pressure required to deliver this preset volume will vary depending on the patient's lung compliance and airway resistance, meaning that pressure is a variable outcome and is *not* directly controlled in this mode.

Question 60: A 45-year-old male is being treated for moderate Diabetic Ketoacidosis. His initial blood glucose was 520 mg/dL. He has received several hours of IV fluids and a continuous insulin infusion. His current blood glucose is 190 mg/dL, but his anion gap remains elevated at 18 mEq/L and his serum bicarbonate is 14 mEq/L. Which of the following is the most appropriate adjustment to his management?

Change the intravenous fluids to 0.45% NaCl without dextrose.
Discontinue the insulin infusion and switch to subcutaneous insulin.
Decrease the insulin infusion rate by half.
Add dextrose to the intravenous fluids and continue the insulin infusion. (Correct answer)

Correct answer: Add dextrose to the intravenous fluids and continue the insulin infusion.

The primary goal in DKA management is the closure of the anion gap, which signifies the resolution of ketoacidosis. It is common for the blood glucose to normalize before the anion gap closes. To prevent hypoglycemia while continuing the insulin infusion necessary to resolve the ketosis, dextrose should be added to the IV fluids once the blood glucose falls to around 200-250 mg/dL. Discontinuing or decreasing the insulin infusion prematurely would halt the clearance of ketones and prolong the resolution of DKA.

Question 61: A 70-year-old man has a WBC of 45,000/µL with small mature lymphocytes on smear. Flow cytometry shows CD5+/CD19+/CD23+. What is the most likely diagnosis?

Hairy cell leukemia
Chronic lymphocytic leukemia (CLL) (Correct answer)
Acute lymphoblastic leukemia
Mantle cell lymphoma

Correct answer: Chronic lymphocytic leukemia (CLL)

CLL is characterized by clonal expansion of mature B-lymphocytes co-expressing CD5 and CD23 (CD5+/CD19+/CD23+), distinguishing it from mantle cell lymphoma (CD23-).

Question 62: 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?

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

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 63: Which antiplatelet agent should be AVOIDED in a patient with ACS who requires urgent coronary artery bypass grafting (CABG)?

Ticagrelor
Low-dose aspirin plus clopidogrel
Aspirin
Prasugrel (Correct answer)

Correct answer: Prasugrel

Prasugrel is contraindicated when CABG is planned because its irreversible and potent platelet inhibition significantly increases surgical bleeding risk; it should be held at least 7 days before CABG.

Question 64: A patient develops AKI after receiving vancomycin. Urinalysis shows eosinophiluria and white blood cell casts. Serum creatinine peaks at 3.1 mg/dL on day 10. What is the primary pathophysiology?

Acute interstitial nephritis (Correct answer)
Acute tubular necrosis
Prerenal azotemia
Glomerulonephritis

Correct answer: Acute interstitial nephritis

Vancomycin-induced AKI commonly causes acute interstitial nephritis, characterized by eosinophiluria, WBC casts, and a delayed onset after drug exposure.

Question 65: 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?

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

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 66: 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?

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

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 67: 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?

Carpal tunnel syndrome
Mononeuritis multiplex due to rheumatoid vasculitis (Correct answer)
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 68: A 62-year-old male with cirrhosis, portal hypertension, and medium-sized esophageal varices noted on a screening endoscopy has no history of gastrointestinal bleeding. He is hemodynamically stable. Which of the following medications is the most appropriate choice for primary prophylaxis against variceal hemorrhage?

Octreotide
Furosemide
Omeprazole
Nadolol (Correct answer)

Correct answer: Nadolol

Non-selective beta-blockers (NSBBs), such as nadolol or propranolol, are the first-line pharmacologic therapy for the primary prevention of bleeding from medium to large esophageal varices. They work by reducing portal pressure through both a decrease in cardiac output (β1 blockade) and splanchnic vasoconstriction (β2 blockade). Octreotide is used for treating active variceal bleeding, not for primary prophylaxis. Furosemide is a diuretic for ascites management, and omeprazole is a proton-pump inhibitor with no role in preventing variceal bleeding.

Question 69: Which of the following is a characteristic feature of Löfgren syndrome in the context of sarcoidosis?

Skin plaques, hypercalcemia, and renal failure
Bilateral hilar adenopathy, erythema nodosum, and polyarthritis (Correct answer)
Pulmonary fibrosis, cor pulmonale, and hemoptysis
Unilateral hilar lymphadenopathy, uveitis, and facial palsy

Correct answer: Bilateral hilar adenopathy, erythema nodosum, and polyarthritis

Löfgren syndrome is an acute form of sarcoidosis presenting with bilateral hilar adenopathy, erythema nodosum, and polyarthritis, and carries an excellent prognosis.

Question 70: 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?

Rifaximin
Lactulose (Correct answer)
Propranolol
Intravenous albumin

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 71: 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
Joint space narrowing
Bone marrow edema (subchondral) (Correct answer)

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 72: A 25-year-old woman presents with high fever, headache, and a non-blanching petechial rash evolving to purpura. CSF shows gram-negative diplococci. What empiric treatment should be administered IMMEDIATELY?

Dexamethasone alone pending cultures
Vancomycin plus ceftriaxone
Penicillin G plus metronidazole
Ceftriaxone 2 g IV immediately (Correct answer)

Correct answer: Ceftriaxone 2 g IV immediately

Meningococcal meningitis/septicemia requires immediate ceftriaxone without delay; dexamethasone adjunctively reduces meningitis complications.

Question 73: 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?

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

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 74: A refugee from Southeast Asia presents with a chronic cough, night sweats, and weight loss for 3 months. Chest X-ray shows upper lobe cavitation. Sputum AFB smear is positive. Initial TB treatment should include how many drugs?

4 drugs (isoniazid + rifampin + pyrazinamide + ethambutol) (Correct answer)
2 drugs (isoniazid + rifampin)
1 drug (isoniazid only)
3 drugs (isoniazid + rifampin + pyrazinamide)

Correct answer: 4 drugs (isoniazid + rifampin + pyrazinamide + ethambutol)

Standard initial phase TB therapy consists of four drugs (RIPE: rifampin, isoniazid, pyrazinamide, ethambutol) for 2 months to prevent resistance while susceptibility results are pending.

Question 75: A 58-year-old female without known cardiovascular disease presents for a routine physical exam. She has a history of hypertension, is a former smoker (quit 10 years ago), and her father had a myocardial infarction at age 55. Her blood pressure is 135/85 mmHg, total cholesterol is 210 mg/dL, and HDL is 45 mg/dL. Her calculated 10-year ASCVD risk is 8.5%. According to 2019 ACC/AHA guidelines on primary prevention, what is the most appropriate next step in management?

Initiate moderate-intensity statin therapy after a clinician-patient risk discussion. (Correct answer)
Order a coronary artery calcium (CAC) score before deciding on statin therapy.
Initiate high-intensity statin therapy immediately.
Recommend lifestyle modifications only.

Correct answer: Initiate moderate-intensity statin therapy after a clinician-patient risk discussion.

The patient falls into the intermediate-risk category (ASCVD risk ≥7.5% to <20%). In this group, the guidelines recommend a clinician-patient risk discussion to review risk-enhancing factors and consider the potential benefits and harms of statin therapy. If a decision is made to treat, initiating a moderate-intensity statin is the recommended first-line approach. A CAC score is a reasonable option if risk-based decisions remain uncertain after this discussion.

Question 76: A 62-year-old woman presents with NSTEMI. Her creatinine is 2.8 mg/dL. Which anticoagulant requires the most careful dose adjustment in this setting?

Enoxaparin (LMWH) (Correct answer)
Unfractionated heparin (UFH)
Bivalirudin
Fondaparinux

Correct answer: Enoxaparin (LMWH)

Enoxaparin is renally cleared and accumulates in renal failure, significantly increasing bleeding risk; dose reduction is required when CrCl <30 mL/min, and UFH is often preferred in severe renal impairment.

Question 77: A patient with Crohn's disease develops a new perianal fistula. Initial treatment with antibiotics (metronidazole) fails. What is the next best pharmacologic therapy?

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

Correct answer: Infliximab (anti-TNF)

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

Question 78: Which of the following is the MOST important measure to prevent catheter-associated urinary tract infections (CAUTIs) in hospitalized patients?

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

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

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 80: A 50-year-old patient with a history of hypertension, hyperlipidemia, and alcoholism arrives at the emergency room with a strong cough, a fever, chills, and generalized weakness. Her family adds that she has been acting confused, and she claims that she has had those symptoms for over a week. She recently resumed drinking and is currently taking Lipitor and Atenolol. Vitals: temperature is 102.5 degrees Fahrenheit, heart rate is 105 beats per minute, blood pressure is 110/75, and respiratory rate is 22. During a physical examination, the right lower lobe (RLL) exhibits diminished breath sounds correlated with an RLL infiltrate on a chest x-ray. What is your prevailing medical opinion?

A post obstructive pneumonia
Increasing hoarseness (Correct answer)
Hemoptysis
Worsening dyspnea
The change in the pattern of cough

Correct answer: Increasing hoarseness

While the stem describes a patient with pneumonia, the question implicitly asks for a symptom that would raise concern for a more serious underlying condition, such as lung cancer, especially in a patient with risk factors like alcoholism. Increasing hoarseness can be a critical red flag, as it may indicate recurrent laryngeal nerve involvement due to a mediastinal tumor. This symptom suggests potential advanced disease and warrants further investigation.

Question 81: A patient with known asthma presents with severe bronchospasm unresponsive to multiple doses of inhaled beta-agonist. What is the most appropriate next step?

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

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 82: A 58-year-old man with CKD stage 3b has a serum potassium of 6.2 mEq/L and ECG changes including peaked T-waves. Which intervention should be given FIRST?

IV calcium gluconate (Correct answer)
Sodium polystyrene sulfonate
Sodium bicarbonate
Furosemide

Correct answer: IV calcium gluconate

IV calcium gluconate stabilizes the cardiac membrane and is the first-line treatment for hyperkalemia with ECG changes.

Question 83: 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)
Hypersensitivity Pneumonitis
Sarcoidosis

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 84: 1) RVH 2) VSF 3) Overriding Aorta 4) Pulmonary Artery Stenosis

What are causes of mildly elevated LFTs?
What is the treatment for Goodpasture's Syndrome?
What are causes of severely elevated LFTs?
What are the 4 features of tetrology of fallot? (Correct answer)

Correct answer: What are the 4 features of tetrology of fallot?

The four features listed—Right Ventricular Hypertrophy (RVH), Ventricular Septal Defect (VSF), Overriding Aorta, and Pulmonary Artery Stenosis—are the classic anatomical defects that collectively define Tetralogy of Fallot. This is a well-known congenital heart condition characterized by these specific structural abnormalities. The question directly asks for the condition described by these four features.

Question 85: A 68-year-old male with a 10-year history of type 2 diabetes mellitus, hypertension, and a previous myocardial infarction is seen for follow-up. His current HbA1c is 8.2% on metformin 1000 mg twice daily. His eGFR is 70 mL/min/1.73m². According to current ADA guidelines, which of the following is the most appropriate medication to add to his regimen?

Empagliflozin (Correct answer)
Sitagliptin
Pioglitazone
Glipizide

Correct answer: Empagliflozin

For patients with type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD), guidelines strongly recommend adding an agent with proven cardiovascular benefit. SGLT2 inhibitors (like empagliflozin) and GLP-1 receptor agonists have demonstrated significant reductions in major adverse cardiovascular events. Sulfonylureas (glipizide) and DPP-4 inhibitors (sitagliptin) are generally considered to have a neutral effect on cardiovascular outcomes, while thiazolidinediones (pioglitazone) can carry a risk of worsening heart failure.

Question 86: A 72-year-old man is diagnosed with his first episode of non-severe Clostridioides difficile infection (CDI). According to the most recent IDSA/SHEA guidelines, which of the following is the preferred first-line treatment?

Fecal Microbiota Transplantation (FMT)
Oral Vancomycin for 10 days
Oral Fidaxomicin for 10 days (Correct answer)
Oral Metronidazole for 14 days

Correct answer: Oral Fidaxomicin for 10 days

The 2021 IDSA/SHEA guidelines suggest fidaxomicin as the preferred agent over oral vancomycin for an initial episode of CDI, based on evidence showing lower rates of recurrence. Oral vancomycin is considered an acceptable alternative. Metronidazole is no longer recommended as a first-line agent for initial episodes due to inferior efficacy. FMT is generally reserved for patients with multiple recurrent infections.

Question 87: A 40-year-old woman with primary biliary cholangitis (PBC) presents with pruritus and fatigue. Labs show elevated alkaline phosphatase and positive anti-mitochondrial antibodies. What is the first-line treatment?

Corticosteroids
Liver transplantation
Cholestyramine alone
Ursodeoxycholic acid (Correct answer)

Correct answer: Ursodeoxycholic acid

Ursodeoxycholic acid (UDCA) slows PBC progression and improves biochemical markers and is the established first-line therapy.

Question 88: A 45-year-old male is found down after a reported seizure. He is confused with diffuse muscle tenderness. His creatinine is 2.1 mg/dL, and a urine dipstick is strongly positive for blood but microscopic analysis shows 0-2 RBCs/hpf. His creatine kinase (CK) level is 45,000 U/L. What is the most critical initial step in managing his acute kidney injury?

Urgent hemodialysis
Aggressive intravenous fluid resuscitation with isotonic saline (Correct answer)
Administration of sodium bicarbonate to alkalinize the urine
Administration of N-acetylcysteine

Correct answer: Aggressive intravenous fluid resuscitation with isotonic saline

The patient has rhabdomyolysis-induced AKI, evidenced by the high CK and myoglobinuria (positive blood on dipstick with no RBCs). The cornerstone of management is early and aggressive intravenous fluid resuscitation with isotonic crystalloids to increase urine flow, flush out myoglobin casts, and prevent further renal tubular injury. While urine alkalinization is sometimes considered, it is secondary to and should not delay aggressive volume repletion. Dialysis is reserved for severe complications like refractory hyperkalemia or fluid overload, and N-acetylcysteine has no role.

Question 89: Which mechanism best explains vancomycin resistance in Enterococcus faecium (VanA phenotype)?

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

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 90: A 50-year-old patient with a history of hypertension, hyperlipidemia, and alcoholism arrives at the emergency room with a strong cough, a fever, chills, and generalized weakness. Her family adds that she has been acting confused, and she claims that she has had those symptoms for over a week. She recently resumed drinking and is currently taking Lipitor and Atenolol. Vitals: temperature is 102.5 degrees Fahrenheit, heart rate is 105 beats per minute, blood pressure is 110/75, and respiratory rate is 22. During a physical examination, the right lower lobe (RLL) exhibits diminished breath sounds correlated with an RLL infiltrate on a chest x-ray. What is your prevailing medical opinion?

Systemic Inflammatory Response System
Multiple Organ Dysfunction Syndrome
Septic shock
Multiple Organ Dysfunction Syndrome
Sepsis (Correct answer)

Correct answer: Sepsis

The patient presents with an infection (pneumonia, indicated by cough, fever, and RLL infiltrate) and meets criteria for Systemic Inflammatory Response Syndrome (SIRS) with a fever, tachycardia, and tachypnea. The new onset of confusion signifies acute organ dysfunction (encephalopathy) secondary to the infection. The combination of infection and associated organ dysfunction defines sepsis, making it the most accurate diagnosis.

Question 91: A 50-year-old woman with atrial fibrillation has a CHA₂DS₂-VASc score of 3. She has no contraindications to anticoagulation. Which therapy is most appropriate?

Aspirin plus clopidogrel
No antithrombotic therapy
Direct oral anticoagulant (DOAC) (Correct answer)
Aspirin alone

Correct answer: Direct oral anticoagulant (DOAC)

A CHA₂DS₂-VASc score ≥2 in women (≥3 in this case) is a Class I indication for oral anticoagulation; DOACs are preferred over warfarin due to superior safety profile.

Question 92: A 60-year-old man with advanced COPD is admitted with fever, productive cough, and a new right lower lobe infiltrate 5 days into his hospital stay. He was intubated for 3 days. Which pathogen is of GREATEST concern for hospital-acquired pneumonia in this setting?

Pseudomonas aeruginosa or MRSA (Correct answer)
Moraxella catarrhalis
Streptococcus pneumoniae
Legionella pneumophila

Correct answer: Pseudomonas aeruginosa or MRSA

Hospital-acquired and ventilator-associated pneumonia are most commonly caused by drug-resistant gram-negatives (including Pseudomonas) and MRSA, requiring empiric coverage of these organisms.

Question 93: A 50-year-old man with chronic HCV infection has a serum-ascites albumin gradient (SAAG) of 1.8 g/dL. Which condition does this SAAG value indicate?

Peritoneal carcinomatosis
Portal hypertension (Correct answer)
Tuberculosis peritonitis
Nephrotic syndrome

Correct answer: Portal hypertension

A SAAG ≥1.1 g/dL indicates portal hypertension as the cause of ascites with 97% accuracy; a value of 1.8 g/dL confirms this etiology.

Question 94: 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?

0.1 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
0.2 units/kg/hour without a bolus
0.05 units/kg/hour without a bolus

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 95: A 60-year-old man with hypertension, diabetes, and dyslipidemia has an LDL of 130 mg/dL despite lifestyle changes. His 10-year ASCVD risk is 22%. What is the LDL goal?

<70 mg/dL with high-intensity statin (Correct answer)
<130 mg/dL with low-intensity statin
<100 mg/dL with moderate-intensity statin
No pharmacologic therapy needed

Correct answer: <70 mg/dL with high-intensity statin

A 10-year ASCVD risk ≥20% is considered high risk, warranting high-intensity statin therapy with an LDL goal of <70 mg/dL.

Question 96: A patient with sickle cell disease presents with an acute vaso-occlusive pain crisis. What is the MOST important initial management step?

Exchange transfusion
IV fluids and adequate analgesia (Correct answer)
Urgent bone marrow transplant evaluation
Initiation of hydroxyurea

Correct answer: IV fluids and adequate analgesia

Acute vaso-occlusive pain crisis is managed with IV hydration to improve blood flow and adequate analgesia (NSAIDs, opioids) to control pain.

Question 97: A 45-year-old female with no significant comorbidities and no recent antibiotic use is diagnosed with outpatient community-acquired pneumonia (CAP), confirmed by chest X-ray. According to the most recent IDSA/ATS guidelines, which of the following is a recommended first-line empiric antibiotic regimen for this patient?

Levofloxacin
Amoxicillin-clavulanate
Azithromycin monotherapy
Doxycycline (Correct answer)

Correct answer: Doxycycline

For healthy outpatients with CAP and no risk factors for resistant pathogens, the IDSA/ATS guidelines recommend monotherapy with amoxicillin, doxycycline, or a macrolide (only if local pneumococcal resistance is <25%). Due to widespread macrolide resistance, doxycycline and amoxicillin are often preferred. Levofloxacin is a respiratory fluoroquinolone, which is typically reserved for patients with comorbidities or recent antibiotic use. Amoxicillin-clavulanate is broader than necessary for this patient and is typically recommended in combination with another agent for patients with comorbidities.

Question 98: A 50-year-old immunocompromised patient develops fever, pleuritic chest pain, and a pulmonary infiltrate with a halo sign on CT chest. Galactomannan is positive. What is first-line treatment?

Amphotericin B deoxycholate
Fluconazole
Voriconazole (Correct answer)
Caspofungin monotherapy

Correct answer: Voriconazole

Voriconazole is first-line therapy for invasive pulmonary aspergillosis, demonstrating superior survival over amphotericin B in landmark trials.

Question 99: 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?

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

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 100: A 55-year-old woman with lupus presents with AKI, RBC casts, proteinuria >2 g/day, and hypertension. Which diagnosis best fits this presentation?

Hepatorenal syndrome
Lupus nephritis causing rapidly progressive glomerulonephritis (Correct answer)
Prerenal AKI from volume depletion
Acute interstitial nephritis from NSAIDs

Correct answer: Lupus nephritis causing rapidly progressive glomerulonephritis

RBC casts, nephrotic-range proteinuria, and hypertension in a lupus patient indicate lupus nephritis with rapidly progressive glomerulonephritis as the cause of AKI.

Question 101: 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?

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

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 102: Which scoring system is currently used to prioritize liver transplant candidates in the United States?

MELD-Na score (Correct answer)
APACHE II score
Child-Pugh score
King's College Criteria

Correct answer: MELD-Na score

The MELD-Na score (incorporating sodium, bilirubin, INR, and creatinine) is used by UNOS to prioritize liver transplant allocation in the US.

Question 103: Which Child-Pugh score component best correlates with the severity of synthetic liver dysfunction?

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

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 104: A 28-year-old with type 1 diabetes presents with DKA. Blood glucose is 520 mg/dL. After 1 hour of insulin infusion, glucose drops to 250 mg/dL. What should be added to IV fluids?

Add dextrose to IV fluids and continue insulin (Correct answer)
Administer IV sodium bicarbonate
Double the insulin infusion rate
Stop insulin and switch to subcutaneous

Correct answer: Add dextrose to IV fluids and continue insulin

Dextrose is added to IV fluids when glucose reaches 200–250 mg/dL to allow continued insulin infusion and ketone clearance.

Question 105: Which hemodynamic pattern is most consistent with constrictive pericarditis on right heart catheterization?

Low CVP with high cardiac output
Elevated PCWP with low RVEDP
Equalization of diastolic pressures (Correct answer)
Elevated pulmonary artery pressure only

Correct answer: Equalization of diastolic pressures

Equalization of diastolic pressures (RVEDP = LVEDP = mean RA = mean PCWP within 5 mmHg) is the hallmark hemodynamic finding of constrictive pericarditis.

Question 106: A 70-year-old man presents with a 4-day history of high fever, a non-productive cough, watery diarrhea, and confusion. He is a retired plumber who recently worked on his home's hot water tank. Laboratory studies are notable for a serum sodium of 127 mEq/L. Which pathogen is the most likely cause of his pneumonia?

Haemophilus influenzae
Legionella pneumophila (Correct answer)
Mycoplasma pneumoniae
Streptococcus pneumoniae

Correct answer: Legionella pneumophila

The clinical presentation of pneumonia accompanied by prominent extrapulmonary symptoms, specifically gastrointestinal distress (diarrhea), neurologic symptoms (confusion), and hyponatremia, is highly characteristic of Legionnaires' disease, caused by *Legionella pneumophila*. [4, 20, 27] The exposure to a contaminated water source (hot water tank) further strengthens this diagnosis. While other pathogens can cause pneumonia, this specific constellation of findings is classic for *Legionella*.

Question 107: A 35-year-old woman with SLE develops new proteinuria (3.5 g/day) and hematuria. Renal biopsy shows diffuse proliferative glomerulonephritis with subendothelial deposits. Which WHO/ISN class is this?

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

Correct answer: Class IV (diffuse proliferative)

Diffuse proliferative lupus nephritis with subendothelial deposits involving >50% of glomeruli is classified as ISN/RPS Class IV and carries the worst prognosis.

Question 108: A 68-year-old nursing home resident develops fever, productive cough, and lobar consolidation on CXR. Which pathogen is MOST likely responsible?

Mycoplasma pneumoniae
Legionella pneumophila
Streptococcus pneumoniae (Correct answer)
Chlamydophila pneumoniae

Correct answer: Streptococcus pneumoniae

S. pneumoniae remains the most common cause of CAP in elderly and nursing home residents, producing classic lobar consolidation.

Question 109: A 32-year-old male is newly diagnosed with moderate-to-severe ileocolonic Crohn's disease. He has not received prior treatment. According to the most recent American Gastroenterological Association (AGA) guidelines, which of the following is the most appropriate initial therapeutic approach?

Early initiation of an anti-TNF agent such as infliximab (Correct answer)
Step-up therapy starting with oral mesalamine
A 12-week course of broad-spectrum antibiotics
A prolonged course of oral corticosteroids as monotherapy

Correct answer: Early initiation of an anti-TNF agent such as infliximab

Current AGA guidelines recommend early initiation of advanced therapies, such as anti-TNF agents (e.g., infliximab), for patients with moderate-to-severe Crohn's disease. This approach is favored over traditional 'step-up' therapy to achieve better long-term outcomes, including mucosal healing and reduced complications. Corticosteroids are used for induction but not for maintenance, oral mesalamine is generally ineffective for moderate-to-severe Crohn's, and antibiotics are reserved for specific complications like abscesses or fistulae.

Question 110: 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?

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

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 111: A 74-year-old woman with a history of hypertension and type 2 diabetes is diagnosed with heart failure with preserved ejection fraction (HFpEF), with an LVEF of 55%. She experiences dyspnea on exertion. Her current medications include lisinopril and metformin. Which of the following medication classes has been shown in major clinical trials to reduce the composite endpoint of cardiovascular death and heart failure hospitalizations in patients with HFpEF?

Loop diuretics
Sodium-glucose cotransporter-2 (SGLT2) inhibitors (Correct answer)
Beta-blockers
Angiotensin receptor-neprilysin inhibitors (ARNIs)

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

Large randomized controlled trials, such as EMPEROR-Preserved and DELIVER, have demonstrated that SGLT2 inhibitors (e.g., empagliflozin, dapagliflozin) significantly reduce the primary composite endpoint of cardiovascular death or hospitalization for heart failure in patients with HFpEF. While ARNIs and MRAs may have a role, particularly in patients with LVEF on the lower end of the preserved spectrum, SGLT2 inhibitors have a broader and stronger recommendation for this patient population. Loop diuretics manage symptoms of congestion but do not have a mortality benefit.

Question 112: Which laboratory test is used to monitor patients on warfarin therapy?

Anti-Xa activity level
Prothrombin time/INR (PT/INR) (Correct answer)
Activated partial thromboplastin time (aPTT)
Platelet count

Correct answer: Prothrombin time/INR (PT/INR)

Warfarin inhibits vitamin K-dependent factors (II, VII, IX, X), which are measured by the PT/INR; the aPTT monitors heparin therapy.

Question 113: Which medication most commonly causes AKI through renal afferent arteriolar vasoconstriction leading to decreased GFR?

Calcineurin inhibitors
NSAIDs (Correct answer)
Aminoglycosides
ACE inhibitors

Correct answer: NSAIDs

NSAIDs inhibit prostaglandin synthesis, impairing afferent arteriolar dilation that normally compensates in states of reduced renal perfusion, causing prerenal AKI.

Question 114: A 50-year-old man with a history of heavy alcohol use is admitted with severe epigastric pain radiating to the back and a serum lipase level five times the upper limit of normal. He is diagnosed with acute pancreatitis. Which of the following interventions is considered the cornerstone of early management?

Immediate ERCP with sphincterotomy
Prophylactic antibiotic administration
Aggressive intravenous fluid resuscitation (Correct answer)
Placement of a nasogastric tube for bowel rest

Correct answer: Aggressive intravenous fluid resuscitation

Aggressive early intravenous fluid resuscitation is the single most critical intervention and cornerstone of management in acute pancreatitis. It is crucial for maintaining pancreatic and systemic perfusion, thereby reducing the risk of complications like pancreatic necrosis and organ failure. Prophylactic antibiotics are not recommended for severe acute pancreatitis without evidence of infection. ERCP is indicated emergently only if there is concurrent cholangitis. Nasogastric tube placement is not routinely required unless there is intractable vomiting or severe ileus.

Question 115: An asymptomatic 72-year-old woman is found to have a serum calcium of 11.4 mg/dL (normal 8.6-10.3 mg/dL) on routine labs. Which of the following findings would most strongly suggest primary hyperparathyroidism as the cause of her hypercalcemia?

An elevated or inappropriately normal intact parathyroid hormone (PTH) level (Correct answer)
An elevated parathyroid hormone-related peptide (PTHrP) level
A suppressed intact parathyroid hormone (PTH) level
A low 24-hour urine calcium excretion

Correct answer: An elevated or inappropriately normal intact parathyroid hormone (PTH) level

Primary hyperparathyroidism is characterized by the autonomous production of PTH from one or more parathyroid glands. This leads to hypercalcemia, and the feedback loop is broken. Therefore, the hallmark finding is an elevated calcium level with a simultaneously elevated or inappropriately normal PTH level. A suppressed PTH would suggest a non-PTH-mediated cause of hypercalcemia, such as malignancy, which is often driven by PTHrP. Low urine calcium suggests familial hypocalciuric hypercalcemia (FHH).

Question 116: A 25-year-old man with a severe asthma attack is admitted to the emergency room. He also feels queasy and reports having diarrhea and vomiting. With many hospitalizations and one intubation five years ago, the patient has a long history of severe asthma. He started having breathing problems two days ago, which have worsened. He attempted home nebulizers for ipratropium, cromolyn treatment, and albuterol, but nothing helped his symptoms. Peak flow rates in the hospital are over 50% lower than the baseline. Which medication from the list below must be added to the patient's treatment plan to help him with his present symptoms?

Theophylline
Inhaled beclomethasone
Intravenous hydrocortisone (Correct answer)
Disodium cromoglycate
Oral prednisone

Correct answer: Intravenous hydrocortisone

This patient is experiencing a severe asthma exacerbation, unresponsive to initial bronchodilator therapy, indicated by his history of severe asthma, previous intubation, and significantly reduced peak flow rates. Systemic corticosteroids are essential for reducing airway inflammation in such severe cases. Given his severe presentation and inability to tolerate oral medications due to nausea, vomiting, and diarrhea, intravenous hydrocortisone is the most appropriate and rapidly acting systemic corticosteroid to administer.

Question 117: In the AKIN staging system, Stage 2 AKI is defined as:

Creatinine increase ≥3× baseline or urine output <0.3 mL/kg/h for 24 hours
Creatinine increase ≥0.3 mg/dL or urine output <0.5 mL/kg/h for 6 hours
Creatinine >4 mg/dL with acute rise ≥0.5 mg/dL
Creatinine increase ≥2× baseline or urine output <0.5 mL/kg/h for 12 hours (Correct answer)

Correct answer: Creatinine increase ≥2× baseline or urine output <0.5 mL/kg/h for 12 hours

AKIN Stage 2 is defined as serum creatinine increase ≥2× but <3× baseline, or urine output <0.5 mL/kg/h for ≥12 hours.

Question 118: 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?

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

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 119: 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?

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

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

Correct answer: HLA-B27

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

Question 121: A 35-year-old male presents with painless genital ulcer and inguinal lymphadenopathy. VDRL is reactive. Which antibiotic is first-line treatment?

Ceftriaxone 250mg IM single dose
Azithromycin 1g single dose
Benzathine penicillin G 2.4 million units IM (Correct answer)
Doxycycline 100mg twice daily for 14 days

Correct answer: Benzathine penicillin G 2.4 million units IM

Benzathine penicillin G 2.4 million units IM single dose is the standard first-line treatment for primary and secondary syphilis.

Question 122: 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?

Ventricular septal rupture (Correct answer)
Dressler syndrome
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 123: A 70-year-old man with atrial fibrillation and CKD stage 3 (eGFR 40) needs anticoagulation. His CHA₂DS₂-VASc score is 4. Which anticoagulant is most appropriate?

Dabigatran at full dose
Rivaroxaban standard dose
Apixaban (Correct answer)
Warfarin

Correct answer: Apixaban

Apixaban is preferred in moderate CKD as it has the least renal clearance (~27%) among DOACs and requires minimal dose adjustment down to eGFR 25.

Question 124: What is the first-line treatment for iron deficiency anemia in a hemodynamically stable patient?

Red blood cell transfusion
Oral ferrous sulfate supplementation (Correct answer)
Subcutaneous erythropoietin injections
Intramuscular vitamin B12 injections

Correct answer: Oral ferrous sulfate supplementation

Oral iron supplementation (ferrous sulfate) is the first-line treatment for iron deficiency anemia in stable patients because it is effective, inexpensive, and replenishes both hemoglobin and iron stores.

Question 125: A 34-year-old female is diagnosed with moderate-to-severe ulcerative colitis. She has failed to respond to a course of oral and rectal mesalamine and required a course of corticosteroids for a recent flare. Which of the following medication classes is an appropriate next step for inducing and maintaining remission?

An anti-TNF biologic agent (e.g., infliximab) (Correct answer)
A proton pump inhibitor (e.g., omeprazole)
Loperamide
An antibiotic (e.g., ciprofloxacin)

Correct answer: An anti-TNF biologic agent (e.g., infliximab)

For patients with moderate-to-severe ulcerative colitis who are refractory to or dependent on corticosteroids, the next step in management is typically the initiation of a biologic agent, such as an anti-TNF agent (infliximab, adalimumab), an anti-integrin (vedolizumab), or an IL-12/23 inhibitor (ustekinumab). These medications are effective for both inducing and maintaining remission. Loperamide is for symptomatic control of diarrhea only. Proton pump inhibitors are not used for treating IBD. Antibiotics have a limited role, primarily for infectious complications.

Question 126: A 58-year-old male with decompensated alcoholic cirrhosis and ascites is hospitalized. His baseline creatinine of 0.9 mg/dL has risen to 2.5 mg/dL over two days. He is not in shock, has not received nephrotoxic drugs, and a renal ultrasound is normal. Urine sodium is < 10 mEq/L. After a 2-day trial of diuretic cessation and volume expansion with 1 g/kg of albumin, his creatinine does not improve. Which of the following is the most appropriate next step in management?

Initiation of broad-spectrum antibiotics for presumed SBP
Administration of midodrine, octreotide, and continued albumin (Correct answer)
Placement of a transjugular intrahepatic portosystemic shunt (TIPS)
Urgent renal replacement therapy

Correct answer: Administration of midodrine, octreotide, and continued albumin

This patient meets the diagnostic criteria for Hepatorenal Syndrome-Acute Kidney Injury (HRS-AKI). After ruling out other causes and failing to respond to a trial of albumin expansion, the standard of care is medical therapy with splanchnic vasoconstrictors (octreotide) and a systemic vasoconstrictor (midodrine), along with continued albumin. This combination counteracts the splanchnic vasodilation and improves renal perfusion. TIPS and dialysis are second-line or bridging therapies to liver transplantation, which is the definitive treatment.

Question 127: According to the most recent guidelines from the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS), at what age should asymptomatic individuals with an average risk for colorectal cancer begin screening?

50
40
45 (Correct answer)
55

Correct answer: 45

Due to a rising incidence of colorectal cancer in younger adults, major organizations including the USPSTF and the American Cancer Society have lowered the recommended age to begin screening for average-risk individuals from 50 to 45. Individuals with a family history or other risk factors may need to start screening earlier.

Question 128: A patient with newly diagnosed pulmonary arterial hypertension has a mean PAP of 28 mmHg, PAWP of 10 mmHg, and PVR of 3.5 WU. What is the correct hemodynamic classification?

Normal hemodynamics
Pre-capillary pulmonary hypertension (Correct answer)
Post-capillary pulmonary hypertension
Combined pre- and post-capillary

Correct answer: Pre-capillary pulmonary hypertension

Pre-capillary PH is defined by mean PAP ≥ 20 mmHg, PAWP ≤ 15 mmHg, and PVR ≥ 2 WU.

Question 129: 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?

Lisinopril
Spironolactone
Amlodipine (Correct answer)
Metoprolol

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 130: A 48-year-old male with a history of iron deficiency anemia and intermittent bloating presents for evaluation. He reports no significant alcohol use or medication changes. Which of the following is the most appropriate initial serologic test to screen for celiac disease?

IgA anti-tissue transglutaminase (tTG) antibody (Correct answer)
Endoscopy with duodenal biopsy
Hydrogen breath test
Anti-saccharomyces cerevisiae antibodies (ASCA)

Correct answer: IgA anti-tissue transglutaminase (tTG) antibody

The most sensitive and specific initial blood test for celiac disease is the IgA anti-tissue transglutaminase (tTG) antibody test. It is recommended as the first-line screening tool. An endoscopy with biopsy is the gold standard for confirmation but is not the initial screening test. ASCA is associated with Crohn's disease, and a hydrogen breath test is used for lactose intolerance or small intestinal bacterial overgrowth.

Question 131: A 62-year-old man is brought to the emergency department with severe chest pain. His ECG is consistent with an acute ST-elevation myocardial infarction (STEMI). He admits to using cocaine approximately one hour prior to the onset of his symptoms. He is hypertensive and tachycardic. In addition to aspirin and emergent reperfusion therapy, which of the following is the most appropriate initial medication?

Intravenous diltiazem
Intravenous labetalol
Intravenous lorazepam (Correct answer)
Intravenous esmolol

Correct answer: Intravenous lorazepam

In patients with cocaine-associated chest pain and ACS, the initial management should focus on benzodiazepines (e.g., lorazepam) to reduce central sympathetic outflow, alleviate anxiety, and decrease myocardial oxygen demand. While the historical concern about using beta-blockers due to 'unopposed alpha-stimulation' has been challenged by recent meta-analyses showing no increased harm, they are not the first-line therapy. Benzodiazepines are the primary treatment to control hypertension and tachycardia in this specific clinical context. Calcium channel blockers like diltiazem can also be used.

Question 132: 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?

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

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 133: A 76-year-old male with a history of a transient ischemic attack (TIA) 2 years ago is admitted with an NSTEMI and undergoes percutaneous coronary intervention with placement of a drug-eluting stent. Which of the following P2Y12 inhibitors is contraindicated in this patient?

Clopidogrel
Ticagrelor
Cangrelor
Prasugrel (Correct answer)

Correct answer: Prasugrel

Prasugrel is contraindicated in patients with a prior history of transient ischemic attack (TIA) or stroke. This is due to an increased risk of significant, sometimes fatal, bleeding, including intracranial hemorrhage, observed in this patient population during clinical trials. The other listed P2Y12 inhibitors do not have this absolute contraindication.

Question 134: Which finding on echocardiography is most consistent with cardiac tamponade?

Aortic root dilation
Mitral valve prolapse
Left ventricular hypertrophy
Right ventricular diastolic collapse (Correct answer)

Correct answer: Right ventricular diastolic collapse

Right ventricular diastolic collapse on echocardiography is the classic finding of cardiac tamponade due to elevated pericardial pressure compressing the low-pressure right heart.

Question 135: A 65-year-old smoker presents with chronic productive cough and FEV1/FVC ratio of 0.62 post-bronchodilator. Which GOLD stage classification applies if FEV1 is 45% predicted?

GOLD 1 (Mild)
GOLD 4 (Very Severe)
GOLD 2 (Moderate)
GOLD 3 (Severe) (Correct answer)

Correct answer: GOLD 3 (Severe)

GOLD Stage 3 (Severe) is defined by FEV1 30-49% predicted with FEV1/FVC < 0.70 post-bronchodilator.

Question 136: A patient develops fever, chills, flank pain, and hemoglobinuria 30 minutes into a blood transfusion. What is the most likely cause?

Febrile non-hemolytic transfusion reaction
Acute hemolytic transfusion reaction due to ABO incompatibility (Correct answer)
Allergic anaphylactic transfusion reaction
Transfusion-related acute lung injury (TRALI)

Correct answer: Acute hemolytic transfusion reaction due to ABO incompatibility

Acute hemolytic transfusion reactions from ABO incompatibility cause intravascular hemolysis, presenting with fever, chills, flank/back pain, and hemoglobinuria within minutes of transfusion.

Question 137: 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?

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

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 138: Which antibiotic combination is recommended for severe CAP requiring ICU admission in a patient with no Pseudomonas risk factors?

Amoxicillin-clavulanate + doxycycline
Beta-lactam + macrolide or respiratory fluoroquinolone (Correct answer)
Azithromycin monotherapy
Vancomycin + piperacillin-tazobactam

Correct answer: Beta-lactam + macrolide or respiratory fluoroquinolone

IDSA/ATS guidelines recommend a beta-lactam combined with either a macrolide or respiratory fluoroquinolone for severe CAP without Pseudomonas risk.

Question 139: Which laboratory finding is most consistent with resolution of DKA and readiness to transition to subcutaneous insulin?

Serum pH > 7.30
Blood glucose < 200 mg/dL
Serum bicarbonate ≥ 18 mEq/L and anion gap ≤ 12 (Correct answer)
Urine ketones negative

Correct answer: Serum bicarbonate ≥ 18 mEq/L and anion gap ≤ 12

Resolution criteria include anion gap ≤12 mEq/L, serum bicarbonate ≥18 mEq/L, and pH >7.3 — all three should be met before transitioning.

Question 140: A 55-year-old undergoes screening colonoscopy revealing a 2 cm sessile polyp in the sigmoid colon. Pathology shows high-grade dysplasia confined to the mucosa without submucosal invasion. What is the next step?

Endoscopic mucosal resection is curative if completely excised (Correct answer)
CT staging of the abdomen and pelvis
Repeat colonoscopy in 1 year
Immediate sigmoid colectomy

Correct answer: Endoscopic mucosal resection is curative if completely excised

High-grade dysplasia (carcinoma in situ) without submucosal invasion can be managed with complete endoscopic resection.

Question 141: A patient with HIV and CD4 count of 50 cells/μL presents with headache, fever, and neck stiffness. India ink stain of CSF shows encapsulated yeast. What is the treatment of choice?

Voriconazole IV
Amphotericin B plus flucytosine (Correct answer)
Fluconazole 400mg daily
Micafungin IV

Correct answer: Amphotericin B plus flucytosine

Induction therapy for cryptococcal meningitis consists of amphotericin B plus flucytosine for at least 2 weeks, followed by fluconazole consolidation.

Question 142: A 40-year-old woman with antiphospholipid syndrome has a second DVT despite therapeutic warfarin (INR 2.5). What is the recommended next step?

Switch to fondaparinux
Increase warfarin target INR to 3.0-4.0 (Correct answer)
Add aspirin 81mg to current warfarin dose
Switch to rivaroxaban

Correct answer: Increase warfarin target INR to 3.0-4.0

Patients with APS who have recurrent thrombosis despite standard anticoagulation should have the warfarin target INR raised to 3.0-4.0.

Question 143: 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?

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

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 144: A patient with antiphospholipid syndrome (APS) is at highest risk for which complication?

Aplastic anemia from bone marrow failure
Severe bleeding diathesis due to factor inhibitors
Autoimmune hemolytic anemia as the primary manifestation
Arterial and venous thrombosis and recurrent pregnancy loss (Correct answer)

Correct answer: Arterial and venous thrombosis and recurrent pregnancy loss

APS is a thrombophilic condition caused by antiphospholipid antibodies that promote clotting, leading to arterial/venous thrombosis and recurrent pregnancy loss.

Question 145: A 62-year-old patient is admitted to the ICU with severe community-acquired pneumonia requiring mechanical ventilation. According to the 2019 IDSA/ATS guidelines, which of the following is the strongest indication to add empiric coverage for Pseudomonas aeruginosa?

Recent hospitalization with receipt of parenteral antibiotics (Correct answer)
Admission to the ICU
Living in a nursing home
History of alcoholism

Correct answer: Recent hospitalization with receipt of parenteral antibiotics

The 2019 IDSA/ATS guidelines recommend empiric treatment for *Pseudomonas aeruginosa* in patients with CAP only if locally validated risk factors are present. The most consistently cited major risk factors are prior respiratory isolation of *P. aeruginosa* or recent hospitalization (within 90 days) where the patient received parenteral antibiotics. [19, 21] While nursing home residence was part of the old HCAP definition, it is no longer considered a standalone indication. Alcoholism and ICU admission alone are not specific risk factors for *Pseudomonas*.

Question 146: A patient with CAP is found to have a parapneumonic effusion. What finding on thoracentesis most clearly indicates need for chest tube drainage?

pH 7.40, glucose 90 mg/dL, LDH 150 U/L
pH 7.30, glucose 70 mg/dL, LDH 500 U/L
pH 7.25, glucose 55 mg/dL, LDH 800 U/L (Correct answer)
pH 7.35, glucose 80 mg/dL, LDH 200 U/L

Correct answer: pH 7.25, glucose 55 mg/dL, LDH 800 U/L

A complicated parapneumonic effusion with pH <7.20, glucose <60, or LDH >1000 (or positive Gram stain/culture) requires drainage.

Question 147: A 48-year-old man develops fever and flank pain 10 days after a kidney transplant. Urinalysis shows pyuria. Urine culture grows Escherichia coli (ESBL-producing). What is the preferred treatment?

Meropenem or ertapenem (Correct answer)
Trimethoprim-sulfamethoxazole based on susceptibilities
Nitrofurantoin
Ceftriaxone

Correct answer: Meropenem or ertapenem

ESBL-producing Enterobacteriaceae are resistant to most cephalosporins and require carbapenems as the definitive treatment for serious infections in immunocompromised hosts.

Question 148: A 60-year-old man with gout has a serum uric acid of 9.8 mg/dL and has experienced 3 flares in the past year. Which medication is first-line for long-term urate-lowering therapy?

Colchicine
Indomethacin
Probenecid
Allopurinol (Correct answer)

Correct answer: Allopurinol

Allopurinol is the first-line urate-lowering therapy for gout, targeting a serum uric acid level below 6 mg/dL.

Question 149: A patient returns from a trip to sub-Saharan Africa with cyclic fevers, chills, and headache. Thick and thin blood smears are ordered. Which Plasmodium species causes the most severe and potentially fatal malaria?

Plasmodium vivax
Plasmodium ovale
Plasmodium falciparum (Correct answer)
Plasmodium malariae

Correct answer: Plasmodium falciparum

Plasmodium falciparum causes the most severe malaria, with complications including cerebral malaria, severe anemia, and multi-organ failure.

Question 150: A 45-year-old woman presents with a butterfly-shaped facial rash, joint pain, and a positive anti-dsDNA antibody. Which complement levels would most likely be found during active disease flare?

Decreased C3 and C4 (Correct answer)
Elevated C3 and C4
Normal C3 with elevated C4
Elevated C3 with decreased C4

Correct answer: Decreased C3 and C4

In active SLE, complement is consumed by immune complex deposition, leading to decreased C3 and C4 levels.

Question 151: A 62-year-old man with cirrhosis and ascites presents with a fever of 38.5°C (101.3°F) and diffuse abdominal pain. A diagnostic paracentesis is performed. Which of the following ascitic fluid findings is diagnostic for spontaneous bacterial peritonitis (SBP)?

Polymorphonuclear (PMN) leukocyte count of 350 cells/mm³ (Correct answer)
Total protein > 2.5 g/dL
Serum-ascites albumin gradient (SAAG) > 1.1 g/dL
Positive bacterial culture with a PMN count of 100 cells/mm³

Correct answer: Polymorphonuclear (PMN) leukocyte count of 350 cells/mm³

The diagnosis of spontaneous bacterial peritonitis (SBP) is established by an ascitic fluid polymorphonuclear (PMN) leukocyte count of ≥250 cells/mm³. Therefore, a count of 350 cells/mm³ is diagnostic and requires immediate initiation of empiric antibiotic therapy. A SAAG > 1.1 g/dL indicates portal hypertension but not infection. A positive culture with a low PMN count is termed bacterascites and may not require treatment if the patient is asymptomatic. Ascitic fluid protein levels are not used for diagnosing SBP.

Question 152: 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?

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

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 153: A 35-year-old nonsmoker presents with spontaneous pneumothorax. Chest X-ray shows a 2.5 cm rim of air. What is the most appropriate next step?

Needle aspiration and discharge if successful (Correct answer)
Urgent VATS pleurodesis
Supplemental O2 and observation for 3 hours
Immediate chest tube thoracostomy

Correct answer: Needle aspiration and discharge if successful

For a primary spontaneous pneumothorax > 2 cm in a stable patient, needle aspiration is first-line per BTS guidelines, with discharge if successful.

Question 154: A 50-year-old woman with RA presents with progressive dyspnea. HRCT shows basal-predominant reticulation and honeycombing. Surgical lung biopsy shows temporal heterogeneity with fibroblastic foci. What pattern is this?

Usual interstitial pneumonia (UIP) (Correct answer)
Desquamative interstitial pneumonia (DIP)
Organizing pneumonia (OP)
Nonspecific interstitial pneumonia (NSIP)

Correct answer: Usual interstitial pneumonia (UIP)

UIP pattern is characterized by temporal and spatial heterogeneity, fibroblastic foci, and honeycombing with basal and subpleural predominance.

Question 155: A cirrhotic patient with esophageal varices is started on non-selective beta-blocker therapy. Which parameter best confirms adequate pharmacologic response?

Normalization of platelet count
Heart rate reduced to <55 bpm
Hepatic venous pressure gradient (HVPG) <12 mmHg or ≥20% reduction (Correct answer)
Reduction of spleen size on ultrasound

Correct answer: Hepatic venous pressure gradient (HVPG) <12 mmHg or ≥20% reduction

Adequate beta-blocker response is confirmed by HVPG reduction to <12 mmHg or ≥20% from baseline, which significantly reduces variceal bleeding risk.

Question 156: 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 dobutamine
Administer intravenous nitroglycerin (Correct answer)
Obtain a B-type natriuretic peptide (BNP) level

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 157: 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 daily for 9 months
Ethambutol and pyrazinamide daily for 2 months
Isoniazid and rifapentine weekly for 3 months (Correct answer)
Rifampin daily for 6 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 158: A patient with primary biliary cholangitis (PBC) is started on ursodeoxycholic acid (UDCA). Which lab trend best indicates an adequate biochemical response?

Normalization of serum bilirubin within 1 month
Reduction in ALT to below 2x upper limit of normal
Decrease in alkaline phosphatase by >40% from baseline (Correct answer)
Decrease in anti-mitochondrial antibody titer

Correct answer: Decrease in alkaline phosphatase by >40% from baseline

The Paris-I and Paris-II criteria use alkaline phosphatase reduction (>40% or to normal) as the primary indicator of adequate UDCA response in PBC.

Question 159: A 67-year-old male with a known diagnosis of severe COPD presents with a 3-day history of increased dyspnea, increased sputum volume, and sputum that has changed from white to green. He has not required hospitalization. According to the GOLD 2024 guidelines, which of the following is the most appropriate management in addition to short-acting bronchodilators?

A long-acting muscarinic antagonist (LAMA) only
Systemic corticosteroids and antibiotics (Correct answer)
Theophylline and supportive care
Inhaled corticosteroids only

Correct answer: Systemic corticosteroids and antibiotics

According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, a COPD exacerbation characterized by all three cardinal symptoms (increased dyspnea, increased sputum volume, and increased sputum purulence) is classified as moderate and warrants treatment with systemic corticosteroids and antibiotics, in addition to short-acting bronchodilators. Systemic corticosteroids (e.g., prednisone for 5 days) shorten recovery time and improve lung function, while antibiotics are indicated when increased sputum purulence is present.

Question 160: A 60-year-old woman with RA develops fever, splenomegaly, and severe neutropenia. Bone marrow biopsy shows hypercellularity. Which treatment should be avoided in this patient?

Rituximab
Prednisone
Hydroxychloroquine
Methotrexate (Correct answer)

Correct answer: Methotrexate

Felty syndrome (RA + splenomegaly + neutropenia) is worsened by methotrexate, which further suppresses neutrophil production.

Question 161: A patient with DKA has a measured serum sodium of 128 mEq/L. Blood glucose is 600 mg/dL. What is the corrected sodium?

140 mEq/L
136 mEq/L (Correct answer)
128 mEq/L (no correction needed)
132 mEq/L

Correct answer: 136 mEq/L

Corrected sodium = measured Na + 1.6 × [(glucose − 100)/100]; here: 128 + 1.6 × 5 = 136 mEq/L.

Question 162: 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?

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

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 163: A 48-year-old male with treatment-resistant hypertension is found to have a serum potassium of 3.1 mEq/L despite not being on diuretics. Which of the following is the best initial screening test to investigate the most likely diagnosis?

Plasma aldosterone-renin ratio (ARR) (Correct answer)
Late-night salivary cortisol
Renal artery duplex ultrasound
24-hour urine metanephrines

Correct answer: Plasma aldosterone-renin ratio (ARR)

The combination of treatment-resistant hypertension and spontaneous hypokalemia is highly suggestive of primary aldosteronism. The Endocrine Society guidelines recommend the plasma aldosterone-renin ratio (ARR) as the initial screening test for this condition. An elevated aldosterone level coupled with a suppressed renin level points towards autonomous aldosterone secretion. While other conditions can cause secondary hypertension, the presence of hypokalemia makes primary aldosteronism the leading diagnosis to investigate first.

Question 164: Heparin-induced thrombocytopenia (HIT) typically develops at what time point after heparin initiation?

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

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 165: 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?

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

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

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 167: 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?

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

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 168: A 68-year-old man presents with acute monoarthritis of the first MTP joint, fever, and serum urate of 9.8 mg/dL. Synovial fluid shows negatively birefringent needle-shaped crystals. Which enzyme deficiency leads to the most severe form of gout?

HGPRT deficiency (Lesch-Nyhan syndrome) (Correct answer)
Xanthine oxidase deficiency
Adenosine deaminase deficiency
Glucose-6-phosphatase deficiency

Correct answer: HGPRT deficiency (Lesch-Nyhan syndrome)

Complete deficiency of HGPRT (hypoxanthine-guanine phosphoribosyltransferase) causes Lesch-Nyhan syndrome with severe hyperuricemia and gout.

Question 169: A 55-year-old male with a history of recurrent sinusitis and recent onset of shortness of breath and hemoptysis is found to have nodular opacities on chest X-ray. Urinalysis reveals red blood cell casts. Which of the following autoantibodies is most specifically associated with this patient's likely diagnosis?

Anti-double-stranded DNA (anti-dsDNA)
Anti-neutrophil cytoplasmic antibody, cytoplasmic pattern (c-ANCA) with anti-proteinase 3 (PR3) (Correct answer)
Anti-Scl-70 (anti-topoisomerase I)
Anti-neutrophil cytoplasmic antibody, perinuclear pattern (p-ANCA) with anti-myeloperoxidase (MPO)

Correct answer: Anti-neutrophil cytoplasmic antibody, cytoplasmic pattern (c-ANCA) with anti-proteinase 3 (PR3)

This patient's constellation of upper airway (sinusitis), lower airway (hemoptysis, lung nodules), and renal (glomerulonephritis with RBC casts) involvement is classic for Granulomatosis with Polyangiitis (GPA). The most specific autoantibody for GPA is c-ANCA with specificity for proteinase 3 (PR3). While p-ANCA/MPO is associated with vasculitis (like Microscopic Polyangiitis), c-ANCA/PR3 is highly characteristic of GPA.

Question 170: 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?

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

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 171: Von Willebrand disease most characteristically presents with which bleeding pattern?

Delayed bleeding after surgery only
Mucocutaneous bleeding such as epistaxis and menorrhagia (Correct answer)
Spontaneous intracranial hemorrhage
Hemarthroses and deep muscle hematomas

Correct answer: Mucocutaneous bleeding such as epistaxis and menorrhagia

Von Willebrand disease impairs platelet adhesion and primary hemostasis, leading to mucocutaneous bleeding; hemarthroses are more typical of hemophilia.

Question 172: A 65-year-old female with a history of hypertension presents with new-onset peripheral edema, fatigue, and 8 grams of proteinuria on a 24-hour urine collection. Her serum creatinine is 1.4 mg/dL and albumin is 2.5 g/dL. A renal biopsy is performed. Which of the following is the most common cause of primary nephrotic syndrome in non-diabetic White adults?

Focal Segmental Glomerulosclerosis (FSGS)
Minimal Change Disease
Membranous Nephropathy (Correct answer)
IgA Nephropathy

Correct answer: Membranous Nephropathy

Membranous nephropathy is the leading cause of primary nephrotic syndrome in non-diabetic White adults. It is an autoimmune disease characterized by the deposition of immune complexes along the glomerular basement membrane. While FSGS is another common cause, it is more prevalent in other populations. Minimal Change Disease is the most common cause in children, and IgA nephropathy typically presents as nephritic syndrome or asymptomatic hematuria.

Question 173: A 35-year-old nonsmoker with recurrent spontaneous pneumothoraces is found to have lung cysts and renal angiomyolipomas on CT. What is the most likely diagnosis?

Pulmonary sarcoidosis
Langerhans cell histiocytosis
Birt-Hogg-Dubé syndrome
Lymphangioleiomyomatosis (LAM) (Correct answer)

Correct answer: Lymphangioleiomyomatosis (LAM)

LAM is characterized by diffuse pulmonary cysts, recurrent pneumothoraces, and renal angiomyolipomas, predominantly in women of childbearing age.

Question 174: A 52-year-old guy with Type 2 diabetes attends the clinic for his yearly checkup. The only drug he takes is metformin. His serum creatinine level was 1.8 mg/dL, and his most recent hemoglobin A1C result was 6.5%. Despite having a high blood pressure of 170–175 mm/Hg, the remainder of his evaluation is negative. Although his chest x-ray is normal, left ventricular hypertrophy is suggested by his EKG. Which medication would be best for treating his hypertension?

Beta-blocker
Thiazide diuretic
Angiotensin receptor blocker (ARB) (Correct answer)
Calcium channel blocker (CCB)

Correct answer: Angiotensin receptor blocker (ARB)

Angiotensin receptor blockers (ARBs) are the preferred medication for treating hypertension in patients with type 2 diabetes and evidence of renal impairment (creatinine 1.8 mg/dL), as they are renoprotective. They also effectively reduce blood pressure and can help regress left ventricular hypertrophy, making them an ideal choice for this patient's complex profile.

Question 175: 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)?

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

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 176: 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.
Implantation of a cardiac resynchronization therapy with defibrillator (CRT-D) device. (Correct answer)
Coronary artery bypass grafting (CABG).
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 177: A 60-year-old male presents to the emergency department with sudden-onset, severe dyspnea and syncope. His blood pressure is 75/45 mmHg and heart rate is 140/min. A bedside echocardiogram shows severe right ventricular dilation and dysfunction. A CT angiogram confirms a saddle pulmonary embolism. In the absence of absolute contraindications, what is the most appropriate immediate intervention?

Catheter-directed thrombolysis
Systemic thrombolysis with tissue plasminogen activator (tPA) (Correct answer)
Initiation of unfractionated heparin infusion alone
Placement of an inferior vena cava (IVC) filter

Correct answer: Systemic thrombolysis with tissue plasminogen activator (tPA)

This patient presents with a massive (high-risk) pulmonary embolism, defined by the presence of persistent hypotension and shock. For patients with massive PE who do not have a high bleeding risk, guidelines recommend immediate reperfusion therapy. Systemic thrombolysis is the most readily available and recommended first-line advanced therapy to rapidly dissolve the clot and improve hemodynamics. While catheter-directed therapy and surgical embolectomy are options, systemic thrombolysis is the preferred initial choice if not contraindicated.

Question 178: 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?

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

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 179: A 72-year-old female presents with a new-onset, unilateral headache, scalp tenderness, and jaw claudication for the past month. Today, she experienced a transient, 'curtain-like' loss of vision in her right eye that lasted several minutes. Her erythrocyte sedimentation rate (ESR) is 95 mm/hr. What is the most critical immediate step in management?

Check a C-reactive protein (CRP) level
Obtain an MRI of the brain and orbits
Schedule an urgent temporal artery biopsy
Administer high-dose glucocorticoids (Correct answer)

Correct answer: Administer high-dose glucocorticoids

In a patient with suspected giant cell arteritis (GCA) presenting with visual symptoms like amaurosis fugax, immediate administration of high-dose glucocorticoids is essential to prevent permanent vision loss. [2, 9, 11] While a temporal artery biopsy is the gold standard for diagnosis, treatment should never be delayed to await the procedure. [4, 14] An MRI and CRP are part of the workup but are not the most critical immediate action when vision is threatened.

Question 180: Which organism should be specifically covered when CAP is associated with recent influenza infection?

Moraxella catarrhalis
Klebsiella pneumoniae
Legionella pneumophila
Staphylococcus aureus (including MRSA) (Correct answer)

Correct answer: Staphylococcus aureus (including MRSA)

Post-influenza bacterial pneumonia most commonly involves S. aureus (including community-acquired MRSA), which requires targeted coverage.

Question 181: Which of the following clinical parameters is a component of the CURB-65 score for assessing the severity of community-acquired pneumonia?

Serum sodium < 130 mEq/L
Multilobar infiltrates on chest x-ray
Oxygen saturation <92%
A respiratory rate ≥ 30 breaths per minute (Correct answer)

Correct answer: A respiratory rate ≥ 30 breaths per minute

The CURB-65 score is an acronym for five clinical features used to predict mortality and determine the site of care for patients with CAP. One point is given for each of the following: Confusion (new onset), Urea > 7 mmol/L (BUN > 19 mg/dL), Respiratory rate ≥ 30 breaths/min, Blood pressure (systolic < 90 mmHg or diastolic ≤ 60 mmHg), and age ≥ 65 years. [1, 2, 6] The other options are indicators of severe pneumonia but are not components of the CURB-65 score.

Question 182: A patient with inferior STEMI develops hypotension and elevated JVP without pulmonary congestion. Which diagnosis should be suspected first?

Right ventricular infarction (Correct answer)
Aortic dissection
Cardiogenic shock from LV failure
Pulmonary embolism

Correct answer: Right ventricular infarction

Right ventricular infarction commonly accompanies inferior STEMI and presents with hypotension, elevated JVP, and clear lungs (Kussmaul's sign may be present).

Question 183: A 65-year-old man presents with symmetric proximal muscle pain and stiffness, elevated ESR of 95 mm/hr, and normal CK. He responds dramatically to prednisone 15mg/day within 48 hours. What is the most concerning complication to monitor for?

Cardiomyopathy
Peripheral neuropathy
Giant cell arteritis with visual loss (Correct answer)
Renal failure

Correct answer: Giant cell arteritis with visual loss

Polymyalgia rheumatica is associated with giant cell (temporal) arteritis in 10-15% of cases, and vision loss from anterior ischemic optic neuropathy is a devastating complication.

Question 184: A 65-year-old male with stage 4 chronic kidney disease (eGFR 25 mL/min/1.73 m²) and hypertension presents with an acutely swollen, erythematous, and exquisitely tender right great toe. Aspiration of the joint fluid reveals needle-shaped, negatively birefringent crystals. Which of the following is the most appropriate initial treatment for this acute flare?

High-dose allopurinol
Probenecid
Indomethacin
Intra-articular glucocorticoid injection (Correct answer)

Correct answer: Intra-articular glucocorticoid injection

This patient has an acute gout flare. In the setting of significant chronic kidney disease, NSAIDs like indomethacin are contraindicated due to the risk of worsening renal function. [16, 20] Allopurinol and probenecid are urate-lowering therapies used for chronic gout management and should not be initiated during an acute flare. An intra-articular glucocorticoid injection is a safe and effective first-line option for a monoarticular gout flare in a patient with contraindications to systemic therapies. [16, 22]

Question 185: A 28-year-old male presents with a six-month history of low back pain and stiffness that is worse in the morning and improves with activity. He notes the pain often wakes him in the second half of the night. On examination, he has tenderness over the sacroiliac joints. Which of the following physical exam maneuvers is most specifically associated with his likely diagnosis?

Limited lumbar flexion on Schober test (Correct answer)
Presence of Heberden's nodes
Ulnar deviation of the metacarpophalangeal joints
Positive Phalen's test

Correct answer: Limited lumbar flexion on Schober test

The patient's presentation is classic for inflammatory back pain, highly suggestive of ankylosing spondylitis (AS). A key physical finding in AS is limited lumbar spine flexion, which is objectively measured by the Schober test. [17, 19] Phalen's test is for carpal tunnel syndrome, Heberden's nodes are characteristic of osteoarthritis, and ulnar deviation is a finding in advanced rheumatoid arthritis.

Question 186: A patient with penicillin allergy (anaphylaxis) requires treatment for neurosyphilis. What is the recommended management?

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

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 187: 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?

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

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 188: Which medication used for COPD management acts by inhibiting phosphodiesterase-4 to reduce exacerbations?

Tiotropium
Indacaterol
Budesonide
Roflumilast (Correct answer)

Correct answer: Roflumilast

Roflumilast is a selective PDE-4 inhibitor that reduces inflammation and decreases exacerbation frequency in severe COPD with chronic bronchitis.

Question 189: A 25-year-old lady who has been experiencing lethargy and polyuria for the past nine months comes into your office for an examination. She also had anorexia and a mysterious 12-pound weight drop. She has also experienced nocturnal sweats for a few months. She exhibited minor hypercalcemia upon evaluation of her lab results from her yearly visit roughly nine months prior, while all other tests, including glucose, were normal. She has been playing tennis outside more frequently and anticipated feeling better as a result of the increased exercise. She doesn't have a history of fractures or nephrolithiasis. No history of hypercalcemia in the family. She doesn't use any prescription drugs. Physical exam: Weight 125 pounds, height 5’2”, blood pressure 102/74 mmHg, heart rate 94 bpm She has dry mucous membranes and delayed deep tendon reflexes. Otherwise unremarkable. You send her to the lab to evaluate her symptoms and history of mild hypercalcemia. Her lab results are remarkable for Calcium = 13.1 mg/dL (8.9-10.1 mg/dL) Phosphorus = 5.0 mg/dL (2.5-4.5 mg/dL) Creatinine = 1.4 mg/dL (0.6-1.1 mg/dL) Serum urea nitrogen = 22 mg/dL (6-21 mg/dL) Intact PTH = 4 pg/mL (10-65 pg/mL) 25-Hydroxyvitamin D = 24 ng/mL (25-80 ng/mL) 1,25-Hydroxyvitamin D = 90 pg/mL (16-65 pg/mL) Alkaline phosphatase = 99 U/L (37-98 U/L) <br) Which medication would best address the cause of this patient’s hypercalcemia?

Cinacalcet
Zolendronic acid
Prednisone (Correct answer)
Calcitonin

Correct answer: Prednisone

The patient's presentation of significant hypercalcemia, suppressed PTH, and elevated 1,25-Hydroxyvitamin D, along with symptoms like weight loss and polyuria, strongly suggests a granulomatous disease (e.g., sarcoidosis) or lymphoma. These conditions can cause unregulated production of 1,25-Hydroxyvitamin D, leading to hypercalcemia. Prednisone, a corticosteroid, is the appropriate treatment as it inhibits the activity of 1-alpha-hydroxylase in granulomas, thereby reducing 1,25-Hydroxyvitamin D production and subsequently lowering calcium levels.

Question 190: A 28-year-old man presents with urethritis, conjunctivitis, and asymmetric oligoarthritis after a recent Chlamydia infection. What is the classic triad associated with this condition?

Urethritis, conjunctivitis, arthritis (Correct answer)
Rash, arthritis, fever
Dactylitis, enthesitis, sacroiliitis
Arthritis, uveitis, aortic regurgitation

Correct answer: Urethritis, conjunctivitis, arthritis

Reactive arthritis (formerly Reiter's syndrome) classically presents with the triad of urethritis, conjunctivitis, and arthritis following genitourinary or GI infection.

Question 191: A patient with diffuse systemic sclerosis develops dyspnea and a dry cough. PFTs show a restrictive pattern with reduced DLCO. CT chest shows bilateral basilar ground-glass opacities and honeycombing. What is the first-line treatment?

Azathioprine
Cyclophosphamide or mycophenolate mofetil (Correct answer)
High-dose prednisone alone
Rituximab

Correct answer: Cyclophosphamide or mycophenolate mofetil

Interstitial lung disease in systemic sclerosis is treated with cyclophosphamide or mycophenolate mofetil as first-line immunosuppressive agents.

Question 192: 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
IV antibiotics alone without drainage
Percutaneous CT-guided drainage and IV antibiotics (Correct answer)
Increase azathioprine dose

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 193: 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?

Start treatment with an ACE inhibitor.
Recommend a 3- to 6-month trial of lifestyle modifications. (Correct answer)
Initiate therapy with a thiazide diuretic.
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 194: A 28-year-old healthy, non-pregnant female presents with a 3-day history of dysuria, urinary frequency, and urgency. She has no fever or flank pain. A urine dipstick is positive for nitrites and leukocyte esterase. Assuming no drug allergies and local E. coli resistance rates to trimethoprim-sulfamethoxazole are known to be >20%, which of the following is the most appropriate first-line oral antibiotic?

Ciprofloxacin
Amoxicillin-clavulanate
Nitrofurantoin (Correct answer)
Cephalexin

Correct answer: Nitrofurantoin

For uncomplicated cystitis in regions where E. coli resistance to trimethoprim-sulfamethoxazole is high (>20%), nitrofurantoin is a recommended first-line agent according to IDSA guidelines. Fluoroquinolones like ciprofloxacin should be reserved for more serious infections to avoid promoting resistance and due to potential side effects. Beta-lactams like amoxicillin-clavulanate and cephalexin are considered alternative agents but generally have lower efficacy for cystitis.

Question 195: 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 196: A 65-year-old man with a history of small cell lung cancer is admitted with confusion. His serum sodium is 118 mEq/L. He is clinically euvolemic. Further labs show serum osmolality of 250 mOsm/kg, urine osmolality of 400 mOsm/kg, and urine sodium of 50 mEq/L. Which of the following is the most appropriate immediate treatment?

Aggressive intravenous 0.9% normal saline infusion
Administration of demeclocycline
Oral fluid restriction to less than 1 liter per day
Intravenous infusion of 3% hypertonic saline (Correct answer)

Correct answer: Intravenous infusion of 3% hypertonic saline

This patient has severe, symptomatic hyponatremia due to the Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a known paraneoplastic syndrome of small cell lung cancer. The presence of neurologic symptoms (confusion) necessitates urgent but controlled correction of the serum sodium to prevent further cerebral edema. The standard of care for this is an intravenous infusion of 3% hypertonic saline. Fluid restriction is the primary treatment for mild or asymptomatic SIADH, while 0.9% saline would worsen the hyponatremia. Demeclocycline is a second-line option for chronic management.

Question 197: 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
Ciprofloxacin
Amoxicillin-clavulanate plus doxycycline (Correct answer)
Azithromycin monotherapy

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 198: Which finding on pulmonary function testing is most consistent with pulmonary fibrosis?

Decreased FEV1/FVC ratio
Increased residual volume
Decreased DLCO with preserved FEV1/FVC ratio (Correct answer)
Increased total lung capacity

Correct answer: Decreased DLCO with preserved FEV1/FVC ratio

Pulmonary fibrosis produces a restrictive pattern with decreased DLCO due to impaired gas exchange across fibrotic lung tissue, and the FEV1/FVC ratio is preserved or elevated.

Question 199: 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
Beta-lactams
Carbapenems
Macrolides (Correct answer)

Correct answer: Macrolides

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

Question 200: 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.

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%

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