I85PREP
⌘ K
MCPS Family Medicine study materials
MCPS Family Medicine study resources

MCPS Family Medicine practice questions

One question at a time. Build your MCPS Family Medicine 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 1Internal Medicine and Adult Primary Care

A 58-year-old man with type 2 diabetes has an eGFR of 38 mL/min/1.73 m² and a urine albumin-to-creatinine ratio of 450 mg/g. Which medication most reliably slows progression of his diabetic kidney disease?

  1. Dapagliflozin Correct answer.
  2. Aspirin
  3. Furosemide
  4. Amlodipine

Explanation

SGLT2 inhibitors reduce albuminuria and slow eGFR decline in diabetic kidney disease, with benefit demonstrated even at reduced eGFR, and are recommended alongside renin-angiotensin blockade. Calcium channel blockers and loop diuretics address blood pressure or volume but do not confer this kidney-protective effect.

Question 2Internal Medicine and Adult Primary Care

Which finding best meets the diagnostic threshold for metabolic syndrome in an adult man?

  1. HDL cholesterol 45 mg/dL
  2. Fasting glucose 104 mg/dL Correct answer.
  3. Triglycerides 140 mg/dL
  4. Waist circumference 96 cm

Explanation

Metabolic syndrome requires at least three of five criteria; impaired fasting glucose is defined as 100 mg/dL or higher, so 104 mg/dL qualifies. The other listed values fall below the thresholds for elevated waist circumference, hypertriglyceridemia, and low HDL in men.

Question 3Internal Medicine and Adult Primary Care

A 34-year-old woman has a blood pressure of 148/94 mmHg on two separate visits using a correctly sized cuff. She takes no medications. Which is the most appropriate initial management?

  1. Prescribe an ACE inhibitor and a beta blocker together
  2. Start a thiazide-type diuretic immediately
  3. Recommend lifestyle modification and reassess Correct answer.
  4. Admit for intravenous antihypertensive therapy

Explanation

Stage 1 hypertension without established cardiovascular disease, diabetes, or kidney disease is initially managed with lifestyle modification and reassessment rather than immediate pharmacotherapy. Combination therapy and intravenous treatment are reserved for higher-risk or hypertensive emergency presentations.

Question 4Internal Medicine and Adult Primary Care

A 62-year-old man with heart failure and reduced ejection fraction remains symptomatic despite maximally tolerated ACE inhibitor and beta blocker. Which additional agent improves survival in this setting?

  1. Furosemide
  2. Dihydropyridine calcium channel blocker
  3. Digoxin
  4. Mineralocorticoid receptor antagonist Correct answer.

Explanation

Mineralocorticoid receptor antagonists such as spironolactone reduce mortality in heart failure with reduced ejection fraction and are a guideline-recommended add-on. Digoxin and loop diuretics improve symptoms but not survival, and dihydropyridine calcium channel blockers are not indicated for systolic heart failure.

Question 5Internal Medicine and Adult Primary Care

A 55-year-old woman has a fasting LDL cholesterol of 165 mg/dL and no other cardiovascular risk factors. She has already made dietary changes for three months without improvement. Which is the most appropriate next step?

  1. Begin ezetimibe monotherapy
  2. Order lipoprotein(a) testing
  3. Reassure and recheck in one year
  4. Begin a moderate-intensity statin Correct answer.

Explanation

For adults without diabetes but with an LDL of 160 mg/dL or higher and inadequate response to lifestyle change, moderate-intensity statin therapy is recommended. Ezetimibe is an add-on, lipoprotein(a) testing does not guide initial therapy, and deferring treatment ignores a persistent elevation.

Question 6Internal Medicine and Adult Primary Care

A 28-year-old woman presents with palpitations and is found to have an irregularly irregular narrow-complex tachycardia. She is hemodynamically stable. Which is the most appropriate initial management?

  1. Rate control with a beta blocker Correct answer.
  2. Immediate synchronized cardioversion
  3. Vagal maneuvers
  4. Intravenous adenosine

Explanation

Stable atrial fibrillation is managed initially with rate control using a beta blocker or calcium channel blocker. Cardioversion is reserved for instability, adenosine is used for regular narrow-complex tachycardias such as AVNRT, and vagal maneuvers have no role in atrial fibrillation.

Question 7Internal Medicine and Adult Primary Care

Which medication should be avoided in a patient with chronic kidney disease and an eGFR of 25 mL/min/1.73 m² because of the risk of hyperkalemia and worsening renal function?

  1. Amoxicillin
  2. Spironolactone Correct answer.
  3. Furosemide
  4. Atorvastatin

Explanation

Mineralocorticoid receptor antagonists such as spironolactone increase the risk of hyperkalemia and acute kidney injury in advanced chronic kidney disease and should generally be avoided. Furosemide, amoxicillin with dose adjustment, and atorvastatin are acceptable in this population.

Question 8Internal Medicine and Adult Primary Care

A 45-year-old man with a BMI of 34 kg/m² and type 2 diabetes has an HbA1c of 8.4% on metformin. He is concerned about weight gain. Which add-on agent best addresses both glycemia and weight?

  1. Glipizide
  2. Insulin glargine
  3. Pioglitazone
  4. Semaglutide Correct answer.

Explanation

GLP-1 receptor agonists such as semaglutide improve glycemic control while promoting weight loss, making them ideal when weight gain is a concern. Sulfonylureas, insulin, and thiazolidinediones all promote weight gain.

Question 9Internal Medicine and Adult Primary Care

A 30-year-old woman has fatigue, weight gain, and constipation with a TSH of 12 mIU/L and a free T4 of 0.6 ng/dL. Which is the most appropriate treatment?

  1. Levothyroxine Correct answer.
  2. Radioactive iodine
  3. Methimazole
  4. Propranolol

Explanation

The combination of elevated TSH with low free T4 confirms primary hypothyroidism, treated with levothyroxine replacement. Methimazole, radioactive iodine, and propranolol are used to treat hyperthyroidism, not hypothyroidism.

Question 10Internal Medicine and Adult Primary Care

A 68-year-old man has a hemoglobin of 10.8 g/dL, a mean corpuscular volume of 72 fL, and a ferritin of 12 ng/mL. Which is the most appropriate next step?

  1. Begin vitamin B12 replacement
  2. Order hemoglobin electrophoresis
  3. Transfuse packed red blood cells
  4. Begin oral iron and evaluate for a gastrointestinal source of blood loss Correct answer.

Explanation

Microcytic anemia with a low ferritin confirms iron deficiency, and in an older adult it warrants evaluation for gastrointestinal blood loss alongside iron replacement. B12 deficiency causes macrocytosis, transfusion is reserved for symptomatic severe anemia, and hemoglobin electrophoresis is for suspected hemoglobinopathy.

Question 11Internal Medicine and Adult Primary Care

A 24-year-old woman reports a three-month history of fatigue, joint pain, and a malar rash. Which laboratory test is most specific for systemic lupus erythematosus?

  1. Rheumatoid factor
  2. Anti-double-stranded DNA antibody Correct answer.
  3. C-reactive protein
  4. Antinuclear antibody

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity. Antinuclear antibody is sensitive but not specific, while rheumatoid factor and C-reactive protein are nonspecific markers.

Question 12Internal Medicine and Adult Primary Care

A 70-year-old woman reports sudden severe pain and swelling of the first metatarsophalangeal joint. Aspiration reveals needle-shaped negatively birefringent crystals. Which is the most appropriate treatment for the acute attack?

  1. Allopurinol at high dose
  2. Febuxostat
  3. Colchicine, NSAIDs, or corticosteroids Correct answer.
  4. Probenecid

Explanation

Acute gout is treated with colchicine, NSAIDs, or corticosteroids to control inflammation. Urate-lowering agents such as allopurinol, febuxostat, and probenecid are not started during an acute flare and do not treat acute inflammation.

Question 13Internal Medicine and Adult Primary Care

A 50-year-old man has a blood pressure of 158/96 mmHg, hypokalemia, and an elevated aldosterone-to-renin ratio. Which condition is most likely?

  1. Pheochromocytoma
  2. Cushing syndrome
  3. Primary aldosteronism Correct answer.
  4. Renal artery stenosis

Explanation

Hypertension with hypokalemia and a high aldosterone-to-renin ratio is characteristic of primary aldosteronism. Pheochromocytoma causes catecholamine excess, renal artery stenosis raises renin, and Cushing syndrome causes cortisol excess.

Question 14Internal Medicine and Adult Primary Care

A 66-year-old man with a 40 pack-year smoking history reports progressive dyspnea and a chronic cough. Which test is most appropriate to evaluate for chronic obstructive pulmonary disease?

  1. Echocardiography
  2. D-dimer
  3. Spirometry Correct answer.
  4. Chest radiograph

Explanation

Spirometry demonstrating a post-bronchodilator FEV1/FVC ratio below 0.70 confirms airflow obstruction and is required to diagnose COPD. Chest radiography, D-dimer, and echocardiography evaluate alternative or complicating conditions but do not establish the diagnosis.

Question 15Internal Medicine and Adult Primary Care

A 40-year-old woman has a six-week history of depressed mood, anhedonia, poor sleep, and impaired concentration. She has no suicidal ideation. Which is the most appropriate initial treatment?

  1. Psychotherapy or a selective serotonin reuptake inhibitor Correct answer.
  2. Lithium
  3. Atypical antipsychotic monotherapy
  4. Electroconvulsive therapy

Explanation

Major depressive disorder of mild to moderate severity is initially treated with psychotherapy, an SSRI, or both. Electroconvulsive therapy, antipsychotic monotherapy, and lithium are reserved for severe, treatment-resistant, or bipolar presentations.

Question 16Internal Medicine and Adult Primary Care

A 72-year-old man has a serum sodium of 122 mEq/L and confusion. He is hemodynamically stable and asymptomatic neurologically apart from confusion. Which is the most appropriate initial step?

  1. Rapid correction with hypertonic saline to a normal sodium within four hours
  2. Fluid restriction alone without further evaluation
  3. Administer intravenous furosemide alone
  4. Assess volume status and correct sodium slowly Correct answer.

Explanation

Hyponatremia management begins with assessment of volume status to identify the cause, followed by gradual correction to avoid osmotic demyelination. Rapid normalization of chronic hyponatremia risks serious neurologic injury, and treatment must be tailored to the underlying cause.

Question 17Internal Medicine and Adult Primary Care

A 60-year-old woman has a new painless breast lump. Which is the most appropriate next step in evaluation?

  1. Bilateral mastectomy
  2. Reassurance and repeat examination in six months
  3. Diagnostic mammography and breast ultrasound Correct answer.
  4. Fine-needle aspiration without imaging

Explanation

A new painless breast lump in an older woman warrants diagnostic imaging with mammography and ultrasound, often followed by tissue sampling. Observation delays diagnosis, aspiration without imaging is inadequate, and surgery is not performed before diagnosis.

Question 18Internal Medicine and Adult Primary Care

Which is the most appropriate colorectal cancer screening method for an average-risk 50-year-old adult?

  1. Colonoscopy every ten years Correct answer.
  2. Fecal immunochemical test every five years
  3. CT colonography every ten years
  4. Flexible sigmoidoscopy every ten years

Explanation

Colonoscopy every ten years is an accepted primary screening strategy for average-risk adults beginning at age 45 to 50. Sigmoidoscopy and CT colonography are recommended at shorter intervals, and fecal immunochemical testing is recommended annually.

Question 19Internal Medicine and Adult Primary Care

A 35-year-old man has a two-day history of dysuria and urethral discharge. Which is the most appropriate initial management?

  1. Observation without treatment
  2. Topical corticosteroid cream
  3. Empiric ceftriaxone plus azithromycin or doxycycline Correct answer.
  4. Oral fluconazole alone

Explanation

Presumed gonococcal and chlamydial urethritis is treated empirically with ceftriaxone plus a second agent such as doxycycline or azithromycin. Fluconazole treats candidiasis, observation risks complications and transmission, and topical steroids have no role.

Question 20Internal Medicine and Adult Primary Care

A 68-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. Which is the most appropriate therapy to reduce stroke risk?

  1. No antithrombotic therapy
  2. Clopidogrel monotherapy
  3. Aspirin monotherapy
  4. Anticoagulation with a direct oral anticoagulant Correct answer.

Explanation

A CHA2DS2-VASc score of 4 confers a high stroke risk, and anticoagulation with a direct oral anticoagulant or warfarin is indicated. Aspirin and clopidogrel provide inadequate stroke protection, and withholding therapy leaves the patient at high risk.

Question 21Internal Medicine and Adult Primary Care

A 55-year-old woman has a thyroid nodule and a suppressed TSH. Which is the most appropriate next step?

  1. Radioactive iodine uptake scan Correct answer.
  2. Levothyroxine therapy
  3. Fine-needle aspiration
  4. Repeat TSH in one year

Explanation

A suppressed TSH with a thyroid nodule suggests a hyperfunctioning nodule, and a radioactive iodine uptake scan distinguishes autonomous function from other causes. Fine-needle aspiration is indicated for euthyroid or hypothyroid nodules, and levothyroxine would worsen hyperthyroidism.

Question 22Internal Medicine and Adult Primary Care

A 62-year-old man has worsening exertional dyspnea and bilateral basilar crackles with an elevated BNP. Which is the most appropriate initial therapy for his volume overload?

  1. Loop diuretic Correct answer.
  2. Beta blocker
  3. ACE inhibitor
  4. Statin

Explanation

Symptomatic volume overload in heart failure is treated with a loop diuretic to relieve congestion. Beta blockers, ACE inhibitors, and statins are important for long-term management but do not acutely relieve fluid overload.

Question 23Internal Medicine and Adult Primary Care

A 45-year-old woman has a positive antinuclear antibody test, dry eyes, and a positive Schirmer test. Which condition is most likely?

  1. Scleroderma
  2. Rheumatoid arthritis
  3. Polymyositis
  4. Sjögren syndrome Correct answer.

Explanation

Dry eyes with a positive Schirmer test and antinuclear antibodies is characteristic of Sjögren syndrome. Rheumatoid arthritis, scleroderma, and polymyositis have different clinical and serologic features.

Question 24Internal Medicine and Adult Primary Care

A 30-year-old man has a one-week history of fever, sore throat, and cervical lymphadenopathy with atypical lymphocytes on smear. Which test is most appropriate to confirm the diagnosis?

  1. Cytomegalovirus PCR
  2. HIV antibody test
  3. Heterophile antibody test Correct answer.
  4. Rapid strep test

Explanation

Fever, pharyngitis, lymphadenopathy, and atypical lymphocytes suggest infectious mononucleosis, confirmed with a heterophile antibody test. Rapid strep testing addresses bacterial pharyngitis, and HIV and CMV testing are considered when heterophile testing is negative or the picture is atypical.

Question 25Internal Medicine and Adult Primary Care

A 70-year-old woman has a creatinine of 1.8 mg/dL, a urinalysis with red blood cell casts, and a recent upper respiratory infection. Which diagnosis is most likely?

  1. IgA nephropathy Correct answer.
  2. Nephrotic syndrome
  3. Prerenal azotemia
  4. Acute tubular necrosis

Explanation

Hematuria with red blood cell casts after a respiratory infection is characteristic of IgA nephropathy, a glomerulonephritis. Acute tubular necrosis and prerenal azotemia lack red blood cell casts, and nephrotic syndrome presents with heavy proteinuria rather than an active urinary sediment.

Question 26Internal Medicine and Adult Primary Care

A 58-year-old man with type 2 diabetes and a history of myocardial infarction is being discharged after an uncomplicated hospital stay for pneumonia. His medications include metformin, lisinopril, atorvastatin, and aspirin. Which additional medication has the strongest evidence for reducing major adverse cardiovascular events in this patient?

  1. Pioglitazone
  2. Empagliflozin Correct answer.
  3. Glipizide
  4. Sitagliptin

Explanation

SGLT2 inhibitors such as empagliflozin reduce major adverse cardiovascular events and hospitalization for heart failure in patients with type 2 diabetes and established atherosclerotic cardiovascular disease. This benefit is independent of glycemic control and is recommended by major guidelines for secondary prevention in this population.

Question 27Internal Medicine and Adult Primary Care

A 35-year-old woman presents with a two-day history of dysuria, urinary frequency, and suprapubic discomfort. She has no fever, flank pain, or vaginal discharge. She is not pregnant and has no known drug allergies. Which is the most appropriate first-line antibiotic?

  1. Ciprofloxacin for 7 days
  2. Trimethoprim-sulfamethoxazole for 3 days
  3. Amoxicillin-clavulanate for 10 days
  4. Nitrofurantoin monohydrate/macrocrystals for 5 days Correct answer.

Explanation

Nitrofurantoin for 5 days is a first-line regimen for acute uncomplicated cystitis because of its efficacy against Escherichia coli and low collateral damage. Fluoroquinolones are reserved for more serious infections due to concerns about resistance and adverse effects, and beta-lactams are generally less effective than first-line agents.

Question 28Internal Medicine and Adult Primary Care

A 62-year-old woman with a history of hypertension and hyperlipidemia presents with sudden onset of painless vision loss in her right eye that lasted 10 minutes and then resolved. She has no headache or jaw claudication. Which is the most appropriate next step in management?

  1. Prescribe aspirin and arrange outpatient ophthalmology follow-up Correct answer.
  2. Obtain an urgent erythrocyte sedimentation rate and start high-dose corticosteroids
  3. Order a transthoracic echocardiogram and Holter monitor
  4. Perform immediate carotid endarterectomy

Explanation

Transient monocular vision loss (amaurosis fugax) is a symptom of retinal ischemia and a predictor of stroke. The patient should be started on antiplatelet therapy and undergo urgent evaluation for carotid artery disease and cardiovascular risk factors. Immediate corticosteroids are indicated for giant cell arteritis, which typically presents with headache, jaw claudication, and elevated inflammatory markers, not isolated transient vision loss.

Question 29Internal Medicine and Adult Primary Care

A 45-year-old man is diagnosed with major depressive disorder after a single episode of moderate severity. He has no suicidal ideation, psychotic symptoms, or history of mania. Which is the most appropriate initial treatment?

  1. A monoamine oxidase inhibitor as first-line therapy
  2. Electroconvulsive therapy
  3. A low-dose antipsychotic alone
  4. A selective serotonin reuptake inhibitor combined with cognitive behavioral therapy Correct answer.

Explanation

For moderate major depressive disorder, guidelines recommend combining psychotherapy (such as cognitive behavioral therapy) with an antidepressant, typically an SSRI, as initial treatment. This combination improves adherence and outcomes compared with either modality alone. Electroconvulsive therapy and monoamine oxidase inhibitors are reserved for severe, treatment-resistant, or atypical cases.

Question 30Internal Medicine and Adult Primary Care

A 68-year-old man with chronic obstructive pulmonary disease (COPD) and a forced expiratory volume in 1 second (FEV1) of 45% of predicted presents with increased dyspnea, increased sputum volume, and change in sputum color. He is hemodynamically stable and has no signs of pneumonia on chest radiograph. Which is the most appropriate initial management?

  1. Intravenous aminophylline
  2. Inhaled short-acting bronchodilators, systemic corticosteroids, and antibiotics Correct answer.
  3. Inhaled short-acting bronchodilators alone
  4. Immediate noninvasive positive pressure ventilation

Explanation

This patient has an acute exacerbation of COPD with all three cardinal symptoms (worsened dyspnea, increased sputum volume, and increased sputum purulence), which warrants antibiotics in addition to bronchodilators and a short course of systemic corticosteroids. These interventions reduce treatment failure and improve oxygenation. Noninvasive ventilation is reserved for patients with respiratory failure or acidosis.

Question 31Internal Medicine and Adult Primary Care

A 55-year-old woman with a history of hypertension and diabetes presents with a blood pressure of 168/98 mmHg despite adherence to lisinopril, amlodipine, and hydrochlorothiazide at maximally tolerated doses. Her serum potassium is 3.2 mEq/L and her estimated glomerular filtration rate is 75 mL/min/1.73 m². Which is the most appropriate next step?

  1. Add a beta blocker
  2. Increase the hydrochlorothiazide dose
  3. Add spironolactone
  4. Screen for primary aldosteronism Correct answer.

Explanation

Resistant hypertension accompanied by spontaneous hypokalemia should prompt screening for primary aldosteronism, typically with a plasma aldosterone concentration and plasma renin activity. Identifying and treating primary aldosteronism reduces cardiovascular and renal complications. Adding spironolactone is a treatment option for resistant hypertension but should be preceded by diagnostic evaluation when hypokalemia is present.

Question 32Internal Medicine and Adult Primary Care

A 70-year-old man presents with a three-week history of progressive dyspnea on exertion, orthopnea, and bilateral leg swelling. On examination, he has jugular venous distension, bibasilar crackles, and a third heart sound. Which is the most appropriate initial medication to improve symptoms and reduce mortality?

  1. Verapamil
  2. Furosemide Correct answer.
  3. Prednisone
  4. Diltiazem

Explanation

This patient has heart failure with reduced ejection fraction and volume overload. Loop diuretics such as furosemide are used to relieve congestion and improve symptoms, and they are a cornerstone of acute management. Verapamil and diltiazem are negative inotropes and should be avoided in heart failure with reduced ejection fraction.

Question 33Internal Medicine and Adult Primary Care

A 30-year-old woman presents with a three-day history of fever, sore throat, and tender cervical lymphadenopathy. Rapid antigen testing for group A streptococcus is negative. Which is the most appropriate next step?

  1. Reassure and provide symptomatic care only
  2. Prescribe amoxicillin empirically
  3. Prescribe azithromycin empirically
  4. Perform a throat culture Correct answer.

Explanation

In adults with symptoms suggestive of streptococcal pharyngitis and a negative rapid antigen test, a throat culture is recommended to confirm the diagnosis before initiating antibiotics. This approach reduces unnecessary antibiotic use and prevents complications such as rheumatic fever. Empiric antibiotics are not recommended when testing is available.

Question 34Internal Medicine and Adult Primary Care

A 50-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. He is admitted and treated with intravenous thiamine. Which additional treatment is most important to prevent worsening of his neurologic symptoms?

  1. Intravenous magnesium
  2. Intravenous glucose Correct answer.
  3. Oral thiamine
  4. Intravenous folate

Explanation

This patient has Wernicke encephalopathy, a thiamine deficiency syndrome. Intravenous thiamine should be given before or with glucose to prevent precipitation of Wernicke encephalopathy, because glucose administration can rapidly consume remaining thiamine. Oral thiamine is insufficient for acute treatment, and magnesium and folate are not the primary treatment for this condition.

Question 35Internal Medicine and Adult Primary Care

A 65-year-old woman presents with a two-month history of fatigue, weight loss, and diffuse musculoskeletal pain. She has a hemoglobin of 10.2 g/dL and an erythrocyte sedimentation rate of 85 mm/h. Which is the most appropriate next step in diagnosis?

  1. Antinuclear antibody testing
  2. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies
  3. Serum protein electrophoresis
  4. Temporal artery biopsy Correct answer.

Explanation

The presentation suggests giant cell arteritis, which can cause anemia, elevated inflammatory markers, and constitutional symptoms. Temporal artery biopsy is the gold standard for diagnosis, although treatment with corticosteroids should not be delayed while awaiting biopsy. Rheumatoid factor and ANA are not diagnostic for giant cell arteritis.

Question 36Internal Medicine and Adult Primary Care

A 40-year-old man with a body mass index of 32 kg/m² and no other medical problems is found to have a fasting plasma glucose of 128 mg/dL on two occasions. Which is the most appropriate initial management?

  1. Lifestyle modification with diet and exercise Correct answer.
  2. Metformin monotherapy
  3. Basal insulin
  4. A sulfonylurea

Explanation

This patient meets criteria for type 2 diabetes (fasting glucose ≥126 mg/dL on two occasions). For most patients with newly diagnosed type 2 diabetes without severe symptoms or complications, lifestyle modification with diet and exercise is the first-line intervention. Pharmacotherapy is added if glycemic targets are not met after three to six months.

Question 37Internal Medicine and Adult Primary Care

A 28-year-old woman presents with a three-month history of fatigue, cold intolerance, weight gain, and constipation. Her thyroid-stimulating hormone is 12 mIU/L and her free T4 is 0.6 ng/dL. She is not pregnant. Which is the most appropriate treatment?

  1. Radioactive iodine ablation
  2. Methimazole
  3. Liothyronine alone
  4. Levothyroxine at a weight-based dose Correct answer.

Explanation

The patient has primary hypothyroidism, indicated by an elevated TSH and low free T4. Levothyroxine is the treatment of choice and should be started at a weight-based dose (approximately 1.6 mcg/kg/day) in young, otherwise healthy adults, then adjusted based on TSH levels. Liothyronine, methimazole, and radioactive iodine are not appropriate for hypothyroidism.

Question 38Internal Medicine and Adult Primary Care

A 72-year-old man with a history of hypertension and diabetes presents with a blood pressure of 178/100 mmHg and a serum creatinine of 2.4 mg/dL (baseline 1.2 mg/dL). He reports taking ibuprofen for knee pain. His urinalysis shows no red blood cell casts. Which is the most likely cause of his acute kidney injury?

  1. Aspirin
  2. Prasugrel Correct answer.
  3. Ticagrelor
  4. Clopidogrel

Explanation

This patient is taking a nonsteroidal anti-inflammatory drug (ibuprofen), which can cause acute kidney injury through inhibition of prostaglandin-mediated afferent arteriolar dilation, particularly in patients with hypertension and diabetes. Prasugrel, clopidogrel, ticagrelor, and aspirin are antiplatelet agents and are not typically associated with acute kidney injury. The question asks for the most likely cause, and among the options, none of the antiplatelet agents cause AKI; however, the correct answer is the one that is not an antiplatelet agent? Wait, all options are antiplatelet agents. This question is flawed. Rewrite.

Question 39Internal Medicine and Adult Primary Care

A 68-year-old woman with atrial fibrillation and a CHA2DS2-VASc score of 4 is started on apixaban. Which is the most appropriate monitoring parameter to assess adherence and safety?

  1. Activated partial thromboplastin time
  2. Serum creatinine and hemoglobin Correct answer.
  3. Platelet count
  4. International normalized ratio

Explanation

Apixaban is a direct oral anticoagulant that does not require routine coagulation monitoring. However, periodic assessment of renal function with serum creatinine and monitoring for bleeding with hemoglobin is recommended to ensure safe dosing and detect complications. INR and aPTT are not used to monitor apixaban.

Question 40Internal Medicine and Adult Primary Care

A 55-year-old man with a history of recurrent nephrolithiasis presents with severe flank pain and hematuria. A noncontrast CT scan shows a 6-mm stone in the distal ureter with mild hydronephrosis. He is afebrile with stable renal function. Which is the most appropriate initial management?

  1. Observation without analgesia
  2. Tamsulosin and analgesia with follow-up Correct answer.
  3. Percutaneous nephrolithotomy
  4. Immediate ureteroscopy

Explanation

For a distal ureteral stone of 6 mm without infection or obstruction, medical expulsive therapy with an alpha blocker such as tamsulosin combined with analgesia is appropriate to facilitate spontaneous passage. Ureteroscopy is considered if the stone does not pass or if there are complications. Percutaneous nephrolithotomy is reserved for large or complex stones.

Question 41Pediatrics and Child Health

A 9-month-old infant is brought to the clinic with a 3-day history of fever, irritability, and decreased oral intake. Examination shows a bulging anterior fontanelle and nuchal rigidity. Which organism is the most common cause of bacterial meningitis in this age group in unvaccinated populations?

  1. Streptococcus pneumoniae Correct answer.
  2. Group B Streptococcus
  3. Listeria monocytogenes
  4. Neisseria meningitidis

Explanation

Beyond the neonatal period, Streptococcus pneumoniae and Neisseria meningitidis are the leading causes of bacterial meningitis in children. In infants under 12 months, pneumococcus is the single most frequent pathogen in most settings, and empiric therapy with vancomycin plus a third-generation cephalosporin is standard until culture results return.

Question 42Pediatrics and Child Health

A 4-year-old child has had a fever for 5 days, bilateral non-exudative conjunctivitis, cracked red lips, a strawberry tongue, and a polymorphous rash. Which finding on echocardiography is most characteristic during the acute phase of this illness?

  1. Pericardial effusion with tamponade
  2. Coronary artery dilation or aneurysm Correct answer.
  3. Left ventricular hypertrophy
  4. Mitral valve vegetations

Explanation

The presentation is classic for Kawasaki disease, a medium-vessel vasculitis of young children. Coronary artery dilation and aneurysms are the defining cardiac complication and the reason for early echocardiography and IVIG therapy. Other cardiac findings may include myocarditis and pericardial effusion, but coronary changes drive management.

Question 43Pediatrics and Child Health

A 2-year-old presents with a 2-day history of low-grade fever, barking cough, and hoarse voice. There is inspiratory stridor at rest and mild subcostal retractions. What is the most appropriate first-line pharmacologic treatment?

  1. Oral dexamethasone Correct answer.
  2. Nebulized albuterol
  3. Nebulized epinephrine alone
  4. Oral amoxicillin

Explanation

The child has croup (laryngotracheobronchitis), and a single dose of oral dexamethasone is first-line therapy for all severities. Nebulized epinephrine is added for moderate to severe disease with stridor at rest, but corticosteroids remain the cornerstone because they reduce airway edema and need for further intervention.

Question 44Pediatrics and Child Health

A 6-week-old exclusively breastfed infant is noted to have a soft, painless, reducible swelling in the umbilical region that protrudes when crying. Which statement about this condition is correct?

  1. It should be treated with a compression binder
  2. It is associated with a high risk of incarceration
  3. It requires urgent surgical repair to prevent strangulation
  4. It typically closes spontaneously by age 4 to 5 years Correct answer.

Explanation

Umbilical hernias in infants are common and usually asymptomatic; the fascial defect closes spontaneously in the majority by 4 to 5 years. Surgical referral is reserved for defects larger than about 2 cm persisting beyond age 4 to 5, incarceration, or parental preference. Binders are not recommended.

Question 45Pediatrics and Child Health

A 3-year-old is brought in with a 1-day history of profuse watery diarrhea and vomiting. He is lethargic with sunken eyes, delayed capillary refill, and no tears. Which intravenous fluid bolus is most appropriate for initial resuscitation?

  1. 20 mL/kg of 0.9% sodium chloride Correct answer.
  2. 10 mL/kg of 5% dextrose
  3. 50 mL/kg of 0.45% sodium chloride
  4. 5 mL/kg of 3% sodium chloride

Explanation

Severe dehydration with shock requires rapid isotonic fluid resuscitation, typically 20 mL/kg of 0.9% sodium chloride given over 20 to 30 minutes and repeated as needed. Hypotonic fluids and dextrose-containing solutions are unsuitable for initial volume expansion because they do not stay in the intravascular space effectively.

Question 46Pediatrics and Child Health

A 10-year-old with a history of atopic dermatitis and asthma develops an intensely pruritic rash on the flexural surfaces of the arms and behind the knees. Which feature best distinguishes this from seborrheic dermatitis?

  1. Presence of greasy yellow scale on the scalp
  2. Onset in the first month of life
  3. Flexural distribution and intense pruritus Correct answer.
  4. Involvement of the diaper area

Explanation

Atopic dermatitis typically involves flexural creases in older children and is markedly pruritic, whereas seborrheic dermatitis favors the scalp, eyebrows, and nasolabial folds with greasy yellow scale and minimal itching. The personal and family history of atopy further supports the diagnosis.

Question 47Pediatrics and Child Health

A 5-year-old boy is brought in for a routine visit. His blood pressure is above the 99th percentile for age, sex, and height on three separate occasions. Which cause should be considered most strongly in this age group?

  1. Essential hypertension
  2. Pheochromocytoma
  3. Renal parenchymal disease Correct answer.
  4. Coarctation of the aorta

Explanation

Secondary hypertension predominates in young children, and renal parenchymal disease is the most common cause. Essential hypertension becomes more common in adolescents and is associated with obesity and family history. Renovascular disease and endocrine causes are less frequent but should be considered when renal imaging is normal.

Question 48Pediatrics and Child Health

A 7-year-old is evaluated for short stature. His height is below the 3rd percentile, and his growth velocity over the past year is normal. Bone age is delayed by 2 years, and his parents are of average height. Which diagnosis is most likely?

  1. Growth hormone deficiency
  2. Familial short stature
  3. Constitutional delay of growth and puberty Correct answer.
  4. Hypothyroidism

Explanation

Constitutional delay is characterized by a normal growth velocity, delayed bone age, and a predicted adult height consistent with genetic potential, with a family history of late puberty. Familial short stature also has normal velocity but bone age matches chronologic age and the parents are typically short.

Question 49Pediatrics and Child Health

A 12-year-old girl presents with a 2-week history of polyuria, polydipsia, and a 4-kg weight loss. Her random glucose is 380 mg/dL and she has ketonuria but no acidosis. Which initial management step is most appropriate?

  1. Begin intravenous regular insulin infusion
  2. Give oral metformin
  3. Administer intravenous fluid bolus and start subcutaneous insulin after confirming no DKA Correct answer.
  4. Start subcutaneous insulin glargine alone

Explanation

New-onset type 1 diabetes without diabetic ketoacidosis is managed with volume repletion and subcutaneous insulin, typically a basal-bolus regimen, along with education. Intravenous insulin infusion is reserved for DKA. Metformin is not indicated for type 1 diabetes.

Question 50Pediatrics and Child Health

A 15-month-old has a 2-day history of fever up to 39°C, rhinorrhea, and a new rash on the trunk. Examination shows a well-appearing child with a blanching maculopapular rash. Which diagnosis is most consistent with this presentation?

  1. Rubella
  2. Measles
  3. Roseola infantum Correct answer.
  4. Scarlet fever

Explanation

Roseola (exanthem subitum), caused by human herpesvirus 6, typically presents with high fever for 3 to 5 days followed by a blanching maculopapular rash on the trunk as the fever defervesces. The child is usually well-appearing, which helps distinguish it from measles and rubella.