, Question 1
A patient with heart failure and reduced ejection fraction is initiated on
sacubitril/valsartan. Which pharmacodynamic mechanism best explains the
combined therapeutic effect?
A. Inhibition of neprilysin increases natriuretic peptides, while valsartan
blocks angiotensin II AT1 receptors.
B. Sacubitril inhibits angiotensin-converting enzyme, and valsartan
blocks aldosterone receptors.
C. Sacubitril enhances bradykinin degradation, and valsartan inhibits
renin release.
D. Sacubitril blocks beta-adrenergic receptors, and valsartan dilates
venous capacitance vessels.
Correct Answer: A - Inhibition of neprilysin increases natriuretic
peptides, while valsartan blocks angiotensin II AT1 receptors.
RATIONALE
Sacubitril inhibits neprilysin, increasing natriuretic peptides that
promote vasodilation and natriuresis. Valsartan blocks AT1 receptors,
reducing vasoconstriction and aldosterone effects. The other options
misstate mechanisms: ACE inhibition is not sacubitril's action,
bradykinin is not degraded by neprilysin inhibition, and beta-blockade
is unrelated.
Question 2
A patient presents with sudden-onset severe abdominal pain, hypotension, and
a pulsatile abdominal mass. Which pathophysiologic process is most likely
responsible for these findings?
A. Acute mesenteric ischemia due to arterial embolism
B. Ruptured abdominal aortic aneurysm with retroperitoneal hemorrhage
C. Perforated peptic ulcer with chemical peritonitis
D. Acute pancreatitis with systemic inflammatory response
Page 2
, Correct Answer: B - Ruptured abdominal aortic aneurysm with
retroperitoneal hemorrhage
RATIONALE
The triad of severe abdominal pain, hypotension, and a pulsatile mass
is classic for a ruptured abdominal aortic aneurysm, leading to
retroperitoneal bleeding and hypovolemic shock. Mesenteric ischemia
typically presents with pain out of proportion to exam but without a
pulsatile mass. Perforated ulcer causes board-like rigidity, and
pancreatitis usually has epigastric pain radiating to the back with
elevated lipase.
Question 3
A patient with major depressive disorder has not responded to adequate trials
of two SSRIs. Which class of antidepressants is most appropriate to consider
next based on current evidence?
A. Tricyclic antidepressants (TCAs)
B. Monoamine oxidase inhibitors (MAOIs)
C. Serotonin-norepinephrine reuptake inhibitors (SNRIs)
D. Atypical antipsychotics as monotherapy
Correct Answer: C - Serotonin-norepinephrine reuptake
inhibitors (SNRIs)
RATIONALE
SNRIs are often considered next-line after SSRI failure due to their
dual mechanism and favorable evidence for treatment-resistant
depression. TCAs and MAOIs are older classes with more adverse
effects and dietary restrictions, typically reserved for later. Atypical
antipsychotics are usually adjunctive, not monotherapy, for
depression.
Page 3
A patient with heart failure and reduced ejection fraction is initiated on
sacubitril/valsartan. Which pharmacodynamic mechanism best explains the
combined therapeutic effect?
A. Inhibition of neprilysin increases natriuretic peptides, while valsartan
blocks angiotensin II AT1 receptors.
B. Sacubitril inhibits angiotensin-converting enzyme, and valsartan
blocks aldosterone receptors.
C. Sacubitril enhances bradykinin degradation, and valsartan inhibits
renin release.
D. Sacubitril blocks beta-adrenergic receptors, and valsartan dilates
venous capacitance vessels.
Correct Answer: A - Inhibition of neprilysin increases natriuretic
peptides, while valsartan blocks angiotensin II AT1 receptors.
RATIONALE
Sacubitril inhibits neprilysin, increasing natriuretic peptides that
promote vasodilation and natriuresis. Valsartan blocks AT1 receptors,
reducing vasoconstriction and aldosterone effects. The other options
misstate mechanisms: ACE inhibition is not sacubitril's action,
bradykinin is not degraded by neprilysin inhibition, and beta-blockade
is unrelated.
Question 2
A patient presents with sudden-onset severe abdominal pain, hypotension, and
a pulsatile abdominal mass. Which pathophysiologic process is most likely
responsible for these findings?
A. Acute mesenteric ischemia due to arterial embolism
B. Ruptured abdominal aortic aneurysm with retroperitoneal hemorrhage
C. Perforated peptic ulcer with chemical peritonitis
D. Acute pancreatitis with systemic inflammatory response
Page 2
, Correct Answer: B - Ruptured abdominal aortic aneurysm with
retroperitoneal hemorrhage
RATIONALE
The triad of severe abdominal pain, hypotension, and a pulsatile mass
is classic for a ruptured abdominal aortic aneurysm, leading to
retroperitoneal bleeding and hypovolemic shock. Mesenteric ischemia
typically presents with pain out of proportion to exam but without a
pulsatile mass. Perforated ulcer causes board-like rigidity, and
pancreatitis usually has epigastric pain radiating to the back with
elevated lipase.
Question 3
A patient with major depressive disorder has not responded to adequate trials
of two SSRIs. Which class of antidepressants is most appropriate to consider
next based on current evidence?
A. Tricyclic antidepressants (TCAs)
B. Monoamine oxidase inhibitors (MAOIs)
C. Serotonin-norepinephrine reuptake inhibitors (SNRIs)
D. Atypical antipsychotics as monotherapy
Correct Answer: C - Serotonin-norepinephrine reuptake
inhibitors (SNRIs)
RATIONALE
SNRIs are often considered next-line after SSRI failure due to their
dual mechanism and favorable evidence for treatment-resistant
depression. TCAs and MAOIs are older classes with more adverse
effects and dietary restrictions, typically reserved for later. Atypical
antipsychotics are usually adjunctive, not monotherapy, for
depression.
Page 3
