Internal Medicine Board Exam — Questions and Answers

Question 1: Procalcitonin (PCT) is most useful in CAP management for which purpose?

Predicting 30-day mortality
Identifying the causative organism
Differentiating bacterial from fungal pneumonia
Guiding antibiotic duration and de-escalation (Correct answer)

Correct answer: Guiding antibiotic duration and de-escalation

Serial PCT measurements guide antibiotic duration — declining PCT levels support stopping antibiotics, reducing unnecessary therapy.

Question 2: A 68-year-old man on warfarin (INR 2.4) for atrial fibrillation presents with NSTEMI. He undergoes PCI with a drug-eluting stent. What is the optimal antithrombotic regimen post-procedure?

Short course of triple therapy, then DOAC + P2Y12 inhibitor (dual therapy) for 12 months (Correct answer)
Warfarin alone long-term
Aspirin + P2Y12 inhibitor without anticoagulation
Warfarin + aspirin + P2Y12 inhibitor (triple therapy) indefinitely

Correct answer: Short course of triple therapy, then DOAC + P2Y12 inhibitor (dual therapy) for 12 months

Current guidelines recommend minimizing triple therapy duration (≤1 month) and transitioning to dual therapy with a DOAC plus P2Y12 inhibitor to reduce bleeding while maintaining thrombotic protection.

Question 3: A patient with idiopathic pulmonary fibrosis has a 6-minute walk distance of 280 meters and SpO2 nadir of 84%. Which therapy is indicated?

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

Correct answer: Pirfenidone or nintedanib to slow fibrosis progression

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

Question 4: Which renal replacement therapy modality is preferred in hemodynamically unstable ICU patients with AKI?

Peritoneal dialysis
Sustained low-efficiency dialysis (SLED) only
Continuous renal replacement therapy (CRRT) (Correct answer)
Intermittent hemodialysis (IHD)

Correct answer: Continuous renal replacement therapy (CRRT)

CRRT is preferred in hemodynamically unstable patients because it removes solutes and fluid slowly and continuously, minimizing hypotension compared to intermittent hemodialysis.

Question 5: A patient with severe sepsis is started on empiric broad-spectrum antibiotics. Blood cultures later grow Pseudomonas aeruginosa sensitive to piperacillin-tazobactam. At 72 hours the patient is clinically improving. What is the appropriate antibiotic de-escalation?

Switch to oral fluoroquinolone regardless of susceptibilities
Discontinue all antibiotics
Continue broad-spectrum regimen for full 14-day course
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 6: A 55-year-old male ex-smoker (40 pack-years, quit 3 years ago) presents for lung cancer screening. Which imaging modality is recommended by USPSTF guidelines?

Low-dose CT (LDCT) annually (Correct answer)
PET-CT every 2 years
Annual chest X-ray
Sputum cytology combined with annual chest X-ray

Correct answer: Low-dose CT (LDCT) annually

USPSTF recommends annual LDCT screening for adults aged 50-80 with ≥ 20 pack-year history who currently smoke or quit within the past 15 years.

Question 7: A 58-year-old man with an ICD for ischemic cardiomyopathy receives three appropriate shocks in 24 hours for ventricular tachycardia (electrical storm). What is the next best step?

Oral mexiletine and discharge
Increase ICD shock energy only
Deactivate the ICD temporarily
IV amiodarone plus IV beta-blocker and urgent electrophysiology consultation (Correct answer)

Correct answer: IV amiodarone plus IV beta-blocker and urgent electrophysiology consultation

Electrical storm requires combined IV amiodarone and beta-blocker to suppress VT triggers, along with urgent EP evaluation for catheter ablation consideration.

Question 8: A 30-year-old woman with SLE develops worsening renal function, proteinuria of 3.5 g/day, and active urinary sediment. Renal biopsy shows diffuse proliferative glomerulonephritis. Which WHO/ISN class is this?

Class II
Class III
Class IV (Correct answer)
Class V

Correct answer: Class IV

ISN/RPS Class IV (diffuse proliferative) lupus nephritis is the most severe form, involving >50% of glomeruli and requiring aggressive immunosuppression.

Question 9: 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?

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

Correct answer: Laparoscopic cholecystectomy

Symptomatic cholelithiasis with cholecystitis is best treated with laparoscopic cholecystectomy.

Question 10: A 55-year-old woman with type 2 diabetes has persistently elevated liver enzymes. Liver biopsy shows hepatocyte ballooning, lobular inflammation, and pericellular fibrosis without significant alcohol use. What is the most likely diagnosis?

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

Correct answer: Nonalcoholic steatohepatitis (NASH)

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

Question 11: A 68-year-old man who is a patient in the emergency room woke up with palpitations, chest pain, dyspnea, and vertigo. He claims his heart is "beating," but he has no history of heart disease or high blood pressure. His pulse is quick and erratic, his blood pressure is 85/60 mmHg, and crackles can be heard at the bases of his lungs. His standard laboratory tests, including a troponin level, are expected. His EKG reveals atrial fibrillation with a 130-beat-per-minute ventricular response. Which course of action is ideal?

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

Correct answer: Intravenous digoxin

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

Question 12: Which finding best differentiates DKA from hyperglycemic hyperosmolar state (HHS)?

Absence of altered mental status
Serum glucose > 600 mg/dL
Anion gap metabolic acidosis with significant ketonemia (Correct answer)
Effective serum osmolality > 320 mOsm/kg

Correct answer: Anion gap metabolic acidosis with significant ketonemia

DKA is characterized by significant ketonemia and anion gap acidosis, whereas HHS has minimal or no ketosis.

Question 13: 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
Ceftriaxone 2 g IV immediately (Correct answer)
Vancomycin plus ceftriaxone
Penicillin G plus metronidazole

Correct answer: Ceftriaxone 2 g IV immediately

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

Question 14: 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 labetalol
Intravenous esmolol
Intravenous lorazepam (Correct answer)
Intravenous diltiazem

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 15: 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?

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

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 16: A patient with cirrhosis and hepatic encephalopathy is found to have hyponatremia (Na 121 mEq/L). Which treatment is most appropriate?

Increased diuretic doses
Isotonic saline infusion
Rapid sodium correction with 3% saline
Fluid restriction and consideration of vaptans (Correct answer)

Correct answer: Fluid restriction and consideration of vaptans

Dilutional hyponatremia in cirrhosis is managed with fluid restriction; vasopressin receptor antagonists (vaptans) may be used in resistant cases.

Question 17: 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
Initiate emergent hemodialysis
Administer intravenous insulin and glucose
Administer intravenous calcium gluconate (Correct answer)

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

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

Correct answer: Perform molecular testing on the FNA sample

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

Question 19: A 58-year-old woman with poorly controlled hypertension develops a new murmur. Echo shows aortic regurgitation with LV end-systolic diameter of 52 mm and EF of 48%. She is mildly symptomatic. What is the best management?

Aortic valve replacement (Correct answer)
Medical therapy until EF drops below 30%
Annual surveillance echo only
Start vasodilator therapy and delay surgery

Correct answer: Aortic valve replacement

Symptomatic severe AR with EF <50% or LVESD >50 mm is a class I indication for aortic valve replacement, as these thresholds predict irreversible LV dysfunction if surgery is further delayed.

Question 20: You are meeting a 20-year-old male who has complained for the previous two months about "puffy eyes" and "swollen ankles." Additionally, he says that his pee "sort of looks frothy and foamy." His vital signs during the examination are within normal ranges, and the funduscopy is uneventful save for minor bilateral edema 2+ in the bilateral feet to the ankle. He has never experienced any health issues or operations. His tests show an average serum creatinine level; a considerable 4-plus protein level without blood or bacteria is found in the urine. He has had a kidney biopsy, which on light microscopy appears normal but, on electron microscopy, reveals diffuse podocyte effacement. Negative immunofluorescence results. Which medical intervention is ideal for this patient?

Tacrolimus
Rituximab
Corticosteroids (Correct answer)
Cyclophosphamide

Correct answer: Corticosteroids

The patient's symptoms (puffy eyes, swollen ankles, frothy urine) and lab findings (significant proteinuria, normal serum creatinine, diffuse podocyte effacement on electron microscopy) are classic for Minimal Change Disease, a common cause of nephrotic syndrome. Corticosteroids are the first-line treatment for inducing remission in Minimal Change Disease due to their potent immunosuppressive and anti-inflammatory effects.

Question 21: A 65-year-old man with hypertension develops AKI with blood pressure of 240/130 mmHg. Urinalysis shows RBC casts and 3+ proteinuria. LDH is elevated and peripheral smear shows schistocytes. What diagnosis best explains his AKI?

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

Correct answer: Thrombotic microangiopathy (malignant hypertension)

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

Question 22: 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?

Beta-lactams
Aminoglycosides
Macrolides (Correct answer)
Carbapenems

Correct answer: Macrolides

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

Question 23: A 72-year-old man with known diverticulosis presents with acute bright red blood per rectum that stops spontaneously. Colonoscopy shows diverticulosis throughout the colon without active bleeding. What is the most common site of diverticular bleeding?

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

Correct answer: Right colon (cecum and ascending colon)

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

Question 24: 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?

Spironolactone
Amlodipine (Correct answer)
Metoprolol
Lisinopril

Correct answer: Amlodipine

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

Question 25: A 45-year-old man presents with nausea, right upper quadrant pain, and AST/ALT >1000 U/L after a camping trip where he consumed wild mushrooms. What toxin is most likely responsible?

Orellanine from Cortinarius species
Amatoxin from Amanita phalloides (Correct answer)
Muscarine from Amanita muscaria
Psilocybin from Psilocybe species

Correct answer: Amatoxin from Amanita phalloides

Amatoxin (alpha-amanitin) from Amanita phalloides causes severe hepatotoxicity by inhibiting RNA polymerase II; it is the most common cause of fatal mushroom poisoning.

Question 26: A patient develops C. difficile infection after a course of clindamycin. He is treated with oral vancomycin for 10 days but has his third recurrence within 8 weeks. What is the most effective treatment for recurrent C. difficile infection?

Extended oral fidaxomicin pulse-taper regimen
IV metronidazole
Fecal microbiota transplantation (FMT) (Correct answer)
Bezlotoxumab infusion alone

Correct answer: Fecal microbiota transplantation (FMT)

FMT achieves cure rates of >85-90% for recurrent C. difficile infection and is now recommended by guidelines after multiple recurrences, superior to antibiotic regimens.

Question 27: A 60-year-old man presents with obstructive sleep apnea confirmed on polysomnography with AHI of 32 events/hour and lowest SpO2 of 81%. He declines CPAP. What is the next best alternative therapy?

Positional therapy alone
Supplemental nocturnal oxygen
Mandibular advancement device (Correct answer)
Protriptyline nightly

Correct answer: Mandibular advancement device

Mandibular advancement devices are the preferred alternative to CPAP in moderate-to-severe OSA when CPAP is declined, repositioning the jaw to enlarge the upper airway.

Question 28: A 45-year-old woman undergoing coronary angiography receives iodinated contrast. Her baseline creatinine is 1.6 mg/dL. Which intervention has the strongest evidence for preventing contrast-induced AKI?

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

Correct answer: Isotonic saline hydration before and after the procedure

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

Question 29: A 40-year-old woman with IBD presents with elevated alkaline phosphatase and fatigue. MRCP shows multifocal strictures and dilations of both intra- and extrahepatic bile ducts. What is the most likely diagnosis?

Autoimmune hepatitis
Ischemic cholangiopathy
Primary sclerosing cholangitis (Correct answer)
Primary biliary cholangitis

Correct answer: Primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) presents with characteristic 'beaded' intra- and extrahepatic biliary strictures on MRCP and is strongly associated with IBD, particularly ulcerative colitis.

Question 30: 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?

Cangrelor
Prasugrel (Correct answer)
Ticagrelor
Clopidogrel

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 31: A 59-year-old female with decompensated alcoholic cirrhosis and ascites is admitted with fever and diffuse abdominal tenderness. A diagnostic paracentesis is performed. Which of the following ascitic fluid findings is the most critical for diagnosing spontaneous bacterial peritonitis (SBP)?

Positive bacterial culture
Total protein < 1.0 g/dL
Serum-ascites albumin gradient (SAAG) > 1.1 g/dL
Polymorphonuclear (PMN) leukocyte count ≥ 250 cells/mm³ (Correct answer)

Correct answer: Polymorphonuclear (PMN) leukocyte count ≥ 250 cells/mm³

The diagnosis of spontaneous bacterial peritonitis (SBP) is established by an ascitic fluid polymorphonuclear (PMN) leukocyte count of 250 cells/mm³ or greater, with or without a positive culture. Treatment should be initiated empirically based on this cell count without waiting for culture results, which may be negative in many cases (culture-negative neutrocytic ascites). A SAAG > 1.1 g/dL indicates portal hypertension but not infection, and a low ascitic protein is a risk factor for SBP, not a diagnostic criterion.

Question 32: Which clinical feature is MOST helpful in distinguishing Legionella pneumonia from pneumococcal pneumonia?

Pleuritic chest pain
Hyponatremia + GI symptoms + elevated LFTs (Correct answer)
High fever with rigors
Productive rusty sputum

Correct answer: Hyponatremia + GI symptoms + elevated LFTs

Legionella characteristically causes hyponatremia, diarrhea, abdominal pain, and transaminase elevation in addition to pneumonia.

Question 33: Which arterial blood gas pattern is most consistent with DKA with appropriate respiratory compensation?

pH 7.42, PaCO2 40, HCO3 24
pH 7.22, PaCO2 28, HCO3 11 (Correct answer)
pH 7.50, PaCO2 30, HCO3 23
pH 7.18, PaCO2 40, HCO3 14

Correct answer: pH 7.22, PaCO2 28, HCO3 11

DKA causes metabolic acidosis with respiratory compensation (Kussmaul breathing lowers PaCO2); the expected PaCO2 = 1.5 × HCO3 + 8 ± 2.

Question 34: 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?

Normal C3 with elevated C4
Elevated C3 and C4
Decreased C3 and C4 (Correct answer)
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 35: A patient with CAP is found to have a parapneumonic effusion. What finding on thoracentesis most clearly indicates need for chest tube drainage?

pH 7.35, glucose 80 mg/dL, LDH 200 U/L
pH 7.40, glucose 90 mg/dL, LDH 150 U/L
pH 7.25, glucose 55 mg/dL, LDH 800 U/L (Correct answer)
pH 7.30, glucose 70 mg/dL, LDH 500 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 36: Which scoring system is currently used to prioritize liver transplant candidates in the United States?

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

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

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

Correct answer: Peripartum cardiomyopathy

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

Question 38: 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 metoprolol
Administer intravenous nitroglycerin

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

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

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

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

Question 40: In DKA, the serum potassium is initially high despite total body potassium depletion. What is the primary mechanism?

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

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

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

Question 41: Which finding on echocardiography is most consistent with cardiac tamponade?

Left ventricular hypertrophy with diastolic dysfunction
Diastolic collapse of the right ventricle (Correct answer)
Dilated cardiomyopathy with global hypokinesis
Mitral valve prolapse with regurgitation

Correct answer: Diastolic collapse of the right ventricle

Diastolic RV collapse due to external pericardial pressure is the hallmark echocardiographic finding of cardiac tamponade.

Question 42: A 62-year-old male presents to the emergency department with 3 hours of substernal chest pressure. His ECG shows ST-segment depression in the lateral leads. Initial troponin levels are elevated. He is diagnosed with NSTE-ACS (Non-ST-Elevation Acute Coronary Syndrome). In addition to aspirin, nitrates, and a high-intensity statin, which of the following is a critical component of initial medical management?

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

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

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

Question 43: Which empiric antibiotic is recommended for CAP in a hospitalized non-ICU patient with a penicillin allergy (non-anaphylactic)?

Azithromycin monotherapy
Vancomycin + azithromycin
Clindamycin + ceftriaxone
Respiratory fluoroquinolone (levofloxacin or moxifloxacin) (Correct answer)

Correct answer: Respiratory fluoroquinolone (levofloxacin or moxifloxacin)

A respiratory fluoroquinolone alone provides adequate monotherapy for non-ICU hospitalized CAP and avoids beta-lactam use in penicillin-allergic patients.

Question 44: A 78-year-old female is diagnosed with osteoporosis after a DEXA scan reveals a T-score of -2.9 at the femoral neck. Her medical history is significant for severe gastroesophageal reflux disease (GERD) and erosive esophagitis. Which of the following is the LEAST appropriate initial treatment for her osteoporosis?

Oral alendronate (Correct answer)
Subcutaneous denosumab
Intravenous zoledronic acid
Subcutaneous teriparatide

Correct answer: Oral alendronate

Oral bisphosphonates, such as alendronate, are known to cause significant upper gastrointestinal irritation, including esophagitis, esophageal erosions, and ulcers. Their use is relatively contraindicated in patients with pre-existing severe esophageal disease like erosive esophagitis. Safer and more appropriate alternatives in this patient would include non-oral options like intravenous zoledronic acid (an IV bisphosphonate), subcutaneous denosumab (a RANKL inhibitor), or subcutaneous teriparatide (an anabolic agent).

Question 45: Which of the following sets of criteria best indicates the resolution of Diabetic Ketoacidosis and readiness to transition from an intravenous insulin infusion to a subcutaneous regimen?

Urine ketones are negative and serum bicarbonate > 20 mEq/L
Blood glucose < 180 mg/dL and anion gap < 16 mEq/L
Blood glucose < 200 mg/dL, serum bicarbonate ≥ 15 mEq/L, and anion gap ≤ 12 mEq/L (Correct answer)
Blood glucose < 250 mg/dL and venous pH > 7.25

Correct answer: Blood glucose < 200 mg/dL, serum bicarbonate ≥ 15 mEq/L, and anion gap ≤ 12 mEq/L

The resolution of DKA is defined by the correction of the metabolic acidosis and ketosis, not just the hyperglycemia. Widely accepted guidelines state that DKA is resolved when the blood glucose is <200-250 mg/dL, the serum bicarbonate is ≥15-18 mEq/L, the venous pH is >7.3, and the anion gap is ≤12 mEq/L. Relying on only one or two parameters, or using less stringent cutoffs, can lead to premature discontinuation of IV insulin and a relapse into ketoacidosis.

Question 46: 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?

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

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 47: Which of the following parameters is used to calculate the Fractional Excretion of Urea (FEUrea), and when is it preferred over FENa?

Preferred in patients on diuretics; less affected by diuretic-induced natriuresis than FENa (Correct answer)
Preferred in oliguric AKI regardless of medications
Used only in hypernatremic patients
Used in all AKI patients; calculated from serum and urine urea and creatinine

Correct answer: Preferred in patients on diuretics; less affected by diuretic-induced natriuresis than FENa

FEUrea <35% suggests prerenal AKI and is preferred over FENa in patients receiving diuretics, since diuretics artificially raise urine sodium excretion independent of volume status.

Question 48: A 72-year-old woman with known bicuspid aortic valve has an aortic root diameter of 4.8 cm on surveillance imaging. She is asymptomatic with normal valve function. When is surgical intervention indicated?

At 4.5 cm in all patients
At 5.5 cm regardless of risk factors
Only when symptoms develop
At 5.0 cm in patients with bicuspid aortic valve (Correct answer)

Correct answer: At 5.0 cm in patients with bicuspid aortic valve

Current guidelines recommend surgical repair of the ascending aorta at a threshold of 5.0 cm in patients with bicuspid aortic valve given the higher risk of dissection at smaller diameters than tricuspid valves.

Question 49: A 25-year-old sexually active woman presents with right upper quadrant pain, fever, and cervical motion tenderness. Liver enzymes are mildly elevated. Which diagnosis best explains all findings?

Budd-Chiari syndrome
Fitz-Hugh-Curtis syndrome (Correct answer)
Acute cholecystitis
Hepatitis A

Correct answer: Fitz-Hugh-Curtis syndrome

Fitz-Hugh-Curtis syndrome is perihepatitis occurring as a complication of pelvic inflammatory disease (typically chlamydia or gonorrhea), causing RUQ pain with perihepatic inflammation.

Question 50: Which biomarker has the fastest rise-and-fall kinetics and was historically used for early diagnosis of re-infarction after STEMI?

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

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

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

Question 51: A 45-year-old HIV-positive patient (CD4 count 80 cells/μL) presents with dry cough, fever, and diffuse bilateral ground-glass opacities. LDH is elevated. What is the most likely diagnosis?

Bacterial pneumonia (Streptococcus pneumoniae)
Pneumocystis jirovecii pneumonia (PCP) (Correct answer)
Mycobacterium avium complex
Cryptococcal pneumonia

Correct answer: Pneumocystis jirovecii pneumonia (PCP)

PCP is the most common AIDS-defining opportunistic lung infection, typically presenting with subacute dry cough, hypoxia, elevated LDH, and bilateral ground-glass opacities when CD4 < 200.

Question 52: 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?

Nadolol (Correct answer)
Octreotide
Omeprazole
Furosemide

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

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

Correct answer: Prior radiation therapy to the skeleton

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

Question 54: Which type of lung cancer is most strongly associated with hypercalcemia without bone metastases?

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

Correct answer: Squamous cell carcinoma

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

Question 55: A 29-year-old woman with a known history of systemic lupus erythematosus (SLE) presents with new-onset peripheral edema, foamy urine, and a blood pressure of 155/95 mmHg. Urinalysis reveals 3+ proteinuria and red blood cell casts. The presence of which autoantibody is most strongly associated with the development of this renal complication?

Anti-Ro/SSA antibody
Anti-dsDNA antibody (Correct answer)
Anti-histone antibody
Anti-centromere antibody

Correct answer: Anti-dsDNA antibody

The patient's presentation is highly suggestive of lupus nephritis. Anti-double-stranded DNA (anti-dsDNA) antibodies are highly specific for SLE, and their titers often correlate with disease activity, particularly with the presence and severity of lupus nephritis. [5, 7, 10] Anti-histone antibodies are associated with drug-induced lupus. Anti-Ro/SSA antibodies are linked to Sjögren's syndrome and neonatal lupus. Anti-centromere antibodies are characteristic of limited cutaneous systemic sclerosis.

Question 56: 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-neutrophil cytoplasmic antibody, cytoplasmic pattern (c-ANCA) with anti-proteinase 3 (PR3) (Correct answer)
Anti-double-stranded DNA (anti-dsDNA)
Anti-neutrophil cytoplasmic antibody, perinuclear pattern (p-ANCA) with anti-myeloperoxidase (MPO)
Anti-Scl-70 (anti-topoisomerase I)

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 57: A 45-year-old man with gout fails allopurinol due to severe hypersensitivity reaction. His eGFR is 35 mL/min. Which urate-lowering agent is preferred?

Febuxostat (Correct answer)
Probenecid
Pegloticase
Rasburicase

Correct answer: Febuxostat

Febuxostat is a non-purine xanthine oxidase inhibitor that can be used in patients with allopurinol hypersensitivity and is safer than probenecid in CKD.

Question 58: A patient with DKA has serum phosphate of 0.8 mg/dL. In which clinical scenario would phosphate replacement be most strongly indicated?

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

Correct answer: Symptomatic hypophosphatemia with cardiac dysfunction or respiratory failure

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

Question 59: A child with DKA develops a sudden headache and altered mental status 6 hours into treatment. What is the most feared complication?

Cerebral edema (Correct answer)
Hypokalemia-induced arrhythmia
Hyperchloremic acidosis
Aspiration pneumonia

Correct answer: Cerebral edema

Cerebral edema is a rare but potentially fatal complication of DKA in children, often occurring 6–12 hours into treatment.

Question 60: A 70-year-old man with known aortic stenosis presents with syncope on exertion. His echocardiogram shows a mean gradient of 48 mmHg and AVA of 0.7 cm². What is the next step?

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

Correct answer: Aortic valve replacement (surgical or TAVR)

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

Question 61: A 45-year-old man presents with a 36-hour history of fever, myalgias, headache, and a non-productive cough during peak influenza season. A rapid influenza antigen test is positive. For an otherwise healthy outpatient, antiviral treatment with a neuraminidase inhibitor is most effective when initiated within what timeframe from symptom onset?

Within 72 hours
Within 48 hours (Correct answer)
Within 24 hours
At any time as long as the patient is symptomatic

Correct answer: Within 48 hours

Clinical trials have demonstrated that neuraminidase inhibitors, such as oseltamivir, provide the greatest clinical benefit by reducing the duration and severity of symptoms when they are initiated within 48 hours of illness onset in outpatients with uncomplicated influenza. Benefit may be seen when started later in hospitalized patients or those with severe disease, but the 48-hour window is key for maximal efficacy in the typical outpatient setting.

Question 62: Which complication of STEMI typically presents 5-10 days after the initial event with new holosystolic murmur and hemodynamic deterioration?

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

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

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

Correct answer: Start sevelamer (non-calcium binder)

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

Question 64: A 25-year-old man with ulcerative colitis has a colonoscopy showing continuous inflammation from the rectum to the splenic flexure. He has 6 bloody stools per day and a heart rate of 102 bpm. What is the most appropriate next step?

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

Correct answer: IV corticosteroids

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

Question 65: Which set of clinical features best describes the CRAB criteria used to diagnose symptomatic multiple myeloma?

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

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

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

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 67: A patient with ACS is found to have a platelet count of 48,000/μL after receiving heparin for 7 days. The most likely diagnosis is:

Dilutional thrombocytopenia
Immune thrombocytopenic purpura (ITP)
Heparin-induced thrombocytopenia (HIT) (Correct answer)
Thrombotic thrombocytopenic purpura (TTP)

Correct answer: Heparin-induced thrombocytopenia (HIT)

HIT is characterized by a >50% platelet drop 5-10 days after heparin initiation, associated with a prothrombotic state rather than bleeding, and requires immediate heparin cessation and alternative anticoagulation.

Question 68: What is the expected rate of glucose decline per hour with appropriate insulin therapy in DKA?

25–50 mg/dL/hr
Over 200 mg/dL/hr
100–150 mg/dL/hr
50–75 mg/dL/hr (Correct answer)

Correct answer: 50–75 mg/dL/hr

Optimal insulin therapy lowers blood glucose by 50–75 mg/dL per hour; faster drops risk cerebral edema especially in children.

Question 69: A 75-year-old man with peripheral artery disease and claudication has an ABI of 0.6. He is a non-smoker on a statin and aspirin. What additional therapy improves walking distance?

Dipyridamole alone
Clopidogrel plus aspirin (dual antiplatelet)
Warfarin
Cilostazol (Correct answer)

Correct answer: Cilostazol

Cilostazol, a phosphodiesterase III inhibitor, is the only FDA-approved medication shown to improve claudication symptoms and walking distance in PAD.

Question 70: Which vaccine has the greatest impact on reducing CAP incidence in adults over 65?

PPSV23 alone
Tdap booster
PCV15 or PCV20 (pneumococcal conjugate vaccine) (Correct answer)
Influenza vaccine alone

Correct answer: PCV15 or PCV20 (pneumococcal conjugate vaccine)

Higher-valency pneumococcal conjugate vaccines (PCV15, PCV20) are now preferred over PPSV23 alone for adults ≥65, providing superior immunogenicity and protection.

Question 71: A patient presents with fever, productive cough, and right lower lobe consolidation on CXR. He lives in a nursing home. Which organism is the most likely causative pathogen?

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

Correct answer: Streptococcus pneumoniae

Streptococcus pneumoniae remains the most common cause of community-acquired pneumonia (CAP) in all settings including nursing homes.

Question 72: A 50-year-old woman with SLE develops a blood pressure of 170/110 mmHg, serum creatinine rising to 2.8 mg/dL, and thrombocytopenia. Anti-dsDNA is markedly elevated. Which intervention is most urgently needed?

Start labetalol for hypertension only
Start high-dose methylprednisolone IV pulse therapy (Correct answer)
Increase hydroxychloroquine dose
Initiate plasmapheresis immediately

Correct answer: Start high-dose methylprednisolone IV pulse therapy

Active lupus nephritis with rising creatinine and serologic flare requires prompt initiation of high-dose IV methylprednisolone pulse therapy followed by cyclophosphamide or mycophenolate.

Question 73: A 40-year-old cave explorer develops progressive pulmonary infiltrates and mediastinal lymphadenopathy 3 weeks after visiting bat-inhabited caves in Ohio. Serum urine antigen is positive. What is the treatment?

Itraconazole 200 mg BID (Correct answer)
Voriconazole IV for 6 weeks
Fluconazole 400 mg daily
Posaconazole plus micafungin

Correct answer: Itraconazole 200 mg BID

Mild-to-moderate pulmonary histoplasmosis is treated with itraconazole for 6–12 weeks; it is the drug of choice for non-severe Histoplasma capsulatum infection.

Question 74: A 28-year-old pregnant woman at 36 weeks is found to have group B Streptococcus (GBS) on vaginal-rectal screening. She is penicillin-allergic with a history of urticaria only (not anaphylaxis). What is the appropriate intrapartum prophylaxis?

Clindamycin IV (if susceptible)
Vancomycin IV
No prophylaxis needed
Cefazolin IV (Correct answer)

Correct answer: Cefazolin IV

For GBS-positive patients with low-risk penicillin allergy (urticaria, not anaphylaxis), cefazolin is safe and preferred for intrapartum prophylaxis.

Question 75: 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?

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

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

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

Correct answer: GABAergic system

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

Question 77: A 66-year-old man presents with melena and hemodynamic instability. Upper endoscopy reveals a 1 cm duodenal ulcer with a visible vessel. After endoscopic hemostasis, which pharmacologic regimen best reduces rebleeding risk?

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

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

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

Question 78: Which HIV-associated opportunistic infection is prevented by trimethoprim-sulfamethoxazole prophylaxis when the CD4 count falls below 200 cells/μL?

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

Correct answer: Pneumocystis jirovecii pneumonia (PCP) and Toxoplasma

TMP-SMX prophylaxis at CD4 < 200 cells/μL prevents both PCP and Toxoplasma encephalitis (the latter when CD4 < 100 and Toxoplasma IgG positive).

Question 79: A patient with SLE is started on hydroxychloroquine. Which baseline test is mandatory before initiating therapy?

Ophthalmologic examination (Correct answer)
Pulmonary function tests
Audiometry
Liver biopsy

Correct answer: Ophthalmologic examination

Hydroxychloroquine can cause irreversible retinal toxicity, so a baseline ophthalmologic exam with retinal imaging is required before starting therapy.

Question 80: 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?

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

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 81: A 60-year-old woman with mitral stenosis (MVA 0.9 cm²) presents with increasing dyspnea. She has no mitral regurgitation and favorable valve morphology (Wilkins score 6). What is the preferred intervention?

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

Correct answer: Percutaneous mitral balloon commissurotomy (PMBC)

Symptomatic severe MS (MVA ≤1.0 cm²) with favorable valve morphology (Wilkins score ≤8, no significant MR) is best treated with PMBC, which is less invasive than surgery with similar outcomes.

Question 82: A 68-year-old man develops acute monoarthritis of the knee with septic joint appearance. Arthrocentesis reveals positively birefringent, rhomboid-shaped crystals. What is the diagnosis?

Calcium oxalate arthropathy
Pseudogout (CPPD) (Correct answer)
Gout
Septic arthritis

Correct answer: Pseudogout (CPPD)

Pseudogout (calcium pyrophosphate deposition disease) is characterized by positively birefringent, rhomboid-shaped crystals, in contrast to the negatively birefringent needle-shaped crystals of gout.

Question 83: A 65-year-old man presents with Hgb 7.5 g/dL, MCV 110 fL, and hypersegmented neutrophils on peripheral smear. What is the most appropriate next step?

Serum B12 and folate levels (Correct answer)
Bone marrow biopsy
Peripheral blood smear for malaria
Iron studies

Correct answer: Serum B12 and folate levels

Macrocytic anemia with hypersegmented neutrophils strongly suggests megaloblastic anemia due to B12 or folate deficiency, which should be confirmed with serum levels.

Question 84: 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?

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

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

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

Correct answer: Cryoglobulinemic vasculitis

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

Question 86: A 52-year-old woman presents with exertional dyspnea, a loud P2, and right heart failure signs. Right heart catheterization shows mean PAP 38 mmHg, PCWP 10 mmHg. What is the diagnosis?

Group 1 pulmonary arterial hypertension (PAH) (Correct answer)
Group 2 pulmonary hypertension (left heart disease)
Pulmonary venous hypertension
Cor pulmonale from COPD

Correct answer: Group 1 pulmonary arterial hypertension (PAH)

PAH (Group 1) is defined by mean PAP ≥25 mmHg with PCWP ≤15 mmHg and elevated pulmonary vascular resistance without left heart disease.

Question 87: A 48-year-old woman with known cirrhosis presents with confusion and asterixis after starting a new medication. Which drug is most likely responsible for precipitating hepatic encephalopathy?

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

Correct answer: Furosemide causing hypokalemia and alkalosis

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

Question 88: What is the appropriate duration of antibiotic therapy for uncomplicated, mild-to-moderate CAP that shows clinical improvement?

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

Correct answer: 5 days

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

Question 89: A 48-year-old presents with dysphagia to solids and liquids equally from the onset, regurgitation of undigested food, and a "bird-beak" appearance on barium swallow. Manometry shows absent peristalsis and incomplete LES relaxation. What is the diagnosis?

Achalasia (Correct answer)
Diffuse esophageal spasm
Scleroderma esophagus
Peptic stricture

Correct answer: Achalasia

Achalasia is characterized by absent esophageal peristalsis and failure of LES relaxation, producing the classic bird-beak appearance on barium swallow.

Question 90: A 48-year-old obese man reports excessive daytime sleepiness, loud snoring, and witnessed apneas. Polysomnography shows an AHI of 32. What is the first-line treatment?

Mandibular advancement device
Uvulopalatopharyngoplasty (UPPP)
Supplemental nocturnal oxygen
Continuous positive airway pressure (CPAP) (Correct answer)

Correct answer: Continuous positive airway pressure (CPAP)

CPAP is the first-line treatment for moderate-to-severe obstructive sleep apnea (AHI ≥15), as it maintains airway patency during sleep.

Question 91: A healthy 30-year-old college student develops low-grade fever, dry cough, and diffuse bilateral interstitial infiltrates over 2 weeks. Which pathogen is most likely?

Klebsiella pneumoniae
Mycoplasma pneumoniae (Correct answer)
Streptococcus pneumoniae
Staphylococcus aureus

Correct answer: Mycoplasma pneumoniae

M. pneumoniae causes 'walking pneumonia' in young adults — insidious onset, dry cough, mild symptoms, and interstitial infiltrates out of proportion to clinical severity.

Question 92: Which ECG finding in a patient with chest pain represents a 'STEMI equivalent' requiring immediate reperfusion?

PR interval prolongation with ST changes
Diffuse ST depression in leads V1-V6
T-wave inversions in leads III and aVF
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 93: It was shown for patients with A. Rate control outperformed rhythm control.

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

Correct answer: What did the AFFIRM trial show?

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

Question 94: Which clinical scenario best describes Dressler syndrome?

Fever, pleuritic chest pain, and pericarditis occurring weeks after MI or cardiac surgery (Correct answer)
Recurrent MI at the same coronary territory within 30 days
Chest pain 24 hours after MI due to pericardial irritation from transmural necrosis
Pericardial effusion causing tamponade immediately post-CABG

Correct answer: Fever, pleuritic chest pain, and pericarditis occurring weeks after MI or cardiac surgery

Dressler syndrome is an autoimmune pericarditis that occurs weeks to months after MI or cardiac surgery, presenting with fever, pleurisy, and pericardial inflammation.

Question 95: 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 a long-acting muscarinic antagonist (LAMA) to her current regimen.
Add montelukast and continue her current regimen.
Increase the dose of her current ICS to medium-dose and continue SABA for relief.
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 96: Which finding on echocardiogram performed after STEMI is associated with the highest risk of systemic embolization?

Apical left ventricular thrombus (Correct answer)
Moderate mitral regurgitation
Mild LV diastolic dysfunction
Trivial pericardial effusion

Correct answer: Apical left ventricular thrombus

LV thrombus, most common after large anterior STEMI with apical akinesis, carries significant risk of systemic embolization and stroke, requiring anticoagulation therapy.

Question 97: 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
Progressive interstitial lung disease
Pulmonary arterial hypertension (Correct answer)
Scleroderma renal crisis

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 98: A 60-year-old patient with COPD develops productive cough with purulent sputum and fever. Sputum Gram stain shows gram-negative coccobacilli. Which organism is most likely?

Haemophilus influenzae (Correct answer)
Klebsiella pneumoniae
Moraxella catarrhalis
Pseudomonas aeruginosa

Correct answer: Haemophilus influenzae

Haemophilus influenzae is the most common gram-negative coccobacillus causing acute exacerbations of COPD.

Question 99: Which occupational lung disease is associated with shipbuilding and insulation work, characterized by pleural plaques and increased risk of mesothelioma?

Berylliosis
Silicosis
Coal workers' pneumoconiosis
Asbestosis (Correct answer)

Correct answer: Asbestosis

Asbestosis results from asbestos fiber inhalation, commonly in shipbuilders and insulators, causing pleural plaques, interstitial fibrosis, and markedly increased mesothelioma risk.

Question 100: A 45-year-old woman presents with fatigue and pallor. Labs show Hgb 8.2 g/dL, MCV 72 fL, and low serum ferritin. What is the most likely diagnosis?

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

Correct answer: Iron deficiency anemia

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

Question 101: A 65-year-old man with CKD stage 4 has serum bicarbonate of 16 mEq/L. He has muscle wasting and accelerated bone disease. What is the most appropriate treatment for his metabolic acidosis?

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

Correct answer: Oral sodium bicarbonate supplementation

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

Question 102: A 48-year-old woman presents with muscle weakness, dysphagia, and anti-Jo-1 antibody positivity. Pulmonary function tests show a restrictive pattern. What is the most likely pulmonary complication?

Interstitial lung disease (Correct answer)
Pulmonary arterial hypertension
Bronchiectasis
Pleural effusion

Correct answer: Interstitial lung disease

Anti-Jo-1 antibody (antisynthetase syndrome) is strongly associated with interstitial lung disease, which is the leading cause of morbidity and mortality in polymyositis/dermatomyositis.

Question 103: 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?

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

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 104: Which screening test is recommended every 6 months for hepatocellular carcinoma surveillance in patients with cirrhosis?

CT scan of abdomen with contrast
Liver ultrasound with or without AFP (Correct answer)
Serum AFP alone
MRI of abdomen with gadolinium

Correct answer: Liver ultrasound with or without AFP

AASLD guidelines recommend abdominal ultrasound every 6 months, with optional AFP, for HCC surveillance in cirrhotic patients.

Question 105: A patient with alcoholic cirrhosis has a prolonged INR of 2.4 but no active bleeding. Surgery is required for cholecystitis. Which intervention is most appropriate to assess true bleeding risk?

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

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

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

Question 106: 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 25 mg daily
Spironolactone 100 mg and furosemide 40 mg daily (Correct answer)
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 107: A 72-year-old woman receives IV contrast for a CT scan. Her baseline creatinine is 1.8 mg/dL. Creatinine rises to 2.6 mg/dL at 48 hours. Which finding best distinguishes contrast-induced nephropathy from pre-renal azotemia?

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

Correct answer: Urine sodium > 40 mEq/L

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

Question 108: A 40-year-old nonsmoking woman with hemoptysis and renal failure has a chest CT showing bilateral pulmonary infiltrates. Serum ANCA is positive (PR3 pattern). What is the most likely diagnosis?

Goodpasture syndrome
Microscopic polyangiitis
Systemic lupus erythematosus
Granulomatosis with polyangiitis (GPA) (Correct answer)

Correct answer: Granulomatosis with polyangiitis (GPA)

GPA (formerly Wegener's) presents with the classic triad of upper airway, lower airway, and renal disease with positive c-ANCA (anti-PR3) in > 90% of cases.

Question 109: A 55-year-old male with type 2 diabetes presents with a 2-day history of a warm, tender, erythematous rash on his left lower leg. The area is non-fluctuant and there is no purulent drainage or abscess. He is afebrile and hemodynamically stable. What is the most appropriate initial oral antibiotic therapy for this patient's non-purulent cellulitis?

Doxycycline
Trimethoprim-sulfamethoxazole
Cephalexin (Correct answer)
Clindamycin

Correct answer: Cephalexin

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

Question 110: A 58-year-old man with hypertension and diabetes presents with exertional chest pain. Stress testing shows ST depression in leads V4-V6. What is the most appropriate next step?

Prescribe long-acting nitrates only
Coronary angiography (Correct answer)
Repeat stress test in 3 months
Start aspirin and observe

Correct answer: Coronary angiography

Significant ST depression on stress testing (≥2 mm) in a high-risk patient warrants coronary angiography to define anatomy and guide revascularization.

Question 111: 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?

Azithromycin monotherapy
Doxycycline (Correct answer)
Levofloxacin
Amoxicillin-clavulanate

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 112: A 63-year-old woman is diagnosed with pulmonary arterial hypertension (WHO Group 1). Her 6-minute walk distance is 340 meters and she is WHO FC III. Which medication is NOT appropriate as initial monotherapy?

High-dose calcium channel blocker without prior vasoreactivity testing (Correct answer)
Ambrisentan (endothelin receptor antagonist)
Riociguat (sGC stimulator)
Sildenafil (PDE-5 inhibitor)

Correct answer: High-dose calcium channel blocker without prior vasoreactivity testing

High-dose CCBs are only appropriate in the rare vasoreactive PAH patients confirmed by acute vasoreactivity testing; using them without testing is dangerous and can worsen PAH.

Question 113: Which of the following best describes the mechanism of action of sildenafil in pulmonary arterial hypertension?

Blocks endothelin receptors A and B, reducing vasoconstriction
Activates prostacyclin receptors, causing pulmonary vasodilation
Blocks calcium channels in pulmonary vascular smooth muscle
Inhibits PDE-5, increasing cGMP and promoting vasodilation (Correct answer)

Correct answer: Inhibits PDE-5, increasing cGMP and promoting vasodilation

Sildenafil inhibits phosphodiesterase-5 (PDE-5), preventing degradation of cGMP, which leads to smooth muscle relaxation and pulmonary vasodilation via the NO-cGMP pathway.

Question 114: A 30-year-old man with no past history develops cola-colored urine, periorbital edema, and hypertension 3 weeks after a streptococcal pharyngitis. C3 is low, C4 is normal. Renal biopsy would most likely show:

Subendothelial deposits with wire-loop lesions
Mesangial IgA deposits on immunofluorescence
Linear IgG along GBM on immunofluorescence
Subepithelial (humps) deposits on electron microscopy (Correct answer)

Correct answer: Subepithelial (humps) deposits on electron microscopy

Post-streptococcal GN shows subepithelial hump-shaped deposits on electron microscopy and granular IgG/C3 on immunofluorescence, with selective C3 consumption.

Question 115: 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?

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

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

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

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

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

Question 117: A 70-year-old woman presents with proximal muscle weakness, difficulty rising from a chair, and heliotrope rash. Which laboratory finding best confirms the diagnosis?

Positive ANA
Positive rheumatoid factor
Elevated ESR
Elevated CK and positive anti-Jo-1 (Correct answer)

Correct answer: Elevated CK and positive anti-Jo-1

Dermatomyositis presents with elevated creatine kinase and myositis-specific antibodies such as anti-Jo-1.

Question 118: 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)
Legionella pneumophila
Streptococcus pneumoniae
Moraxella catarrhalis

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 119: What is the recommended initial fluid bolus for an adult presenting in DKA with moderate dehydration?

1 liter 0.9% NaCl over 1 hour (Correct answer)
250 mL colloid solution over 30 minutes
500 mL 0.45% NaCl over 4 hours
1 liter D5W over 1 hour

Correct answer: 1 liter 0.9% NaCl over 1 hour

Initial resuscitation in DKA uses 1 L of isotonic (0.9%) normal saline over the first hour.

Question 120: 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?

Normal inflammatory markers and a positive human leukocyte antigen B27 (HLA-B27) test.
Elevated C-reactive protein (CRP) and a positive antinuclear antibody (ANA) test.
Elevated erythrocyte sedimentation rate (ESR) and hyperuricemia.
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 121: A 35-year-old woman presents with bilateral knee pain and swelling, erythema nodosum on her shins, and bilateral hilar adenopathy on chest X-ray. Which rheumatologic diagnosis fits this picture?

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

Correct answer: Löfgren's syndrome (acute sarcoidosis)

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

Question 122: 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?

Calcitonin
Prednisone (Correct answer)
Zolendronic acid
Cinacalcet

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 123: A 70-year-old man with known COPD presents with increased dyspnea and purulent sputum. ABG shows pH 7.28, PaCO2 68, PaO2 54 on room air. Which intervention has the strongest evidence for reducing mortality in this setting?

High-flow nasal cannula at 40 L/min
Heliox therapy via simple face mask
Immediate intubation and mechanical ventilation
Noninvasive positive pressure ventilation (NIPPV) (Correct answer)

Correct answer: Noninvasive positive pressure ventilation (NIPPV)

NIPPV is the first-line ventilatory support for acute hypercapnic respiratory failure in COPD exacerbation, reducing mortality, intubation rates, and hospital stay.

Question 124: 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)
3 drugs (isoniazid + rifampin + pyrazinamide)
2 drugs (isoniazid + rifampin)
1 drug (isoniazid only)

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 125: Which chest X-ray finding is most suggestive of a tension pneumothorax?

Ipsilateral lung collapse with tracheal deviation toward the affected side
Bilateral pleural effusions with blunting of costophrenic angles
Unilateral hilar enlargement
Ipsilateral lung collapse with tracheal deviation away from the affected side (Correct answer)

Correct answer: Ipsilateral lung collapse with tracheal deviation away from the affected side

Tension pneumothorax causes contralateral tracheal deviation and mediastinal shift away from the affected side due to positive pressure buildup.

Question 126: A patient with DKA has a measured serum sodium of 128 mEq/L. Blood glucose is 600 mg/dL. What is the corrected sodium?

136 mEq/L (Correct answer)
132 mEq/L
128 mEq/L (no correction needed)
140 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 127: 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?

No prophylaxis is needed if the resident's baseline rapid HIV test is negative.
Zidovudine (AZT) monotherapy for 28 days.
A two-drug regimen with tenofovir and emtricitabine 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 128: A cirrhotic patient develops portopulmonary hypertension (PoPH). Which finding on echocardiography is most consistent with this diagnosis?

Reduced left ventricular ejection fraction <40%
Pericardial effusion with tamponade physiology
Elevated right ventricular systolic pressure >50 mmHg with right heart strain (Correct answer)
Severe mitral regurgitation

Correct answer: Elevated right ventricular systolic pressure >50 mmHg with right heart strain

PoPH is characterized by pulmonary arterial hypertension in the setting of portal hypertension; echo shows elevated RVSP and right heart dilation/strain.

Question 129: A 58-year-old coal miner presents with progressive dyspnea and a chest X-ray showing 'eggshell calcifications' of hilar lymph nodes and upper-lobe nodules. What is the most likely diagnosis?

Silicosis (Correct answer)
Caplan syndrome
Coal workers' pneumoconiosis (simple)
Berylliosis

Correct answer: Silicosis

Eggshell calcification of hilar lymph nodes is pathognomonic of silicosis, caused by crystalline silica inhalation with upper-lobe predominant nodularity.

Question 130: A 48-year-old woman with no prior cardiac history presents with chest pain and is found to have ST elevation in leads II, III, and aVF. Coronary angiography shows no obstructive disease but a spiral dissection in the right coronary artery. What is the most likely diagnosis?

Cocaine-induced coronary spasm
Spontaneous coronary artery dissection (SCAD) (Correct answer)
Coronary artery vasospasm
Takayasu arteritis

Correct answer: Spontaneous coronary artery dissection (SCAD)

SCAD predominantly affects young women without traditional cardiac risk factors and presents as ACS with angiographic spiral dissection; conservative management is preferred over PCI.

Question 131: Which of the following clinical parameters is a component of the CURB-65 score for assessing the severity of community-acquired pneumonia?

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

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

Acute pericarditis (Correct answer)
Aortic dissection
STEMI
Pleuritis

Correct answer: Acute pericarditis

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

Question 133: A patient with cirrhosis has ascites refractory to diuretics. Diagnostic paracentesis shows SAAG of 1.8 g/dL. What is the most appropriate next management step?

Liver biopsy
TIPS procedure
Increase spironolactone dose
Large-volume paracentesis with albumin infusion (Correct answer)

Correct answer: Large-volume paracentesis with albumin infusion

Refractory ascites is managed with large-volume paracentesis (LVP) plus IV albumin (6–8 g per liter removed) to prevent paracentesis-induced circulatory dysfunction.

Question 134: A 65-year-old female is admitted to the hospital from a nursing home with a 3-day history of fever, productive cough, and confusion. A chest x-ray confirms a right lower lobe infiltrate. She was hospitalized and treated with intravenous antibiotics for a urinary tract infection 60 days ago. According to the 2019 IDSA/ATS guidelines for community-acquired pneumonia (CAP), which of the following is an essential component of her initial empiric antibiotic regimen?

Routine use of corticosteroids
Coverage for atypical pathogens with a macrolide
Coverage for methicillin-resistant Staphylococcus aureus (MRSA) (Correct answer)
Monotherapy with a respiratory fluoroquinolone

Correct answer: Coverage for methicillin-resistant Staphylococcus aureus (MRSA)

The 2019 IDSA/ATS guidelines recommend empiric coverage for MRSA in patients with CAP who have locally validated risk factors. A key risk factor is prior hospitalization and receipt of parenteral antibiotics within the past 90 days. Therefore, this patient requires coverage for both MRSA and Pseudomonas aeruginosa in addition to standard CAP therapy.

Question 135: Which of the following is an ABSOLUTE indication for emergent dialysis in AKI?

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

Correct answer: Uremic pericarditis with friction rub

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

Question 136: A 66-year-old man with known HFrEF (EF 30%) develops worsening renal function after ACE inhibitor dose uptitration. Creatinine rose from 1.2 to 1.8 mg/dL. What is the most appropriate action?

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

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

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

Question 137: A patient with recurrent furunculosis caused by MRSA is cleared but continues to have household transmission. Which decolonization strategy is most appropriate?

Oral clindamycin prophylaxis indefinitely
Systemic vancomycin for all household contacts
No treatment needed after the index case resolves
Intranasal mupirocin ointment plus chlorhexidine body wash (Correct answer)

Correct answer: Intranasal mupirocin ointment plus chlorhexidine body wash

Intranasal mupirocin and chlorhexidine bathing decolonize MRSA carriage in both the index patient and household contacts, reducing recurrence.

Question 138: 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?

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

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 139: A 40-year-old bird handler develops CAP with headache, dry cough, and splenomegaly. Which pathogen is most likely?

Francisella tularensis
Chlamydophila psittaci (Correct answer)
Coxiella burnetii
Histoplasma capsulatum

Correct answer: Chlamydophila psittaci

Psittacosis (C. psittaci) is a zoonotic atypical pneumonia associated with bird exposure, characterized by headache, dry cough, and splenomegaly.

Question 140: 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?

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

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 141: A 35-year-old woman presents with livedo reticularis, recurrent spontaneous abortions, thrombocytopenia, and a prolonged PTT that does not correct with mixing study. Which antibody panel is most diagnostic?

Anti-dsDNA and anti-Smith
Lupus anticoagulant, anticardiolipin IgG/IgM, and anti-β2-glycoprotein I (Correct answer)
Anti-centromere and anti-Scl-70
Anti-Ro/SSA and anti-La/SSB

Correct answer: Lupus anticoagulant, anticardiolipin IgG/IgM, and anti-β2-glycoprotein I

Antiphospholipid syndrome is diagnosed by the combination of clinical criteria (thrombosis or pregnancy morbidity) and confirmed positive antiphospholipid antibodies on two occasions 12 weeks apart.

Question 142: A 55-year-old man with multiple myeloma presents with AKI, hypercalcemia, and Bence Jones proteinuria. Which mechanism directly causes AKI in this condition?

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

Correct answer: Light chain cast nephropathy obstructing tubular lumens

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

Question 143: A 38-year-old woman with hypertension refractory to three medications has a serum potassium of 2.8 mEq/L and metabolic alkalosis. Aldosterone-to-renin ratio is 40 (ng/dL)/(ng/mL/hr). CT shows a 1.8 cm left adrenal adenoma. What is the best next step?

Obtain MRI of the adrenals
Start spironolactone empirically
Proceed directly to left adrenalectomy
Perform adrenal vein sampling (Correct answer)

Correct answer: Perform adrenal vein sampling

Adrenal vein sampling is required before surgery to confirm unilateral aldosterone hypersecretion, as CT can miss contralateral disease or misidentify non-functioning adenomas.

Question 144: A 48-year-old man is diagnosed with Wilson's disease presenting as acute liver failure. Which finding on labs would be most characteristic?

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

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

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

Question 145: A 70-year-old man presents with steatorrhea, weight loss, and a fasting serum glucose of 160 mg/dL. CT shows diffuse pancreatic atrophy and calcifications. What is the most likely underlying diagnosis?

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

Correct answer: Chronic pancreatitis

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

Question 146: A 35-year-old athlete collapses during a basketball game. ECG shows asymmetric septal hypertrophy and dynamic LVOT obstruction of 50 mmHg. Which medication is most appropriate for symptom management?

Amlodipine
Metoprolol succinate (Correct answer)
Nitroglycerin
Furosemide

Correct answer: Metoprolol succinate

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

Question 147: A 44-year-old woman presents with sudden onset of pulmonary edema. Echo reveals severe mitral regurgitation with a flail posterior leaflet. Her blood pressure is 85/60 mmHg. What is the most appropriate immediate intervention?

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

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

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

Question 148: Which criterion defines 'severe CAP' requiring ICU admission per IDSA/ATS major criteria?

Bilateral infiltrates on CXR
CURB-65 ≥3
Oxygen saturation <94% on room air
Need for mechanical ventilation OR septic shock requiring vasopressors (Correct answer)

Correct answer: Need for mechanical ventilation OR septic shock requiring vasopressors

IDSA/ATS major criteria for severe CAP are: need for invasive mechanical ventilation OR septic shock requiring vasopressors.

Question 149: 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?

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

Correct answer: Clindamycin + Quinine+ Doxycycline

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

Question 150: A 65-year-old woman with rheumatoid arthritis develops bilateral interstitial infiltrates and restrictive pulmonary physiology. Biopsy shows usual interstitial pneumonia (UIP) pattern. Which medication is most appropriate?

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

Correct answer: Nintedanib or pirfenidone

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

Question 151: Hereditary spherocytosis is caused by a defect in which cellular component?

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

Correct answer: Spectrin or ankyrin proteins in the RBC membrane

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

Question 152: What is the most common cause of secondary hypertension in adults under 40 years of age?

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

Correct answer: Renal artery stenosis due to fibromuscular dysplasia

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

Question 153: A patient with primary biliary cholangitis (PBC) is started on ursodeoxycholic acid (UDCA). Which lab trend best indicates an adequate biochemical response?

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

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 154: A 60-year-old man with a history of asbestos exposure presents with pleural plaques and mild dyspnea. Which malignancy is he at highest risk for?

Mesothelioma (Correct answer)
Small cell lung cancer
Squamous cell carcinoma of the lung
Adenocarcinoma of the lung

Correct answer: Mesothelioma

Asbestos exposure is the leading cause of malignant mesothelioma, a tumor arising from the pleural mesothelium.

Question 155: What is the most common cause of a transudative pleural effusion in the United States?

Congestive heart failure (Correct answer)
Pulmonary embolism
Malignancy
Hepatic hydrothorax

Correct answer: Congestive heart failure

Congestive heart failure accounts for approximately 500,000 cases annually and is the leading cause of transudative pleural effusion in the US.

Question 156: 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 157: A traveler returning from the Ohio River Valley presents with fever, mediastinal lymphadenopathy, and yeast forms with intracellular inclusions on bronchoalveolar lavage. Which antifungal is first-line treatment for disseminated disease?

Micafungin
Voriconazole
Fluconazole
Liposomal amphotericin B (Correct answer)

Correct answer: Liposomal amphotericin B

Disseminated histoplasmosis is treated with liposomal amphotericin B for severe disease, followed by step-down to itraconazole.

Question 158: Which of the following is the MOST important measure to prevent catheter-associated urinary tract infections (CAUTIs) in hospitalized patients?

Silver-coated catheters in all ICU patients
Routine prophylactic antibiotics in catheterized patients
Daily antimicrobial bladder washouts
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 159: A 55-year-old woman with RA develops leg ulcers, splenomegaly, and neutropenia. What is the most likely diagnosis?

Felty's syndrome (Correct answer)
Large granular lymphocyte syndrome
Vasculitis
Drug-induced agranulocytosis

Correct answer: Felty's syndrome

Felty's syndrome is the triad of rheumatoid arthritis, splenomegaly, and neutropenia, associated with severe seropositive RA.

Question 160: A 45-year-old man presents with fever, right upper quadrant pain, and jaundice after a trip to Egypt. Ultrasound shows a cystic liver lesion. Serology is positive for Entamoeba histolytica. What is the treatment?

Metronidazole followed by paromomycin (Correct answer)
Mebendazole for 3 months
Albendazole alone
Praziquantel single dose

Correct answer: Metronidazole followed by paromomycin

Amebic liver abscess is treated with metronidazole to eradicate invasive disease, followed by a luminal agent like paromomycin to eliminate intestinal cysts.

Question 161: A 50-year-old with known esophageal varices presents with acute hematemesis. After resuscitation, what pharmacologic therapy should be started immediately before endoscopy?

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

Correct answer: IV octreotide (somatostatin analogue)

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

Question 162: A 68-year-old man with NYHA class III heart failure has a biventricular pacemaker (CRT). His EF was 25% six months ago. Repeat echo now shows EF of 42%. Which statement about his ICD is most accurate?

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

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

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

Question 163: What is the first-line treatment for iron deficiency anemia in a hemodynamically stable patient?

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

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 164: A 70-year-old man with decompensated heart failure has oliguria, BUN 48 mg/dL, creatinine 2.2 mg/dL, and urine sodium 10 mEq/L. His kidney injury is best classified as:

Intrinsic AKI from ischemic ATN
Pre-renal AKI from reduced effective circulating volume (Correct answer)
Cardiorenal syndrome type 3
Post-renal AKI from urethral obstruction

Correct answer: Pre-renal AKI from reduced effective circulating volume

Low urine sodium (<20 mEq/L) and elevated BUN:creatinine ratio in heart failure indicate pre-renal AKI from reduced effective arterial blood volume.

Question 165: 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.
Initiate therapy with a thiazide diuretic.
Recommend a 3- to 6-month trial of lifestyle modifications. (Correct answer)
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 166: 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 167: A 50-year-old woman with a history of recurrent UTIs presents with flank pain and imaging showing a staghorn calculus filling the right renal pelvis. Urine culture grows Proteus mirabilis. What type of stone is this?

Struvite (magnesium ammonium phosphate) (Correct answer)
Cystine
Uric acid
Calcium oxalate

Correct answer: Struvite (magnesium ammonium phosphate)

Struvite stones form in the setting of urease-producing organisms (Proteus, Klebsiella) that alkalinize urine, causing precipitation of magnesium ammonium phosphate.

Question 168: A 66-year-old woman is started on amiodarone for atrial fibrillation. Which baseline workup is most important before initiating therapy?

Renal function tests and urinalysis only
Thyroid function tests, liver function tests, pulmonary function tests, and ophthalmologic exam (Correct answer)
Complete blood count and ESR
Echocardiogram and stress test only

Correct answer: Thyroid function tests, liver function tests, pulmonary function tests, and ophthalmologic exam

Amiodarone affects thyroid, liver, lung, cornea, and skin; baseline TFTs, LFTs, PFTs, chest X-ray, and eye exam are essential to detect organ toxicity.

Question 169: 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 170: A 55-year-old woman presents with bilateral hand pain, Heberden's nodes at the DIP joints, and Bouchard's nodes at the PIP joints. X-ray shows joint space narrowing without erosions. What is the most likely diagnosis?

Psoriatic arthritis
Rheumatoid arthritis
Gout
Osteoarthritis (Correct answer)

Correct answer: Osteoarthritis

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

Question 171: A patient with inferior STEMI is brought to the cath lab. Coronary angiography reveals 100% occlusion of a large dominant RCA. After successful PCI to the RCA, which hemodynamic complication is most likely to respond to IV fluids?

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

Correct answer: Right ventricular failure from RV infarction

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

Question 172: A traveler returns from Southeast Asia with watery diarrhea, nausea, and abdominal cramps starting 6 hours after eating rice. No fever is present. Which pathogen is most consistent with this presentation?

Campylobacter jejuni
Salmonella typhi
Vibrio cholerae
Bacillus cereus (emetic toxin) (Correct answer)

Correct answer: Bacillus cereus (emetic toxin)

Bacillus cereus emetic syndrome presents within 1–6 hours of ingesting preformed toxin in starchy foods like rice, causing vomiting and cramps without fever.

Question 173: A 64-year-old woman is diagnosed with Takotsubo (stress) cardiomyopathy after an emotional stressor. Which angiographic finding distinguishes this from anterior STEMI?

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

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

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

Question 174: Which precipitating factor accounts for the majority of DKA cases in known diabetics?

Infection or illness
Medication non-compliance (Correct answer)
Excessive alcohol use
New diagnosis of diabetes

Correct answer: Medication non-compliance

Insulin omission or non-compliance with insulin therapy is the most common precipitant of DKA in patients with known diabetes.

Question 175: A 55-year-old woman presents with chronic diarrhea and is found to have a normal colonoscopy but colonic biopsy reveals thickened subepithelial collagen band > 10 µm. What is the diagnosis?

Ulcerative colitis
Crohn's colitis
Collagenous colitis (microscopic colitis) (Correct answer)
Ischemic colitis

Correct answer: Collagenous colitis (microscopic colitis)

Collagenous colitis is a form of microscopic colitis characterized by a thickened collagen band beneath the epithelium, presenting with chronic watery diarrhea and normal colonoscopy.

Question 176: 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 177: 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)
Hypercalcemia
Osteosarcoma
Avascular necrosis of the hip

Correct answer: Atypical femur fracture

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

Question 178: 1) RVH 2) VSF 3) Overriding Aorta 4) Pulmonary Artery Stenosis

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

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 179: A patient in the ICU develops a wide-complex tachycardia at 180 bpm. She is hypotensive with BP of 78/50 mmHg. What is the immediate treatment?

IV amiodarone infusion over 10 minutes
IV adenosine
Synchronized direct current cardioversion (Correct answer)
IV verapamil

Correct answer: Synchronized direct current cardioversion

Unstable wide-complex tachycardia with hemodynamic compromise requires immediate synchronized DC cardioversion regardless of the underlying rhythm.

Question 180: Wellens' syndrome (Type A and B T-wave patterns in V2-V3) in a patient with resolved chest pain indicates which critical finding?

Prior completed MI with scar formation
Benign early repolarization
Critical proximal LAD stenosis with intermittent reperfusion (Correct answer)
Hyperkalemia causing diffuse T-wave changes

Correct answer: Critical proximal LAD stenosis with intermittent reperfusion

Wellens' syndrome represents reperfusion T-wave changes from a critical proximal LAD lesion; stress testing is contraindicated as it can precipitate massive anterior STEMI.

Question 181: 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?

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

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 182: Which statement about the management of community-acquired pneumonia (CAP) requiring ICU admission is correct?

Antifungal coverage must always be added empirically
Monotherapy with a respiratory fluoroquinolone is sufficient
MRSA coverage with vancomycin is routinely required for all ICU CAP
Beta-lactam plus macrolide or beta-lactam plus respiratory fluoroquinolone is recommended (Correct answer)

Correct answer: Beta-lactam plus macrolide or beta-lactam plus respiratory fluoroquinolone is recommended

IDSA/ATS guidelines recommend combination therapy with a beta-lactam plus either a macrolide or a respiratory fluoroquinolone for severe CAP requiring ICU admission.

Question 183: A patient recovering from AKI due to sepsis now has a urine output of 4 L/day with a fixed urine osmolality of 310 mOsm/kg. This pattern is most consistent with which phase of AKI recovery?

Anuric phase
Complete recovery with normal tubular function
Oliguric phase
Polyuric recovery phase with impaired tubular concentrating ability (Correct answer)

Correct answer: Polyuric recovery phase with impaired tubular concentrating ability

The polyuric phase of ATN recovery shows high urine volume but isosthenuria (fixed osmolality ~300 mOsm/kg) due to persistent tubular dysfunction before full recovery.

Question 184: A 28-year-old man presents with hematuria and deafness since childhood. Electron microscopy of his renal biopsy shows thinning and splitting of the glomerular basement membrane in a 'basket-weave' pattern. What is the inheritance pattern of this condition?

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

Correct answer: X-linked (most common form)

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

Question 185: 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 186: Which finding on serum protein electrophoresis (SPEP) is characteristic of multiple myeloma?

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

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

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 188: Which ketone body is predominantly elevated in DKA but NOT detected by the nitroprusside urine ketone test?

Acetone
Pyruvate
Acetoacetate
Beta-hydroxybutyrate (Correct answer)

Correct answer: Beta-hydroxybutyrate

Beta-hydroxybutyrate is the predominant ketone in DKA but is not detected by nitroprusside-based urine/serum ketone tests.

Question 189: A 28-year-old man presents with urethritis, asymmetric oligoarthritis, conjunctivitis, and oral ulcers 3 weeks after a chlamydial infection. What is the classic triad of reactive arthritis?

Diarrhea, arthritis, and sacroiliitis
Urethritis, arthritis, and conjunctivitis (Correct answer)
Arthritis, uveitis, and oral ulcers
Arthritis, psoriasis, and iritis

Correct answer: Urethritis, arthritis, and conjunctivitis

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

Question 190: A patient with nephrotic syndrome develops sudden flank pain and hematuria. CT shows right renal vein thrombosis. Which underlying condition most predisposes to renal vein thrombosis in nephrotic syndrome?

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

Correct answer: Membranous nephropathy

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

Question 191: 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?

Systemic corticosteroids and antibiotics (Correct answer)
Theophylline and supportive care
A long-acting muscarinic antagonist (LAMA) only
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 192: 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?

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

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 193: A 72-year-old man with chronic kidney disease (eGFR 20) and a recent STEMI requires anticoagulation for concurrent atrial fibrillation. Which DOAC dose adjustment is most critical?

Dabigatran 150 mg twice daily
Rivaroxaban 20 mg daily without adjustment
No dose adjustment needed for any DOAC
Apixaban 2.5 mg twice daily if criteria met; avoid dabigatran (Correct answer)

Correct answer: Apixaban 2.5 mg twice daily if criteria met; avoid dabigatran

Dabigatran is primarily renally cleared and should be avoided in severe CKD; apixaban has the least renal clearance and can be used with dose reduction (2.5 mg BID) in eligible patients.

Question 194: Which hemodynamic pattern is most consistent with constrictive pericarditis on right heart catheterization?

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

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 195: A patient in DKA is started on a normal saline infusion. After 2 liters, serum chloride is 112 mEq/L. What complication is developing?

Hyperkalemia from saline load
Dilutional hyponatremia
Iatrogenic metabolic alkalosis
Hyperchloremic non-anion gap metabolic acidosis (Correct answer)

Correct answer: Hyperchloremic non-anion gap metabolic acidosis

Large volumes of normal saline can cause hyperchloremic non-anion gap metabolic acidosis, which may obscure DKA resolution.

Question 196: A 62-year-old man develops new bundle branch block and cardiogenic shock 6 hours after anterior STEMI. Echocardiography shows a ventricular septal defect. What is the definitive treatment?

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

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

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

Question 197: A patient with AKI has serum potassium of 6.8 mEq/L. ECG shows peaked T waves, widened QRS, and a sine wave pattern. What is the FIRST treatment to administer?

Sodium polystyrene sulfonate (Kayexalate)
Insulin plus dextrose IV
Sodium bicarbonate IV
Calcium gluconate IV (Correct answer)

Correct answer: Calcium gluconate IV

Calcium gluconate IV is given first to stabilize the cardiac membrane and protect against life-threatening arrhythmias, though it does not lower serum potassium.

Question 198: Which finding on echocardiography is most consistent with cardiac tamponade?

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

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 199: A 55-year-old man presents with painless jaundice, 15 lb weight loss, and a palpable, non-tender gallbladder. What is the most likely diagnosis?

Primary sclerosing cholangitis
Acute cholecystitis
Choledocholithiasis
Pancreatic head adenocarcinoma (Correct answer)

Correct answer: Pancreatic head adenocarcinoma

Courvoisier's sign (palpable non-tender gallbladder with painless jaundice) in an older patient strongly suggests malignant biliary obstruction, most commonly pancreatic head carcinoma.

Question 200: A 55-year-old woman with limited cutaneous systemic sclerosis has esophageal dysmotility and Raynaud's phenomenon. Which antibody is most specific for CREST syndrome?

Anti-Scl-70 (anti-topoisomerase I)
Anti-Jo-1
Anti-RNA polymerase III
Anti-centromere antibody (Correct answer)

Correct answer: Anti-centromere antibody

Anti-centromere antibody is highly specific for limited cutaneous systemic sclerosis (CREST syndrome) and associated with a better prognosis than diffuse disease.

Internal Medicine Board Exam

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

200

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240 min

Time Limit

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