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HKCP Intermediate - independent subject foundations study materials
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HKCP Intermediate - independent subject foundations practice questions

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Question 1Cardiovascular and renal mechanisms in internal medicine

An adult with a diagnostic anterior STEMI presents 2 hours after symptom onset. The PCI laboratory is unavailable and the anticipated delay to primary PCI exceeds the relevant guideline target. The patient has been assessed as eligible for fibrinolysis with no contraindication. Which listed immediate reperfusion strategy is appropriate?

  1. Immediate intravenous fibrinolytic therapy Correct answer.
  2. Immediate transfer for primary percutaneous coronary intervention (PCI)
  3. Intravenous infusion of glycoprotein IIb/IIIa inhibitor and wait for the catheterization lab to clear
  4. Coronary artery bypass grafting (CABG)

Explanation

According to STEMI guidelines, if the time from first medical contact to primary PCI is expected to exceed 120 minutes, fibrinolytic therapy should be administered immediately (within 30 minutes of presentation) if there are no contraindications. Since the estimated transfer and PCI time is 140 minutes, immediate fibrinolytic therapy is the class I recommendation.

Question 2Cardiovascular and renal mechanisms in internal medicine

A 62-year-old man presents with sudden-onset, severe, tearing chest pain radiating to his back. His blood pressure is 185/110 mmHg and heart rate is 105 bpm. A CT angiogram confirms a Stanford Type B aortic dissection. Which of the following is the initial drug treatment of choice?

  1. Intravenous nitroprusside alone
  2. Intravenous labetalol Correct answer.
  3. Intravenous hydralazine
  4. Intravenous diltiazem

Explanation

For Stanford Type B aortic dissection, initial medical management focuses on heart rate and blood pressure control. Intravenous beta-blockers, specifically labetalol or esmolol, are first-line. Labetalol reduces both heart rate and blood pressure, lowering the shear stress (dP/dt) on the aortic wall. The target heart rate is < 60 bpm and systolic blood pressure is 100-120 mmHg.

Question 3Cardiovascular and renal mechanisms in internal medicine

A 65-year-old woman with a history of hypertension and ischemic heart disease presents with progressive dyspnea on exertion. An echocardiogram reveals a left ventricular ejection fraction (LVEF) of 32%. She is currently taking enalapril 10 mg twice daily and carvedilol 25 mg twice daily. Her blood pressure is 125/75 mmHg, heart rate is 68 bpm, and eGFR is 45 mL/min/1.73m2. What is the most appropriate medication to add next to optimize her guideline-directed medical therapy?

  1. Spironolactone
  2. Dapagliflozin Correct answer.
  3. Digoxin
  4. Amlodipine

Explanation

SGLT2 inhibitors, such as dapagliflozin or empagliflozin, are now class I recommended therapies for all patients with HFrEF (LVEF <= 40%) regardless of the presence of diabetes. They reduce cardiovascular mortality and heart failure hospitalizations. Given her eGFR is 45 (which is above the threshold for initiation), adding dapagliflozin is the next logical step. Mineralocorticoid receptor antagonists (MRAs) like spironolactone are also indicated, but SGLT2 inhibitors have shown rapid benefits and are highly recommended.

Question 4Cardiovascular and renal mechanisms in internal medicine

A 24-year-old asymptomatic male is referred for evaluation after his older brother suffered sudden cardiac death at age 28. Echocardiography reveals asymmetric septal hypertrophy with a maximum wall thickness of 32 mm. No left ventricular outflow tract gradient is detected at rest. Which of the following is the most appropriate next step in his management?

  1. Reassure the patient and schedule a repeat echocardiogram in 5 years
  2. Propose insertion of an implantable cardioverter-defibrillator (ICD) Correct answer.
  3. Initiate therapy with high-dose beta-blockers
  4. Refer for surgical septal myectomy

Explanation

This patient has Hypertrophic Cardiomyopathy (HCM) with a high risk of sudden cardiac death (SCD). A maximum LV wall thickness >= 30 mm is an independent major risk factor for SCD. Along with the family history of SCD in a young first-degree relative, an ICD is strongly indicated for primary prevention of SCD.

Question 5Cardiovascular and renal mechanisms in internal medicine

A 45-year-old active intravenous drug user presents with fever, chills, and a new murmur. Blood cultures grow Staphylococcus aureus in 3 out of 3 bottles. Echocardiography demonstrates a 12-mm mobile vegetation on the aortic valve with moderate aortic regurgitation. While hospitalized, he develops acute pulmonary edema. What is the most appropriate next step?

  1. Add rifampicin to the current antibiotic regimen
  2. Increase the dose of intravenous penicillin
  3. Urgent surgical valve replacement Correct answer.
  4. Perform repeat blood cultures and await results

Explanation

The patient has infective endocarditis complicated by acute heart failure (pulmonary edema) due to aortic regurgitation. Heart failure is the strongest indication for urgent surgery in infective endocarditis, overriding other criteria such as vegetation size. Delaying surgery carries a very high mortality risk.

Question 6Cardiovascular and renal mechanisms in internal medicine

A 78-year-old woman with severe symptomatic aortic stenosis presents for management. She has severe dyspnea (NYHA Class III). Echocardiography shows an aortic valve area of 0.7 cm2 and a mean pressure gradient of 48 mmHg. Her Society of Thoracic Surgeons (STS) score is calculated at 9%, indicating high surgical risk. What is the preferred intervention?

  1. Surgical aortic valve replacement (SAVR)
  2. Transcatheter aortic valve implantation (TAVI) Correct answer.
  3. Balloon aortic valvuloplasty as definitive therapy
  4. Medical management with high-dose loop diuretics only

Explanation

In patients with severe symptomatic aortic stenosis who are at high surgical risk (STS score > 8% or age > 75), transcatheter aortic valve implantation (TAVI) is preferred over surgical aortic valve replacement (SAVR) as it is associated with lower periprocedural mortality and faster recovery.

Question 7Cardiovascular and renal mechanisms in internal medicine

An asymptomatic adult with severe primary mitral regurgitation from a flail P2 leaflet has LVEF 55% and LV end-systolic diameter 42 mm. The patient can exercise normally. Which listed management recommendation addresses the demonstrated ventricular response?

  1. Conservative outpatient follow-up every 12 months
  2. Referral for mitral valve repair surgery Correct answer.
  3. Initiate treatment with an ACE inhibitor
  4. Transcatheter edge-to-edge repair (TEER) with MitraClip

Explanation

For patients with severe primary mitral regurgitation, surgery is indicated even in asymptomatic patients if there is evidence of early LV dysfunction, defined as LVEF <= 60% or LVESD >= 40 mm (Class I recommendation). Mitral valve repair is preferred over replacement when feasible.

Question 8Cardiovascular and renal mechanisms in internal medicine

A 71-year-old woman with a history of hypertension and type 2 diabetes presents with palpitations. Her ECG shows atrial fibrillation with a ventricular rate of 115 bpm. She has no chest pain or dyspnea. Her blood pressure is 130/80 mmHg. What is the most appropriate long-term management strategy for stroke prevention?

  1. Aspirin 81 mg daily
  2. Aspirin 81 mg daily and clopidogrel 75 mg daily
  3. Oral anticoagulation with a DOAC (e.g., apixaban) Correct answer.
  4. No antithrombotic therapy is required

Explanation

The patient's CHA2DS2-VASc score is 4 (Age = 1, Female = 1, Hypertension = 1, Diabetes = 1). For patients with atrial fibrillation and a CHA2DS2-VASc score >= 2 in men or >= 3 in women, oral anticoagulation is strongly indicated to reduce the risk of stroke. Direct oral anticoagulants (DOACs) are preferred over warfarin unless contraindicated.

Question 9Cardiovascular and renal mechanisms in internal medicine

A 19-year-old female presents with recurrent episodes of syncope, typically triggered by loud noises or sudden emotional stress. Her ECG reveals a QTc interval of 510 ms. Her genetic testing is positive for a KCNH2 mutation (LQT2). Which of the following medications is the first-line treatment for this condition?

  1. Amiodarone
  2. Propranolol Correct answer.
  3. Verapamil
  4. Flecainide

Explanation

Beta-blockers, particularly nadolol or propranolol, are the cornerstone of therapy for congenital Long QT Syndrome (LQTS). They reduce the frequency of cardiac events by blunting sympathetic surges. Propranolol or nadolol are preferred for LQT1 and LQT2. Amiodarone is contraindicated as it prolongs the QT interval further.

Question 10Cardiovascular and renal mechanisms in internal medicine

A 48-year-old man presents with progressive abdominal distension and peripheral edema. On examination, he has elevated jugular venous pressure that increases during inspiration. A pericardial knock is heard on auscultation. Which of the following hemodynamic findings is most supportive of constrictive pericarditis rather than restrictive cardiomyopathy?

  1. Discordance in ventricular pressure changes during respiration Correct answer.
  2. Equalization of diastolic pressures in all four cardiac chambers
  3. Marked elevation of brain natriuretic peptide (BNP) levels
  4. A 'dip and plateau' pattern in ventricular diastolic pressures

Explanation

Hemodynamic differentiation between constrictive pericarditis and restrictive cardiomyopathy is critical. Constrictive pericarditis is characterized by ventricular discordance (during inspiration, LV peak systolic pressure decreases while RV peak systolic pressure increases due to ventricular interaction within a fixed pericardial space). Restrictive cardiomyopathy shows ventricular concordance (both decrease or remain unchanged in tandem).

Question 11Cardiovascular and renal mechanisms in internal medicine

A 68-year-old woman is admitted for a severe skin infection and is started on intravenous antibiotics. On day 3, her serum creatinine rises from a baseline of 80 umol/L to 180 umol/L. Urine output has decreased to 25 mL/hour over the last 12 hours. Urinalysis shows 1+ protein, 10-15 white blood cells per high-power field, and white blood cell casts. Eosinophiluria is detected. Which of the following is the most likely diagnosis?

  1. Acute tubular necrosis (ATN)
  2. Acute interstitial nephritis (AIN) Correct answer.
  3. Prerenal azotemia
  4. Postrenal obstruction

Explanation

The presentation of AKI after starting antibiotics, combined with sterile pyuria, WBC casts, and eosinophiluria, is highly suggestive of drug-induced Acute Interstitial Nephritis (AIN). Common culprit drugs include beta-lactams, sulfonamides, NSAIDs, and proton pump inhibitors.

Question 12Cardiovascular and renal mechanisms in internal medicine

A 32-year-old Chinese woman presents with generalized edema. Urinalysis shows 4+ protein, and 24-hour urine protein is 6.8 g. Serum albumin is 21 g/L. Renal biopsy is performed and light microscopy shows normal-appearing glomeruli. Immunofluorescence is negative. Electron microscopy shows diffuse effacement of podocyte foot processes. What is the initial treatment of choice?

  1. Intravenous cyclophosphamide
  2. High-dose oral corticosteroids Correct answer.
  3. Mycophenolate mofetil
  4. Rituximab

Explanation

The biopsy findings (normal light microscopy, negative immunofluorescence, and diffuse podocyte foot process effacement on EM) are diagnostic of Minimal Change Disease (MCD). While more common in children, MCD accounts for 10-15% of adult nephrotic syndrome. The first-line treatment is high-dose oral corticosteroids (e.g., prednisolone 1 mg/kg/day).

Question 13Cardiovascular and renal mechanisms in internal medicine

A 35-year-old man presents with recurrent episodes of gross hematuria, typically occurring 1-2 days after an upper respiratory tract infection. His serum creatinine is 95 umol/L, blood pressure is 135/85 mmHg, and 24-hour urine protein is 0.8 g. Renal biopsy confirms IgA nephropathy. What is the most appropriate initial management?

  1. Observation only
  2. Initiation of an ACE inhibitor or ARB Correct answer.
  3. Start oral prednisolone
  4. Start tonsillectomy referral

Explanation

The cornerstone of management for IgA nephropathy with proteinuria > 0.5 g/day or hypertension is optimized supportive care with an ACE inhibitor or angiotensin receptor blocker (ARB) titrated to the maximum tolerated dose. The goal is to control blood pressure (< 120/80 mmHg) and reduce proteinuria.

Question 14Cardiovascular and renal mechanisms in internal medicine

A 28-year-old female presents with resistant hypertension. A renal artery duplex ultrasound shows findings suspicious for fibromuscular dysplasia (FMD) of the right renal artery. What is the gold standard diagnostic method and the preferred treatment if significant stenosis is confirmed?

  1. CT angiography; surgical revascularization
  2. Digital subtraction angiography (DSA); percutaneous transluminal angioplasty (PTA) without stenting Correct answer.
  3. Magnetic resonance angiography (MRA); renal artery stenting
  4. Renal scintigraphy; medical therapy with ACE inhibitors only

Explanation

Digital subtraction angiography (DSA) remains the gold standard diagnostic method for FMD, showing the classic 'string of beads' appearance. In patients with FMD and symptomatic hypertension, percutaneous transluminal angioplasty (PTA) without stenting is the intervention of choice and often cures the hypertension. Stenting is reserved for dissection or technical complications.

Question 15Cardiovascular and renal mechanisms in internal medicine

A 42-year-old man with Autosomal Dominant Polycystic Kidney Disease (ADPKD) presents for follow-up. He has a family history of end-stage kidney disease. His eGFR is 55 mL/min/1.73m2. A recent MRI shows a total kidney volume (TKV) of 1600 mL, which classifies him as Mayo Class 1D (rapidly progressive). Which of the following therapies has been shown to slow the decline of kidney function in this patient population?

  1. Tolvaptan Correct answer.
  2. Octreotide
  3. Rapamycin (sirolimus)
  4. High-dose loop diuretics

Explanation

Tolvaptan, a vasopressin V2 receptor antagonist, has been shown in the TEMPO 3:4 and REPRISE trials to slow the increase in total kidney volume and the decline in eGFR in patients with ADPKD who are at high risk for rapid progression (e.g., Mayo Classes 1C, 1D, and 1E).

Question 16Cardiovascular and renal mechanisms in internal medicine

A 74-year-old man with CKD Stage 4 presents with severe generalized weakness. His serum potassium is found to be 6.8 mmol/L. The ECG shows peaked T waves and widening of the QRS complex. What is the most immediate life-saving intervention?

  1. Intravenous administration of 10% calcium gluconate Correct answer.
  2. Intravenous infusion of insulin and dextrose
  3. Nebulized salbutamol therapy
  4. Emergency hemodialysis

Explanation

In severe hyperkalemia with ECG changes, the most immediate life-saving step is the administration of intravenous calcium (calcium gluconate or calcium chloride) to stabilize the cardiac myocyte membrane and prevent lethal ventricular arrhythmias. It does not lower serum potassium; it acts within minutes and lasts 30-60 minutes.

Question 17Cardiovascular and renal mechanisms in internal medicine

A 45-year-old woman presents with persistent muscle weakness. Laboratory testing reveals: Serum K+ 2.8 mmol/L, HCO3- 16 mmol/L, Cl- 112 mmol/L, Serum pH 7.31. Urine pH is 6.2. Urinary anion gap is positive. Which type of Renal Tubular Acidosis (RTA) does this patient most likely have?

  1. Type 1 (Distal) RTA Correct answer.
  2. Type 2 (Proximal) RTA
  3. Type 4 (Hyperkalemic) RTA
  4. Fanconi Syndrome

Explanation

The patient has a normal anion gap metabolic acidosis (hyperchloremic metabolic acidosis) with hypokalemia. The key finding is a urine pH > 5.5 (6.2) in the setting of systemic acidosis, which indicates an inability of the distal tubule to secrete hydrogen ions. This is diagnostic of Type 1 (distal) RTA.

Question 18Cardiovascular and renal mechanisms in internal medicine

A 55-year-old man with CKD Stage 5 on hemodialysis has persistent secondary hyperparathyroidism. His labs show: Calcium 2.65 mmol/L (elevated), Phosphate 2.1 mmol/L (elevated), Parathyroid Hormone (PTH) 85 pmol/L (markedly elevated). Which of the following is the most appropriate treatment to manage his secondary hyperparathyroidism?

  1. Calcitriol
  2. Cinacalcet Correct answer.
  3. Calcium carbonate
  4. Alfacalcidol

Explanation

The patient has hypercalcemia, hyperphosphatemia, and secondary hyperparathyroidism. Calcitriol or alfacalcidol (active vitamin D analogs) would worsen hypercalcemia and hyperphosphatemia by increasing intestinal absorption. Calcium-based phosphate binders like calcium carbonate would also increase calcium. Cinacalcet (a calcimimetic) increases the sensitivity of the calcium-sensing receptor on the parathyroid gland, reducing PTH, serum calcium, and serum phosphate, making it the drug of choice.

Question 19Respiratory failure, ventilation and systemic critical illness

A 68-year-old man with severe COPD presents with increased dyspnea, increased sputum volume, and sputum purulence. His arterial blood gas on room air shows: pH 7.28, PaCO2 7.8 kPa (58 mmHg), PaO2 6.8 kPa (51 mmHg), HCO3- 28 mmol/L. He is alert and cooperative. What is the most appropriate next step in respiratory support?

  1. High-flow nasal cannula (HFNC) oxygen therapy
  2. Non-invasive positive pressure ventilation (NIV) Correct answer.
  3. Endotracheal intubation and mechanical ventilation
  4. Low-flow oxygen via nasal cannulae at 2 L/min

Explanation

This patient has an acute exacerbation of COPD with acute-on-chronic respiratory acidosis (pH < 7.35, PaCO2 > 6.0 kPa). For patients with acute hypercapnic respiratory failure secondary to COPD exacerbation, non-invasive ventilation (NIV) is the first-line therapy (Class I recommendation) as it decreases intubation rates, hospital stay, and mortality.

Question 20Respiratory failure, ventilation and systemic critical illness

An 82-year-old man presents with a 2-day history of productive cough, fever, and confusion. On examination, his respiratory rate is 32 bpm, blood pressure is 88/54 mmHg, and heart rate is 108 bpm. Chest radiograph demonstrates right lower lobe consolidation. Blood tests show a urea of 8.2 mmol/L. What is his CURB-65 score and the recommended management setting?

  1. Score 2; outpatient management
  2. Score 3; inpatient management (medical ward)
  3. Score 5; urgent inpatient admission, consider ICU Correct answer.
  4. Score 5; immediate intubation and ICU admission

Explanation

The CURB-65 score is calculated as follows: Confusion (1 point), Urea > 7 mmol/L (8.2 is > 7, so 1 point), Respiratory rate >= 30 bpm (32 is >= 30, so 1 point), Blood pressure < 90 SBP or <= 60 DBP (88/54 matches both, so 1 point), Age >= 65 years (82 is >= 65, so 1 point). Total score = 5. A score of 4 or 5 indicates severe pneumonia and high mortality risk, requiring urgent hospital admission and consideration for ICU placement.

Question 21Respiratory failure, ventilation and systemic critical illness

A 34-year-old woman presents with painful red nodules on her shins, bilateral ankle swelling, and dry cough. A chest radiograph demonstrates bilateral hilar lymphadenopathy. Blood tests show an elevated serum angiotensin-converting enzyme (ACE) level. What is the diagnosis and the most appropriate initial management?

  1. Lofgren syndrome (sarcoidosis); oral NSAIDs and supportive care Correct answer.
  2. Pulmonary tuberculosis; quad-therapy (HRZE)
  3. Erythema nodosum secondary to streptococcal infection; penicillin
  4. Stage II sarcoidosis; high-dose oral corticosteroids

Explanation

The triad of erythema nodosum, bilateral hilar lymphadenopathy, and polyarthritis (often ankles) is classic for Lofgren syndrome, an acute presentation of sarcoidosis. Lofgren syndrome has a very high rate of spontaneous resolution (> 80-90%). In the absence of organ-threatening disease (such as cardiac, ocular, or severe pulmonary involvement), initial management is symptomatic, consisting of NSAIDs or low-dose steroids for joint pain, and observation.

Question 22Respiratory failure, ventilation and systemic critical illness

A 54-year-old man is admitted with a right-sided bacterial pneumonia. Over the next 48 hours, he develops a pleural effusion on the same side. Thoracentesis is performed and pleural fluid analysis shows: pH 7.02, glucose 1.8 mmol/L, LDH 1200 U/L, Gram stain shows Gram-positive cocci. What is the most appropriate next step in management?

  1. Send fluid for culture and observe the patient on intravenous antibiotics
  2. Insertion of a chest tube (tube thoracostomy) Correct answer.
  3. Repeat thoracentesis in 48 hours to monitor fluid chemistry
  4. Immediate thoracoscopy and decortication

Explanation

The pleural fluid analysis demonstrates a complicated parapneumonic effusion / empyema, as indicated by pH < 7.2, glucose < 3.3 mmol/L, LDH > 1000 U/L, and a positive Gram stain/culture. These findings are indicators that the effusion will not resolve with antibiotics alone and requires prompt drainage via a chest tube (tube thoracostomy) to prevent loculation and sepsis.

Question 23Respiratory failure, ventilation and systemic critical illness

A 48-year-old obese man is referred for evaluation of daytime somnolence and loud snoring. Polysomnography reveals an Apnea-Hypopnea Index (AHI) of 34 events per hour. He has a history of difficult-to-control hypertension. What is the gold standard first-line treatment for his condition?

  1. Mandibular advancement device
  2. Continuous Positive Airway Pressure (CPAP) Correct answer.
  3. Uvulopalatopharyngoplasty (UPPP)
  4. Weight loss and sleep hygiene advice alone

Explanation

This patient has severe obstructive sleep apnea (OSA), defined by an AHI > 30 events/hour. Continuous Positive Airway Pressure (CPAP) is the gold standard and first-line treatment for moderate-to-severe OSA. It acts as a pneumatic splint to keep the upper airway open during sleep, resolving somnolence and helping to lower blood pressure.

Question 24Respiratory failure, ventilation and systemic critical illness

A 52-year-old construction worker who worked in tunnel excavation in Hong Kong for 25 years presents with progressive exertional dyspnea. A chest radiograph reveals multiple small rounded opacities (1-3 mm) predominantly in the upper lobes, along with calcification of the hilar lymph nodes ('eggshell calcification'). What is the most likely diagnosis?

  1. Asbestosis
  2. Silicosis Correct answer.
  3. Coal worker's pneumoconiosis
  4. Berylliosis

Explanation

Tunnel excavation exposes workers to silica dust. The radiographic findings of small rounded opacities predominantly in the upper lobes, combined with eggshell calcification of hilar lymph nodes, are classic for silicosis. Silicosis also significantly increases the risk of developing pulmonary tuberculosis (silicotuberculosis).

Question 25Respiratory failure, ventilation and systemic critical illness

A 45-year-old man with severe acute pancreatitis develops worsening hypoxia and tachypnea. Chest radiograph shows bilateral alveolar infiltrates sparing the costophrenic angles. Arterial blood gas on mechanical ventilation with a FiO2 of 0.60 and PEEP of 10 cmH2O shows a PaO2 of 8.0 kPa (60 mmHg). The pulmonary artery wedge pressure is 12 mmHg. What is the patient's PaO2/FiO2 ratio, and which ventilator strategy is recommended?

  1. P/F ratio 100; low tidal volume ventilation (6 mL/kg predicted body weight) Correct answer.
  2. P/F ratio 150; high tidal volume ventilation (10 mL/kg predicted body weight) to clear CO2
  3. P/F ratio 200; use of low PEEP (< 5 cmH2O) to prevent barotrauma
  4. P/F ratio 250; immediate extubation to non-invasive ventilation

Explanation

The patient's PaO2 is 60 mmHg and FiO2 is 0.60, giving a PaO2/FiO2 (P/F) ratio of 100 (60 / 0.60). This indicates severe ARDS (P/F ratio <= 100 under Berlin criteria). The cornerstone of ARDS mechanical ventilation is a lung-protective strategy utilizing low tidal volumes (6 mL/kg of predicted body weight) and limiting plateau pressures to <= 30 cmH2O to prevent ventilator-induced lung injury (VILI).

Question 26Respiratory failure, ventilation and systemic critical illness

A 64-year-old woman is admitted with urosepsis. Her blood pressure is 82/44 mmHg despite the administration of 30 mL/kg of intravenous crystalloids. Her lactate is 3.2 mmol/L. What is the most appropriate next step in management?

  1. Administer another 2 L of crystalloid fluids
  2. Initiate intravenous noradrenaline (norepinephrine) infusion Correct answer.
  3. Start intravenous dopamine infusion
  4. Administer intravenous hydrocortisone 200 mg daily

Explanation

The patient is in septic shock, defined by persistent hypotension requiring vasopressors to maintain MAP >= 65 mmHg and serum lactate > 2 mmol/L despite adequate fluid resuscitation. Noradrenaline is the first-line vasopressor of choice (Class I recommendation) to restore perfusion pressure.

Question 27Respiratory failure, ventilation and systemic critical illness

A 72-year-old woman is admitted with acute cardiogenic pulmonary edema. She is severely dyspneic, tachypneic (34 bpm), and has accessory muscle use. Her oxygen saturation is 86% on a high-concentration oxygen mask. Her blood pressure is 160/95 mmHg. Which of the following is the most appropriate non-invasive respiratory intervention?

  1. Continuous Positive Airway Pressure (CPAP) Correct answer.
  2. High-Flow Nasal Cannula (HFNC)
  3. Bi-level Positive Airway Pressure (BiPAP)
  4. Immediate endotracheal intubation

Explanation

In acute cardiogenic pulmonary edema, Continuous Positive Airway Pressure (CPAP) or Bi-level Positive Airway Pressure (BiPAP) is indicated. CPAP is the preferred initial choice. CPAP increases intrathoracic pressure, which decreases venous return (preload) and afterload, improving left ventricular function and clearing alveolar fluid. It rapidly improves dyspnea and oxygenation.

Question 28Respiratory failure, ventilation and systemic critical illness

A 45-year-old firefighter is brought to the emergency department after being rescued from a burning building. He is confused and has a headache. His oxygen saturation is 100% on a standard pulse oximeter. Arterial blood gas shows a normal PaO2 of 13.3 kPa (100 mmHg), but a carboxyhemoglobin (COHb) level of 32%. What is the most appropriate next step in management?

  1. Discharge home as the PaO2 and oxygen saturation are normal
  2. Administer 100% high-flow oxygen via a non-rebreather mask Correct answer.
  3. Initiate non-invasive positive pressure ventilation (NIV)
  4. Administer intravenous sodium thiosulfate

Explanation

The patient has carbon monoxide (CO) poisoning. Pulse oximetry cannot distinguish between oxyhemoglobin and carboxyhemoglobin, leading to a falsely normal SpO2 reading of 100%. The PaO2 on ABG measures dissolved oxygen in plasma, which is also normal. The treatment is 100% normobaric oxygen via a tight-fitting non-rebreather mask, which reduces the half-life of COHb from ~5 hours to 90 minutes. If the patient has severe neurological symptoms, pregnancy, or COHb > 25-30%, hyperbaric oxygen should be considered.

Question 29Respiratory failure, ventilation and systemic critical illness

A 58-year-old intubated patient in the ICU on mechanical ventilation for 5 days develops a new fever of 38.8 C, purulent endotracheal secretions, and worsening oxygenation. A chest radiograph demonstrates a new progressive infiltrate in the left lower lobe. What is the most appropriate next step to guide antimicrobial therapy?

  1. Start empiric broad-spectrum antibiotics after obtaining endotracheal aspirate cultures Correct answer.
  2. Perform a bronchoalveolar lavage (BAL) and defer antibiotics until the culture results are available
  3. Change the endotracheal tube immediately
  4. Initiate systemic corticosteroids

Explanation

The patient has clinical features of Ventilator-Associated Pneumonia (VAP) (onset > 48 hours after intubation, fever, purulent secretions, new radiographic infiltrate, decline in oxygenation). The standard of care is to obtain lower respiratory tract samples (endotracheal aspirate or bronchoscopic BAL) for culture and immediately initiate empiric broad-spectrum antibiotics targeting local pathogens (e.g., Pseudomonas and MRSA). Deferring antibiotics increases mortality.

Question 30Respiratory failure, ventilation and systemic critical illness

A 26-year-old woman presents to the emergency department 8 hours after ingesting a large amount of paracetamol in a suicide attempt. Her serum paracetamol level is found to be above the treatment line on the Rumack-Matthew nomogram. What is the mechanism of toxicity, and what is the specific antidote?

  1. Depletion of glutathione; N-acetylcysteine Correct answer.
  2. Inhibition of cytochrome P450; activated charcoal
  3. Direct mitochondrial toxicity; sodium bicarbonate
  4. Binding to GABA receptors; flumazenil

Explanation

Paracetamol is metabolized in the liver. At toxic doses, the primary pathway (conjugation) is saturated, and more drug is metabolized by CYP2E1 to NAPQI, a highly reactive toxic metabolite. NAPQI depletes glutathione stores and binds directly to hepatocytes, causing necrosis. The antidote is N-acetylcysteine (NAC), which restores glutathione stores and acts as a glutathione surrogate.

Question 31Respiratory failure, ventilation and systemic critical illness

A 62-year-old intubated patient with severe ARDS is receiving mechanical ventilation in Volume Control mode. The ventilator screen shows a peak inspiratory pressure (PIP) of 38 cmH2O and a plateau pressure of 26 cmH2O. What is the most likely cause of this pressure pattern?

  1. Decreased respiratory system compliance (e.g., worsening pulmonary edema)
  2. Increased airway resistance (e.g., bronchospasm or tube obstruction) Correct answer.
  3. An air leak in the ventilator circuit
  4. Patient-ventilator dyssynchrony (active fighting against the ventilator)

Explanation

In volume-controlled ventilation, the Peak Inspiratory Pressure (PIP) is the sum of resistive pressure (flow x resistance) and elastic pressure (volume / compliance + PEEP). The Plateau Pressure (measured during an end-inspiratory pause) reflects only elastic pressure and compliance. Here, the PIP is high (38) but the plateau pressure is normal (26), indicating a high resistive component (PIP - Plateau = 12 cmH2O; normal is < 5). This points to an airway resistance issue, such as bronchospasm, secretions, or endotracheal tube obstruction/kinking.

Question 32Gastrointestinal, pancreatic and hepatic clinical patterns

A 28-year-old man presents with chronic diarrhea, crampy right lower quadrant abdominal pain, and weight loss. On examination, a tender mass is palpable in the right iliac fossa. Colonoscopy reveals patchy, transmural inflammation in the terminal ileum with a cobblestone appearance and deep linear ulcers. Granulomas are noted on biopsy. Which of the following is the most likely diagnosis?

  1. Ulcerative colitis
  2. Crohn's disease Correct answer.
  3. Intestinal tuberculosis
  4. Celiac disease

Explanation

The clinical features (patchy, transmural inflammation, cobblestone appearance, terminal ileum involvement, and non-caseating granulomas) are characteristic of Crohn's disease. Transmural involvement can lead to complications such as strictures, fistulae, and inflammatory masses, often presenting in the right lower quadrant.

Question 33Gastrointestinal, pancreatic and hepatic clinical patterns

A 32-year-old woman is admitted with a severe flare of ulcerative colitis. She reports 8 bloody bowel movements per day, has a heart rate of 105 bpm, temperature of 38.0 C, and hemoglobin of 92 g/L. Abdominal X-ray shows a colonic diameter of 4.5 cm with no free air. She is started on intravenous hydrocortisone 100 mg every 6 hours. On day 3, her symptoms remain unchanged. What is the most appropriate next step in management?

  1. Continue intravenous steroids for another 7 days before assessing response
  2. Initiate rescue therapy with intravenous infliximab or cyclosporine Correct answer.
  3. Proceed to emergency total colectomy
  4. Switch to oral prednisolone and discharge home

Explanation

The patient meets the Truelove and Witts criteria for acute severe ulcerative colitis (>= 6 bloody stools/day plus systemic toxicity). In patients who fail to respond to intravenous corticosteroids by day 3 (known as steroid-refractory acute severe colitis), rescue therapy with intravenous infliximab or cyclosporine must be initiated promptly to avoid clinical deterioration and emergency surgery.

Question 34Gastrointestinal, pancreatic and hepatic clinical patterns

A 35-year-old woman presents with persistent bloating, flatulence, and iron deficiency anemia. Serological screening is positive for IgA anti-tissue transglutaminase (anti-tTG) antibodies. An upper endoscopy is performed. Which of the following histological findings in the duodenum is most consistent with the diagnosis?

  1. Non-caseating granulomas and mucosal ulceration
  2. Intraepithelial lymphocytosis, crypt hyperplasia, and villous atrophy Correct answer.
  3. Foamy macrophages accumulating in the lamina propria
  4. Metaplastic gastric mucosa in the duodenum

Explanation

The histological triad of celiac disease consists of intraepithelial lymphocytosis (increased intraepithelial lymphocytes), crypt hyperplasia, and blunting or complete atrophy of the duodenal villi (Marsh classification). This leads to malabsorption and chronic iron deficiency anemia.

Question 35Gastrointestinal, pancreatic and hepatic clinical patterns

A 26-year-old woman presents with a 6-month history of recurrent abdominal pain, typically occurring 2-3 times per week, associated with bloating. The pain is relieved by defecation and is accompanied by a change in stool frequency and form. Her weight is stable, and she has no rectal bleeding, nocturnal symptoms, or family history of inflammatory bowel disease or colorectal cancer. What is the most likely diagnosis and initial management strategy?

  1. Inflammatory bowel disease; refer for urgent colonoscopy
  2. Irritable bowel syndrome (IBS); dietary modification (low FODMAP) and reassurance Correct answer.
  3. Celiac disease; place on a gluten-free diet immediately
  4. Colon cancer; perform urgent CT abdomen and pelvis

Explanation

The patient meets the Rome IV criteria for Irritable Bowel Syndrome (IBS): recurrent abdominal pain at least 1 day/week in the last 3 months associated with defecation, change in frequency, or change in appearance of stool. In the absence of 'alarm features' (weight loss, bleeding, fever, older age of onset, family history), diagnostic testing can be minimized. Initial management includes reassurance, dietary modification (such as a low FODMAP diet), and lifestyle changes.

Question 36Gastrointestinal, pancreatic and hepatic clinical patterns

A 58-year-old chronic alcoholic man presents with chronic abdominal pain radiating to his back, oily stools (steatorrhea), and weight loss. Abdominal CT demonstrates calcifications throughout the pancreatic parenchyma and dilatation of the main pancreatic duct. What is the most appropriate treatment for his malabsorption?

  1. High-dose oral PPI alone
  2. Pancreatic enzyme replacement therapy (PERT) administered with meals Correct answer.
  3. Subcutaneous octreotide injections
  4. Low-protein, high-fat diet

Explanation

The patient has chronic pancreatitis with exocrine pancreatic insufficiency, presenting with steatorrhea and weight loss. The treatment of choice is pancreatic enzyme replacement therapy (PERT) containing lipase, amylase, and protease, administered during or immediately after meals. This improves fat absorption and reduces steatorrhea.

Question 37Gastrointestinal, pancreatic and hepatic clinical patterns

An adult with cirrhosis has mild diuretic-controlled ascites and no encephalopathy. Bilirubin is 38 umol/L, albumin 28 g/L and INR 1.6. Using the conventional Child-Pugh table with those specified clinical grades, which listed class and score apply?

  1. Class A (Score 5)
  2. Class B (Score 8) Correct answer.
  3. Class B (Score 9)
  4. Class C (Score 10)

Explanation

Using the stated conventional table: bilirubin 38 umol/L contributes 2 points, albumin 28 g/L contributes 2, INR 1.6 contributes 1, mild controlled ascites contributes 2 and absent encephalopathy contributes 1. Total is 8, corresponding to Child-Pugh class B. The ascites and encephalopathy grades must actually be specified for an exact total.

Question 38Gastrointestinal, pancreatic and hepatic clinical patterns

A 60-year-old man with cirrhosis secondary to chronic hepatitis B presents with abdominal swelling. On examination, shifting dullness is present. A diagnostic paracentesis is performed. The ascitic fluid analysis shows: Total protein 15 g/L, Albumin 10 g/L. The patient's concurrent serum albumin is 28 g/L. What is the serum-ascites albumin gradient (SAAG), and what does it indicate?

  1. SAAG 18 g/L; portal hypertension-related ascites Correct answer.
  2. SAAG 10 g/L; non-portal hypertension-related ascites (e.g., peritoneal carcinomatosis)
  3. SAAG 38 g/L; biliary leak
  4. SAAG 0.36; tuberculous peritonitis

Explanation

The paired serum-minus-ascites albumin gradient is 28 - 10 = 18 g/L, equivalent to 1.8 g/dL. In the appropriate assessment this supports a portal-hypertension mechanism. It does not identify cirrhosis as the only possible cause or replace the rest of the ascitic-fluid and clinical evaluation.

Question 39Gastrointestinal, pancreatic and hepatic clinical patterns

A 55-year-old man with cirrhosis is admitted with confusion, lethargy, and a flapping tremor (asterixis) of his hands. He was recently started on a loop diuretic for ascites. His serum potassium is 3.1 mmol/L and creatinine is 145 umol/L. What is the primary initial pharmacological treatment for his confusion, and what pathophysiological mechanism does it address?

  1. Intravenous metronidazole; reduces gut anaerobes that produce toxins
  2. Oral lactulose; converts ammonia to non-absorbable ammonium in the colon Correct answer.
  3. Intravenous sodium bicarbonate; treats metabolic acidosis
  4. Oral rifaximin alone; decreases systemic ammonia production

Explanation

The patient has hepatic encephalopathy (Grade 2), likely precipitated by hypokalemia and dehydration from diuretic therapy. The first-line pharmacological treatment is lactulose, a non-absorbable disaccharide. Lactulose is metabolized by colonic bacteria to organic acids, lowering colonic pH. This converts ammonia (NH3) to non-absorbable ammonium (NH4+), trapping it in the gut, and acts as an osmotic laxative to promote its clearance.

Question 40Gastrointestinal, pancreatic and hepatic clinical patterns

An adult with cirrhosis presents with hematemesis, blood pressure 85/50 mmHg and pulse 118 bpm. Following initial monitored resuscitation, which listed coordinated medication and endoscopy strategy is appropriate for suspected acute variceal bleeding?

  1. Intravenous terlipressin, intravenous antibiotic prophylaxis, and urgent endoscopy Correct answer.
  2. Intravenous omeprazole infusion and scheduling an elective endoscopy
  3. Intravenous vasopressin and immediate placement of a TIPS shunt
  4. Oral propranolol and active cooling

Explanation

For suspected variceal hemorrhage, the immediate management consists of: 1) Hemodynamic stabilization (restrictive transfusion strategy to target Hb 70-80 g/L); 2) Vasoactive therapy (terlipressin, somatostatin, or octreotide) started prior to endoscopy; 3) Prophylactic antibiotics (ceftriaxone or quinolones) to reduce bacterial infections and mortality; and 4) Urgent endoscopy (within 12 hours) for variceal ligation.

Question 41Gastrointestinal, pancreatic and hepatic clinical patterns

A 48-year-old man is found to be positive for anti-HCV antibodies. A follow-up HCV RNA test is positive, confirming chronic hepatitis C (Genotype 1b). His liver stiffness measurement by FibroScan is 6.5 kPa, indicating minimal fibrosis (F0-F1). What is the recommended management?

  1. Monitor with liver function tests and repeat FibroScan in 2 years; defer therapy as fibrosis is minimal
  2. Initiate a 12-week course of pegylated interferon and ribavirin
  3. Initiate treatment with direct-acting antivirals (DAAs) such as glecaprevir/pibrentasvir or sofosbuvir/velpatasvir Correct answer.
  4. Advise lifestyle modifications only; treatment is only indicated for F3-F4 fibrosis

Explanation

Current guidelines recommend direct-acting antiviral (DAA) therapy for virtually all patients with chronic HCV infection, regardless of the stage of hepatic fibrosis (except those with short life expectancy). All-oral, interferon-free regimens (e.g., glecaprevir/pibrentasvir or sofosbuvir/velpatasvir) achieve cure rates (Sustained Virologic Response at 12 weeks, SVR12) > 95% with excellent tolerability.

Question 42Gastrointestinal, pancreatic and hepatic clinical patterns

A 45-year-old obese female with type 2 diabetes is found to have elevated transaminases (AST 45 U/L, ALT 58 U/L). A liver ultrasound demonstrates diffuse hyperechogeneity consistent with fatty liver. Other causes of liver disease are excluded. Her FIB-4 score is calculated at 2.4, which falls in the intermediate-risk category. What is the most appropriate next step to assess her risk of advanced fibrosis?

  1. Repeat liver enzymes in 12 months
  2. Perform a liver biopsy
  3. Obtain a transient elastography (FibroScan) Correct answer.
  4. Initiate treatment with pioglitazone

Explanation

In patients with non-alcoholic fatty liver disease (NAFLD / MASLD), risk stratification for advanced fibrosis is key. For patients with an intermediate FIB-4 score (1.3 to 2.67), a secondary non-invasive test such as transient elastography (FibroScan) or magnetic resonance elastography (MRE) is recommended to measure liver stiffness. A liver stiffness measurement < 8.0 kPa rules out advanced fibrosis.

Question 43Gastrointestinal, pancreatic and hepatic clinical patterns

A 28-year-old woman presents with fatigue and mild jaundice. Laboratory evaluation reveals: Bilirubin 42 umol/L, ALT 450 U/L, AST 380 U/L, Alkaline Phosphatase 110 U/L. Her IgG level is 24 g/L (elevated). Serum autoantibody screening is positive for Antinuclear Antibodies (ANA) at 1:320 and Anti-Smooth Muscle Antibodies (ASMA) at 1:160. Viral hepatitis markers are negative. What is the most likely diagnosis and first-line therapy?

  1. Primary biliary cholangitis; ursodeoxycholic acid
  2. Autoimmune hepatitis; oral prednisolone and azathioprine Correct answer.
  3. Wilson's disease; oral penicillamine
  4. Non-alcoholic steatohepatitis; weight loss and vitamin E

Explanation

The clinical presentation (young female with marked transaminitis, hypergammaglobulinemia, positive ANA and ASMA) is classic for Autoimmune Hepatitis (Type 1). The first-line therapy is immunosuppression, typically initiated with systemic corticosteroids (prednisolone) to induce remission, followed by the addition of azathioprine as a steroid-sparing agent for maintenance.

Question 44Gastrointestinal, pancreatic and hepatic clinical patterns

A 48-year-old woman presents with chronic pruritus and fatigue. On examination, she has xanthelasma and hepatomegaly. Her laboratory studies show: Bilirubin 25 umol/L, ALT 45 U/L, AST 40 U/L, Alkaline Phosphatase (ALP) 420 U/L (normal < 120), GGT 280 U/L. Serum anti-mitochondrial antibodies (AMA) are positive at a titer of 1:640. What is the diagnosis and preferred first-line therapy?

  1. Primary sclerosing cholangitis; oral prednisolone
  2. Primary biliary cholangitis (PBC); Ursodeoxycholic acid (UDCA) Correct answer.
  3. Choledocholithiasis; endoscopic retrograde cholangiopancreatography (ERCP)
  4. Autoimmune hepatitis; azathioprine

Explanation

The clinical presentation of pruritus, fatigue, high ALP and GGT, and positive anti-mitochondrial antibodies (AMA) is diagnostic of Primary Biliary Cholangitis (formerly primary biliary cirrhosis). The preferred first-line therapy is Ursodeoxycholic acid (UDCA) at 13-15 mg/kg/day, which improves liver biochemistry, delays progression to cirrhosis, and prolongs transplant-free survival.

Question 45Gastrointestinal, pancreatic and hepatic clinical patterns

A 24-year-old man presents with dysarthria, tremors, and abnormal gait. On slit-lamp examination of the eyes, golden-brown rings are observed at the limbus of the cornea. His liver enzymes show mild chronic elevation. What is the underlying genetic defect, and which biochemical findings are diagnostic?

  1. HFE gene mutation; high ferritin and transferrin saturation
  2. ATP7B gene mutation; low serum ceruloplasmin and high 24-hour urinary copper excretion Correct answer.
  3. SERPINA1 gene mutation; low alpha-1 antitrypsin level
  4. AIP gene mutation; elevated urine porphobilinogen

Explanation

The combination of neurological findings, Kayser-Fleischer rings and liver abnormalities raises concern for Wilson disease involving ATP7B. Low ceruloplasmin and increased urinary copper support evaluation but no isolated biochemical result is universally diagnostic. Integrate the clinical findings, relevant laboratory tests and specialist assessment.

Question 46Endocrine patterns, metabolic emergencies and infectious disease

A 56-year-old man with type 2 diabetes mellitus, hypertension, and chronic kidney disease (eGFR 48 mL/min/1.73m2, albuminuria 350 mg/g creatinine) presents for a treatment review. His HbA1c is 7.8% despite taking metformin 1000 mg twice daily. He has no history of cardiovascular disease. Which of the following is the most appropriate class of glucose-lowering medication to add next?

  1. Sulfonylurea (e.g., gliclazide)
  2. DPP-4 inhibitor (e.g., sitagliptin)
  3. SGLT2 inhibitor (e.g., empagliflozin) Correct answer.
  4. Thiazolidinedione (e.g., pioglitazone)

Explanation

According to the ADA/EASD and KDIGO guidelines, for patients with type 2 diabetes and chronic kidney disease with albuminuria, an SGLT2 inhibitor (e.g., empagliflozin, dapagliflozin) is indicated as first-line therapy (along with metformin) due to its proven benefits in slowing CKD progression and reducing cardiovascular events, independent of glycemic control.

Question 47Endocrine patterns, metabolic emergencies and infectious disease

A 62-year-old type 2 diabetic patient presents with burning and tingling sensations in both feet, which are worse at night. On examination, there is decreased sensation to vibration and light touch in a stocking-like distribution. Ankle reflexes are absent. What is the most appropriate first-line pharmacological treatment for this patient's symptoms?

  1. Amitriptyline or Duloxetine Correct answer.
  2. Oxycodone
  3. Ibuprofen
  4. Vitamin B12 supplementation

Explanation

The patient has symptomatic painful diabetic peripheral neuropathy. First-line agents for neuropathic pain include tricyclic antidepressants (e.g., amitriptyline), serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine), or gabapentinoids (pregabalin/gabapentin). Choice of agent depends on patient comorbidities and side effect profiles.

Question 48Endocrine patterns, metabolic emergencies and infectious disease

A 48-year-old woman is found to have asymptomatic hypercalcemia (serum calcium 2.72 mmol/L, normal < 2.60) on a routine biochemistry screen. Her parathyroid hormone (PTH) is elevated at 9.8 pmol/L. A 24-hour urinary calcium excretion is 7.2 mmol (elevated). Renal function is normal, and dual-energy X-ray absorptiometry (DEXA) shows a T-score of -1.5 at the lumbar spine. Which of the following is an indication for parathyroidectomy in this patient?

  1. Her age (under 50 years) Correct answer.
  2. The T-score of -1.5 (osteopenia)
  3. The asymptomatic nature of the hypercalcemia
  4. The 24-hour urinary calcium of 7.2 mmol

Explanation

According to the consensus guidelines for the management of asymptomatic primary hyperparathyroidism, surgery is indicated if the patient meets any of the following criteria: 1) Age < 50 years; 2) Serum calcium > 0.25 mmol/L (> 1.0 mg/dL) above the upper limit of normal; 3) Skeletal indications (T-score <= -2.5 at spine/hip/distal radius, or vertebral fracture); 4) Renal indications (eGFR < 60 mL/min, 24-hour urine calcium > 400 mg/day [> 10 mmol/day] with stone risk, or nephrolithiasis/nephrocalcinosis on imaging). Since this patient is 48 years old, her age (< 50) is an indication for surgery.

Question 49Endocrine patterns, metabolic emergencies and infectious disease

A 35-year-old woman presents with proximal muscle weakness, easy bruising, and weight gain. On examination, she has a round face, truncal obesity, and wide purple striae on her abdomen. Which of the following represents the most appropriate initial screening test for Cushing's syndrome?

  1. Single midnight serum cortisol measurement during hospitalization
  2. Low-dose (1 mg) overnight dexamethasone suppression test Correct answer.
  3. Random daytime serum ACTH level
  4. Plasma metanephrines

Explanation

The recommended initial screening tests for Cushing's syndrome include: 1) 24-hour urinary free cortisol (at least two measurements); 2) Late-night salivary cortisol (at least two measurements); or 3) 1 mg overnight dexamethasone suppression test (DST) (cortisol should suppress to < 50 nmol/L or < 1.8 ug/dL; failure to suppress is positive). A random daytime ACTH is not a screening test and is only used to differentiate ACTH-dependent from ACTH-independent causes once Cushing's is confirmed.

Question 50Endocrine patterns, metabolic emergencies and infectious disease

A 42-year-old man with persistent hypertension (165/105 mmHg) is found to have a serum potassium of 3.2 mmol/L. He is not taking any diuretics. Screening tests show a plasma aldosterone concentration (PAC) of 24 ng/dL and a plasma renin activity (PRA) of 0.6 ng/mL/h, yielding an aldosterone-to-renin ratio (ARR) of 40 (high). What is the next step to confirm the diagnosis of primary aldosteronism?

  1. CT scan of the adrenal glands to look for an adenoma
  2. Adrenal vein sampling (AVS)
  3. Oral sodium loading test or saline infusion test Correct answer.
  4. Initiate spironolactone therapy immediately

Explanation

An elevated ARR is a screening test and requires a confirmatory test to diagnose primary aldosteronism. The four accepted confirmatory tests are: oral sodium loading, saline infusion (intravenous administration of 2 L of normal saline over 4 hours; failure of aldosterone to suppress to < 5 ng/dL is positive), fludrocortisone suppression, or captopril challenge. Once confirmed, adrenal imaging (CT) is performed, followed by adrenal vein sampling if surgery is considered.