NBME Comprehensive Clinical Science 4

Question 1

A 72-year-old man with heart failure on digoxin presents with nausea, yellow-green visual halos, and bradycardia.
ECG shows second-degree heart block.
Serum digoxin level is 3.4 ng/mL.
What is the most appropriate intervention?

Accepted Answer

Digoxin-specific antibody fragments (Digibind)

Answer

Activated charcoal via nasogastric tube

Answer

IV calcium gluconate infusion

Answer

Temporary transvenous pacemaker placement

Question 2

A 58-year-old woman with type 2 diabetes and CKD stage 4 (eGFR 22 mL/min/1.73m²) has an HbA1c of 8.4%. Which medication is contraindicated?

Accepted Answer

Metformin

Answer

Insulin glargine

Answer

Sitagliptin (dose-adjusted)

Answer

Linagliptin

Question 3

A 65-year-old man with post-MI systolic heart failure (EF 32%) is started on carvedilol. He develops mild peripheral edema managed with increased furosemide. What is the appropriate action regarding carvedilol?

Accepted Answer

Continue carvedilol and optimize diuresis

Answer

Discontinue carvedilol immediately due to fluid retention

Answer

Switch carvedilol to a calcium channel blocker

Answer

Hold carvedilol until edema fully resolves

Question 4

A 48-year-old woman with rheumatoid arthritis on prednisone 10 mg/day for 2 years has a DEXA T-score of −2.7 at the lumbar spine and no prior fractures. What is the most appropriate treatment?

Accepted Answer

Alendronate plus calcium and vitamin D

Answer

Calcium and vitamin D supplementation only

Answer

Teriparatide SC injection

Answer

Raloxifene

Question 5

A 35-year-old man is found unresponsive. RR is 5 breaths/min, pupils are pinpoint bilaterally, and he is cyanotic. Bystanders report he uses opioids. What is the immediate treatment?

Accepted Answer

IV naloxone 0.4–2 mg

Answer

Activated charcoal via nasogastric tube

Answer

Bag-mask ventilation alone

Answer

IV flumazenil 0.2 mg

Question 6

A 62-year-old man with CKD (eGFR 35) and HFrEF (EF 28%) on lisinopril develops serum potassium of 5.8 mEq/L after spironolactone is added. What is the most appropriate action?

Accepted Answer

Discontinue spironolactone due to hyperkalemia

Answer

Continue spironolactone and increase lisinopril dose

Answer

Switch lisinopril to an ARB

Answer

Add sodium polystyrene sulfonate to manage potassium

Question 7

A 52-year-old asymptomatic woman has incidental serum calcium of 11.9 mg/dL on routine labs. PTH is 98 pg/mL (elevated). 24-hour urine calcium is elevated. What is the most common underlying cause?

Accepted Answer

Primary hyperparathyroidism

Answer

Malignancy-associated hypercalcemia via PTHrP

Answer

Vitamin D toxicity

Answer

Sarcoidosis