NCCPA Clinical Medicine 3 — Questions and Answers
Question 1: A 60-year-old woman with type 2 diabetes and CKD stage 3b (eGFR 32) requires better glycemic control. Which antidiabetic agent should be avoided due to risk of lactic acidosis?
- Sitagliptin
- Metformin (Correct answer)
- Insulin glargine
- Glipizide
Correct answer: Metformin
Metformin is contraindicated when eGFR falls below 30 mL/min/1.73m² due to accumulation and risk of lactic acidosis; it should be used cautiously with eGFR 30–45.
Question 2: A 35-year-old woman develops bilateral ptosis, diplopia, and generalized weakness that worsens with repetitive muscle use and improves with rest. Anti-AChR antibodies are positive. What is the most likely diagnosis?
- Lambert-Eaton myasthenic syndrome
- Multiple sclerosis
- Myasthenia gravis (Correct answer)
- Guillain-Barré syndrome
Correct answer: Myasthenia gravis
Myasthenia gravis is an autoimmune disorder with antibodies against acetylcholine receptors, causing fatigable weakness that worsens with activity.
Question 3: A 70-year-old man presents with progressive dysphagia to solids, 15-lb weight loss over 3 months, and iron-deficiency anemia. He drinks alcohol daily and smokes 2 packs/day. Upper endoscopy reveals a mid-esophageal mass. Which histology is most expected?
- Adenocarcinoma
- Squamous cell carcinoma (Correct answer)
- Leiomyosarcoma
- Carcinoid tumor
Correct answer: Squamous cell carcinoma
Squamous cell carcinoma arises in the mid-esophagus and is strongly associated with smoking and alcohol use, while adenocarcinoma arises in the distal esophagus from Barrett's.
Question 4: A 28-year-old pregnant woman (32 weeks) presents with sudden-onset severe headache, visual changes, BP 160/110 mmHg, and 3+ proteinuria. Platelet count is 85,000/µL, LDH is elevated, and AST is 3x normal. Which syndrome does she have?
- Eclampsia
- HELLP syndrome (Correct answer)
- Thrombotic thrombocytopenic purpura
- Acute fatty liver of pregnancy
Correct answer: HELLP syndrome
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe variant of preeclampsia requiring urgent delivery.
Question 5: A patient with long-standing GERD develops Barrett's esophagus. Which cellular change characterizes this condition?
- Squamous to pseudostratified columnar metaplasia
- Squamous to intestinal-type columnar metaplasia (Correct answer)
- Columnar to squamous metaplasia
- Squamous dysplasia without metaplasia
Correct answer: Squamous to intestinal-type columnar metaplasia
Barrett's esophagus is defined by replacement of normal squamous epithelium with specialized intestinal columnar metaplasia (goblet cells) due to chronic acid exposure.
Question 6: A 50-year-old man with HIV (CD4 count 60 cells/µL) presents with ring-enhancing brain lesions on MRI, headache, and hemiparesis. Toxoplasma IgG is positive. What is the first-line empiric treatment?
- Amphotericin B
- Ganciclovir
- Pyrimethamine + sulfadiazine + leucovorin (Correct answer)
- Trimethoprim-sulfamethoxazole alone
Correct answer: Pyrimethamine + sulfadiazine + leucovorin
Empiric treatment for cerebral toxoplasmosis is pyrimethamine plus sulfadiazine with leucovorin (to prevent bone marrow suppression) for at least 6 weeks.
Question 7: A 42-year-old woman presents with episodic hypertension, headache, diaphoresis, and palpitations. 24-hour urine shows elevated catecholamines and metanephrines. CT reveals a 4-cm right adrenal mass. What is the next step before surgery?
- Start beta-blocker first
- Start alpha-blocker first, then beta-blocker (Correct answer)
- Proceed directly to adrenalectomy
- Start ACE inhibitor
Correct answer: Start alpha-blocker first, then beta-blocker
In pheochromocytoma, alpha-blockade (phenoxybenzamine) must be established before beta-blockade to prevent unopposed alpha-adrenergic vasoconstriction and hypertensive crisis.
NCCPA Clinical Medicine 3
A 60-year-old woman with type 2 diabetes and CKD stage 3b (eGFR 32) requires better glycemic control.
Which antidiabetic agent should be avoided due to risk of lactic acidosis?