Internal Medicine Board Exam — Questions and Answers

Question 1: A 62-year-old man with myeloma presents with AKI, hypercalcemia, and anemia. Urinalysis shows no blood or protein by dipstick but urine protein electrophoresis reveals a spike. Which cast type is pathognomonic on renal biopsy?

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

Correct answer: Myeloma (Bence Jones) casts

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

Question 2: A 48-year-old man develops fever and flank pain 10 days after a kidney transplant. Urinalysis shows pyuria. Urine culture grows Escherichia coli (ESBL-producing). What is the preferred treatment?

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

Correct answer: Meropenem or ertapenem

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

Question 3: 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?

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

Correct answer: Silicosis

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

Question 4: 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 esmolol
Intravenous lorazepam (Correct answer)
Intravenous diltiazem
Intravenous labetalol

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

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

Correct answer: Ophthalmologic examination

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

Question 6: 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 repair
Percutaneous mitral balloon commissurotomy (PMBC) (Correct answer)
Mitral valve replacement with mechanical prosthesis
Medical therapy with diuretics indefinitely

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

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

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

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

Question 8: A 33-year-old man presents with recurrent oral ulcers, genital ulcers, and uveitis. He also reports bloody diarrhea. Which GI condition is most strongly associated with this systemic disorder?

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

Correct answer: Behçet's disease with GI involvement

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

Question 9: 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?

Elevated C3 and C4
Elevated C3 with decreased C4
Decreased C3 and C4 (Correct answer)
Normal C3 with elevated 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 10: Which lab finding best distinguishes iron deficiency anemia from anemia of chronic disease?

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

Correct answer: Low serum ferritin

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

Question 11: 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
Dietary protein restriction alone
Oral sodium bicarbonate supplementation (Correct answer)
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 12: A patient with known type 1 diabetes is NPO for surgery scheduled tomorrow morning. How should insulin be managed to prevent DKA?

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

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

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

Question 13: Differential cell count, total protein, pH, glucose, amylase, triglycerides, microbiology, and cytology. Effusions must meet a minimum of one requirement (Light's requirement). 1) Pleural/serum protein: >0.5 2) > 0.6 LDH (pleural/serum) 3) LDH above three times the average serum LDH

What is the difference between Transudative effusion and Exudative effusions?
What laboratory findings are consistent with PBC? Treatment?
If exudative effusion is suspected, what should be performed on fluid? (Correct answer)
What test is used to differentiate between sarcoidosis and Berylliosis?

Correct answer: If exudative effusion is suspected, what should be performed on fluid?

The provided text explicitly lists the various components of fluid analysis—such as differential cell count, total protein, pH, glucose, amylase, triglycerides, microbiology, and cytology—that are performed to characterize an effusion. It also includes Light's criteria, which are used to differentiate between transudative and exudative effusions. Therefore, the question asking what should be performed on fluid if an exudative effusion is suspected directly aligns with the given information.

Question 14: A 35-year-old woman with SLE develops new proteinuria (3.5 g/day) and hematuria. Renal biopsy shows diffuse proliferative glomerulonephritis with subendothelial deposits. Which WHO/ISN class is this?

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

Correct answer: Class IV (diffuse proliferative)

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

Question 15: A 50-year-old man with Wegener granulomatosis (GPA) presents with hematuria, proteinuria, and rising creatinine. Renal biopsy shows a pauci-immune crescentic glomerulonephritis. Which antibody is most likely positive?

c-ANCA (PR3-ANCA) (Correct answer)
Anti-GBM antibody
ANA and anti-dsDNA
p-ANCA (MPO-ANCA)

Correct answer: c-ANCA (PR3-ANCA)

GPA (Wegener's) is associated with c-ANCA targeting proteinase 3 (PR3), while microscopic polyangiitis is more commonly p-ANCA/MPO-positive.

Question 16: Which finding on echocardiography is most consistent with cardiac tamponade?

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

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

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

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

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

Question 18: 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
Discontinue ACE inhibitor immediately
Continue ACE inhibitor if creatinine rise is ≤30% above baseline (Correct answer)
Add aldosterone antagonist to offset renal effects

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 19: 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
Administer IV albumin 6-8 g per liter removed (Correct answer)
Start oral midodrine immediately after procedure
Restrict sodium to less than 1 g per day

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

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

Question 20: Which finding on echocardiogram is an absolute indication for surgical intervention in infective endocarditis regardless of hemodynamic stability?

Vegetation >10 mm on the mitral valve
Mild mitral regurgitation with vegetation <5 mm
Mild aortic regurgitation with preserved EF
Periannular abscess or fistula formation (Correct answer)

Correct answer: Periannular abscess or fistula formation

Periannular abscess or fistula indicates local invasion and structural destruction, which is an absolute surgical indication regardless of hemodynamic status.

Question 21: A cirrhotic patient with known varices has not bled. What is the recommended primary prophylaxis approach for large varices?

TIPS procedure
Non-selective beta-blockers or endoscopic band ligation (Correct answer)
Shunt surgery
Sclerotherapy alone

Correct answer: Non-selective beta-blockers or endoscopic band ligation

Non-selective beta-blockers (propranolol, nadolol, carvedilol) or endoscopic band ligation are equally effective first-line primary prophylaxis for large esophageal varices.

Question 22: 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?

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

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

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

Correct answer: Oral corticosteroids

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

Question 24: A 35-year-old woman presents with recurrent watery diarrhea, bloating, and abdominal pain relieved by defecation. Colonoscopy and labs are normal. What is the most likely diagnosis?

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

Correct answer: Irritable bowel syndrome (IBS)

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

Question 25: 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)
N-acetylcysteine administration
Sodium bicarbonate infusion
Furosemide administration before contrast

Correct answer: Isotonic saline hydration before and after the procedure

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

Question 26: A patient develops AKI after receiving vancomycin. Urinalysis shows eosinophiluria and white blood cell casts. Serum creatinine peaks at 3.1 mg/dL on day 10. What is the primary pathophysiology?

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

Correct answer: Acute interstitial nephritis

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

Question 27: A 60-year-old woman presents with Raynaud's phenomenon, dysphagia, and progressive dyspnea. PFTs show a restrictive pattern with reduced DLCO. HRCT reveals basilar ground-glass and honeycombing. What is the most likely underlying systemic condition?

Rheumatoid arthritis
Systemic sclerosis (scleroderma) (Correct answer)
Sjögren syndrome
Systemic lupus erythematosus

Correct answer: Systemic sclerosis (scleroderma)

Systemic sclerosis is strongly associated with interstitial lung disease (typically NSIP or UIP pattern) combined with Raynaud's phenomenon and dysphagia from esophageal dysmotility.

Question 28: A patient with diffuse systemic sclerosis develops dyspnea and a dry cough. PFTs show a restrictive pattern with reduced DLCO. CT chest shows bilateral basilar ground-glass opacities and honeycombing. What is the first-line treatment?

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

Correct answer: Cyclophosphamide or mycophenolate mofetil

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

Question 29: A 28-year-old man with Crohn's disease on azathioprine develops fever, right lower quadrant pain, and a palpable mass. CT reveals a 4 cm periappendiceal abscess. What is the best initial management?

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

Correct answer: Percutaneous CT-guided drainage and IV antibiotics

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

Question 30: A 59-year-old patient on treatment for latent tuberculosis with isoniazid develops fatigue, nausea, and right upper quadrant discomfort. Laboratory tests reveal an AST of 350 U/L and an ALT of 410 U/L (baseline was normal). Which of the following patterns of liver injury is most characteristically associated with isoniazid toxicity?

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

Correct answer: Hepatocellular injury

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

Question 31: A 30-year-old man presents with urethral discharge and dysuria. Gram stain shows gram-negative intracellular diplococci. In addition to treating gonorrhea, empiric treatment for which co-infection is mandatory?

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

Correct answer: Chlamydia trachomatis

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

Question 32: 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)
Posaconazole plus micafungin
Voriconazole IV for 6 weeks
Fluconazole 400 mg daily

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 33: A patient on isoniazid for latent TB develops peripheral neuropathy. Which vitamin deficiency is responsible?

Vitamin B12 (cobalamin)
Vitamin D
Vitamin B6 (pyridoxine) (Correct answer)
Vitamin B1 (thiamine)

Correct answer: Vitamin B6 (pyridoxine)

Isoniazid inhibits pyridoxine (B6) metabolism, causing peripheral neuropathy; B6 supplementation is given prophylactically.

Question 34: An intermittent, mid-sternal chest ache that typically lasts 5 to 10 minutes affects a 57-year-old male. Both when we are working and when we are not. His throat also feels sore, which occasionally gets better with antacids. He stopped smoking around the age of 50. He denies having other serious medical issues. His type 2 diabetes and hypertension run in the family. His height is 70 inches, weight is 210 pounds, blood pressure is 135/85 mmHg, and pulse is regular at 76. Auscultation reveals his chest is clean and free of cardiac rubs or murmurs. The overall evaluation is unfavorable. He has a normal electrocardiogram. What logical step would result in the best chance of a diagnosis?

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

Correct answer: Technetium Tc99m Sestamibi stress test

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

Question 35: 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 36: A patient with HIV and CD4 count of 50 cells/μL presents with headache, fever, and neck stiffness. India ink stain of CSF shows encapsulated yeast. What is the treatment of choice?

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

Correct answer: Amphotericin B plus flucytosine

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

Question 37: A post-ACS patient is intolerant of ACE inhibitors due to cough. Which agent provides equivalent mortality benefit in patients with reduced ejection fraction?

Angiotensin receptor blocker (ARB) such as valsartan (Correct answer)
Long-acting nitrate
Hydralazine alone
Calcium channel blocker

Correct answer: Angiotensin receptor blocker (ARB) such as valsartan

ARBs (e.g., valsartan, losartan) provide equivalent cardiovascular mortality reduction post-MI with reduced EF and are the recommended alternative when ACE inhibitors are not tolerated due to cough.

Question 38: A 50-year-old diabetic man develops AKI after starting an ACE inhibitor. Renal artery duplex shows >70% stenosis bilaterally. What is the mechanism of AKI in this patient?

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

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

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

Question 39: A 65-year-old woman with HFrEF (EF 30%) is already on maximally tolerated ACE inhibitor and beta-blocker. Her NT-proBNP remains elevated. Which medication should be added next?

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

Correct answer: Sacubitril/valsartan replacing the ACE inhibitor

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

Question 40: A 32-year-old male is newly diagnosed with moderate-to-severe ileocolonic Crohn's disease. He has not received prior treatment. According to the most recent American Gastroenterological Association (AGA) guidelines, which of the following is the most appropriate initial therapeutic approach?

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

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

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

Question 41: A 55-year-old with a history of NSAID use presents with melena and hematemesis. EGD shows a 1 cm duodenal ulcer with a visible vessel at its base. After endoscopic hemostasis, what is the next best pharmacologic management?

Oral H2-blocker
Sucralfate suspension
H. pylori eradication therapy immediately
High-dose IV proton pump inhibitor infusion for 72 hours (Correct answer)

Correct answer: High-dose IV proton pump inhibitor infusion for 72 hours

High-risk ulcers treated endoscopically require high-dose IV PPI (bolus + infusion) for 72 hours to reduce rebleeding risk.

Question 42: A 45-year-old female presents with a four-month history of symmetric pain and swelling in the small joints of her hands and wrists, accompanied by morning stiffness lasting over an hour. Laboratory tests are positive for rheumatoid factor and anti-CCP antibodies. What is the most appropriate initial disease-modifying therapy?

Etanercept
Hydroxychloroquine
Methotrexate (Correct answer)
Prednisone monotherapy

Correct answer: Methotrexate

Methotrexate is the cornerstone and initial disease-modifying antirheumatic drug (DMARD) of choice for most patients with newly diagnosed moderate-to-severe rheumatoid arthritis. [1, 3, 6] It has a proven track record of improving symptoms and slowing radiographic progression. Hydroxychloroquine is typically reserved for milder disease. Etanercept, a biologic DMARD, is generally used after an inadequate response to methotrexate. Prednisone is used for its rapid anti-inflammatory effects, often as a 'bridge' therapy until DMARDs take effect, but it is not recommended as a long-term monotherapy due to its side effect profile.

Question 43: Five days after an extensive anterior wall myocardial infarction, a 70-year-old female becomes acutely hypotensive and develops respiratory distress. On examination, a new, loud, harsh holosystolic murmur is heard best at the left lower sternal border, accompanied by a palpable thrill. Which of the following is the most likely diagnosis?

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

Correct answer: Ventricular septal rupture

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

Question 44: A 28-year-old male presents with a 3-year history of chronic inflammatory back pain and stiffness that improves with exercise but not with rest. A plain radiograph of the pelvis is obtained. Which of the following radiographic findings in the sacroiliac joints would be most characteristic of ankylosing spondylitis?

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

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

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

Question 45: 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?

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

Correct answer: Aortic valve replacement (surgical or TAVR)

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

Question 46: 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
Scleroderma renal crisis
Pulmonary arterial hypertension (Correct answer)

Correct answer: Pulmonary arterial hypertension

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

Question 47: A 25-year-old woman presents with intermittent episodes of wheezing, shortness of breath, and chest tightness. These symptoms occur 3-4 days a week and awaken her from sleep about twice a month. She uses an albuterol inhaler for symptom relief, which she needs several times a week. According to the most recent GINA guidelines, which of the following is the preferred initial controller therapy?

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

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

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

Question 48: Which of the following is the MOST important measure to prevent catheter-associated urinary tract infections (CAUTIs) in hospitalized patients?

Routine prophylactic antibiotics in catheterized patients
Silver-coated catheters in all ICU 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 49: What is the recommended initial fluid bolus for an adult presenting in DKA with moderate dehydration?

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

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 50: 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?

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

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

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

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

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

Question 52: A cirrhotic patient develops sudden onset of right-sided pleural effusion. Thoracentesis reveals transudative fluid with SAAG >1.1. No pulmonary pathology is identified. What is the diagnosis?

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

Correct answer: Hepatic hydrothorax

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

Question 53: A 48-year-old man is found to have a 4.2 cm ascending aortic aneurysm incidentally. He is asymptomatic with no connective tissue disorder. What is the recommended management?

Immediate surgical repair
Surveillance imaging every 6–12 months and aggressive blood pressure control (Correct answer)
Endovascular stent grafting
Beta-blockers and repeat imaging in 5 years

Correct answer: Surveillance imaging every 6–12 months and aggressive blood pressure control

Asymptomatic ascending aortic aneurysms <5.0–5.5 cm (without high-risk features) are managed with surveillance imaging and risk factor modification including BP control.

Question 54: A patient with bronchiectasis has repeated Pseudomonas aeruginosa infections. Which maintenance therapy is most appropriate to reduce exacerbation frequency?

Daily oral amoxicillin-clavulanate
Daily trimethoprim-sulfamethoxazole
Monthly IV ceftazidime
Inhaled tobramycin or aztreonam alternating monthly (Correct answer)

Correct answer: Inhaled tobramycin or aztreonam alternating monthly

Inhaled anti-pseudomonal antibiotics (tobramycin or aztreonam on alternating month schedules) suppress Pseudomonas colonization and reduce exacerbations in bronchiectasis.

Question 55: A patient with idiopathic pulmonary fibrosis has a 6-minute walk distance of 280 meters and SpO2 nadir of 84%. Which therapy is indicated?

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

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

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

Correct answer: Initiate a norepinephrine infusion.

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

Question 57: A 30-year-old woman with SLE is found to have a positive lupus anticoagulant and has a history of one DVT. What is the recommended long-term management?

6-month anticoagulation with DOAC
Antiplatelet therapy with aspirin alone
Hydroxychloroquine alone
Indefinite anticoagulation with warfarin (INR 2-3) (Correct answer)

Correct answer: Indefinite anticoagulation with warfarin (INR 2-3)

SLE patients with antiphospholipid antibodies and thrombotic events require indefinite anticoagulation with warfarin targeting INR 2-3, as DOACs have shown inferior outcomes.

Question 58: 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
Minimal change disease
Lupus nephritis

Correct answer: Thrombotic microangiopathy (malignant hypertension)

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

Question 59: 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:

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

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

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

Correct answer: Constrictive pericarditis

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

Question 61: A 28-year-old woman presents with dysuria, frequency, and suprapubic pain for 2 days. Urinalysis shows pyuria and bacteriuria. What is the most appropriate initial treatment?

Amoxicillin for 3 days
Nitrofurantoin for 5 days (Correct answer)
Ciprofloxacin for 14 days
Trimethoprim-sulfamethoxazole for 10 days

Correct answer: Nitrofurantoin for 5 days

Nitrofurantoin for 5 days is first-line therapy for uncomplicated UTI in non-pregnant women due to efficacy and low resistance rates.

Question 62: 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?

Mycobacterium avium complex
Pneumocystis jirovecii pneumonia (PCP) (Correct answer)
Bacterial pneumonia (Streptococcus pneumoniae)
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 63: Which radiographic pattern is MOST characteristic of Pneumocystis jirovecii pneumonia (PCP) in an immunocompromised host?

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

Correct answer: Bilateral interstitial/perihilar infiltrates

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

Question 64: A patient with COPD exacerbation receives supplemental oxygen and develops worsening somnolence. ABG shows pH 7.28, PaCO2 72 mmHg, PaO2 68 mmHg. What is the best next intervention?

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

Correct answer: Start noninvasive positive pressure ventilation (NIPPV)

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

Question 65: A 35-year-old asymptomatic healthcare worker undergoes routine annual screening and has a positive Interferon-Gamma Release Assay (IGRA) test. A subsequent chest X-ray is normal. What is the most appropriate next step in the management of this patient?

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

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

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

Question 66: A patient develops fever, chills, flank pain, and hemoglobinuria 30 minutes into a blood transfusion. What is the most likely cause?

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

Correct answer: Acute hemolytic transfusion reaction due to ABO incompatibility

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

Question 67: A patient with Sjögren's syndrome develops peripheral neuropathy and purpura. Serum protein electrophoresis shows a monoclonal spike. Which complication should be suspected?

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

Correct answer: Cryoglobulinemic vasculitis

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

Question 68: 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?

Choledocholithiasis
Acute cholecystitis
Primary sclerosing cholangitis
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 69: A 40-year-old bird handler develops CAP with headache, dry cough, and splenomegaly. Which pathogen is most likely?

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

Correct answer: Chlamydophila psittaci

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

Question 70: 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?

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

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

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

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 72: 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?

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

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 73: 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:

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

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 74: 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 mildly elevated LFTs?
What are causes of severely elevated LFTs?
What is the treatment for Goodpasture's Syndrome?

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

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

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

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

Question 76: A 65-year-old man with a 3 cm hepatocellular carcinoma (HCC) on a background of cirrhosis has a Child-Pugh A score and no extrahepatic spread. Which staging criteria determines treatment eligibility for curative resection?

Edmondson-Steiner grading
Milan criteria
Pittsburgh modified TNM
Barcelona Clinic Liver Cancer (BCLC) criteria (Correct answer)

Correct answer: Barcelona Clinic Liver Cancer (BCLC) criteria

The BCLC staging system is the most widely used guideline for HCC that links staging to prognosis and treatment allocation, including candidacy for resection.

Question 77: 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 78: A 30-year-old African American woman presents with dyspnea, bilateral hilar lymphadenopathy on CXR, and elevated serum ACE. Transbronchial biopsy shows noncaseating granulomas. What is the diagnosis?

Sarcoidosis (Correct answer)
Hypersensitivity pneumonitis
Berylliosis
Tuberculosis

Correct answer: Sarcoidosis

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

Question 79: A 50-year-old immunocompromised patient develops fever, pleuritic chest pain, and a pulmonary infiltrate with a halo sign on CT chest. Galactomannan is positive. What is first-line treatment?

Voriconazole (Correct answer)
Amphotericin B deoxycholate
Fluconazole
Caspofungin monotherapy

Correct answer: Voriconazole

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

Question 80: A 58-year-old man with NSTEMI has a TIMI risk score of 5. Which management strategy is most appropriate?

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

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

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

Question 81: Which of the following is a characteristic feature of Löfgren syndrome in the context of sarcoidosis?

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

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

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

Question 82: 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?

Theophylline and supportive care
Inhaled corticosteroids only
Systemic corticosteroids and antibiotics (Correct answer)
A long-acting muscarinic antagonist (LAMA) 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 83: A 62-year-old female with severe acute kidney injury (creatinine 6.8 mg/dL) secondary to sepsis is being managed in the ICU. Which of the following findings is the most urgent indication for initiating renal replacement therapy?

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

Correct answer: Pericardial friction rub on auscultation

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

Question 84: A 28-year-old man presents with hematuria and deafness since childhood. Electron microscopy of his renal biopsy shows thinning and splitting of the glomerular basement membrane in a 'basket-weave' pattern. What is the inheritance pattern of this condition?

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

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

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

Correct answer: Positive blood culture with a typical microorganism

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

Question 86: Which of the following urine microscopy findings is most specific for acute tubular necrosis?

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

Correct answer: Muddy brown granular casts

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

Question 87: A 64-year-old man with cirrhosis due to non-alcoholic steatohepatitis presents with increasing confusion, lethargy, and asterixis. His family notes he has been more forgetful over the past week. He has no fever or abdominal pain. What is the most appropriate initial pharmacologic therapy for this patient's condition?

Intravenous albumin
Rifaximin
Propranolol
Lactulose (Correct answer)

Correct answer: Lactulose

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

Question 88: Procalcitonin (PCT) is most useful in CAP management for which purpose?

Identifying the causative organism
Predicting 30-day mortality
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 89: A 55-year-old woman with type 2 diabetes has persistently elevated liver enzymes. Liver biopsy shows hepatocyte ballooning, lobular inflammation, and pericellular fibrosis without significant alcohol use. What is the most likely diagnosis?

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

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 90: A 45-year-old presents with dyspepsia, early satiety, and bloating. Upper endoscopy shows a 3 cm submucosal gastric mass with overlying normal mucosa. EUS reveals a hypoechoic lesion arising from the muscularis propria. What is the most likely diagnosis?

Gastric carcinoid
Gastric lymphoma
Gastrointestinal stromal tumor (GIST) (Correct answer)
Gastric adenocarcinoma

Correct answer: Gastrointestinal stromal tumor (GIST)

GISTs are the most common submucosal gastric tumors, arising from the muscularis propria and appearing hypoechoic on EUS.

Question 91: 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?

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

Correct answer: GABAergic system

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

Question 92: A 45-year-old man with HIV (CD4 count 60 cells/µL) presents with fever, non-productive cough, and progressive dyspnea. CXR shows bilateral interstitial infiltrates. LDH is elevated. What is the most likely diagnosis?

Bacterial pneumonia with Streptococcus pneumoniae
Tuberculosis reactivation
Cytomegalovirus pneumonitis
Pneumocystis jirovecii pneumonia (PCP) (Correct answer)

Correct answer: Pneumocystis jirovecii pneumonia (PCP)

PCP classically presents in severely immunocompromised HIV patients (CD4 <200) with bilateral interstitial infiltrates, elevated LDH, and gradual onset dyspnea.

Question 93: A 72-year-old male recently treated with clindamycin presents with 5-6 watery, non-bloody stools per day for three days. He has lower abdominal cramping but no fever. His WBC count is 10,500/μL and serum creatinine is 1.0 mg/dL. A stool test is positive for Clostridioides difficile toxin. According to the most recent IDSA guidelines, which of the following is the most appropriate initial treatment for this patient's non-severe C. difficile infection?

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

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

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

Question 94: Which type of lung cancer is most strongly associated with hypercalcemia without bone metastases?

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

Correct answer: Squamous cell carcinoma

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

Question 95: A 50-year-old patient with a history of hypertension, hyperlipidemia, and alcoholism arrives at the emergency room with a strong cough, a fever, chills, and generalized weakness. Her family adds that she has been acting confused, and she claims that she has had those symptoms for over a week. She recently resumed drinking and is currently taking Lipitor and Atenolol. Vitals: temperature is 102.5 degrees Fahrenheit, heart rate is 105 beats per minute, blood pressure is 110/75, and respiratory rate is 22. During a physical examination, the right lower lobe (RLL) exhibits diminished breath sounds correlated with an RLL infiltrate on a chest x-ray. What is your prevailing medical opinion?

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

Correct answer: Sepsis

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

Question 96: A 68-year-old man with NYHA class III heart failure has a biventricular pacemaker (CRT). His EF was 25% six months ago. Repeat echo now shows EF of 42%. Which statement about his ICD is most accurate?

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

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

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

Question 97: It was shown for patients with A. Rate control outperformed rhythm control.

How does USA differ from NSTEMI?
What treatment is required for TOF
What is Churg-Strauss syndrome?
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 98: Which electrocardiographic pattern is characteristic of Wolff-Parkinson-White (WPW) syndrome during sinus rhythm?

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

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

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

Question 99: Which of the following findings is an absolute indication for initiating urgent hemodialysis in a patient with acute kidney injury?

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

Correct answer: Uremic pericarditis with a friction rub

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

Question 100: Which laboratory test provides the most accurate real-time assessment of ketone clearance in DKA?

Serum acetoacetate level
Urine ketones by dipstick
Urine specific gravity
Serum beta-hydroxybutyrate level (Correct answer)

Correct answer: Serum beta-hydroxybutyrate level

Serum beta-hydroxybutyrate directly measures the predominant ketone in DKA and is more accurate than urine dipstick or acetoacetate alone.

Question 101: 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 teriparatide
Subcutaneous denosumab
Intravenous zoledronic acid

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

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

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

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

Question 103: 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 104: Which antibiotic class is the treatment of choice for community-acquired pneumonia caused by atypical organisms such as Mycoplasma pneumoniae in an otherwise healthy outpatient adult?

Aminoglycosides
Carbapenems
Beta-lactams
Macrolides (Correct answer)

Correct answer: Macrolides

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

Question 105: A 64-year-old woman is diagnosed with Takotsubo (stress) cardiomyopathy after an emotional stressor. Which angiographic finding distinguishes this from anterior STEMI?

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

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

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

Correct answer: Ongoing cigarette smoking within the past 6 months

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

Question 107: 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?

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

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 108: A 58-year-old woman with RA presents with a painless effusion in her right knee. Joint aspiration yields 80 mL of clear, straw-colored fluid with WBC 1,200/mm³ and glucose equal to serum. What does this synovial fluid analysis indicate?

Septic arthritis
Crystal-induced arthritis
Noninflammatory (Group I) fluid consistent with RA remission or osteoarthritis overlay (Correct answer)
Hemorrhagic effusion

Correct answer: Noninflammatory (Group I) fluid consistent with RA remission or osteoarthritis overlay

Noninflammatory synovial fluid (WBC <2,000/mm³, clear, normal glucose) suggests inactive RA or a concurrent non-inflammatory process like OA.

Question 109: A 70-year-old lifelong smoker with a 50 pack-year history is screened by low-dose CT and found to have a 10 mm solid pulmonary nodule. What is the recommended next step per Fleischner Society guidelines?

Repeat CT in 3 months
Immediate surgical resection
No follow-up needed
PET-CT scan or CT-guided biopsy (Correct answer)

Correct answer: PET-CT scan or CT-guided biopsy

In a high-risk patient, a solid nodule ≥8 mm warrants PET-CT, CT-guided biopsy, or surgical resection for definitive characterization per Fleischner guidelines.

Question 110: Which duration of dual antiplatelet therapy (DAPT) is generally recommended after drug-eluting stent (DES) placement for ACS?

Lifelong DAPT
At least 12 months (Correct answer)
1 month
3 months

Correct answer: At least 12 months

Current ACC/AHA guidelines recommend at least 12 months of DAPT after DES placement in ACS patients to reduce stent thrombosis and recurrent ischemic events.

Question 111: Which of the following triggers is most classically associated with DKA in a previously well-controlled type 1 diabetic who is NOT missing insulin doses?

Psychological stress alone
Occult infection (e.g., UTI, pneumonia) (Correct answer)
Change in insulin brand
Dietary indiscretion

Correct answer: Occult infection (e.g., UTI, pneumonia)

Infection is the most common medical precipitant of DKA in compliant type 1 diabetic patients, as counter-regulatory hormones from illness increase insulin resistance.

Question 112: A 45-year-old man presents to the emergency department with the sudden onset of a severely painful, swollen, and warm right knee, making him unable to bear weight. He has a fever of 38.5°C (101.3°F). What is the most critical next step in the management of this patient?

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

Correct answer: Perform an arthrocentesis of the knee

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

Question 113: A 28-year-old woman presents with chronic diarrhea, bloating, and newly diagnosed iron deficiency anemia. Celiac disease is suspected. Which of the following is the most appropriate initial serologic test for this condition in an adult who is not IgA deficient?

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

Correct answer: Tissue transglutaminase (tTG)-IgA antibody

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

Question 114: 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?

Legionella pneumophila
Streptococcus pneumoniae (Correct answer)
Mycoplasma pneumoniae
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 115: A patient with penicillin allergy (anaphylaxis) requires treatment for neurosyphilis. What is the recommended management?

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

Correct answer: Penicillin desensitization followed by IV penicillin G

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

Question 116: 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?

Vancomycin plus ceftriaxone
Dexamethasone alone pending cultures
Ceftriaxone 2 g IV immediately (Correct answer)
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 117: A patient with chronic stable heart failure (EF 25%) develops a 3-second pause on Holter monitoring and near-syncope. What is the most appropriate next step?

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

Correct answer: Implantable cardioverter-defibrillator (ICD) evaluation

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

Question 118: A 50-year-old with cirrhosis develops confusion, asterixis, and elevated ammonia. His medications include furosemide and spironolactone. What is the most appropriate immediate treatment for hepatic encephalopathy?

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

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

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

Question 119: During evaluation of AKI, a renal ultrasound shows bilateral small echogenic kidneys. What does this finding most likely indicate?

Acute tubular necrosis (reversible)
Bilateral renal artery stenosis
Chronic kidney disease as the underlying condition, not true AKI (Correct answer)
Polycystic kidney disease

Correct answer: Chronic kidney disease as the underlying condition, not true AKI

Small echogenic kidneys on ultrasound indicate chronic scarring and fibrosis, suggesting the elevated creatinine reflects CKD rather than a true acute process.

Question 120: A patient with ESRD on peritoneal dialysis develops fever, abdominal pain, and cloudy dialysate. Dialysate WBC count is 380 cells/µL (>50% neutrophils). Gram stain is negative. What is the most likely organism?

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

Correct answer: Staphylococcus epidermidis

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

Question 121: An asymptomatic 72-year-old woman is found to have a serum calcium of 11.4 mg/dL (normal 8.6-10.3 mg/dL) on routine labs. Which of the following findings would most strongly suggest primary hyperparathyroidism as the cause of her hypercalcemia?

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

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

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

Question 122: An elderly patient with DKA develops oliguria despite 3 liters of IV fluids. Creatinine rises from 1.2 to 3.8 mg/dL. What complication has occurred?

Diabetic nephropathy exacerbation
Contrast-induced nephropathy
Acute kidney injury from hypovolemia and hypoperfusion (Correct answer)
Rhabdomyolysis from insulin therapy

Correct answer: Acute kidney injury from hypovolemia and hypoperfusion

Severe dehydration and hypoperfusion in DKA commonly cause prerenal or intrinsic acute kidney injury, which may not reverse promptly with fluid resuscitation.

Question 123: Which of the following is the most common cause of massive hemoptysis (>300 mL/24h) in the United States?

Bronchiectasis (Correct answer)
Acute bronchitis
Lung adenocarcinoma
Pulmonary embolism

Correct answer: Bronchiectasis

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

Question 124: Heparin-induced thrombocytopenia (HIT) typically develops at what time point after heparin initiation?

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

Correct answer: 5-10 days after starting heparin

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

Question 125: The GRACE risk score is used in ACS to predict which outcome?

Probability of requiring CABG vs. PCI
Risk of contrast-induced nephropathy during angiography
Likelihood of successful thrombolysis
In-hospital and 6-month mortality to guide invasive vs. conservative strategy (Correct answer)

Correct answer: In-hospital and 6-month mortality to guide invasive vs. conservative strategy

The GRACE score stratifies ACS mortality risk (low/intermediate/high) using variables like age, heart rate, BP, creatinine, cardiac arrest, ST deviation, troponin, and Killip class to guide invasive strategy timing.

Question 126: A patient with Wilson's disease presents with liver disease, Kayser-Fleischer rings, and neuropsychiatric symptoms. Serum ceruloplasmin is low. What is the first-line treatment for symptomatic Wilson's disease?

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

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

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

Question 127: 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?

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

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 128: A cirrhotic patient on lactulose for hepatic encephalopathy develops diarrhea and worsening confusion. Serum sodium is 128 mEq/L. What is the most appropriate adjustment?

Reduce lactulose dose and add rifaximin (Correct answer)
Increase lactulose dose to achieve 4 bowel movements/day
Add neomycin to enhance ammonia clearance
Start zinc supplementation immediately

Correct answer: Reduce lactulose dose and add rifaximin

Diarrhea from lactulose can cause dehydration and electrolyte disturbances that worsen encephalopathy; reducing the dose and adding rifaximin is the preferred adjustment.

Question 129: Legionella urinary antigen testing detects which serogroup of Legionella pneumophila?

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

Correct answer: Serogroup 1 only

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

Question 130: A 60-year-old with CAP is started on levofloxacin. On day 3, he remains febrile with worsening infiltrates. What is the most appropriate next step?

Add vancomycin empirically
Broaden to meropenem
Perform CT chest and bronchoscopy with BAL (Correct answer)
Switch to azithromycin monotherapy

Correct answer: Perform CT chest and bronchoscopy with BAL

Failure to improve by 72 hours warrants diagnostic workup including CT chest and bronchoscopy to identify resistant pathogens, alternative diagnoses, or complications.

Question 131: A 55-year-old woman with RA develops a painful, hot knee joint while on methotrexate. What must be excluded before attributing the flare to RA?

Avascular necrosis
Hemarthrosis
Septic arthritis (Correct answer)
Crystal arthropathy

Correct answer: Septic arthritis

Septic arthritis must be urgently excluded in any immunosuppressed patient with an acute hot joint, as it is a surgical emergency requiring prompt joint aspiration and culture.

Question 132: 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 133: A patient with psoriatic arthritis has predominantly distal interphalangeal joint involvement with nail pitting and 'sausage digit.' Which HLA type is most strongly associated with this condition?

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

Correct answer: HLA-B27

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

Question 134: According to the American Association for the Study of Liver Diseases (AASLD) guidelines, which of the following is the recommended surveillance strategy for hepatocellular carcinoma (HCC) in an adult patient with compensated cirrhosis?

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

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

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

Question 135: Which anticoagulant requires NO dose adjustment in patients with severe renal failure?

Warfarin (Correct answer)
Rivaroxaban
Dabigatran
Enoxaparin (LMWH)

Correct answer: Warfarin

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

Question 136: A 68-year-old nursing home resident develops fever, productive cough, and lobar consolidation on CXR. Which pathogen is MOST likely responsible?

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

Correct answer: Streptococcus pneumoniae

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

Question 137: 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?

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

Correct answer: Isoniazid and rifapentine weekly for 3 months

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

Question 138: A 70-year-old develops CAP. Blood cultures are ordered. According to IDSA guidelines, blood cultures are routinely recommended in which scenario?

CAP requiring ICU admission (Correct answer)
All outpatient CAP
All hospitalized CAP patients
CAP in patients over 65

Correct answer: CAP requiring ICU admission

Current IDSA guidelines recommend blood cultures primarily for severe CAP requiring ICU care, not for all hospitalized patients.

Question 139: A patient presents with 8 weeks of dyspepsia unresponsive to antacids. Urea breath test is positive. What is the most appropriate treatment regimen?

Amoxicillin monotherapy for 7 days
Bismuth quadruple therapy as first-line in all patients
Clarithromycin-based triple therapy (PPI + clarithromycin + amoxicillin) for 14 days (Correct answer)
PPI alone for 4 weeks

Correct answer: Clarithromycin-based triple therapy (PPI + clarithromycin + amoxicillin) for 14 days

Clarithromycin-based triple therapy for 14 days is a standard first-line H. pylori eradication regimen in areas with low clarithromycin resistance.

Question 140: A 40-year-old man develops severe low back pain radiating to the buttocks, alternating sides, worse in the morning and improving with exercise. MRI shows sacroiliac joint edema. Which HLA type is most commonly associated?

HLA-DR4
HLA-DR3
HLA-B5
HLA-B27 (Correct answer)

Correct answer: HLA-B27

HLA-B27 is present in approximately 90% of patients with ankylosing spondylitis and is associated with all seronegative spondyloarthropathies.

Question 141: A patient with inferior STEMI develops hypotension and elevated JVP without pulmonary congestion. Which diagnosis should be suspected first?

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

Correct answer: Right ventricular infarction

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

Question 142: 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
Osteoarthritis (Correct answer)
Gout
Rheumatoid arthritis

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 143: A patient with DKA on insulin infusion develops glucose of 180 mg/dL but still has an anion gap of 20. What is the appropriate management?

Stop insulin and reassess in 2 hours
Add dextrose to IV fluids and continue insulin infusion (Correct answer)
Switch to subcutaneous insulin immediately
Reduce insulin infusion by 50%

Correct answer: Add dextrose to IV fluids and continue insulin infusion

When glucose reaches 200–250 mg/dL but the anion gap remains elevated, add dextrose to maintain glucose while continuing insulin to clear ketones.

Question 144: A 72-year-old male with a new diagnosis of idiopathic pulmonary fibrosis (IPF) presents for management. His FVC is 75% of predicted. He complains of a persistent dry cough and exertional dyspnea. Which of the following treatments has been shown to slow the rate of FVC decline in patients with IPF?

N-acetylcysteine
Azathioprine
Prednisone
Pirfenidone (Correct answer)

Correct answer: Pirfenidone

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

Question 145: In AKI due to tumor lysis syndrome, which metabolic abnormalities are most characteristic?

Hyponatremia, hypocalcemia, hypophosphatemia, hypokalemia
Hypercalcemia and hypernatremia
Hyperuricemia, hyperphosphatemia, hypocalcemia, hyperkalemia (Correct answer)
Metabolic alkalosis with hypokalemia

Correct answer: Hyperuricemia, hyperphosphatemia, hypocalcemia, hyperkalemia

Tumor lysis syndrome causes massive release of intracellular contents, producing hyperuricemia, hyperphosphatemia, hypocalcemia (from phosphate binding calcium), and hyperkalemia.

Question 146: A 55-year-old male presents to the emergency department with acute onset of pleuritic chest pain and dyspnea. His heart rate is 115 bpm, and he has a history of a deep vein thrombosis (DVT) 5 years ago. He is otherwise healthy and takes no medications. His Wells score for pulmonary embolism (PE) is calculated to be 4.5. What is the most appropriate next step in the diagnostic workup?

Order a D-dimer test and proceed based on the result
Start empiric anticoagulation without further imaging
Proceed directly to CT pulmonary angiography (CTPA) (Correct answer)
Discharge the patient as PE is unlikely

Correct answer: Proceed directly to CT pulmonary angiography (CTPA)

A Wells score of 4.5 falls into the 'PE likely' category (score > 4). In patients with a likely pre-test probability for pulmonary embolism, the recommended next step is definitive diagnostic imaging, such as a CT pulmonary angiography (CTPA). A D-dimer test is not recommended in this high-probability scenario because it lacks sufficient specificity, and a positive result would not change the need for imaging, while a negative result would not be reliable enough to rule out PE.

Question 147: A 76-year-old female with a history of hypertension and type 2 diabetes mellitus is diagnosed with non-valvular atrial fibrillation. Her CHA2DS2-VASc score is calculated to be 4. Which of the following is the most appropriate management for stroke prevention in this patient?

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

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

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

Question 148: Which laboratory test is used to monitor patients on warfarin therapy?

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

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

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

Question 149: A 72-year-old with COPD develops CAP. Which outpatient antibiotic regimen is recommended by IDSA guidelines?

Azithromycin monotherapy
Trimethoprim-sulfamethoxazole
Amoxicillin 500 mg TID
Respiratory fluoroquinolone OR beta-lactam + macrolide (Correct answer)

Correct answer: Respiratory fluoroquinolone OR beta-lactam + macrolide

Patients with comorbidities (COPD, DM, heart failure, etc.) should receive a respiratory fluoroquinolone or beta-lactam/macrolide combination to cover resistant organisms.

Question 150: A 25-year-old presents with fatigue, iron-deficiency anemia, bloating, and diarrhea. Tissue transglutaminase IgA antibody is markedly elevated. Small bowel biopsy shows villous atrophy and crypt hyperplasia. What dietary modification is curative?

Strict gluten-free diet (Correct answer)
Low-fat diet
Lactose-free diet
Low-FODMAP diet

Correct answer: Strict gluten-free diet

Celiac disease is an immune-mediated enteropathy triggered by gluten; strict lifelong gluten avoidance leads to mucosal healing.

Question 151: A 68-year-old woman with osteoporosis takes high-dose vitamin D supplements. She now has polyuria, polydipsia, constipation, confusion, and serum calcium of 13.2 mg/dL. Her PTH is suppressed. The most likely mechanism of hypercalcemia is:

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

Correct answer: Vitamin D toxicity causing excess intestinal calcium absorption

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

Question 152: A 58-year-old male with a 15-year history of poorly controlled type 2 diabetes and CKD stage 3 is noted to have a persistent, non-anion gap metabolic acidosis and a serum potassium of 5.8 mEq/L despite dietary counseling. His urine pH is 5.0. Which of the following is the most likely diagnosis?

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

Correct answer: Type 4 (Hyperkalemic) Renal Tubular Acidosis

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

Question 153: Which HIV-associated opportunistic infection is prevented by trimethoprim-sulfamethoxazole prophylaxis when the CD4 count falls below 200 cells/μL?

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

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

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

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

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

Question 155: A 68-year-old male with a 40-pack-year smoking history presents with chronic dyspnea and cough. Spirometry reveals a post-bronchodilator FEV1/FVC ratio of 0.65 and an FEV1 of 45% predicted. He has had three exacerbations in the past year, one requiring hospitalization. His blood eosinophil count is 350 cells/µL. According to the 2024 GOLD guidelines, what is the most appropriate initial pharmacologic management?

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

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

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

Question 156: A 68-year-old develops profuse, watery, non-bloody diarrhea after a 10-day course of clindamycin for a skin infection. Stool PCR is positive for C. difficile toxin. This is his first episode. What is the first-line treatment?

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

Correct answer: Oral vancomycin or fidaxomicin

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

Question 157: Which spirometry pattern is consistent with a diagnosis of restrictive lung disease?

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

Correct answer: FEV1/FVC ≥ 0.70 with reduced TLC

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

Question 158: Portal vein thrombosis (PVT) is found incidentally in a patient with cirrhosis. It is non-occlusive and asymptomatic. What is the most appropriate management?

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

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

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

Question 159: 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 sodium bicarbonate to alkalinize the urine
Aggressive intravenous fluid resuscitation with isotonic saline (Correct answer)
Administration of N-acetylcysteine
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 160: Which scoring system is preferred in the ED to determine ICU admission criteria for CAP?

PSI/PORT score
IDSA/ATS minor criteria (Correct answer)
APACHE II
CURB-65

Correct answer: IDSA/ATS minor criteria

IDSA/ATS minor criteria (≥3 of 9) best identify patients requiring ICU-level care, including vasopressors or mechanical ventilation.

Question 161: 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 162: 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?

Behçet's disease
Reactive arthritis
Rheumatic fever
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 163: Which ECG finding is most specific for left ventricular hypertrophy?

QRS duration >120 ms
Sokolow-Lyon voltage criteria (S in V1 + R in V5 ≥35 mm) (Correct answer)
Prolonged PR interval
Right axis deviation

Correct answer: Sokolow-Lyon voltage criteria (S in V1 + R in V5 ≥35 mm)

The Sokolow-Lyon criterion (S in V1 + R in V5 or V6 ≥35 mm) is the most widely used voltage criterion for left ventricular hypertrophy on ECG.

Question 164: A patient with DKA has serum phosphate of 0.8 mg/dL. In which clinical scenario would phosphate replacement be most strongly indicated?

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

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 165: A 65-year-old woman presents with shoulder and hip girdle pain and stiffness lasting >45 minutes in the morning, ESR of 85 mm/hr, and rapid response to low-dose prednisone. What is the diagnosis?

Polymyalgia rheumatica (Correct answer)
Polymyositis
Giant cell arteritis
Fibromyalgia

Correct answer: Polymyalgia rheumatica

Polymyalgia rheumatica presents with bilateral shoulder and hip girdle stiffness, markedly elevated ESR, and dramatic response to low-dose prednisone (15-20 mg/day).

Question 166: Which biomarker has emerged as an early indicator of AKI that rises before serum creatinine?

BUN
NGAL (neutrophil gelatinase-associated lipocalin) (Correct answer)
Serum cystatin C
Serum phosphorus

Correct answer: NGAL (neutrophil gelatinase-associated lipocalin)

NGAL is released rapidly from injured tubular cells and rises within 2 hours of AKI, making it a sensitive early biomarker before creatinine elevation occurs.

Question 167: A 35-year-old man with ankylosing spondylitis has failed NSAIDs. Which biologic class is most appropriate as next-line therapy?

TNF-alpha inhibitors (Correct answer)
CTLA-4 Ig fusion proteins
IL-6 inhibitors
IL-12/23 inhibitors

Correct answer: TNF-alpha inhibitors

TNF-alpha inhibitors (e.g., adalimumab, etanercept) are the recommended biologic class for ankylosing spondylitis refractory to NSAIDs.

Question 168: A 50-year-old man with chronic HCV infection has a serum-ascites albumin gradient (SAAG) of 1.8 g/dL. Which condition does this SAAG value indicate?

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

Correct answer: Portal hypertension

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

Question 169: A 72-year-old with COPD has resting SpO2 of 87% on room air. Which statement about long-term oxygen therapy (LTOT) is correct?

LTOT is indicated only in patients with concurrent cor pulmonale
LTOT at ≥ 15 hours/day improves survival in patients with PaO2 ≤ 55 mmHg (Correct answer)
LTOT should target SpO2 of 95-98% to maximize benefit
LTOT improves mortality only when used > 12 hours/day

Correct answer: LTOT at ≥ 15 hours/day improves survival in patients with PaO2 ≤ 55 mmHg

The MRC and NOTT trials showed LTOT used ≥ 15 hours/day improves survival in COPD patients with PaO2 ≤ 55 mmHg (or ≤ 59 mmHg with cor pulmonale or polycythemia).

Question 170: Which insulin regimen is standard for inpatient DKA management in adults?

Subcutaneous insulin glargine once daily
Continuous IV regular insulin infusion at 0.1 units/kg/hr (Correct answer)
IM regular insulin every 4 hours
Subcutaneous rapid-acting insulin every 6 hours

Correct answer: Continuous IV regular insulin infusion at 0.1 units/kg/hr

Continuous IV regular insulin at 0.1 units/kg/hr (after potassium is replete) is the standard of care for adult DKA.

Question 171: In DKA management, when is sodium bicarbonate administration currently recommended by most guidelines?

pH < 7.30
All DKA patients to speed resolution
pH < 7.20
pH < 7.10 with hemodynamic instability or severe hyperkalemia (Correct answer)

Correct answer: pH < 7.10 with hemodynamic instability or severe hyperkalemia

Sodium bicarbonate is generally reserved for severe acidosis (pH <7.0–7.1) complicated by hemodynamic compromise or life-threatening hyperkalemia.

Question 172: A 72-year-old man is diagnosed with his first episode of non-severe Clostridioides difficile infection (CDI). According to the most recent IDSA/SHEA guidelines, which of the following is the preferred first-line treatment?

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

Correct answer: Oral Fidaxomicin for 10 days

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

Question 173: A 68-year-old male with a 10-year history of type 2 diabetes mellitus, hypertension, and a previous myocardial infarction is seen for follow-up. His current HbA1c is 8.2% on metformin 1000 mg twice daily. His eGFR is 70 mL/min/1.73m². According to current ADA guidelines, which of the following is the most appropriate medication to add to his regimen?

Empagliflozin (Correct answer)
Sitagliptin
Pioglitazone
Glipizide

Correct answer: Empagliflozin

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

Question 174: 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?

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

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

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

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

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

Question 177: A 58-year-old male with NSTEMI undergoes successful PCI with the placement of a new-generation drug-eluting stent in the left anterior descending artery. He has no history of bleeding disorders and is considered at low bleeding risk. According to current ACC/AHA guidelines, what is the minimum recommended duration of dual antiplatelet therapy (DAPT) for this patient?

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

Correct answer: 12 months

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

Question 178: A 45-year-old marathon runner collapses during a race. ECG shows right bundle branch block with ST elevation in V1–V3 and a family history of sudden cardiac death. What is the most likely diagnosis?

Long QT syndrome type 1
Arrhythmogenic right ventricular cardiomyopathy
Brugada syndrome (Correct answer)
Hypertrophic cardiomyopathy

Correct answer: Brugada syndrome

The spontaneous Type 1 Brugada pattern (coved ST elevation in V1–V3 with RBBB morphology) combined with family history of SCD is diagnostic of Brugada syndrome.

Question 179: 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
Streptococcus pneumoniae
Mycoplasma pneumoniae (Correct answer)
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 180: 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:

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

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

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

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 182: 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?

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

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 183: Which of the following best explains thrombocytopenia in patients with cirrhosis and portal hypertension?

Autoimmune platelet destruction
Vitamin K deficiency
Splenic sequestration due to splenomegaly (Correct answer)
Disseminated intravascular coagulation

Correct answer: Splenic sequestration due to splenomegaly

Splenomegaly from portal hypertension causes splenic sequestration of platelets, and reduced thrombopoietin synthesis by the liver also contributes.

Question 184: A 72-year-old man with BPH presents with AKI and bilateral hydronephrosis on ultrasound. Bladder scan shows 800 mL of residual urine. After Foley catheter placement, urine output is 400 mL/hour. What electrolyte complication is most expected?

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

Correct answer: Post-obstructive diuresis causing hypokalemia and hyponatremia

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

Question 185: Which occupational lung disease is associated with shipbuilding and insulation work, characterized by pleural plaques and increased risk of mesothelioma?

Coal workers' pneumoconiosis
Berylliosis
Silicosis
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 186: A patient on long-term lithium therapy presents with polyuria (5 L/day) and dilute urine despite water deprivation. Urine osmolality fails to rise with exogenous ADH. What is the diagnosis?

Central diabetes insipidus
Primary polydipsia
SIADH
Nephrogenic diabetes insipidus (Correct answer)

Correct answer: Nephrogenic diabetes insipidus

Lithium causes nephrogenic diabetes insipidus by blocking ADH action on collecting duct V2 receptors, so exogenous ADH has no effect.

Question 187: A 45-year-old woman is found to have a QTc of 520 ms on routine ECG. She is asymptomatic. Which medication should be avoided?

Metoprolol
Lisinopril
Ondansetron (Correct answer)
Amlodipine

Correct answer: Ondansetron

Ondansetron is a 5-HT3 antagonist that prolongs the QT interval and can precipitate torsades de pointes in patients with baseline QT prolongation.

Question 188: When symptoms persist despite receiving the best care possible from b-blockers, ACEI, diuretics, and aldosterone antagonists in patients with EF 40%, digoxin should be given.

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

Correct answer: When should digoxin be used in CHF patients

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

Question 189: 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?

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

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 190: In a STEMI patient presenting 3 hours after symptom onset at a non-PCI-capable hospital, what is the recommended door-to-device (DTD) time if transfer for primary PCI is chosen?

Within 240 minutes
Within 90 minutes
Within 120 minutes (Correct answer)
Within 180 minutes

Correct answer: Within 120 minutes

If primary PCI is chosen at a non-PCI-capable hospital, the total first-medical-contact-to-device time should be ≤120 minutes; otherwise, fibrinolysis should be administered first.

Question 191: A 40-year-old woman with lupus presents with pleuritic chest pain and a friction rub. CXR shows a small pleural effusion. What is the expected pleural fluid finding?

Exudative fluid meeting Light's criteria (Correct answer)
Chylous fluid with triglycerides >110 mg/dL
Transudative fluid with protein <2.5 g/dL
pH <7.2, glucose <60 mg/dL, LDH >1000

Correct answer: Exudative fluid meeting Light's criteria

Lupus pleuritis produces an exudative pleural effusion meeting Light's criteria due to pleural inflammation from immune complex deposition.

Question 192: A 28-year-old with type 1 diabetes presents with DKA. Blood glucose is 520 mg/dL. After 1 hour of insulin infusion, glucose drops to 250 mg/dL. What should be added to IV fluids?

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

Correct answer: Add dextrose to IV fluids and continue insulin

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

Question 193: A patient with decompensated cirrhosis develops oliguria, rising creatinine, and a FENa <0.01% despite adequate volume status. Urine microscopy is bland. What is the most likely diagnosis?

Hepatorenal syndrome type 1 (Correct answer)
Pre-renal azotemia
Contrast nephropathy
Acute tubular necrosis

Correct answer: Hepatorenal syndrome type 1

HRS type 1 presents with rapidly progressive renal failure, FENa <0.01%, bland urine sediment, and normal renal parenchyma in a cirrhotic patient without alternative cause.

Question 194: Which complication of cirrhosis is characterized by intrapulmonary vascular dilatations leading to hypoxemia that improves with 100% oxygen administration?

Transfusion-related acute lung injury
Hepatopulmonary syndrome (Correct answer)
Portopulmonary hypertension
Hepatic hydrothorax

Correct answer: Hepatopulmonary syndrome

Hepatopulmonary syndrome results from intrapulmonary vasodilation causing V/Q mismatch and right-to-left shunting, with PaO2 improving on 100% O2.

Question 195: 1) Both IV antibiotics and IV hydration 2) Monitor blood pressure and urine output; once symptoms have subsided for 48 hours, perform an ERCP to determine the cause 3) The most significant consequence is a liver abscess.

What is the cause of Goodpasture's syndrome?
What is the triad of symptoms indicating a ruptured AAA?
What is the treatment for cholangitis? (Correct answer)
What is Crigler-Nijjar Syndrome?

Correct answer: What is the treatment for cholangitis?

The provided information details the standard management for acute cholangitis, which involves immediate broad-spectrum intravenous antibiotics and fluid resuscitation to stabilize the patient. Subsequently, an ERCP (Endoscopic Retrograde Cholangiopancreatography) is performed to relieve biliary obstruction once the patient's condition has improved. The text also correctly identifies a liver abscess as a significant potential consequence of cholangitis.

Question 196: 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?

Pegloticase
Febuxostat (Correct answer)
Probenecid
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 197: A 28-year-old man presents with urethritis, conjunctivitis, and asymmetric oligoarthritis after a recent Chlamydia infection. What is the classic triad associated with this condition?

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

Correct answer: Urethritis, conjunctivitis, arthritis

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

Question 198: A 70-year-old female with a history of heart failure and hypertension presents to the emergency department with acute-onset severe dyspnea, orthopnea, and a cough producing pink, frothy sputum. On examination, her blood pressure is 180/100 mmHg, heart rate is 110 bpm, and respiratory rate is 30/min. Auscultation reveals diffuse crackles throughout both lung fields. Oxygen saturation is 88% on room air. After applying oxygen, what is the most critical next step in management?

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

Correct answer: Administer intravenous nitroglycerin

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

Question 199: 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?

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

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 200: Which antibiotic class is contraindicated in a pregnant woman diagnosed with a chlamydial infection?

Beta-lactams
Macrolides
Sulfonamides in first trimester
Tetracyclines (Correct answer)

Correct answer: Tetracyclines

Tetracyclines (including doxycycline) are contraindicated in pregnancy due to effects on fetal bone and tooth development; azithromycin is the preferred alternative.

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

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