, Question 1
A patient with stage 3b chronic kidney disease (eGFR 38 mL/min/1.73 m²)
and type 2 diabetes requires glycemic optimization. Which medication best
balances efficacy, cardiovascular benefit, and renal safety?
A. Metformin 1000 mg PO twice daily
B. Empagliflozin 10 mg PO once daily
C. Glyburide 5 mg PO once daily
D. Pioglitazone 30 mg PO once daily
Correct Answer: B - Empagliflozin 10 mg PO once daily
RATIONALE
SGLT2 inhibitors such as empagliflozin are recommended in CKD
stage 3b (eGFR 20) for both glycemic control and cardiorenal
protection per ADA/KDIGO 2024 guidance. Metformin requires dose
reduction and is contraindicated below eGFR 30 but is still
permissible at 38 only if carefully monitored; the SGLT2 inhibitor
offers superior cardiorenal outcomes. Glyburide risks hypoglycemia in
renal impairment, and pioglitazone causes fluid retention without
cardiorenal benefit.
Question 2
A patient reports 3 weeks of intermittent substernal chest pressure provoked by
exertion and relieved within 5 minutes of rest. Which next step most
appropriately aligns with current AHA/ACC guidance for stable angina
evaluation?
A. Immediate exercise treadmill stress test without further workup
B. Coronary CT angiography as the initial diagnostic test
C. 12-lead ECG and risk stratification, then functional or anatomic testing
based on pretest probability
D. Empiric sublingual nitroglycerin trial without diagnostic testing
Correct Answer: C - 12-lead ECG and risk stratification, then
Page 2
,functional or anatomic testing based on pretest probability
RATIONALE
AHA/ACC 2021 Chest Pain Guideline directs that patients with stable
chest pain undergo ECG and structured risk assessment (e.g., pretest
probability), followed by either functional or anatomic testing
depending on probability and patient characteristics. Jumping directly
to exercise testing or CCTA without ECG/risk stratification is not
guideline-concordant. Empiric nitroglycerin without diagnosis is
unsafe and delays risk-appropriate evaluation.
Question 3
A patient with bipolar I disorder maintained on lithium presents with tremor,
polyuria, and a lithium level of 1.8 mEq/L. Which action is most appropriate?
A. Continue current lithium dose and recheck level in 1 week
B. Hold lithium, provide isotonic IV fluids, and recheck level; consider
hemodialysis if neurotoxicity develops
C. Add a beta-blocker to manage tremor and continue lithium
D. Switch immediately to valproate without addressing the lithium level
Correct Answer: B - Hold lithium, provide isotonic IV fluids, and
recheck level; consider hemodialysis if neurotoxicity develops
RATIONALE
A lithium level of 1.8 mEq/L exceeds the therapeutic range (0.6-1.2
mEq/L) and is consistent with moderate toxicity; management
includes holding the drug, restoring volume with isotonic fluids, and
monitoring for neurotoxicity, with hemodialysis reserved for severe
toxicity. Beta-blockade and medication substitution do not address the
acute toxicity. Continued dosing risks progression to life-threatening
arrhythmias and seizures.
Page 3
, Question 4
Which finding on a 12-lead ECG most strongly suggests hyperkalemia in a
patient with advanced CKD and no pacemaker?
A. Peaked T waves with widened QRS and loss of P waves
B. Diffuse ST elevation with PR depression
C. Prolonged QT interval with U waves
D. Sawtooth flutter waves at 300 bpm
Correct Answer: A - Peaked T waves with widened QRS and loss
of P waves
RATIONALE
Hyperkalemia classically produces tall peaked T waves, PR
prolongation, loss of P waves, and QRS widening that can progress to
a sine wave and cardiac arrest. Diffuse ST elevation with PR
depression suggests pericarditis, QT prolongation with U waves
suggests hypokalemia, and sawtooth flutter waves indicate atrial
flutter. Recognition of hyperkalemic ECG progression is critical to
preventing fatal arrhythmias.
Question 5
A patient with COPD (FEV1 55% predicted, 2 exacerbations in the past year,
no asthma features) is on tiotropium. Which addition best aligns with the 2024
GOLD strategy?
A. Add inhaled corticosteroid (ICS) monotherapy
B. Add a long-acting beta-2 agonist (LABA) to the LAMA
C. Add chronic oral prednisone 10 mg daily
D. Add a short-acting beta-2 agonist as scheduled maintenance therapy
Correct Answer: B - Add a long-acting beta-2 agonist (LABA) to
the LAMA
Page 4
A patient with stage 3b chronic kidney disease (eGFR 38 mL/min/1.73 m²)
and type 2 diabetes requires glycemic optimization. Which medication best
balances efficacy, cardiovascular benefit, and renal safety?
A. Metformin 1000 mg PO twice daily
B. Empagliflozin 10 mg PO once daily
C. Glyburide 5 mg PO once daily
D. Pioglitazone 30 mg PO once daily
Correct Answer: B - Empagliflozin 10 mg PO once daily
RATIONALE
SGLT2 inhibitors such as empagliflozin are recommended in CKD
stage 3b (eGFR 20) for both glycemic control and cardiorenal
protection per ADA/KDIGO 2024 guidance. Metformin requires dose
reduction and is contraindicated below eGFR 30 but is still
permissible at 38 only if carefully monitored; the SGLT2 inhibitor
offers superior cardiorenal outcomes. Glyburide risks hypoglycemia in
renal impairment, and pioglitazone causes fluid retention without
cardiorenal benefit.
Question 2
A patient reports 3 weeks of intermittent substernal chest pressure provoked by
exertion and relieved within 5 minutes of rest. Which next step most
appropriately aligns with current AHA/ACC guidance for stable angina
evaluation?
A. Immediate exercise treadmill stress test without further workup
B. Coronary CT angiography as the initial diagnostic test
C. 12-lead ECG and risk stratification, then functional or anatomic testing
based on pretest probability
D. Empiric sublingual nitroglycerin trial without diagnostic testing
Correct Answer: C - 12-lead ECG and risk stratification, then
Page 2
,functional or anatomic testing based on pretest probability
RATIONALE
AHA/ACC 2021 Chest Pain Guideline directs that patients with stable
chest pain undergo ECG and structured risk assessment (e.g., pretest
probability), followed by either functional or anatomic testing
depending on probability and patient characteristics. Jumping directly
to exercise testing or CCTA without ECG/risk stratification is not
guideline-concordant. Empiric nitroglycerin without diagnosis is
unsafe and delays risk-appropriate evaluation.
Question 3
A patient with bipolar I disorder maintained on lithium presents with tremor,
polyuria, and a lithium level of 1.8 mEq/L. Which action is most appropriate?
A. Continue current lithium dose and recheck level in 1 week
B. Hold lithium, provide isotonic IV fluids, and recheck level; consider
hemodialysis if neurotoxicity develops
C. Add a beta-blocker to manage tremor and continue lithium
D. Switch immediately to valproate without addressing the lithium level
Correct Answer: B - Hold lithium, provide isotonic IV fluids, and
recheck level; consider hemodialysis if neurotoxicity develops
RATIONALE
A lithium level of 1.8 mEq/L exceeds the therapeutic range (0.6-1.2
mEq/L) and is consistent with moderate toxicity; management
includes holding the drug, restoring volume with isotonic fluids, and
monitoring for neurotoxicity, with hemodialysis reserved for severe
toxicity. Beta-blockade and medication substitution do not address the
acute toxicity. Continued dosing risks progression to life-threatening
arrhythmias and seizures.
Page 3
, Question 4
Which finding on a 12-lead ECG most strongly suggests hyperkalemia in a
patient with advanced CKD and no pacemaker?
A. Peaked T waves with widened QRS and loss of P waves
B. Diffuse ST elevation with PR depression
C. Prolonged QT interval with U waves
D. Sawtooth flutter waves at 300 bpm
Correct Answer: A - Peaked T waves with widened QRS and loss
of P waves
RATIONALE
Hyperkalemia classically produces tall peaked T waves, PR
prolongation, loss of P waves, and QRS widening that can progress to
a sine wave and cardiac arrest. Diffuse ST elevation with PR
depression suggests pericarditis, QT prolongation with U waves
suggests hypokalemia, and sawtooth flutter waves indicate atrial
flutter. Recognition of hyperkalemic ECG progression is critical to
preventing fatal arrhythmias.
Question 5
A patient with COPD (FEV1 55% predicted, 2 exacerbations in the past year,
no asthma features) is on tiotropium. Which addition best aligns with the 2024
GOLD strategy?
A. Add inhaled corticosteroid (ICS) monotherapy
B. Add a long-acting beta-2 agonist (LABA) to the LAMA
C. Add chronic oral prednisone 10 mg daily
D. Add a short-acting beta-2 agonist as scheduled maintenance therapy
Correct Answer: B - Add a long-acting beta-2 agonist (LABA) to
the LAMA
Page 4
