SPEX Exam Family Medicine 4

Question 1

A 52-year-old woman with type 2 diabetes, CKD stage 3b (eGFR 38), and heart failure with reduced ejection fraction (HFrEF, EF 35%) presents for medication review. Which antidiabetic agent provides both cardiovascular mortality benefit and renal protection most appropriate for her combined conditions?

Accepted Answer

Empagliflozin

Answer

Empagliflozin (an SGLT2 inhibitor) is the most appropriate choice because it has demonstrated cardiovascular mortality reduction in HFrEF patients (EMPEROR-Reduced trial) AND slows CKD progression (EMPA-KIDNEY trial). It is approved down to eGFR ≥20 for heart failure benefit. Sitagliptin is heart-failure neutral but has no renal protection signal. Pioglitazone causes fluid retention and is contraindicated in HFrEF. Liraglutide (GLP-1 RA) reduces MACE in atherosclerotic CVD but has not shown benefit—and may worsen outcomes—in HFrEF, and its renal benefit is secondary to the SGLT2 inhibitors in this scenario.

Question 2

A 68-year-old man on warfarin for atrial fibrillation (INR target 2.0–3.0) starts clarithromycin for community-acquired pneumonia. His INR is checked 5 days later and is 4.9 with no bleeding. What is the most appropriate next step?

Accepted Answer

Hold warfarin 1–2 doses, recheck INR in 1–2 days, resume at a lower dose

Answer

With a supratherapeutic INR of 4.9 and no active bleeding, the guideline-recommended approach (CHEST guidelines) is to hold 1–2 warfarin doses and recheck INR in 1–2 days, then resume at a reduced dose. IV vitamin K 10 mg is reserved for serious/life-threatening bleeding or INR >10. Switching to a DOAC is a separate clinical decision not warranted urgently here. Continuing unchanged risks bleeding as clarithromycin inhibits CYP3A4 and P-glycoprotein, amplifying warfarin's effect.

Question 3

A 34-year-old woman presents with episodic hypertension, palpitations, diaphoresis, and headaches. Plasma free metanephrines are elevated at 3× the upper limit of normal. She is scheduled for adrenalectomy in 4 weeks. Which preoperative medication regimen is most critical to initiate first?

Accepted Answer

Alpha-adrenergic blockade (phenoxybenzamine), then add beta-blockade after adequate alpha blockade is achieved

Answer

For pheochromocytoma, alpha-blockade MUST precede beta-blockade. Initiating a beta-blocker first (or simultaneously) can cause unopposed alpha-adrenergic stimulation, triggering a hypertensive crisis because catecholamine-mediated vasodilation via beta-2 receptors is blocked while alpha-1-mediated vasoconstriction remains uninhibited. Phenoxybenzamine (non-selective, irreversible alpha-blocker) is standard for 7–14 days before surgery; only then is a beta-blocker added for reflex tachycardia. Calcium channel blockers are an acceptable alternative or adjunct but not first-line monotherapy when metanephrines are markedly elevated.

Question 4

A 71-year-old man with COPD GOLD Group E (multiple exacerbations, CAT score 24) remains symptomatic on dual bronchodilator therapy (LABA + LAMA). Spirometry shows FEV1 42% predicted. Blood eosinophil count is 380 cells/μL. What is the most evidence-supported next step?

Accepted Answer

Escalate to triple therapy by adding an inhaled corticosteroid (ICS)

Answer

Per GOLD 2024 guidelines, patients in Group E with blood eosinophils ≥300 cells/μL have a strong predictor of ICS response, and escalation to triple therapy (ICS + LABA + LAMA) is the recommended step after dual bronchodilator failure — supported by the IMPACT and ETHOS trials showing exacerbation reduction and mortality benefit. Roflumilast is an option for chronic bronchitis phenotype with frequent exacerbations but is not first-line before triple therapy in this eosinophilic profile. Long-term oral corticosteroids are not recommended in COPD due to systemic side effects. Removing the LAMA (switching to ICS+LABA alone) is a downgrade, not an escalation.

Question 5

A 28-year-old woman at 10 weeks gestation is found to have a TSH of 6.8 mIU/L with a free T4 of 0.7 ng/dL (low). She has no history of thyroid disease and is asymptomatic. Anti-TPO antibodies are positive. What is the most appropriate management?

Accepted Answer

Start levothyroxine therapy targeting TSH < 2.5 mIU/L

Answer

Overt hypothyroidism in pregnancy (elevated TSH with low free T4) requires immediate levothyroxine treatment regardless of symptoms. Current ATA guidelines recommend a TSH target of <2.5 mIU/L in the first trimester. Positive anti-TPO antibodies confirm Hashimoto's thyroiditis as the etiology and indicate higher risk of progression, further supporting treatment. Watching and waiting to TSH >10 is inappropriate in pregnancy as untreated hypothyroidism increases risks of miscarriage, preterm birth, and impaired fetal neurodevelopment. Methimazole is for hyperthyroidism. Termination is not indicated.

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SPEX Exam Practice Test

SPEX Exam Family Medicine 4