, Question 1
A patient presents with a 3-day history of unilateral headache, scalp tenderness,
and jaw claudication. Erythrocyte sedimentation rate is 78 mm/hr. Which of
the following is the most appropriate immediate action?
A. Start high-dose oral prednisone and schedule temporal artery biopsy
within 2 weeks.
B. Initiate high-dose intravenous corticosteroids immediately and arrange
urgent temporal artery biopsy.
C. Prescribe sumatriptan and obtain outpatient MRI of the brain.
D. Administer intramuscular ketorolac and refer to neurology for elective
evaluation.
Correct Answer: B - Initiate high-dose intravenous
corticosteroids immediately and arrange urgent temporal artery
biopsy.
RATIONALE
This presentation is highly suspicious for giant cell arteritis (GCA)
with impending vision loss; high-dose IV corticosteroids should be
started immediately, and temporal artery biopsy should be performed
urgently (within 1-2 weeks) but must not delay treatment. Oral
prednisone is insufficient for acute severe GCA, and triptans or
NSAIDs do not address the vasculitic process. Immediate IV steroids
are standard of care to prevent irreversible blindness.
Question 2
Which of the following best describes the mechanism by which SGLT2
inhibitors confer cardiorenal protection in patients with type 2 diabetes and
heart failure?
A. They increase insulin secretion from pancreatic beta cells, reducing
glucotoxicity.
B. They inhibit sodium-glucose cotransport in the proximal tubule,
promoting natriuresis and reducing intraglomerular pressure.
Page 2
, C. They activate PPAR-gamma receptors, improving insulin sensitivity
and reducing inflammation.
D. They block hepatic gluconeogenesis and enhance peripheral glucose
uptake.
Correct Answer: B - They inhibit sodium-glucose cotransport in
the proximal tubule, promoting natriuresis and reducing
intraglomerular pressure.
RATIONALE
SGLT2 inhibitors reduce glucose reabsorption in the proximal tubule,
leading to glycosuria, natriuresis, and decreased intraglomerular
pressure, which contributes to cardiorenal protection. They do not
primarily increase insulin secretion (sulfonylureas), activate
PPAR-gamma (thiazolidinediones), or block hepatic gluconeogenesis
(metformin). This mechanism underlies their benefit in heart failure
and chronic kidney disease.
Question 3
A 45-year-old patient with no prior history of cardiovascular disease asks about
aspirin for primary prevention. Based on the latest USPSTF recommendations,
which statement is most accurate?
A. Aspirin should be routinely recommended for all adults aged 40-59 to
prevent myocardial infarction.
B. Aspirin is not recommended for primary prevention in adults aged 60
or older due to increased bleeding risk.
C. Aspirin is recommended for primary prevention in all adults regardless
of age, with bleeding risk being negligible.
D. Aspirin should be initiated only in patients with a 10-year risk of
cardiovascular disease greater than 20%.
Correct Answer: B - Aspirin is not recommended for primary
prevention in adults aged 60 or older due to increased bleeding
risk.
Page 3
, RATIONALE
The USPSTF 2022 recommendation states that for adults aged 60
years or older, aspirin should not be initiated for primary prevention of
cardiovascular disease due to lack of net benefit and increased
bleeding risk. For adults aged 40-59 with higher risk, the decision
should be individualized. Routine use in all adults or based solely on a
>20% risk threshold is not supported by current evidence.
Question 4
A patient with asthma is prescribed a low-dose inhaled corticosteroid (ICS) but
reports frequent rescue inhaler use. Which of the following is the most
appropriate next step according to current GINA guidelines?
A. Add a long-acting beta-agonist (LABA) to the ICS.
B. Switch to a leukotriene receptor antagonist (LTRA) monotherapy.
C. Increase the ICS dose to medium and reassess in 4-6 weeks.
D. Recommend a short-acting beta-agonist (SABA) only as needed and
avoid controller therapy.
Correct Answer: A - Add a long-acting beta-agonist (LABA) to
the ICS.
RATIONALE
For patients with uncontrolled asthma on low-dose ICS, GINA
recommends adding a LABA to the ICS as the preferred step-up
therapy. LTRA monotherapy is less effective than ICS-LABA.
Increasing ICS to medium dose is an alternative but adding LABA is
preferred for most adults. SABA-only therapy is not recommended for
persistent asthma.
Question 5
Which of the following findings on a peripheral blood smear is most
characteristic of iron deficiency anemia?
A. Macrocytosis with hypersegmented neutrophils
Page 4
A patient presents with a 3-day history of unilateral headache, scalp tenderness,
and jaw claudication. Erythrocyte sedimentation rate is 78 mm/hr. Which of
the following is the most appropriate immediate action?
A. Start high-dose oral prednisone and schedule temporal artery biopsy
within 2 weeks.
B. Initiate high-dose intravenous corticosteroids immediately and arrange
urgent temporal artery biopsy.
C. Prescribe sumatriptan and obtain outpatient MRI of the brain.
D. Administer intramuscular ketorolac and refer to neurology for elective
evaluation.
Correct Answer: B - Initiate high-dose intravenous
corticosteroids immediately and arrange urgent temporal artery
biopsy.
RATIONALE
This presentation is highly suspicious for giant cell arteritis (GCA)
with impending vision loss; high-dose IV corticosteroids should be
started immediately, and temporal artery biopsy should be performed
urgently (within 1-2 weeks) but must not delay treatment. Oral
prednisone is insufficient for acute severe GCA, and triptans or
NSAIDs do not address the vasculitic process. Immediate IV steroids
are standard of care to prevent irreversible blindness.
Question 2
Which of the following best describes the mechanism by which SGLT2
inhibitors confer cardiorenal protection in patients with type 2 diabetes and
heart failure?
A. They increase insulin secretion from pancreatic beta cells, reducing
glucotoxicity.
B. They inhibit sodium-glucose cotransport in the proximal tubule,
promoting natriuresis and reducing intraglomerular pressure.
Page 2
, C. They activate PPAR-gamma receptors, improving insulin sensitivity
and reducing inflammation.
D. They block hepatic gluconeogenesis and enhance peripheral glucose
uptake.
Correct Answer: B - They inhibit sodium-glucose cotransport in
the proximal tubule, promoting natriuresis and reducing
intraglomerular pressure.
RATIONALE
SGLT2 inhibitors reduce glucose reabsorption in the proximal tubule,
leading to glycosuria, natriuresis, and decreased intraglomerular
pressure, which contributes to cardiorenal protection. They do not
primarily increase insulin secretion (sulfonylureas), activate
PPAR-gamma (thiazolidinediones), or block hepatic gluconeogenesis
(metformin). This mechanism underlies their benefit in heart failure
and chronic kidney disease.
Question 3
A 45-year-old patient with no prior history of cardiovascular disease asks about
aspirin for primary prevention. Based on the latest USPSTF recommendations,
which statement is most accurate?
A. Aspirin should be routinely recommended for all adults aged 40-59 to
prevent myocardial infarction.
B. Aspirin is not recommended for primary prevention in adults aged 60
or older due to increased bleeding risk.
C. Aspirin is recommended for primary prevention in all adults regardless
of age, with bleeding risk being negligible.
D. Aspirin should be initiated only in patients with a 10-year risk of
cardiovascular disease greater than 20%.
Correct Answer: B - Aspirin is not recommended for primary
prevention in adults aged 60 or older due to increased bleeding
risk.
Page 3
, RATIONALE
The USPSTF 2022 recommendation states that for adults aged 60
years or older, aspirin should not be initiated for primary prevention of
cardiovascular disease due to lack of net benefit and increased
bleeding risk. For adults aged 40-59 with higher risk, the decision
should be individualized. Routine use in all adults or based solely on a
>20% risk threshold is not supported by current evidence.
Question 4
A patient with asthma is prescribed a low-dose inhaled corticosteroid (ICS) but
reports frequent rescue inhaler use. Which of the following is the most
appropriate next step according to current GINA guidelines?
A. Add a long-acting beta-agonist (LABA) to the ICS.
B. Switch to a leukotriene receptor antagonist (LTRA) monotherapy.
C. Increase the ICS dose to medium and reassess in 4-6 weeks.
D. Recommend a short-acting beta-agonist (SABA) only as needed and
avoid controller therapy.
Correct Answer: A - Add a long-acting beta-agonist (LABA) to
the ICS.
RATIONALE
For patients with uncontrolled asthma on low-dose ICS, GINA
recommends adding a LABA to the ICS as the preferred step-up
therapy. LTRA monotherapy is less effective than ICS-LABA.
Increasing ICS to medium dose is an alternative but adding LABA is
preferred for most adults. SABA-only therapy is not recommended for
persistent asthma.
Question 5
Which of the following findings on a peripheral blood smear is most
characteristic of iron deficiency anemia?
A. Macrocytosis with hypersegmented neutrophils
Page 4
