, Question 1
A patient with type 2 diabetes and an eGFR of 42 mL/min/1.73 m² is currently
on metformin 1000 mg BID. Which of the following represents the most
appropriate management according to the 2025 ADA Standards of Care?
A. Continue metformin at the current dose and monitor renal function
every 6 months.
B. Discontinue metformin and initiate a DPP-4 inhibitor.
C. Reduce metformin to 500 mg BID and add an SGLT2 inhibitor.
D. Discontinue metformin and initiate an SGLT2 inhibitor with proven
renal benefit.
Correct Answer: D - Discontinue metformin and initiate an
SGLT2 inhibitor with proven renal benefit.
RATIONALE
The 2025 ADA Standards recommend discontinuing metformin when
eGFR falls below 45 mL/min/1.73 m² due to increased risk of lactic
acidosis. An SGLT2 inhibitor with proven renal benefit (e.g.,
empagliflozin, dapagliflozin) should be initiated for cardiorenal
protection. Continuing or dose-reducing metformin is unsafe, and a
DPP-4 inhibitor lacks renal outcome benefits.
Question 2
A patient presents with sudden-onset unilateral vision loss described as a
'curtain coming down.' Fundoscopic exam reveals a pale retina with a
cherry-red spot. Which of the following is the most appropriate immediate
action?
A. Administer topical beta-blocker and schedule ophthalmology
follow-up in 24 hours.
B. Start high-dose oral corticosteroids and obtain ESR/C-reactive protein.
C. Immediately refer to the emergency department for evaluation by
ophthalmology for possible central retinal artery occlusion.
Page 2
, D. Prescribe artificial tears and recommend warm compresses.
Correct Answer: C - Immediately refer to the emergency
department for evaluation by ophthalmology for possible central
retinal artery occlusion.
RATIONALE
The presentation is classic for central retinal artery occlusion (CRAO),
an ophthalmologic emergency requiring immediate evaluation to
salvage vision. Topical beta-blockers, corticosteroids, and artificial
tears are inappropriate and delay time-sensitive intervention. CRAO is
associated with stroke risk, so emergency referral is critical.
Question 3
Which of the following best describes the pathophysiologic mechanism of
action of GLP-1 receptor agonists in achieving glycemic control and weight
loss?
A. Inhibition of dipeptidyl peptidase-4, increasing endogenous GLP-1
and GIP levels.
B. Activation of GLP-1 receptors leading to glucose-dependent insulin
secretion, glucagon suppression, delayed gastric emptying, and central
appetite suppression.
C. Blockade of sodium-glucose cotransporter-2 in the proximal tubule,
promoting glycosuria and natriuresis.
D. Stimulation of peroxisome proliferator-activated receptor gamma,
increasing insulin sensitivity in adipose tissue.
Correct Answer: B - Activation of GLP-1 receptors leading to
glucose-dependent insulin secretion, glucagon suppression,
delayed gastric emptying, and central appetite suppression.
Page 3
, RATIONALE
GLP-1 receptor agonists directly activate GLP-1 receptors, enhancing
glucose-dependent insulin release, suppressing glucagon, slowing
gastric emptying, and reducing appetite via central mechanisms.
Option A describes DPP-4 inhibitors, Option C describes SGLT2
inhibitors, and Option D describes thiazolidinediones.
Question 4
A patient with major depressive disorder has not responded to an adequate trial
of sertraline. Which of the following is the most evidence-based next step
according to the 2024 APA guidelines?
A. Switch to a monoamine oxidase inhibitor (MAOI) immediately.
B. Augment with aripiprazole or switch to venlafaxine.
C. Add buspirone to sertraline.
D. Initiate thyroid hormone augmentation with liothyronine.
Correct Answer: B - Augment with aripiprazole or switch to
venlafaxine.
RATIONALE
The 2024 APA guidelines recommend either switching to a different
antidepressant (e.g., venlafaxine) or augmenting with an atypical
antipsychotic (e.g., aripiprazole) after inadequate response to an SSRI.
MAOIs require washout and are not first-line, buspirone has weaker
evidence, and thyroid augmentation is less supported.
Question 5
A 55-year-old patient with no prior cardiovascular disease presents for routine
care. According to the 2023 AHA/ACC guidelines, which of the following is
the most appropriate primary prevention strategy for a patient with a 10-year
ASCVD risk of 12% and no contraindications?
A. Initiate high-intensity statin therapy (atorvastatin 40-80 mg daily).
B. Initiate moderate-intensity statin therapy (atorvastatin 20 mg daily).
Page 4
A patient with type 2 diabetes and an eGFR of 42 mL/min/1.73 m² is currently
on metformin 1000 mg BID. Which of the following represents the most
appropriate management according to the 2025 ADA Standards of Care?
A. Continue metformin at the current dose and monitor renal function
every 6 months.
B. Discontinue metformin and initiate a DPP-4 inhibitor.
C. Reduce metformin to 500 mg BID and add an SGLT2 inhibitor.
D. Discontinue metformin and initiate an SGLT2 inhibitor with proven
renal benefit.
Correct Answer: D - Discontinue metformin and initiate an
SGLT2 inhibitor with proven renal benefit.
RATIONALE
The 2025 ADA Standards recommend discontinuing metformin when
eGFR falls below 45 mL/min/1.73 m² due to increased risk of lactic
acidosis. An SGLT2 inhibitor with proven renal benefit (e.g.,
empagliflozin, dapagliflozin) should be initiated for cardiorenal
protection. Continuing or dose-reducing metformin is unsafe, and a
DPP-4 inhibitor lacks renal outcome benefits.
Question 2
A patient presents with sudden-onset unilateral vision loss described as a
'curtain coming down.' Fundoscopic exam reveals a pale retina with a
cherry-red spot. Which of the following is the most appropriate immediate
action?
A. Administer topical beta-blocker and schedule ophthalmology
follow-up in 24 hours.
B. Start high-dose oral corticosteroids and obtain ESR/C-reactive protein.
C. Immediately refer to the emergency department for evaluation by
ophthalmology for possible central retinal artery occlusion.
Page 2
, D. Prescribe artificial tears and recommend warm compresses.
Correct Answer: C - Immediately refer to the emergency
department for evaluation by ophthalmology for possible central
retinal artery occlusion.
RATIONALE
The presentation is classic for central retinal artery occlusion (CRAO),
an ophthalmologic emergency requiring immediate evaluation to
salvage vision. Topical beta-blockers, corticosteroids, and artificial
tears are inappropriate and delay time-sensitive intervention. CRAO is
associated with stroke risk, so emergency referral is critical.
Question 3
Which of the following best describes the pathophysiologic mechanism of
action of GLP-1 receptor agonists in achieving glycemic control and weight
loss?
A. Inhibition of dipeptidyl peptidase-4, increasing endogenous GLP-1
and GIP levels.
B. Activation of GLP-1 receptors leading to glucose-dependent insulin
secretion, glucagon suppression, delayed gastric emptying, and central
appetite suppression.
C. Blockade of sodium-glucose cotransporter-2 in the proximal tubule,
promoting glycosuria and natriuresis.
D. Stimulation of peroxisome proliferator-activated receptor gamma,
increasing insulin sensitivity in adipose tissue.
Correct Answer: B - Activation of GLP-1 receptors leading to
glucose-dependent insulin secretion, glucagon suppression,
delayed gastric emptying, and central appetite suppression.
Page 3
, RATIONALE
GLP-1 receptor agonists directly activate GLP-1 receptors, enhancing
glucose-dependent insulin release, suppressing glucagon, slowing
gastric emptying, and reducing appetite via central mechanisms.
Option A describes DPP-4 inhibitors, Option C describes SGLT2
inhibitors, and Option D describes thiazolidinediones.
Question 4
A patient with major depressive disorder has not responded to an adequate trial
of sertraline. Which of the following is the most evidence-based next step
according to the 2024 APA guidelines?
A. Switch to a monoamine oxidase inhibitor (MAOI) immediately.
B. Augment with aripiprazole or switch to venlafaxine.
C. Add buspirone to sertraline.
D. Initiate thyroid hormone augmentation with liothyronine.
Correct Answer: B - Augment with aripiprazole or switch to
venlafaxine.
RATIONALE
The 2024 APA guidelines recommend either switching to a different
antidepressant (e.g., venlafaxine) or augmenting with an atypical
antipsychotic (e.g., aripiprazole) after inadequate response to an SSRI.
MAOIs require washout and are not first-line, buspirone has weaker
evidence, and thyroid augmentation is less supported.
Question 5
A 55-year-old patient with no prior cardiovascular disease presents for routine
care. According to the 2023 AHA/ACC guidelines, which of the following is
the most appropriate primary prevention strategy for a patient with a 10-year
ASCVD risk of 12% and no contraindications?
A. Initiate high-intensity statin therapy (atorvastatin 40-80 mg daily).
B. Initiate moderate-intensity statin therapy (atorvastatin 20 mg daily).
Page 4
