I85PREP
⌘ K
PANRE study materials
PANRE study resources

PANRE practice questions

One question at a time. Build your PANRE understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Cardiovascular

A 52-year-old man with newly diagnosed stage 1 hypertension has no other cardiovascular risk factors or comorbid conditions. Which medication is the most appropriate initial antihypertensive therapy?

  1. Metoprolol succinate
  2. Chlorthalidone Correct answer.
  3. Terazosin
  4. Furosemide

Explanation

Thiazide-type diuretics such as chlorthalidone are recommended first-line therapy for uncomplicated hypertension because they lower blood pressure, reduce cardiovascular events, and can be dosed once daily.

Question 2Cardiovascular

A 60-year-old man arrives in the emergency department 45 minutes after the onset of crushing substernal chest pain, and acute myocardial infarction is suspected. Which antiplatelet should be administered immediately?

  1. Apixaban 5 mg PO
  2. Aspirin 325 mg chewed Correct answer.
  3. Clopidogrel 75 mg PO daily
  4. Warfarin 5 mg PO

Explanation

Chewed aspirin at 162 to 325 mg is given as early as possible in suspected acute coronary syndrome because buccal and gastric absorption of a chewed dose produces rapid platelet inhibition.

Question 3Cardiovascular

Which medication has been shown to reduce mortality in a patient with heart failure and a reduced ejection fraction of 30%?

  1. Furosemide
  2. Carvedilol Correct answer.
  3. Amlodipine
  4. Digoxin

Explanation

Beta blockers with proven outcome benefit, including carvedilol, reduce all-cause mortality in heart failure with reduced ejection fraction by blocking chronic sympathetic activation.

Question 4Cardiovascular

Which electrocardiographic pattern is characteristic of atrial fibrillation?

  1. Prolonged PR interval with dropped beats
  2. Sawtooth flutter waves at about 300 per minute
  3. Regular narrow-complex tachycardia at 150 per minute
  4. Irregularly irregular rhythm with absent P waves Correct answer.

Explanation

Atrial fibrillation produces disorganized atrial activity with no discrete P waves and an irregularly irregular ventricular response.

Question 5Cardiovascular

Which electrocardiographic finding is most consistent with acute pericarditis?

  1. Diffuse concave ST elevation Correct answer.
  2. Peaked T waves with QRS widening
  3. ST elevation in V1 to V3 with reciprocal depression
  4. Short PR interval with a delta wave

Explanation

Acute pericarditis causes diffuse, concave-upward ST elevation with PR-segment depression reflecting generalized epicardial inflammation rather than a single coronary territory.

Question 6Cardiovascular

Which valve is most commonly damaged in rheumatic heart disease?

  1. Aortic valve
  2. Mitral valve Correct answer.
  3. Tricuspid valve
  4. Pulmonary valve

Explanation

Rheumatic carditis most often produces leaflet thickening, commissural fusion, and chordal shortening of the mitral valve, leading to stenosis and often regurgitation.

Question 7Cardiovascular

A 58-year-old man presents to a hospital with a PCI-capable catheterization laboratory 90 minutes after the onset of an anterior STEMI. He has no contraindications to reperfusion. Which strategy is preferred?

  1. Coronary CT angiography
  2. Fibrinolysis with alteplase
  3. Observation with serial troponins
  4. Primary PCI Correct answer.

Explanation

Primary percutaneous coronary intervention is preferred for STEMI when it can be performed promptly, because it produces higher rates of infarct artery patency and lower rates of intracranial hemorrhage than fibrinolysis.

Question 8Cardiovascular

A patient with nonvalvular atrial fibrillation is started on warfarin for stroke prevention. What INR range should be targeted?

  1. 1.0 to 2.0
  2. 3.0 to 4.5
  3. 0.5 to 1.5
  4. 2.0 to 3.0 Correct answer.

Explanation

An INR of 2.0 to 3.0 provides effective thromboembolic protection for atrial fibrillation while limiting hemorrhagic risk.

Question 9Cardiovascular

A 29-year-old woman with chronic hypertension is planning pregnancy. Which antihypertensive is the preferred choice?

  1. Atenolol
  2. Losartan
  3. Labetalol Correct answer.
  4. Enalapril

Explanation

Labetalol is a preferred agent for hypertension in pregnancy because it is effective and has an established safety record for the fetus.

Question 10Cardiovascular

A 74-year-old man reports exertional dyspnea and exertional dizziness. Auscultation reveals a crescendo-decrescendo systolic murmur at the right upper sternal border that radiates to the carotids. Which valvular lesion is most likely?

  1. Mitral stenosis
  2. Aortic stenosis Correct answer.
  3. Aortic regurgitation
  4. Mitral regurgitation

Explanation

Aortic stenosis produces a crescendo-decrescendo systolic ejection murmur at the right upper sternal border that radiates along the carotid arteries, often with a delayed and diminished carotid upstroke.

Question 11Cardiovascular

A 55-year-old woman has a holosystolic murmur at the apex that radiates to the axilla and is loudest during handgrip. Which valvular abnormality does this represent?

  1. Mitral stenosis
  2. Aortic stenosis
  3. Mitral regurgitation Correct answer.
  4. Patent ductus arteriosus

Explanation

Mitral regurgitation causes a holosystolic apical murmur radiating to the axilla, and maneuvers that increase systemic vascular resistance such as handgrip augment the regurgitant flow and intensify the murmur.

Question 12Cardiovascular

A 30-year-old man has sharp pleuritic chest pain that improves when sitting forward, a pericardial friction rub, and diffuse ST elevation. Which regimen is most appropriate?

  1. Furosemide and digoxin
  2. Corticosteroids as sole therapy
  3. Broad-spectrum antibiotics
  4. NSAIDs plus colchicine Correct answer.

Explanation

Acute idiopathic or viral pericarditis is treated with an NSAID plus colchicine, which relieves inflammation and reduces the rate of recurrent pericarditis.

Question 13Cardiovascular

A 72-year-old woman with heart failure and an ejection fraction of 60% remains symptomatic despite diuretic therapy. Which medication has been shown to reduce heart failure hospitalization in this population?

  1. Sacubitril-valsartan
  2. Dapagliflozin Correct answer.
  3. Spironolactone
  4. Ivabradine

Explanation

SGLT2 inhibitors such as dapagliflozin reduce the composite of cardiovascular death and worsening heart failure in patients with preserved ejection fraction.

Question 14Cardiovascular

A 68-year-old man with advanced kidney disease is found to have a potassium level of 7.2 mEq/L. Which electrocardiographic finding is most characteristic?

  1. Peaked T waves with widened QRS Correct answer.
  2. Diffuse ST elevation with PR depression
  3. Sawtooth flutter waves
  4. Prolonged QT interval with prominent U waves

Explanation

Hyperkalemia initially produces tall peaked T waves and, as severity increases, QRS widening and loss of P waves that can progress to a sine wave pattern and cardiac arrest.

Question 15Cardiovascular

Which patient requires antibiotic prophylaxis before a dental procedure involving gingival manipulation?

  1. A patient with mitral valve prolapse and no regurgitation
  2. A patient with a prosthetic aortic valve Correct answer.
  3. A patient with prior coronary artery bypass grafting
  4. A patient with hypertrophic cardiomyopathy without obstruction

Explanation

Prosthetic heart valves carry a high risk of adverse outcomes from infective endocarditis, so prophylaxis is recommended before dental procedures that involve manipulation of gingival tissue or the periapical region.

Question 16Cardiovascular

A 24-year-old woman faints while having blood drawn. Witnesses describe pallor and brief myoclonic jerks, and she recovers fully within a minute. Which cause is most likely?

  1. Aortic stenosis
  2. Complete heart block
  3. Ventricular tachycardia
  4. Vasovagal syncope Correct answer.

Explanation

Vasovagal syncope typically follows a trigger such as phlebotomy or emotional stress and is preceded by prodromal warmth, nausea, and pallor; brief myoclonic jerks from cerebral hypoperfusion are common and do not indicate a seizure.

Question 17Cardiovascular

A 58-year-old man has sudden tearing chest pain radiating to the back. Blood pressure is 190/100 mm Hg in the right arm and 150/90 mm Hg in the left arm. What is the most appropriate initial pharmacologic therapy?

  1. Intravenous alteplase
  2. Sublingual nitroglycerin
  3. Oral aspirin and clopidogrel
  4. Intravenous esmolol Correct answer.

Explanation

In acute aortic dissection, a beta blocker such as esmolol is started first to lower heart rate and reduce the shear force of left ventricular ejection before a vasodilator is added.

Question 18Cardiovascular

A 66-year-old man has a regular wide-complex tachycardia at 190 per minute with blood pressure 78/50 mm Hg and altered mental status. What is the most appropriate immediate treatment?

  1. IV adenosine 6 mg rapid push
  2. Unsynchronized defibrillation at 200 J
  3. IV amiodarone 150 mg over 10 minutes
  4. Synchronized cardioversion Correct answer.

Explanation

A wide-complex tachycardia with hemodynamic instability and impaired mentation requires immediate synchronized cardioversion rather than a trial of antiarrhythmic therapy.

Question 19Cardiovascular

A 60-year-old woman with a large pericardial effusion develops hypotension, distended neck veins, and a 14 mm Hg fall in systolic pressure during inspiration. What is echocardiography most likely to show?

  1. Left ventricular hypertrophy
  2. Severe aortic stenosis
  3. Left atrial appendage thrombus
  4. Right ventricular collapse Correct answer.

Explanation

These findings describe cardiac tamponade, in which elevated intrapericardial pressure equalizes diastolic pressures and causes right ventricular diastolic collapse, along with pulsus paradoxus and elevated jugular venous pressure.

Question 20Cardiovascular

A 78-year-old man with severe aortic stenosis and a valve area of 0.7 cm2 reports exertional syncope and dyspnea. Ejection fraction is 35%. What is the most appropriate management?

  1. Statin therapy alone
  2. Aortic valve replacement Correct answer.
  3. Balloon aortic valvotomy
  4. Serial echocardiography every 6 months

Explanation

Once severe aortic stenosis produces symptoms such as syncope, angina, or dyspnea, prognosis without intervention is poor, and aortic valve replacement by surgery or transcatheter approach is indicated.

Question 21Pulmonary

Which spirometric finding establishes a diagnosis of COPD in a symptomatic adult with a compatible exposure history?

  1. Post-bronchodilator FEV1/FVC ratio below 0.70 Correct answer.
  2. Post-bronchodilator FEV1/FVC ratio below 0.85
  3. A 15% increase in FEV1 after bronchodilator
  4. Total lung capacity greater than 120% of predicted value

Explanation

COPD is confirmed when the post-bronchodilator FEV1/FVC ratio remains below 0.70, documenting airflow obstruction that does not fully reverse. Severity is then graded by the FEV1 percent predicted.

Question 22Pulmonary

Which organism is the most common cause of community-acquired pneumonia in adults?

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

Explanation

Streptococcus pneumoniae remains the single most frequently identified cause of community-acquired pneumonia across all adult age groups. Atypical organisms and gram-negatives are less common overall and cluster in specific hosts.

Question 23Pulmonary

A trauma patient becomes suddenly hypotensive and hypoxic with absent breath sounds on the right, distended neck veins, and tracheal deviation to the left. What is the immediate management?

  1. Observation with supplemental oxygen and serial films
  2. Flexible bronchoscopy with bronchial blocker placement
  3. Chest tube insertion after a confirmatory radiograph
  4. Immediate needle decompression of the chest Correct answer.

Explanation

These findings indicate tension pneumothorax, a clinical diagnosis that requires immediate decompression before any imaging. Needle or finger thoracostomy is followed by tube thoracostomy.

Question 24Pulmonary

A patient with suspected cavitary pulmonary tuberculosis is admitted. Which infection-control measure is indicated?

  1. Airborne precautions with an N95 respirator Correct answer.
  2. Standard precautions with gloves and gown
  3. Contact precautions with dedicated equipment
  4. Droplet precautions with a surgical mask and eye protection

Explanation

Pulmonary tuberculosis spreads by airborne droplet nuclei, so an N95 respirator and a negative-pressure room are required until the patient is proven noninfectious. Standard, droplet, and contact precautions alone do not prevent airborne transmission.

Question 25Pulmonary

Which finding is characteristic of asthma on pulmonary function testing?

  1. Reversible airflow obstruction on post-bronchodilator spirometry Correct answer.
  2. Diffusing capacity below 60% of predicted despite normal spirometry
  3. A restrictive pattern with reduced total lung capacity
  4. Increased residual volume with a normal FEV1/FVC ratio

Explanation

Asthma produces variable airflow obstruction that improves after a bronchodilator, typically by at least 12% and 200 mL in FEV1. Documentation of reversibility or bronchial hyperresponsiveness supports the diagnosis.

Question 26Pulmonary

A hemodynamically stable patient has high pretest probability for acute pulmonary embolism and no contraindication to contrast. Which study best confirms the diagnosis?

  1. Ventilation-perfusion lung scan
  2. CT pulmonary angiography Correct answer.
  3. Duplex ultrasonography of the lower extremities
  4. Plain chest radiograph

Explanation

CT pulmonary angiography directly visualizes thrombus in the pulmonary arteries and is the preferred confirmatory study in stable patients with high pretest probability. A negative D-dimer is not sufficient to exclude embolism in this group.

Question 27Pulmonary

A patient with an acute COPD exacerbation is started on supplemental oxygen. What target oxygen saturation should guide titration?

  1. 88% to 92% Correct answer.
  2. 94% to 98%
  3. 98% to 100%
  4. No specific target is needed

Explanation

In COPD with chronic hypercapnia, oxygen is titrated to 88% to 92% because uncontrolled high-flow oxygen can worsen hypercapnia through ventilation-perfusion mismatch and the Haldane effect. Higher saturations are used only when the patient is not at risk for CO2 retention.

Question 28Pulmonary

A patient with mild persistent asthma is not controlled with an as-needed short-acting beta-agonist. What is the preferred controller regimen?

  1. Long-acting beta-agonist monotherapy
  2. As-needed short-acting beta-agonist only
  3. Low-dose inhaled corticosteroid Correct answer.
  4. Daily oral prednisone

Explanation

Inhaled corticosteroids are the cornerstone of controller therapy for persistent asthma and are first-line at the mild persistent step. Long-acting beta-agonists are never used as monotherapy in asthma because of the risk of severe exacerbation.

Question 29Pulmonary

A 72-year-old man with community-acquired pneumonia has confusion, respiratory rate 32/min, blood pressure 118/70 mmHg, BUN 25 mg/dL, and temperature 38.5 C. What is his CURB-65 score?

  1. 5
  2. 2
  3. 4 Correct answer.
  4. 3

Explanation

CURB-65 assigns one point each for confusion, urea above 7 mmol/L (BUN above 19 mg/dL), respiratory rate 30/min or greater, low blood pressure, and age 65 or older. This patient scores for confusion, BUN, respiratory rate, and age, giving 4 points and high mortality risk.

Question 30Pulmonary

Thoracentesis in a patient with a large pleural effusion shows a pleural fluid protein of 4.2 g/dL with a serum protein of 6.0 g/dL. How is this fluid classified?

  1. Exudate, because the fluid-to-serum protein ratio exceeds 0.5 Correct answer.
  2. Exudate, because the pleural LDH is low
  3. Transudate, because the pleural glucose is normal
  4. Transudate, because the pleural pH is normal

Explanation

Light's criteria classify an effusion as exudative when the pleural-to-serum protein ratio exceeds 0.5, the pleural-to-serum LDH ratio exceeds 0.6, or pleural LDH exceeds two-thirds the upper limit of normal serum LDH. A ratio of 4.2/6.0 equals 0.70 and meets criteria.

Question 31Pulmonary

Which finding satisfies diagnostic criteria for obstructive sleep apnea in an adult with compatible symptoms?

  1. An apnea-hypopnea index of 30 or greater regardless of symptoms
  2. An apnea-hypopnea index of 2 or greater
  3. An apnea-hypopnea index of 5 or greater with daytime sleepiness Correct answer.
  4. Oxygen saturation below 90% for at least 5 minutes

Explanation

Obstructive sleep apnea is diagnosed when the apnea-hypopnea index is 5 or more accompanied by symptoms such as excessive daytime sleepiness, or when the index is 15 or more regardless of symptoms. The threshold separates abnormal from borderline respiratory event rates.

Question 32Pulmonary

A 45-year-old lifelong nonsmoker has emphysema. Which feature should raise suspicion for alpha-1 antitrypsin deficiency?

  1. A 40 pack-year smoking history
  2. Predominantly apical bullous disease
  3. Disease onset after age 65
  4. Basilar-predominant emphysema Correct answer.

Explanation

Alpha-1 antitrypsin deficiency classically causes panacinar emphysema that is worse at the lung bases, often presenting before age 50 in nonsmokers, and may be accompanied by liver disease. Smoking-related emphysema is typically centrilobular and upper-lobe predominant.

Question 33Pulmonary

Which chest imaging finding is most characteristic of pulmonary sarcoidosis?

  1. Cavitary lesions in the upper lobes
  2. Bilateral hilar lymphadenopathy Correct answer.
  3. Peripheral honeycombing with traction bronchiectasis
  4. A large unilateral pleural effusion

Explanation

Sarcoidosis typically produces symmetric bilateral hilar adenopathy, sometimes with right paratracheal involvement, and biopsy shows noncaseating granulomas. Effusions and cavitation are uncommon and suggest alternative diagnoses.

Question 34Pulmonary

Which pulmonary function pattern is expected in idiopathic pulmonary fibrosis?

  1. Normal spirometry with a reduced residual volume
  2. Obstructive pattern that reverses with a bronchodilator
  3. Obstructive pattern with an elevated diffusing capacity
  4. Restrictive pattern with a reduced diffusing capacity Correct answer.

Explanation

Idiopathic pulmonary fibrosis causes restrictive physiology with reduced lung volumes and impaired gas transfer from alveolar-capillary membrane thickening. Examination typically shows bibasilar fine crackles and clubbing.

Question 35Pulmonary

Which patient meets criteria for annual low-dose CT lung cancer screening?

  1. A 65-year-old lifelong nonsmoker with a family history
  2. A 55-year-old with 15 pack-years who quit 20 years ago
  3. A 40-year-old with a 5 pack-year history
  4. A 60-year-old with 30 pack-years who still smokes Correct answer.

Explanation

Screening is recommended for adults aged 50 to 80 with at least a 20 pack-year history who currently smoke or quit within the past 15 years. This patient meets age and exposure criteria and remains a current smoker.

Question 36Pulmonary

A patient in status asthmaticus remains severely wheezing with a PaCO2 of 48 mmHg despite continuous nebulized albuterol, ipratropium, and systemic corticosteroids. Which adjunct is indicated?

  1. Intravenous antibiotics
  2. Oral montelukast
  3. Intravenous magnesium sulfate Correct answer.
  4. Nebulized racemic epinephrine

Explanation

Intravenous magnesium sulfate provides smooth muscle relaxation and is recommended as an adjunct for severe asthma exacerbations that respond poorly to first-line bronchodilators and steroids. A rising PaCO2 signals impending respiratory failure and warrants close monitoring for intubation.

Question 37Pulmonary

Which presentation meets the Berlin definition of acute respiratory distress syndrome?

  1. Bilateral opacities with PaO2/FiO2 of 400 on PEEP 5, onset 5 days after sepsis
  2. Bilateral fibrosis with PaO2/FiO2 of 200, unchanged for 8 months
  3. Bilateral opacities with PaO2/FiO2 of 150 on PEEP 10, onset 2 days after pneumonia Correct answer.
  4. Unilateral infiltrate with PaO2/FiO2 of 250 on PEEP 8, onset 3 days after surgery

Explanation

ARDS requires onset within one week of a known insult, bilateral opacities not fully explained by cardiac failure, and a PaO2/FiO2 of 300 or less on PEEP of at least 5 cm H2O. A ratio of 150 on PEEP 10 represents moderate ARDS.

Question 38Pulmonary

A patient with COPD exacerbation has a pH of 7.28 and PaCO2 of 65 mmHg after bronchodilators and controlled oxygen therapy. What is the most appropriate next step?

  1. High-flow oxygen to maintain saturation above 95%
  2. Noninvasive positive pressure ventilation Correct answer.
  3. Discharge home with oral antibiotics
  4. Immediate endotracheal intubation

Explanation

Noninvasive ventilation is indicated for COPD exacerbations with respiratory acidosis in the pH range of about 7.20 to 7.35 and hypercapnia, reducing intubation rates and mortality. Intubation is reserved for failure of noninvasive support, severe acidosis, or inability to protect the airway.

Question 39Pulmonary

A patient with stable COPD has chronic hypercapnia with a PaCO2 of 60 mmHg and pH 7.34. Using standard compensation rules, which serum bicarbonate value is expected?

  1. 12 mEq/L
  2. 44 mEq/L
  3. 32 mEq/L Correct answer.
  4. 24 mEq/L

Explanation

In chronic respiratory acidosis the kidneys retain bicarbonate, raising it roughly 4 mEq/L for every 10 mmHg rise in PaCO2 above 40. A PaCO2 of 60 mmHg predicts a bicarbonate near 32 mEq/L, which explains the near-normal pH.

Question 40Pulmonary

Which patient with severe COPD is the best candidate for lung volume reduction surgery?

  1. Continued smoking with FEV1 20% and no rehabilitation
  2. Homogeneous emphysema with FEV1 15% and continued smoking
  3. Upper-lobe predominant emphysema with FEV1 30% after rehabilitation Correct answer.
  4. Severe bronchiectasis with daily purulent sputum

Explanation

Lung volume reduction surgery benefits patients with upper-lobe predominant emphysema, FEV1 between roughly 20% and 45%, low exercise capacity after pulmonary rehabilitation, and abstinence from smoking. Heterogeneous upper-lobe disease allows targeted resection of hyperinflated tissue.

Question 41Gastrointestinal and Nutrition

A 30-year-old with chronic diarrhea and iron deficiency anemia is being screened for celiac disease while still eating gluten. Which test is most appropriate?

  1. Fecal calprotectin
  2. Antimitochondrial antibody
  3. Anti-smooth muscle antibody
  4. tTG-IgA with total IgA Correct answer.

Explanation

IgA tissue transglutaminase combined with a total IgA level is the preferred screen, because selective IgA deficiency can cause a false-negative serologic result; the patient must remain on a gluten-containing diet for accuracy. Positive serology is then confirmed with duodenal biopsy.

Question 42Gastrointestinal and Nutrition

A patient with 8 hours of severe epigastric pain radiating to the back is being evaluated for acute pancreatitis. Which laboratory test is the most specific marker of pancreatic injury?

  1. Serum amylase
  2. Serum ALT
  3. Serum alkaline phosphatase
  4. Serum lipase Correct answer.

Explanation

Lipase is more specific than amylase for pancreatic injury, stays elevated longer, and a value greater than three times the upper limit of normal strongly supports the diagnosis. Amylase also rises with salivary gland disease, bowel ischemia, and renal failure.

Question 43Gastrointestinal and Nutrition

A 40-year-old woman has 6 hours of constant right upper quadrant pain, fever, and a positive Murphy sign. Which imaging study is the best initial choice?

  1. Plain abdominal radiograph
  2. Right upper quadrant ultrasound Correct answer.
  3. HIDA scan
  4. CT of the abdomen with contrast

Explanation

Ultrasound is the initial imaging test of choice for suspected acute cholecystitis because it is rapid, inexpensive, and identifies stones, wall thickening, and pericholecystic fluid. Cholescintigraphy is reserved for cases with an equivocal ultrasound.

Question 44Gastrointestinal and Nutrition

A 28-year-old woman reports 8 months of recurrent abdominal pain that improves with defecation, alternating constipation and diarrhea, and no weight loss or rectal bleeding. Examination and screening laboratories are normal. What is the most likely diagnosis?

  1. Celiac disease
  2. Irritable bowel syndrome Correct answer.
  3. Ulcerative colitis
  4. Chronic pancreatitis

Explanation

Pain relieved by defecation together with a change in stool frequency or form, in the absence of alarm features, satisfies symptom-based criteria for irritable bowel syndrome. Normal laboratories and the absence of bleeding, weight loss, or anemia support a functional disorder.

Question 45Gastrointestinal and Nutrition

A 62-year-old with osteoarthritis and a prior peptic ulcer needs to continue an NSAID for pain control. Which agent best reduces the risk of recurrent ulcer?

  1. Misoprostol twice daily
  2. Daily proton pump inhibitor Correct answer.
  3. Bedtime H2-receptor antagonist
  4. Sucralfate four times daily

Explanation

A proton pump inhibitor is the preferred gastroprotective agent for patients on chronic NSAIDs, particularly those with a history of ulcer disease. Standard-dose H2 blockers are less effective, and misoprostol is limited by diarrhea and cramping.

Question 46Gastrointestinal and Nutrition

A 70-year-old is hospitalized after a stroke with dysphagia but a normally functioning gastrointestinal tract. Which feeding strategy is preferred?

  1. Enteral nutrition by nasogastric tube Correct answer.
  2. Total parenteral nutrition
  3. Nothing by mouth with intravenous fluids only
  4. Peripheral parenteral nutrition

Explanation

Enteral feeding is preferred whenever the gut works because it maintains mucosal integrity, costs less, and causes fewer infectious complications than parenteral nutrition. Parenteral nutrition is reserved for intestinal failure or an unusable gastrointestinal tract.

Question 47Gastrointestinal and Nutrition

A 57-year-old man with a 6-year history of heartburn now reports progressive dysphagia and 6 kg of unintentional weight loss. He has taken a proton pump inhibitor daily for 3 months. What is the most appropriate next step?

  1. Barium swallow study
  2. Esophagogastroduodenoscopy Correct answer.
  3. Continue the current proton pump inhibitor for another 8 weeks
  4. H. pylori stool antigen testing

Explanation

Dysphagia and unintentional weight loss are alarm features that warrant prompt upper endoscopy to exclude stricture, Barrett esophagus with dysplasia, and malignancy, regardless of prior acid suppression. Endoscopy also allows biopsy of any identified lesion.

Question 48Gastrointestinal and Nutrition

A 45-year-old with a duodenal ulcer has confirmed H. pylori infection, no prior antibiotic exposure, and lives in a region with low clarithromycin resistance. Which regimen is most appropriate?

  1. PPI plus amoxicillin and clarithromycin for 14 days Correct answer.
  2. Proton pump inhibitor alone for 8 weeks
  3. Amoxicillin and clarithromycin for 7 days without acid suppression
  4. Bismuth subsalicylate for 4 weeks

Explanation

Standard triple therapy consisting of a proton pump inhibitor plus amoxicillin and clarithromycin for 14 days is an accepted first-line regimen where clarithromycin resistance is low. Adequate acid suppression is essential, and 14-day courses achieve higher eradication rates than shorter ones.

Question 49Gastrointestinal and Nutrition

A 58-year-old with alcohol-related cirrhosis and ascites undergoes diagnostic paracentesis for fever and abdominal pain. Ascitic fluid shows 400 polymorphonuclear cells per mm3. What is the most appropriate immediate management?

  1. Await cytology results before treating
  2. Start intravenous ceftriaxone Correct answer.
  3. Repeat paracentesis in 72 hours before treating
  4. Start oral lactulose

Explanation

An ascitic polymorphonuclear count of 250 cells per mm3 or greater establishes spontaneous bacterial peritonitis, and treatment must begin immediately without waiting for culture. A third-generation cephalosporin such as ceftriaxone is standard, with intravenous albumin added in high-risk patients to reduce renal failure.

Question 50Gastrointestinal and Nutrition

A patient with cirrhosis presents with confusion, asterixis, and active gastrointestinal bleeding. Which approach to the encephalopathy is correct?

  1. Lactulose to four to six loose stools daily
  2. Rifaximin as monotherapy
  3. Lactulose to two or three soft stools daily Correct answer.
  4. Metronidazole for 7 days

Explanation

Lactulose is first-line therapy and is titrated to two or three soft stools per day; heavier dosing causes dehydration and electrolyte disturbance. Rifaximin is added for secondary prophylaxis after recurrent episodes rather than as initial monotherapy.