, Question 1
A patient with type 2 diabetes and an eGFR of 28 mL/min/1.73 m² is already
on maximally tolerated metformin. Which add-on therapy offers the strongest
dual cardiorenal protection per current ADA/KDIGO guidance?
A. Sitagliptin
B. Dapagliflozin
C. Pioglitazone
D. Glipizide
Correct Answer: B - Dapagliflozin
RATIONALE
SGLT2 inhibitors such as dapagliflozin reduce CKD progression, heart
failure hospitalization, and cardiovascular death in diabetic kidney
disease and are recommended by ADA/KDIGO irrespective of A1c.
Sitagliptin and glipizide lack cardiorenal outcome benefit, and
pioglitazone may worsen fluid retention and heart failure.
Question 2
A patient presents with sudden painless monocular vision loss and a cherry-red
macula on fundoscopy. Which management step is most appropriate in the
primary care setting?
A. Start high-dose oral prednisone and reassess in 48 hours
B. Apply topical timolol and refer routinely to ophthalmology
C. Immediately refer to ophthalmology for possible intra-arterial
thrombolysis and stroke workup
D. Prescribe erythropoietin and monitor visual acuity
Correct Answer: C - Immediately refer to ophthalmology for
possible intra-arterial thrombolysis and stroke workup
Page 2
, RATIONALE
The presentation is central retinal artery occlusion (CRAO), an ocular
stroke; emergent ophthalmology referral for possible thrombolysis and
concurrent stroke workup is indicated. Corticosteroids are used for
giant cell arteritis, timolol for glaucoma, and erythropoietin is not a
treatment for CRAO.
Question 3
Which finding best distinguishes bipolar I from bipolar II disorder?
A. Presence of psychotic features during mood episodes
B. History of at least one full manic episode
C. Rapid cycling pattern over 12 months
D. Predominance of depressive episodes over time
Correct Answer: B - History of at least one full manic episode
RATIONALE
Bipolar I requires at least one manic episode; bipolar II requires
hypomanic and major depressive episodes without mania. Psychosis
can occur in either, rapid cycling is a specifier, and depressive
predominance is common in bipolar II but not diagnostic.
Question 4
A patient with COPD (GOLD group E) has had two exacerbations in the past
year. Which inhaled regimen is most consistent with current GOLD
recommendations?
A. LABA + LAMA + ICS
B. SABA monotherapy
C. LAMA + ICS
D. LABA monotherapy
Correct Answer: A - LABA + LAMA + ICS
Page 3
, RATIONALE
GOLD group E (high exacerbation risk) recommends LABA + LAMA
as initial therapy, with ICS added for those with elevated eosinophils
or continued exacerbations. SABA monotherapy is for intermittent
symptoms, and LAMA+ICS or LABA monotherapy are not preferred
initial strategies for group E.
Question 5
Which serologic pattern most strongly supports a diagnosis of systemic lupus
erythematosus in a patient with compatible clinical features?
A. Anti-SSA/Ro with rheumatoid factor
B. Anti-dsDNA with low complement C3/C4
C. Anti-CCP with elevated ESR
D. ANA-negative with anti-histone antibodies
Correct Answer: B - Anti-dsDNA with low complement C3/C4
RATIONALE
Anti-dsDNA and low C3/C4 are highly specific for SLE and often
correlate with active nephritis. Anti-SSA/Ro is associated with
Sjögren and neonatal lupus, anti-CCP with rheumatoid arthritis, and
anti-histone antibodies with drug-induced lupus.
Question 6
A patient with major depressive disorder has not responded to an adequate trial
of an SSRI. Which augmentation strategy has the strongest evidence for
improving outcomes?
A. Adding aripiprazole
B. Adding buspirone
C. Adding mirtazapine
D. Switching to another SSRI
Correct Answer: A - Adding aripiprazole
Page 4
A patient with type 2 diabetes and an eGFR of 28 mL/min/1.73 m² is already
on maximally tolerated metformin. Which add-on therapy offers the strongest
dual cardiorenal protection per current ADA/KDIGO guidance?
A. Sitagliptin
B. Dapagliflozin
C. Pioglitazone
D. Glipizide
Correct Answer: B - Dapagliflozin
RATIONALE
SGLT2 inhibitors such as dapagliflozin reduce CKD progression, heart
failure hospitalization, and cardiovascular death in diabetic kidney
disease and are recommended by ADA/KDIGO irrespective of A1c.
Sitagliptin and glipizide lack cardiorenal outcome benefit, and
pioglitazone may worsen fluid retention and heart failure.
Question 2
A patient presents with sudden painless monocular vision loss and a cherry-red
macula on fundoscopy. Which management step is most appropriate in the
primary care setting?
A. Start high-dose oral prednisone and reassess in 48 hours
B. Apply topical timolol and refer routinely to ophthalmology
C. Immediately refer to ophthalmology for possible intra-arterial
thrombolysis and stroke workup
D. Prescribe erythropoietin and monitor visual acuity
Correct Answer: C - Immediately refer to ophthalmology for
possible intra-arterial thrombolysis and stroke workup
Page 2
, RATIONALE
The presentation is central retinal artery occlusion (CRAO), an ocular
stroke; emergent ophthalmology referral for possible thrombolysis and
concurrent stroke workup is indicated. Corticosteroids are used for
giant cell arteritis, timolol for glaucoma, and erythropoietin is not a
treatment for CRAO.
Question 3
Which finding best distinguishes bipolar I from bipolar II disorder?
A. Presence of psychotic features during mood episodes
B. History of at least one full manic episode
C. Rapid cycling pattern over 12 months
D. Predominance of depressive episodes over time
Correct Answer: B - History of at least one full manic episode
RATIONALE
Bipolar I requires at least one manic episode; bipolar II requires
hypomanic and major depressive episodes without mania. Psychosis
can occur in either, rapid cycling is a specifier, and depressive
predominance is common in bipolar II but not diagnostic.
Question 4
A patient with COPD (GOLD group E) has had two exacerbations in the past
year. Which inhaled regimen is most consistent with current GOLD
recommendations?
A. LABA + LAMA + ICS
B. SABA monotherapy
C. LAMA + ICS
D. LABA monotherapy
Correct Answer: A - LABA + LAMA + ICS
Page 3
, RATIONALE
GOLD group E (high exacerbation risk) recommends LABA + LAMA
as initial therapy, with ICS added for those with elevated eosinophils
or continued exacerbations. SABA monotherapy is for intermittent
symptoms, and LAMA+ICS or LABA monotherapy are not preferred
initial strategies for group E.
Question 5
Which serologic pattern most strongly supports a diagnosis of systemic lupus
erythematosus in a patient with compatible clinical features?
A. Anti-SSA/Ro with rheumatoid factor
B. Anti-dsDNA with low complement C3/C4
C. Anti-CCP with elevated ESR
D. ANA-negative with anti-histone antibodies
Correct Answer: B - Anti-dsDNA with low complement C3/C4
RATIONALE
Anti-dsDNA and low C3/C4 are highly specific for SLE and often
correlate with active nephritis. Anti-SSA/Ro is associated with
Sjögren and neonatal lupus, anti-CCP with rheumatoid arthritis, and
anti-histone antibodies with drug-induced lupus.
Question 6
A patient with major depressive disorder has not responded to an adequate trial
of an SSRI. Which augmentation strategy has the strongest evidence for
improving outcomes?
A. Adding aripiprazole
B. Adding buspirone
C. Adding mirtazapine
D. Switching to another SSRI
Correct Answer: A - Adding aripiprazole
Page 4
