, Question 1
A patient with resistant hypertension and unexplained hypokalemia is found to
have a suppressed plasma renin activity and elevated aldosterone. Which
confirmatory test best distinguishes primary aldosteronism from secondary
causes, and what is the expected result?
A. Captopril challenge test - aldosterone fails to suppress
B. Saline infusion test - aldosterone remains elevated
C. Renal vein renin sampling - bilateral elevation
D. 24-hour urinary metanephrines - elevated
Correct Answer: B - Saline infusion test - aldosterone remains
elevated
RATIONALE
The saline infusion test confirms primary aldosteronism when
aldosterone fails to suppress despite volume expansion; suppressed
renin plus elevated aldosterone is the hallmark. Captopril challenge is
an alternative but less definitive; renal vein sampling is for
lateralization, and metanephrines evaluate pheochromocytoma.
Question 2
A patient on warfarin for atrial fibrillation is prescribed fluconazole for
candidiasis. Which mechanism best explains the anticipated INR elevation, and
what is the most appropriate monitoring action?
A. CYP2C9 inhibition by fluconazole increases warfarin levels; check
INR in 3-5 days and reduce warfarin dose
B. CYP3A4 induction by fluconazole decreases warfarin levels; increase
warfarin dose
C. Protein binding displacement by fluconazole; no INR change expected
D. Renal clearance inhibition by fluconazole; monitor serum creatinine
only
Correct Answer: A - CYP2C9 inhibition by fluconazole increases
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, warfarin levels; check INR in 3-5 days and reduce warfarin dose
RATIONALE
Fluconazole is a potent inhibitor of CYP2C9, which metabolizes
S-warfarin, leading to increased warfarin effect and bleeding risk.
Close INR monitoring and preemptive dose reduction are standard;
CYP3A4 and renal mechanisms are not the primary interaction here.
Question 3
During an advanced cardiovascular assessment, a mid-systolic click followed
by a late systolic murmur is heard at the apex. Which maneuver will most
reliably intensify the click and murmur?
A. Squatting
B. Valsalva strain phase
C. Isometric handgrip
D. Passive leg raise
Correct Answer: B - Valsalva strain phase
RATIONALE
The click and murmur of mitral valve prolapse occur earlier and
intensify with maneuvers that decrease left ventricular volume, such as
the Valsalva strain phase. Squatting, handgrip, and leg raise increase
preload and diminish the findings.
Question 4
A patient with type 2 diabetes and an eGFR of 38 mL/min/1.73 m² is on
metformin. Which action is most consistent with current FDA and ADA
guidance?
A. Continue metformin at current dose
B. Discontinue metformin immediately
C. Reduce metformin dose by 50% and monitor renal function every 3
months
Page 3
A patient with resistant hypertension and unexplained hypokalemia is found to
have a suppressed plasma renin activity and elevated aldosterone. Which
confirmatory test best distinguishes primary aldosteronism from secondary
causes, and what is the expected result?
A. Captopril challenge test - aldosterone fails to suppress
B. Saline infusion test - aldosterone remains elevated
C. Renal vein renin sampling - bilateral elevation
D. 24-hour urinary metanephrines - elevated
Correct Answer: B - Saline infusion test - aldosterone remains
elevated
RATIONALE
The saline infusion test confirms primary aldosteronism when
aldosterone fails to suppress despite volume expansion; suppressed
renin plus elevated aldosterone is the hallmark. Captopril challenge is
an alternative but less definitive; renal vein sampling is for
lateralization, and metanephrines evaluate pheochromocytoma.
Question 2
A patient on warfarin for atrial fibrillation is prescribed fluconazole for
candidiasis. Which mechanism best explains the anticipated INR elevation, and
what is the most appropriate monitoring action?
A. CYP2C9 inhibition by fluconazole increases warfarin levels; check
INR in 3-5 days and reduce warfarin dose
B. CYP3A4 induction by fluconazole decreases warfarin levels; increase
warfarin dose
C. Protein binding displacement by fluconazole; no INR change expected
D. Renal clearance inhibition by fluconazole; monitor serum creatinine
only
Correct Answer: A - CYP2C9 inhibition by fluconazole increases
Page 2
, warfarin levels; check INR in 3-5 days and reduce warfarin dose
RATIONALE
Fluconazole is a potent inhibitor of CYP2C9, which metabolizes
S-warfarin, leading to increased warfarin effect and bleeding risk.
Close INR monitoring and preemptive dose reduction are standard;
CYP3A4 and renal mechanisms are not the primary interaction here.
Question 3
During an advanced cardiovascular assessment, a mid-systolic click followed
by a late systolic murmur is heard at the apex. Which maneuver will most
reliably intensify the click and murmur?
A. Squatting
B. Valsalva strain phase
C. Isometric handgrip
D. Passive leg raise
Correct Answer: B - Valsalva strain phase
RATIONALE
The click and murmur of mitral valve prolapse occur earlier and
intensify with maneuvers that decrease left ventricular volume, such as
the Valsalva strain phase. Squatting, handgrip, and leg raise increase
preload and diminish the findings.
Question 4
A patient with type 2 diabetes and an eGFR of 38 mL/min/1.73 m² is on
metformin. Which action is most consistent with current FDA and ADA
guidance?
A. Continue metformin at current dose
B. Discontinue metformin immediately
C. Reduce metformin dose by 50% and monitor renal function every 3
months
Page 3
