, Question 1
A patient presents with sudden-onset unilateral vision loss described as a
'curtain descending.' Fundoscopic exam is normal. Which finding most
strongly supports the diagnosis of retinal artery occlusion over vitreous
hemorrhage?
A. Cherry-red spot at the macula with pale retinal background
B. Red-orange fundus reflex with absent red reflex on the affected side
C. Flame-shaped hemorrhages along the superior arcade
D. Disc edema with spontaneous venous pulsations
Correct Answer: A - Cherry-red spot at the macula with pale
retinal background
RATIONALE
Central retinal artery occlusion produces ischemic retinal whitening
with a cherry-red spot at the fovea due to preserved choroidal
perfusion. Vitreous hemorrhage obscures the red reflex and typically
presents with floaters or a red hue, not a cherry-red spot. Flame
hemorrhages suggest hypertensive or venous occlusive disease, and
disc edema with venous pulsations is nonspecific.
Question 2
Which pharmacologic strategy best reflects current guideline-concordant initial
therapy for a patient with newly diagnosed heart failure with reduced ejection
fraction (HFrEF) and NYHA class II symptoms?
A. Furosemide monotherapy titrated to symptom relief
B. Sacubitril/valsartan plus a beta-blocker, with an SGLT2 inhibitor
added early
C. Digoxin plus a loop diuretic for rate and volume control
D. Amlodipine plus hydralazine to reduce afterload
Correct Answer: B - Sacubitril/valsartan plus a beta-blocker, with
an SGLT2 inhibitor added early
Page 2
, RATIONALE
Current ACC/AHA/HFSA guidelines recommend early initiation of
guideline-directed medical therapy (GDMT) for HFrEF, including
ARNI (sacubitril/valsartan), evidence-based beta-blocker, MRA, and
SGLT2 inhibitor. Diuretic monotherapy only relieves congestion
without mortality benefit, digoxin is adjunctive, and amlodipine is not
recommended for routine HFrEF management.
Question 3
A patient with type 2 diabetes has an A1c of 8.9%, eGFR 52 mL/min/1.73 m²,
and established atherosclerotic cardiovascular disease. Which add-on therapy
provides the greatest combined cardiorenal benefit?
A. Sulfonylurea
B. DPP-4 inhibitor
C. SGLT2 inhibitor
D. Basal insulin
Correct Answer: C - SGLT2 inhibitor
RATIONALE
SGLT2 inhibitors reduce major adverse cardiovascular events, heart
failure hospitalization, and slow CKD progression in patients with
ASCVD and reduced eGFR. Sulfonylureas and DPP-4 inhibitors lack
cardiorenal benefit, and basal insulin addresses glycemia without
proven cardiovascular outcome benefit.
Question 4
Which finding on a 12-lead ECG most reliably differentiates supraventricular
tachycardia with aberrancy from ventricular tachycardia in a hemodynamically
stable patient?
A. Regularity of the rhythm
B. Presence of a fusion beat or AV dissociation
C. Rate greater than 150 beats per minute
Page 3
, D. Narrow QRS complexes in lead II
Correct Answer: B - Presence of a fusion beat or AV dissociation
RATIONALE
AV dissociation and fusion/capture beats are highly specific for
ventricular tachycardia and are not features of SVT with aberrancy.
Regularity, rate, and QRS width alone are unreliable discriminators;
SVT with aberrancy can be regular and wide, mimicking VT.
Question 5
A patient reports unilateral throbbing headache with nausea and photophobia,
worsened by routine activity. Which acute treatment is most appropriate if
triptans are contraindicated due to coronary artery disease?
A. Ergotamine tartrate
B. High-flow oxygen
C. A gepant (ubrogepant or rimegepant)
D. Intramuscular ketorolac plus metoclopramide
Correct Answer: C - A gepant (ubrogepant or rimegepant)
RATIONALE
Gepants are CGRP receptor antagonists approved for acute migraine
and are not associated with vasoconstriction, making them safe in
patients with CAD. Ergotamine and triptans are contraindicated due to
vasospastic risk, oxygen is for cluster headache, and ketorolac with
metoclopramide is a reasonable alternative but not the most specific
first-line when triptans are contraindicated.
Question 6
A sexually active patient presents with dysuria, urinary frequency, and a
mucopurulent cervical discharge. NAAT is positive for Chlamydia trachomatis.
Which regimen is first-line per current CDC STI guidelines?
A. Azithromycin 1 g orally once
Page 4
A patient presents with sudden-onset unilateral vision loss described as a
'curtain descending.' Fundoscopic exam is normal. Which finding most
strongly supports the diagnosis of retinal artery occlusion over vitreous
hemorrhage?
A. Cherry-red spot at the macula with pale retinal background
B. Red-orange fundus reflex with absent red reflex on the affected side
C. Flame-shaped hemorrhages along the superior arcade
D. Disc edema with spontaneous venous pulsations
Correct Answer: A - Cherry-red spot at the macula with pale
retinal background
RATIONALE
Central retinal artery occlusion produces ischemic retinal whitening
with a cherry-red spot at the fovea due to preserved choroidal
perfusion. Vitreous hemorrhage obscures the red reflex and typically
presents with floaters or a red hue, not a cherry-red spot. Flame
hemorrhages suggest hypertensive or venous occlusive disease, and
disc edema with venous pulsations is nonspecific.
Question 2
Which pharmacologic strategy best reflects current guideline-concordant initial
therapy for a patient with newly diagnosed heart failure with reduced ejection
fraction (HFrEF) and NYHA class II symptoms?
A. Furosemide monotherapy titrated to symptom relief
B. Sacubitril/valsartan plus a beta-blocker, with an SGLT2 inhibitor
added early
C. Digoxin plus a loop diuretic for rate and volume control
D. Amlodipine plus hydralazine to reduce afterload
Correct Answer: B - Sacubitril/valsartan plus a beta-blocker, with
an SGLT2 inhibitor added early
Page 2
, RATIONALE
Current ACC/AHA/HFSA guidelines recommend early initiation of
guideline-directed medical therapy (GDMT) for HFrEF, including
ARNI (sacubitril/valsartan), evidence-based beta-blocker, MRA, and
SGLT2 inhibitor. Diuretic monotherapy only relieves congestion
without mortality benefit, digoxin is adjunctive, and amlodipine is not
recommended for routine HFrEF management.
Question 3
A patient with type 2 diabetes has an A1c of 8.9%, eGFR 52 mL/min/1.73 m²,
and established atherosclerotic cardiovascular disease. Which add-on therapy
provides the greatest combined cardiorenal benefit?
A. Sulfonylurea
B. DPP-4 inhibitor
C. SGLT2 inhibitor
D. Basal insulin
Correct Answer: C - SGLT2 inhibitor
RATIONALE
SGLT2 inhibitors reduce major adverse cardiovascular events, heart
failure hospitalization, and slow CKD progression in patients with
ASCVD and reduced eGFR. Sulfonylureas and DPP-4 inhibitors lack
cardiorenal benefit, and basal insulin addresses glycemia without
proven cardiovascular outcome benefit.
Question 4
Which finding on a 12-lead ECG most reliably differentiates supraventricular
tachycardia with aberrancy from ventricular tachycardia in a hemodynamically
stable patient?
A. Regularity of the rhythm
B. Presence of a fusion beat or AV dissociation
C. Rate greater than 150 beats per minute
Page 3
, D. Narrow QRS complexes in lead II
Correct Answer: B - Presence of a fusion beat or AV dissociation
RATIONALE
AV dissociation and fusion/capture beats are highly specific for
ventricular tachycardia and are not features of SVT with aberrancy.
Regularity, rate, and QRS width alone are unreliable discriminators;
SVT with aberrancy can be regular and wide, mimicking VT.
Question 5
A patient reports unilateral throbbing headache with nausea and photophobia,
worsened by routine activity. Which acute treatment is most appropriate if
triptans are contraindicated due to coronary artery disease?
A. Ergotamine tartrate
B. High-flow oxygen
C. A gepant (ubrogepant or rimegepant)
D. Intramuscular ketorolac plus metoclopramide
Correct Answer: C - A gepant (ubrogepant or rimegepant)
RATIONALE
Gepants are CGRP receptor antagonists approved for acute migraine
and are not associated with vasoconstriction, making them safe in
patients with CAD. Ergotamine and triptans are contraindicated due to
vasospastic risk, oxygen is for cluster headache, and ketorolac with
metoclopramide is a reasonable alternative but not the most specific
first-line when triptans are contraindicated.
Question 6
A sexually active patient presents with dysuria, urinary frequency, and a
mucopurulent cervical discharge. NAAT is positive for Chlamydia trachomatis.
Which regimen is first-line per current CDC STI guidelines?
A. Azithromycin 1 g orally once
Page 4
