, Question 1
Which of the following best explains why a patient with compensated heart
failure may exhibit a normal resting ejection fraction yet still experience
exertional dyspnea?
A. Diastolic dysfunction impairs ventricular filling, leading to elevated
filling pressures and pulmonary congestion during exertion.
B. Systolic dysfunction reduces stroke volume only during exercise,
while resting function remains preserved.
C. Increased afterload causes a reflexive tachycardia that masks resting
symptoms but not exertional ones.
D. Reduced preload from venous pooling during exercise limits cardiac
output despite normal contractility.
Correct Answer: A - Diastolic dysfunction impairs ventricular
filling, leading to elevated filling pressures and pulmonary
congestion during exertion.
RATIONALE
Heart failure with preserved ejection fraction (HFpEF) is characterized
by diastolic dysfunction, where impaired relaxation and increased
stiffness elevate left atrial pressure, causing pulmonary congestion
with exertion despite normal ejection fraction. Systolic dysfunction
would typically reduce resting ejection fraction. The other options
misattribute the mechanism to afterload or preload changes that are
not the primary cause.
Question 2
A patient on warfarin for atrial fibrillation is prescribed a course of fluconazole
for a fungal infection. Which INR monitoring strategy is most appropriate?
A. Recheck INR in 3-5 days and reduce warfarin dose proactively due to
CYP2C9 inhibition.
B. Continue current warfarin dose and check INR weekly as usual; no
interaction exists.
Page 2
, C. Switch to a direct oral anticoagulant immediately to avoid interaction.
D. Increase warfarin dose to compensate for fluconazole's induction of
metabolism.
Correct Answer: A - Recheck INR in 3-5 days and reduce
warfarin dose proactively due to CYP2C9 inhibition.
RATIONALE
Fluconazole inhibits CYP2C9, which metabolizes warfarin, increasing
INR and bleeding risk. Proactive dose reduction and close INR
monitoring within 3-5 days are recommended. The other options
either ignore the interaction or incorrectly suggest enzyme induction
or unnecessary anticoagulant switching.
Question 3
Which statement accurately reflects the 2023 American College of
Cardiology/American Heart Association guideline for the primary prevention
of atherosclerotic cardiovascular disease?
A. Low-dose aspirin is routinely recommended for primary prevention in
all adults over 40.
B. Statin therapy should be considered for adults with LDL-C 70-189
mg/dL and a 10-year ASCVD risk 7.5%.
C. Ezetimibe is first-line for primary prevention when LDL-C is above
100 mg/dL.
D. Bempedoic acid is recommended as initial therapy for statin-intolerant
patients.
Correct Answer: B - Statin therapy should be considered for
adults with LDL-C 70-189 mg/dL and a 10-year ASCVD risk
7.5%.
Page 3
, RATIONALE
The 2023 ACC/AHA guideline recommends statin therapy for primary
prevention in adults with LDL-C 70-189 mg/dL and 10-year ASCVD
risk 7.5%, after risk discussion. Aspirin is not routinely recommended
for primary prevention due to bleeding risk. Ezetimibe and bempedoic
acid are not first-line.
Question 4
A patient presents with sudden onset of severe unilateral headache, ptosis, and
miosis. Which diagnostic step is most critical to prevent a life-threatening
complication?
A. Immediate non-contrast head CT to rule out subarachnoid hemorrhage.
B. Urgent MRI/MRA of the brain and neck to evaluate for carotid artery
dissection.
C. Lumbar puncture to assess for xanthochromia.
D. Erythrocyte sedimentation rate and temporal artery biopsy.
Correct Answer: B - Urgent MRI/MRA of the brain and neck to
evaluate for carotid artery dissection.
RATIONALE
The triad of severe headache, ptosis, and miosis suggests Horner
syndrome, which can result from carotid artery dissection-a medical
emergency. MRI/MRA is the preferred imaging to diagnose dissection
and guide treatment. Other options address different emergencies like
subarachnoid hemorrhage or giant cell arteritis, which do not typically
present with Horner syndrome.
Question 5
Which of the following is the most appropriate first-line pharmacologic
treatment for a patient with generalized anxiety disorder and a history of
alcohol use disorder?
A. Alprazolam as needed for acute anxiety.
Page 4
Which of the following best explains why a patient with compensated heart
failure may exhibit a normal resting ejection fraction yet still experience
exertional dyspnea?
A. Diastolic dysfunction impairs ventricular filling, leading to elevated
filling pressures and pulmonary congestion during exertion.
B. Systolic dysfunction reduces stroke volume only during exercise,
while resting function remains preserved.
C. Increased afterload causes a reflexive tachycardia that masks resting
symptoms but not exertional ones.
D. Reduced preload from venous pooling during exercise limits cardiac
output despite normal contractility.
Correct Answer: A - Diastolic dysfunction impairs ventricular
filling, leading to elevated filling pressures and pulmonary
congestion during exertion.
RATIONALE
Heart failure with preserved ejection fraction (HFpEF) is characterized
by diastolic dysfunction, where impaired relaxation and increased
stiffness elevate left atrial pressure, causing pulmonary congestion
with exertion despite normal ejection fraction. Systolic dysfunction
would typically reduce resting ejection fraction. The other options
misattribute the mechanism to afterload or preload changes that are
not the primary cause.
Question 2
A patient on warfarin for atrial fibrillation is prescribed a course of fluconazole
for a fungal infection. Which INR monitoring strategy is most appropriate?
A. Recheck INR in 3-5 days and reduce warfarin dose proactively due to
CYP2C9 inhibition.
B. Continue current warfarin dose and check INR weekly as usual; no
interaction exists.
Page 2
, C. Switch to a direct oral anticoagulant immediately to avoid interaction.
D. Increase warfarin dose to compensate for fluconazole's induction of
metabolism.
Correct Answer: A - Recheck INR in 3-5 days and reduce
warfarin dose proactively due to CYP2C9 inhibition.
RATIONALE
Fluconazole inhibits CYP2C9, which metabolizes warfarin, increasing
INR and bleeding risk. Proactive dose reduction and close INR
monitoring within 3-5 days are recommended. The other options
either ignore the interaction or incorrectly suggest enzyme induction
or unnecessary anticoagulant switching.
Question 3
Which statement accurately reflects the 2023 American College of
Cardiology/American Heart Association guideline for the primary prevention
of atherosclerotic cardiovascular disease?
A. Low-dose aspirin is routinely recommended for primary prevention in
all adults over 40.
B. Statin therapy should be considered for adults with LDL-C 70-189
mg/dL and a 10-year ASCVD risk 7.5%.
C. Ezetimibe is first-line for primary prevention when LDL-C is above
100 mg/dL.
D. Bempedoic acid is recommended as initial therapy for statin-intolerant
patients.
Correct Answer: B - Statin therapy should be considered for
adults with LDL-C 70-189 mg/dL and a 10-year ASCVD risk
7.5%.
Page 3
, RATIONALE
The 2023 ACC/AHA guideline recommends statin therapy for primary
prevention in adults with LDL-C 70-189 mg/dL and 10-year ASCVD
risk 7.5%, after risk discussion. Aspirin is not routinely recommended
for primary prevention due to bleeding risk. Ezetimibe and bempedoic
acid are not first-line.
Question 4
A patient presents with sudden onset of severe unilateral headache, ptosis, and
miosis. Which diagnostic step is most critical to prevent a life-threatening
complication?
A. Immediate non-contrast head CT to rule out subarachnoid hemorrhage.
B. Urgent MRI/MRA of the brain and neck to evaluate for carotid artery
dissection.
C. Lumbar puncture to assess for xanthochromia.
D. Erythrocyte sedimentation rate and temporal artery biopsy.
Correct Answer: B - Urgent MRI/MRA of the brain and neck to
evaluate for carotid artery dissection.
RATIONALE
The triad of severe headache, ptosis, and miosis suggests Horner
syndrome, which can result from carotid artery dissection-a medical
emergency. MRI/MRA is the preferred imaging to diagnose dissection
and guide treatment. Other options address different emergencies like
subarachnoid hemorrhage or giant cell arteritis, which do not typically
present with Horner syndrome.
Question 5
Which of the following is the most appropriate first-line pharmacologic
treatment for a patient with generalized anxiety disorder and a history of
alcohol use disorder?
A. Alprazolam as needed for acute anxiety.
Page 4
