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PANRE-LA practice questions

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Question 1Cardiovascular System

A 52-year-old man with no prior cardiovascular disease has two office blood pressure readings averaging 152/94 mm Hg on separate visits. According to the 2017 ACC/AHA guideline, how should this blood pressure be classified?

  1. Stage 1 hypertension
  2. Stage 2 hypertension Correct answer.
  3. Elevated blood pressure
  4. Hypertensive urgency

Explanation

The 2017 ACC/AHA guideline defines stage 2 hypertension as a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher. His average of 152/94 mm Hg meets that threshold. Stage 1 hypertension is 130-139/80-89 mm Hg, and elevated blood pressure is 120-129/<80 mm Hg. Hypertensive urgency requires severe elevation with acute end-organ damage.

Question 2Cardiovascular System

A 61-year-old woman arrives with 40 minutes of crushing substernal chest pain, diaphoresis, and ST-segment elevation in leads V2-V4. She has no aspirin allergy, active bleeding, or recent gastrointestinal bleed. Which medication should be given immediately while reperfusion is being arranged?

  1. Oral warfarin
  2. Sublingual nifedipine
  3. Intravenous furosemide
  4. Chewed aspirin Correct answer.

Explanation

Chewed aspirin at a dose of 162-325 mg is a class I recommendation at initial presentation of ST-elevation myocardial infarction because it rapidly inhibits platelet thromboxane A2 and reduces mortality. Warfarin is a slower oral anticoagulant and is not the immediate antiplatelet therapy. Furosemide treats volume overload rather than reperfusion, and sublingual nifedipine can cause reflex tachycardia and is not indicated in acute STEMI.

Question 3Cardiovascular System

Which medication class has been shown to reduce cardiovascular mortality in patients with heart failure and reduced ejection fraction (HFrEF)?

  1. ARNI Correct answer.
  2. Cardiac glycosides
  3. Loop diuretics
  4. Dihydropyridine calcium channel blockers

Explanation

Angiotensin receptor-neprilysin inhibitors (ARNIs), such as sacubitril/valsartan, reduce cardiovascular death and heart failure hospitalization in HFrEF and are recommended in place of an ACE inhibitor or ARB in eligible patients. Loop diuretics relieve congestion but do not improve survival. Cardiac glycosides reduce hospitalizations without a mortality benefit, and dihydropyridine calcium channel blockers are not guideline mortality-reducing therapy.

Question 4Cardiovascular System

A 74-year-old man with nonvalvular atrial fibrillation has hypertension and type 2 diabetes. He has no history of stroke, transient ischemic attack, heart failure, or vascular disease. His CHA2DS2-VASc score is 3. Which management is most appropriate?

  1. Aspirin plus clopidogrel
  2. No antithrombotic therapy
  3. Oral anticoagulation Correct answer.
  4. Aspirin 81 mg daily alone

Explanation

A CHA2DS2-VASc score of 2 or greater in men warrants oral anticoagulation, and his score of 3 reflects age 65-74, hypertension, and diabetes. Aspirin monotherapy is not adequate stroke prevention in this risk group. Dual antiplatelet therapy is used for acute coronary syndrome or after PCI, not for routine atrial fibrillation stroke prevention.

Question 5Cardiovascular System

Which auscultatory finding is most characteristic of severe aortic stenosis?

  1. Early diastolic decrescendo murmur at the left upper sternal border
  2. Holosystolic murmur at the apex radiating to the axilla
  3. Late-peaking systolic ejection murmur at the right upper sternal border Correct answer.
  4. Continuous machinery murmur beneath the left clavicle

Explanation

Aortic stenosis produces a crescendo-decrescendo systolic ejection murmur that peaks later in systole as stenosis worsens; it is best heard at the right upper sternal border and often radiates to the carotids. The apical holosystolic murmur describes mitral regurgitation, the early diastolic murmur describes aortic regurgitation, and the continuous murmur describes a patent ductus arteriosus.

Question 6Cardiovascular System

A 28-year-old man has sharp pleuritic chest pain that worsens with inspiration and improves when leaning forward. ECG shows diffuse ST-segment elevations and PR-segment depression. He is hemodynamically stable and has no contraindications. Which is the most appropriate initial treatment?

  1. NSAID plus colchicine Correct answer.
  2. High-dose corticosteroids alone
  3. Immediate pericardiocentesis
  4. Fibrinolytic therapy

Explanation

Acute idiopathic pericarditis is treated with an NSAID plus colchicine, which reduces symptoms and recurrence. Corticosteroids are generally reserved for specific indications because they increase recurrence risk. Pericardiocentesis is reserved for tamponade or diagnostic uncertainty, and fibrinolytics are not indicated for pericarditis with diffuse ST elevation.

Question 7Cardiovascular System

A 19-year-old athlete has exertional syncope and a systolic murmur. The murmur becomes louder with Valsalva and softer with squatting. Which condition is most likely?

  1. Patent ductus arteriosus with continuous murmur
  2. Mitral stenosis with an opening snap
  3. Hypertrophic cardiomyopathy Correct answer.
  4. Aortic regurgitation with a diastolic murmur

Explanation

Hypertrophic cardiomyopathy produces dynamic left ventricular outflow tract obstruction. Maneuvers that decrease preload, such as Valsalva, increase the gradient and make the murmur louder, while squatting increases preload and softens it. Aortic regurgitation and mitral stenosis have diastolic murmurs, and patent ductus arteriosus produces a continuous murmur.

Question 8Cardiovascular System

A 58-year-old man with sudden tearing chest pain radiating to the back has a blood pressure of 190/105 mm Hg and a widened mediastinum on chest radiography. CT angiography confirms a Stanford type B aortic dissection. Which medication should be started first to reduce aortic wall stress?

  1. Intravenous esmolol Correct answer.
  2. Intravenous hydralazine
  3. Oral lisinopril
  4. Intravenous nitroprusside alone

Explanation

In acute aortic dissection, beta-blockade with intravenous esmolol is started first to reduce heart rate and dP/dt, lowering aortic wall stress. Vasodilators are added only after beta-blockade to avoid reflex tachycardia. Nitroprusside alone can cause reflex tachycardia that increases shear force, hydralazine has unpredictable parenteral onset with reflex tachycardia, and oral lisinopril is too slow for acute treatment.

Question 9Cardiovascular System

A 46-year-old woman with a large pericardial effusion becomes hypotensive and tachycardic. Which echocardiographic finding is most specific for cardiac tamponade?

  1. Concentric left ventricular hypertrophy
  2. Severe mitral annular calcification
  3. Right ventricular diastolic collapse Correct answer.
  4. Calcific aortic valve sclerosis

Explanation

Cardiac tamponade physiology is marked by right ventricular diastolic collapse, which reflects elevated pericardial pressure exceeding right ventricular filling pressure. Left ventricular hypertrophy, mitral annular calcification, and aortic valve sclerosis are structural findings unrelated to tamponade. Pulsus paradoxus and electrical alternans can support the diagnosis but are less specific.

Question 10Cardiovascular System

A 62-year-old man has exertional chest pressure relieved by rest and sublingual nitroglycerin. He has no history of myocardial infarction, heart failure, or asthma. Which medication is recommended as first-line antianginal therapy for chronic stable angina?

  1. Short-acting dihydropyridine calcium channel blocker
  2. Nicorandil
  3. Beta-blocker Correct answer.
  4. Ranolazine

Explanation

Beta-blockers are first-line antianginal therapy for chronic stable angina because they reduce heart rate, contractility, and myocardial oxygen demand; they also improve survival after myocardial infarction. Ranolazine is typically added for refractory symptoms. Short-acting dihydropyridines can cause reflex tachycardia and are not preferred, and nicorandil is not standard first-line therapy in the United States.

Question 11Cardiovascular System

A 64-year-old woman with hypertension and type 2 diabetes has taken lisinopril for 3 weeks. She reports a persistent dry nocturnal cough that interferes with sleep. Physical examination and chest radiograph are unremarkable. Which is the most appropriate next step?

  1. Switch lisinopril to sacubitril/valsartan.
  2. Switch lisinopril to losartan. Correct answer.
  3. Add an inhaled corticosteroid.
  4. Reduce the lisinopril dose by half.

Explanation

ACE inhibitor cough is mediated by bradykinin accumulation and typically resolves within 1 to 4 weeks after switching to an angiotensin receptor blocker, which does not inhibit kininase II. Dose reduction rarely helps because the mechanism is class-specific rather than dose-dependent. Inhaled corticosteroids and other asthma therapies do not address the underlying cause.

Question 12Cardiovascular System

A 58-year-old man with type 2 diabetes reports cramping calf pain that occurs after walking two blocks and resolves with rest. Ankle-brachial index testing is performed. Which value is most consistent with peripheral arterial disease?

  1. 1.25
  2. 0.92
  3. 1.05
  4. 0.62 Correct answer.

Explanation

An ankle-brachial index of 0.90 or less is abnormal and supports a diagnosis of peripheral arterial disease; a value of 0.62 indicates moderate disease and fits the claudication history. Values between 0.91 and 1.40 are normal, while a value above 1.40 suggests noncompressible, calcified arteries rather than normal flow.

Question 13Cardiovascular System

A 68-year-old woman with heart failure and preserved ejection fraction (58%) has NYHA class II symptoms despite furosemide and metoprolol. Which added medication has been shown to reduce heart failure hospitalizations in this population?

  1. Amlodipine
  2. Sacubitril/valsartan
  3. Digoxin
  4. Dapagliflozin Correct answer.

Explanation

SGLT2 inhibitors such as dapagliflozin and empagliflozin reduce the composite of cardiovascular death and heart failure hospitalization in HFpEF, as demonstrated in the EMPEROR-Preserved and DELIVER trials. Sacubitril/valsartan is primarily indicated for HFrEF and did not meet its primary endpoint in HFpEF. Digoxin and amlodipine do not improve heart failure outcomes in this setting.

Question 14Cardiovascular System

A 55-year-old man with a known Wolff-Parkinson-White pattern presents with palpitations. The ECG shows an irregularly irregular wide-complex tachycardia at 200 bpm. Which intravenous agent is most strongly contraindicated in this setting?

  1. Ibutilide
  2. Procainamide
  3. Diltiazem Correct answer.
  4. Amiodarone

Explanation

In pre-excited atrial fibrillation, AV nodal blocking agents such as diltiazem, verapamil, digoxin, and adenosine can increase antegrade conduction down the accessory pathway and may degenerate into ventricular fibrillation. Procainamide and ibutilide slow accessory pathway conduction and are preferred pharmacologic options for hemodynamically stable patients. Synchronized cardioversion is indicated for instability.

Question 15Cardiovascular System

A 42-year-old woman who immigrated from a region with limited access to health care reports progressive exertional dyspnea. Auscultation reveals a loud S1, an opening snap, and a mid-diastolic rumble at the apex. Which is the most likely underlying cause?

  1. Rheumatic heart disease Correct answer.
  2. Infective endocarditis
  3. Aortic root dilation
  4. Mitral valve prolapse

Explanation

Mitral stenosis in a young adult from an area with limited access to care is most often rheumatic in origin, producing leaflet thickening, commissural fusion, and the characteristic opening snap with a mid-diastolic rumble. Mitral valve prolapse causes a mid-systolic click and late systolic murmur. Aortic root dilation and infective endocarditis do not produce this constellation.

Question 16Cardiovascular System

A 38-year-old man who injects drugs presents with fever, a new tricuspid regurgitation murmur, and septic pulmonary emboli. He is hemodynamically stable. Which is the most appropriate initial diagnostic step?

  1. Complete a transthoracic echocardiogram first and then draw blood cultures.
  2. Obtain one blood culture from the existing peripheral intravenous catheter.
  3. Obtain blood cultures from three separate sites before antibiotics. Correct answer.
  4. Start empirical vancomycin and obtain blood cultures after 24 hours of therapy.

Explanation

In suspected infective endocarditis, at least three sets of blood cultures from separate venipuncture sites should be obtained before antibiotics whenever the patient is hemodynamically stable, because prior antibiotics reduce culture yield. Drawing cultures from an existing line increases contamination risk. Echocardiography is important but should not delay cultures.

Question 17Cardiovascular System

A 62-year-old man with a prior anterior myocardial infarction presents with palpitations. The ECG shows a regular wide-complex tachycardia at 170 bpm. Which finding most strongly supports ventricular tachycardia over supraventricular tachycardia with aberrant conduction?

  1. A history of myocardial infarction
  2. Presence of fusion beats Correct answer.
  3. A regular rhythm at 170 bpm
  4. A QRS duration of 140 ms

Explanation

Fusion beats, capture beats, and AV dissociation are highly specific for ventricular tachycardia and are not features of supraventricular tachycardia with aberrancy. A prior myocardial infarction raises pretest probability but does not by itself establish the diagnosis. QRS duration and regularity overlap substantially between the two rhythms.

Question 18Cardiovascular System

A 24-year-old woman with congenital long QT syndrome and a corrected QT interval of 520 ms presents with nausea and vomiting. Which antiemetic should be avoided because it further prolongs the QT interval?

  1. Metoprolol
  2. Ondansetron Correct answer.
  3. Aspirin
  4. Lisinopril

Explanation

Ondansetron is a known QT-prolonging drug and may precipitate torsades de pointes in patients with congenital long QT syndrome. Beta-blockers such as metoprolol are first-line therapy for long QT syndrome and reduce arrhythmic risk. Lisinopril and aspirin do not meaningfully affect the QT interval.

Question 19Pulmonary System

A 24-year-old with asthma uses a short-acting beta-agonist two or three times weekly and wakes with symptoms twice a month. Spirometry shows an FEV1 of 85% predicted. What is the most appropriate controller therapy?

  1. Oral montelukast as sole therapy
  2. Scheduled short-acting beta-agonist before bedtime
  3. Daily long-acting beta-agonist monotherapy
  4. Low-dose inhaled corticosteroid Correct answer.

Explanation

Persistent asthma symptoms more than twice monthly warrant a daily anti-inflammatory controller, and inhaled corticosteroids are first-line. A long-acting beta-agonist is not used as monotherapy in asthma because of the risk of serious exacerbations. Montelukast is less effective than an inhaled corticosteroid and is not preferred as sole therapy.

Question 20Pulmonary System

A 58-year-old with a 30 pack-year smoking history has spirometry performed because of progressive dyspnea. Which result is most consistent with an obstructive ventilatory defect?

  1. FVC of 55% predicted with a normal FEV1/FVC ratio
  2. FEV1/FVC ratio of 0.61 Correct answer.
  3. Reduced diffusing capacity with a normal FEV1/FVC ratio
  4. FEV1/FVC ratio of 0.82

Explanation

An obstructive defect is defined by a reduced FEV1/FVC ratio, typically below 0.70 after bronchodilator testing in a patient with compatible symptoms. A normal ratio with a reduced FVC suggests restriction rather than obstruction. Diffusing capacity can be reduced in emphysema but does not define the obstructive pattern.

Question 21Pulmonary System

A tall, thin 20-year-old man develops sudden right-sided pleuritic chest pain and dyspnea while at rest. He is hemodynamically stable. On examination, which finding most supports a primary spontaneous pneumothorax?

  1. Dullness to percussion at the right base
  2. Egophony over the right lower lobe
  3. Hyperresonance with reduced breath sounds Correct answer.
  4. Inspiratory crackles at the right base

Explanation

A pneumothorax produces increased resonance to percussion and diminished breath sounds on the affected side because air separates the lung from the chest wall. Dullness, crackles, and egophony suggest consolidation or pleural fluid rather than pleural air.

Question 22Pulmonary System

A previously healthy 38-year-old man is diagnosed with outpatient community-acquired pneumonia. He has no comorbidities, has not taken antibiotics in the past 3 months, and is hemodynamically stable. Which regimen is the guideline-preferred first-line empiric therapy?

  1. Levofloxacin 750 mg daily
  2. Amoxicillin 1 g three times daily Correct answer.
  3. Ceftriaxone plus azithromycin
  4. Vancomycin plus piperacillin-tazobactam

Explanation

For an otherwise healthy outpatient without recent antibiotic exposure, guideline recommendations favor a narrow-spectrum agent such as amoxicillin or doxycycline; a macrolide is an alternative where pneumococcal resistance is low. Respiratory fluoroquinolones and combination beta-lactam/macrolide therapy are reserved for patients with comorbidities or other risk factors. Broad MRSA and Pseudomonas coverage is not indicated in this low-risk patient.

Question 23Pulmonary System

A 68-year-old with a COPD exacerbation is hypoxemic and retains CO2. He is started on supplemental oxygen. What SpO2 target is most appropriate while awaiting further treatment?

  1. 100% to maximize oxygen delivery
  2. 88% to 92% Correct answer.
  3. 80% to 85%
  4. 94% to 98%

Explanation

In patients with COPD who are at risk for hypercapnia, oxygen should be titrated to a target saturation of 88% to 92% to reduce the risk of worsening CO2 retention while correcting hypoxemia. Higher targets increase the risk of hyperoxia and respiratory acidosis in this population.

Question 24Pulmonary System

A 45-year-old woman presents with acute pleuritic chest pain and dyspnea 2 days after a long-haul flight. Heart rate is 112/min, blood pressure is 118/72, and oxygen saturation is 93% on room air. Her Wells score is high. Which diagnostic test is most appropriate next?

  1. Lower extremity venous ultrasound
  2. D-dimer
  3. CT pulmonary angiography Correct answer.
  4. Ventilation-perfusion scan

Explanation

With a high pretest probability of pulmonary embolism, a D-dimer cannot exclude the diagnosis and definitive imaging is required; CT pulmonary angiography is the preferred test in a hemodynamically stable patient. Ventilation-perfusion scanning is generally reserved for when CT is contraindicated or unavailable. Leg ultrasound is useful only when it demonstrates deep vein thrombosis.

Question 25Pulmonary System

A pleural effusion is sampled. Which laboratory finding meets Light's criteria for an exudate?

  1. Pleural fluid LDH/serum LDH ratio of 0.50
  2. Pleural fluid protein/serum protein ratio of 0.40
  3. Pleural fluid protein/serum protein ratio of 0.60 Correct answer.
  4. Serum-pleural albumin gradient greater than 1.2 g/dL

Explanation

Light's criteria classify an effusion as exudative if the pleural protein/serum protein ratio exceeds 0.5, the pleural LDH/serum LDH ratio exceeds 0.6, or pleural LDH exceeds two-thirds the upper limit of normal serum LDH. A protein ratio of 0.60 meets the protein criterion. A serum-pleural albumin gradient above 1.2 g/dL instead suggests a transudate such as heart failure.

Question 26Pulmonary System

A 52-year-old obese man reports loud snoring, witnessed apneas, and daytime sleepiness. He has hypertension and no cardiopulmonary instability. Which test is most appropriate to confirm obstructive sleep apnea and grade its severity?

  1. Nocturnal pulse oximetry alone
  2. Attended polysomnography Correct answer.
  3. Empiric CPAP trial
  4. Chest CT during wakefulness

Explanation

Attended polysomnography is the reference standard for diagnosing obstructive sleep apnea and quantifying the apnea-hypopnea index. Home sleep apnea testing is an alternative in selected uncomplicated patients, but oximetry alone cannot reliably confirm or grade the disorder. Imaging during wakefulness does not assess dynamic upper airway obstruction during sleep.

Question 27Pulmonary System

A 70-year-old with severe COPD presents with worsening dyspnea. Arterial blood gas shows pH 7.28, PaCO2 65 mm Hg, and HCO3 28 mEq/L. Which interpretation best fits these values?

  1. Acute-on-chronic respiratory acidosis Correct answer.
  2. Metabolic alkalosis with respiratory compensation
  3. Chronic respiratory acidosis with full metabolic compensation
  4. Acute respiratory alkalosis

Explanation

The acidemia with elevated PaCO2 indicates respiratory acidosis. A bicarbonate of 28 reflects metabolic compensation, but the pH remains low, showing that compensation is incomplete and that an acute rise in CO2 has occurred on top of chronic CO2 retention.

Question 28Pulmonary System

Which patient meets current US Preventive Services Task Force criteria for annual low-dose CT lung cancer screening?

  1. A 45-year-old current smoker with a 10 pack-year history
  2. A 60-year-old with 30 pack-years who quit 5 years ago Correct answer.
  3. A 35-year-old current smoker with a 5 pack-year history
  4. A 75-year-old who smoked 15 pack-years and quit 20 years ago

Explanation

USPSTF screening criteria are age 50 to 80 years, a 20 pack-year or greater smoking history, and current smoking or quitting within the past 15 years. The 60-year-old with 30 pack-years who quit 5 years ago meets all three criteria.

Question 29Pulmonary System

A previously healthy 40-year-old man presents with fever, productive cough, and a lobar infiltrate on chest radiograph. He is treated as an outpatient. Which organism is the most common cause of community-acquired pneumonia in this setting?

  1. Mycoplasma pneumoniae
  2. Legionella pneumophila
  3. Haemophilus influenzae
  4. Streptococcus pneumoniae Correct answer.

Explanation

Streptococcus pneumoniae remains the most frequently identified cause of community-acquired pneumonia across outpatient and inpatient settings. Atypical organisms such as Mycoplasma are more common in young adults, but they do not surpass pneumococcus overall. Haemophilus influenzae is more typical in patients with underlying COPD, and Legionella is usually linked to outbreaks or water exposure.

Question 30Pulmonary System

A 65-year-old man with COPD asks which vaccine is recommended annually to reduce the risk of respiratory exacerbations. Which vaccine should be administered every year?

  1. Pneumococcal polysaccharide vaccine every year
  2. Inactivated influenza vaccine annually Correct answer.
  3. Tdap every 5 years
  4. Zoster vaccine every year

Explanation

Annual inactivated influenza vaccination is recommended for adults with COPD because infection can precipitate exacerbations and pneumonia. Pneumococcal vaccination is also indicated, but it is not given every year with the polysaccharide formulation. Tdap is boosted every 10 years, and zoster vaccination is not an annual recommendation.

Question 31Pulmonary System

A 50-year-old woman with scleroderma has progressive dyspnea. Spirometry shows an FEV1/FVC ratio of 0.82, FVC 60% of predicted, and total lung capacity 65% of predicted. Which ventilatory pattern does this represent?

  1. Restrictive Correct answer.
  2. Obstructive
  3. Mixed
  4. Normal

Explanation

A normal or elevated FEV1/FVC ratio with reduced FVC and reduced total lung capacity defines a restrictive ventilatory defect. Obstructive disease lowers the FEV1/FVC ratio, and a mixed pattern shows both obstruction and restriction. Normal spirometry would not show these reduced lung volumes.

Question 32Pulmonary System

A 72-year-old man is admitted with community-acquired pneumonia. Which finding meets a minor IDSA/ATS criterion for severe community-acquired pneumonia?

  1. Temperature of 38.3°C
  2. Unilateral lobar infiltrate
  3. Respiratory rate of 32 breaths/min Correct answer.
  4. White blood cell count of 15,000/mm³

Explanation

The IDSA/ATS minor criteria for severe CAP include respiratory rate of 30 breaths/min or higher, confusion, uremia, leukopenia, thrombocytopenia, hypothermia, multilobar infiltrates, and PaO2/FiO2 of 250 or less. Temperature, white blood cell count, and a single lobar infiltrate are not minor severity criteria.

Question 33Pulmonary System

A 55-year-old man with sepsis develops bilateral pulmonary opacities and hypoxemia. He is receiving mechanical ventilation with PEEP 10 cm H2O, and his PaO2/FiO2 ratio is 150. Echocardiography shows normal left ventricular function. Which ARDS severity category applies?

  1. Moderate ARDS Correct answer.
  2. Severe ARDS
  3. Mild ARDS
  4. No ARDS

Explanation

The Berlin definition classifies ARDS as mild when PaO2/FiO2 is 200 to 300, moderate when it is 100 to 200, and severe when it is below 100, all on PEEP of at least 5 cm H2O. A value of 150 with bilateral opacities and no cardiac cause therefore fits moderate ARDS.

Question 34Pulmonary System

A 68-year-old man with stable COPD has a resting SpO2 of 86% on room air and a PaO2 of 54 mm Hg. Which intervention has been shown to improve survival in this setting?

  1. Inhaled long-acting muscarinic antagonist
  2. Long-term home oxygen therapy Correct answer.
  3. Nocturnal noninvasive ventilation
  4. Oral theophylline

Explanation

Long-term oxygen therapy improves survival in stable COPD when resting PaO2 is 55 mm Hg or less or SpO2 is 88% or less. The benefit is established with at least 15 hours of use per day. Inhaled bronchodilators improve symptoms but have not been shown to confer the same mortality benefit in chronic hypoxemia.

Question 35Pulmonary System

A 67-year-old man has idiopathic pulmonary fibrosis with a forced vital capacity of 75% of predicted. Which medication has been shown to slow the decline in lung function?

  1. N-acetylcysteine monotherapy
  2. Inhaled ipratropium
  3. Pirfenidone Correct answer.
  4. Prednisone plus azathioprine

Explanation

Pirfenidone and nintedanib are antifibrotic agents that slow the rate of decline in forced vital capacity in idiopathic pulmonary fibrosis. The combination of prednisone, azathioprine, and N-acetylcysteine was associated with harm in a major trial and is not recommended. N-acetylcysteine monotherapy has not been shown to provide a meaningful benefit.

Question 36Pulmonary System

A 60-year-old man coughs up 600 mL of blood and has an SpO2 of 88% on room air. He remains hemodynamically stable but continues to bleed. What is the most appropriate first step?

  1. High-dose systemic corticosteroids
  2. Emergent CT angiography before any airway intervention
  3. Chest tube placement
  4. Endotracheal intubation Correct answer.

Explanation

Massive hemoptysis can rapidly compromise ventilation and cause asphyxiation, so securing the airway with endotracheal intubation takes priority. After the airway is protected, bronchoscopy or CT angiography can localize the bleeding, and definitive therapy may include bronchial artery embolization or surgery. Corticosteroids and chest tubes do not address the airway or the bleeding source.

Question 37Gastrointestinal System and Nutrition

A 32-year-old presents with chronic diarrhea, bloating, and iron-deficiency anemia. Celiac disease is suspected. Which serologic test is most appropriate for initial screening?

  1. Anti-Saccharomyces cerevisiae antibody
  2. Fecal calprotectin
  3. IgG anti-gliadin antibody
  4. IgA tissue transglutaminase antibody Correct answer.

Explanation

IgA tissue transglutaminase is the preferred initial serologic screen for celiac disease because it has high sensitivity and specificity. Total IgA should also be checked, since IgA deficiency can produce a false-negative result.

Question 38Gastrointestinal System and Nutrition

Which laboratory result best supports a diagnosis of acute pancreatitis in a patient with severe epigastric pain radiating to the back?

  1. Serum ALT of 60 U/L
  2. Total bilirubin of 0.8 mg/dL
  3. Serum lipase greater than three times the upper limit of normal Correct answer.
  4. Serum amylase within the reference range

Explanation

A serum lipase level greater than three times the upper limit of normal is a diagnostic criterion for acute pancreatitis. Lipase is more specific than amylase and remains elevated longer, so a normal amylase does not exclude the diagnosis.

Question 39Gastrointestinal System and Nutrition

A 60-year-old with fatigue and paresthesias has macrocytic anemia. Which deficiency is most likely to produce both megaloblastic anemia and neurologic symptoms?

  1. Niacin
  2. Vitamin B12 Correct answer.
  3. Folate
  4. Thiamine

Explanation

Vitamin B12 deficiency causes megaloblastic anemia and neurologic deficits such as paresthesias, impaired proprioception, and cognitive changes. Folate deficiency also causes megaloblastic anemia but does not typically produce the neurologic findings.

Question 40Gastrointestinal System and Nutrition

A 45-year-old has 8 weeks of heartburn responding partially to a proton pump inhibitor. Which feature should prompt urgent upper endoscopy?

  1. Heartburn occurring after spicy meals
  2. Progressive dysphagia Correct answer.
  3. Mild epigastric discomfort after eating
  4. Regurgitation when lying flat

Explanation

Progressive dysphagia is an alarm symptom that raises concern for esophageal stricture or malignancy and warrants urgent upper endoscopy. Typical postprandial heartburn, regurgitation, and mild epigastric discomfort are common GERD symptoms without alarm features.

Question 41Gastrointestinal System and Nutrition

Which pattern of intestinal involvement is most characteristic of ulcerative colitis?

  1. Skip lesions with transmural inflammation
  2. Granulomas on mucosal biopsy
  3. Continuous inflammation beginning in the rectum Correct answer.
  4. Perianal fistulas and abscesses

Explanation

Ulcerative colitis classically begins in the rectum and extends proximally in a continuous pattern limited to the mucosa. Skip lesions, transmural inflammation, perianal fistulas, and granulomas are features of Crohn disease.

Question 42Gastrointestinal System and Nutrition

A patient with cirrhosis and ascites undergoes paracentesis for fever and abdominal pain. Ascitic fluid shows 320 polymorphonuclear cells/mm3. What is the most appropriate next step?

  1. Give intravenous albumin alone
  2. Start intravenous ceftriaxone Correct answer.
  3. Repeat paracentesis in 48 hours
  4. Increase the spironolactone dose

Explanation

An ascitic fluid polymorphonuclear cell count of at least 250/mm3 establishes spontaneous bacterial peritonitis, and empiric intravenous ceftriaxone should be started promptly. Albumin may be added for renal protection, but antibiotics are the primary treatment.

Question 43Gastrointestinal System and Nutrition

A severely malnourished patient is being started on enteral nutrition. Which electrolyte should be monitored most closely during the first week because of refeeding syndrome?

  1. Phosphate Correct answer.
  2. Chloride
  3. Calcium
  4. Sodium

Explanation

Refeeding syndrome is characterized by a rapid intracellular shift of phosphate, potassium, and magnesium, causing hypophosphatemia that can lead to cardiac and respiratory failure. Phosphate should be checked and repleted closely during the first week of feeding.

Question 44Gastrointestinal System and Nutrition

A 50-year-old presents with right upper quadrant pain, fever, and leukocytosis. Acute cholecystitis is suspected. Which imaging study is the most appropriate initial test?

  1. Endoscopic retrograde cholangiopancreatography
  2. Abdominal computed tomography
  3. Right upper quadrant ultrasound Correct answer.
  4. Magnetic resonance cholangiopancreatography

Explanation

Right upper quadrant ultrasound is the initial imaging study for suspected acute cholecystitis and can show gallstones, gallbladder wall thickening, and pericholecystic fluid. CT is less sensitive for gallstones, and MRCP and ERCP are reserved for evaluating or treating biliary duct disease.

Question 45Gastrointestinal System and Nutrition

A patient with cirrhosis presents with hematemesis from suspected esophageal varices. Which medication should be started early to reduce infectious complications and mortality?

  1. Intravenous pantoprazole
  2. Intravenous ceftriaxone Correct answer.
  3. Oral lactulose
  4. Subcutaneous octreotide

Explanation

Prophylactic antibiotics, commonly intravenous ceftriaxone, are recommended early in cirrhotic patients with upper gastrointestinal bleeding because they reduce bacterial infection, rebleeding, and mortality. Octreotide lowers portal pressure but does not prevent infection.

Question 46Gastrointestinal System and Nutrition

A patient with severe acute pancreatitis has persistent vomiting and has not eaten for 5 days. Which nutritional strategy is preferred once resuscitation is complete?

  1. Clear liquids only until lipase normalizes
  2. Total parenteral nutrition as first-line therapy
  3. Nothing by mouth for another week
  4. Enteral nutrition through a nasojejunal tube Correct answer.

Explanation

Enteral nutrition, often delivered through a nasojejunal or nasogastric tube, is preferred in severe acute pancreatitis to maintain gut mucosal integrity and reduce infectious complications. It should be started as soon as the patient is hemodynamically stable and tolerating tube feeding.

Question 47Gastrointestinal System and Nutrition

A 72-year-old man is hospitalized after an acute ischemic stroke with persistent dysphagia and aspiration risk. He is hemodynamically stable, has a functioning gastrointestinal tract, and is expected to require nutrition support for about 3 weeks. Which feeding access is most appropriate?

  1. Total parenteral nutrition as the primary route
  2. Clear liquid diet with bedside swallow evaluation only
  3. Percutaneous endoscopic gastrostomy placement before any oral intake
  4. Nasogastric tube feeding begun within 24 to 48 hours Correct answer.

Explanation

A functioning gastrointestinal tract and an expected need under about four weeks favor short-term nasoenteric feeding. Early enteral nutrition is preferred after stroke when swallowing is unsafe, and gastrostomy is reserved for longer-term access.

Question 48Gastrointestinal System and Nutrition

A 58-year-old man with chronic alcohol use disorder and poor dietary intake is admitted with confusion, horizontal nystagmus, and ataxia. Which nutritional deficiency most likely explains this presentation?

  1. Folate
  2. Thiamine (vitamin B1) Correct answer.
  3. Vitamin B12
  4. Vitamin C

Explanation

Wernicke encephalopathy classically causes confusion, nystagmus, and ataxia in patients with chronic alcohol use and poor intake. Thiamine replacement must be given promptly, preferably before glucose, to prevent irreversible neurologic injury.

Question 49Gastrointestinal System and Nutrition

A 46-year-old man with a duodenal ulcer completed a 14-day bismuth-based quadruple regimen for Helicobacter pylori. He is asymptomatic 4 weeks later and has not taken a proton pump inhibitor for 2 weeks. Which test is most appropriate to confirm eradication?

  1. Repeat upper endoscopy with biopsy at this visit
  2. Stool antigen test performed during the final week of treatment
  3. Urea breath test performed now Correct answer.
  4. Immunoglobulin G serology for H. pylori

Explanation

Test of cure for H. pylori should use a direct method at least four weeks after antibiotics and one to two weeks after stopping a proton pump inhibitor. Urea breath testing meets these conditions, while serology cannot distinguish past from current infection.

Question 50Gastrointestinal System and Nutrition

A 41-year-old woman with type 1 diabetes has recurrent nausea, early satiety, and postprandial fullness; gastric emptying scintigraphy is delayed. Which dietary approach is most appropriate initial management?

  1. A clear liquid diet for 6 weeks
  2. Three large high-fiber meals daily
  3. Small, frequent, low-fat, low-fiber meals Correct answer.
  4. High-fat small meals to slow gastric emptying

Explanation

Dietary therapy for gastroparesis emphasizes small, frequent meals that are low in fat and fiber to reduce gastric retention and symptom flares. A clear liquid diet is not a durable strategy, and large or high-fat meals typically worsen symptoms.