1|P a g e
AANP BOARD FINAL EXAM 2026 | ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES |
ALREADY A GRADED | NEW AND
REVISED
1. A 52-year-old woman presents with fatigue, cold
intolerance, and weight gain over 6 months. On
examination, she has dry skin, brittle nails, and delayed
reflex relaxation. Laboratory studies reveal TSH 12 mIU/L
(normal 0.5–4.5) and free T4 0.6 ng/dL (normal 0.8–1.8).
The most appropriate next step is:
A. Start levothyroxine 25 mcg daily and recheck labs in 6
weeks
B. Start levothyroxine 75–100 mcg daily and recheck
labs in 6–8 weeks
C. Reassure the patient and repeat labs in 3 months
D. Order a thyroid ultrasound
Rationale: The patient presents with primary hypothyroidism.
Symptomatic adults without cardiac disease usually start 75–
100 mcg/day of levothyroxine, adjusting dose based on TSH
levels. Reassurance without treatment would worsen
symptoms. Ultrasound is not indicated unless there is
suspicion for nodules.
,2|P a g e
2. A 28-year-old male presents with dysuria, urethral
discharge, and a history of new sexual partners. Gram stain
shows intracellular Gram-negative diplococci. The
recommended treatment is:
A. Azithromycin 1 g orally single dose
B. Doxycycline 100 mg orally twice daily for 7 days
C. Ceftriaxone 500 mg IM single dose
D. Ciprofloxacin 500 mg orally twice daily for 3 days
Rationale: Intracellular Gram-negative diplococci indicate
gonorrhea. First-line therapy per CDC guidelines is
ceftriaxone 500 mg IM single dose. Azithromycin and
doxycycline are indicated for chlamydia.
3. A 65-year-old man with type 2 diabetes presents for routine
follow-up. His HbA1c is 8.5%. He is currently on
metformin 1000 mg twice daily. Which is the next best step
in management?
A. Continue metformin and reassess in 3 months
B. Add a GLP-1 receptor agonist or SGLT2 inhibitor
C. Switch metformin to insulin
D. Recommend lifestyle modification only
Rationale: For patients not at goal on metformin, guidelines
recommend adding a second agent with proven cardiovascular
or renal benefit, such as GLP-1 receptor agonists or SGLT2
inhibitors, alongside lifestyle changes.
4. A patient presents with acute onset dyspnea and pleuritic
chest pain. On examination: tachycardia, mild hypotension,
and decreased breath sounds at the right base. Chest X-ray
shows right-sided pleural effusion. The most likely
,3|P a g e
diagnosis is:
A. Pneumonia
B. Pulmonary embolism with pleural effusion
C. Congestive heart failure
D. Pneumothorax
Rationale: Acute dyspnea, pleuritic pain, and unilateral
pleural effusion suggest PE, which can cause small effusions.
Pneumonia typically presents with fever and consolidation.
CHF is usually bilateral. Pneumothorax presents with
hyperresonance and absent breath sounds.
5. A 34-year-old woman presents with a sudden severe
headache, photophobia, and neck stiffness. On
examination, she has a positive Brudzinski sign. What is
the most appropriate initial investigation?
A. Lumbar puncture
B. MRI brain
C. CT angiography
D. EEG
Rationale: The classic triad suggests meningitis. Lumbar
puncture is required to obtain CSF for definitive diagnosis.
Imaging is only indicated before LP if there are focal
neurologic deficits or risk of increased intracranial pressure.
6. A 72-year-old patient with chronic kidney disease stage 3 is
being considered for NSAID therapy for osteoarthritis.
Which is the best recommendation?
A. Start ibuprofen 400 mg daily
B. Avoid NSAIDs and consider acetaminophen
, 4|P a g e
C. Use naproxen as needed
D. Prescribe a COX-2 selective NSAID
Rationale: NSAIDs can worsen renal function in CKD.
Acetaminophen is safer. COX-2 inhibitors still carry renal
risk.
7. A 25-year-old male presents with fever, cough, and
pleuritic chest pain. He returned from a camping trip 10
days ago. Chest X-ray shows patchy infiltrates. Which
empiric therapy is most appropriate?
A. Amoxicillin
B. Ceftriaxone
C. Doxycycline
D. Azithromycin
Rationale: Given history of outdoor exposure and atypical
pneumonia signs, doxycycline covers atypical organisms
including Rickettsia and Mycoplasma. Macrolides may also be
used, but doxycycline is first-line in certain endemic
exposures.
8. A 45-year-old patient with hypertension is on lisinopril 20
mg daily. Lab results reveal potassium 5.8 mEq/L. Which
action is most appropriate?
A. Increase lisinopril
B. Hold lisinopril and check for contributing factors
C. Start a loop diuretic
D. Start potassium supplement
Rationale: ACE inhibitors can cause hyperkalemia. The drug
should be held, and contributing factors evaluated. Increasing
AANP BOARD FINAL EXAM 2026 | ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES |
ALREADY A GRADED | NEW AND
REVISED
1. A 52-year-old woman presents with fatigue, cold
intolerance, and weight gain over 6 months. On
examination, she has dry skin, brittle nails, and delayed
reflex relaxation. Laboratory studies reveal TSH 12 mIU/L
(normal 0.5–4.5) and free T4 0.6 ng/dL (normal 0.8–1.8).
The most appropriate next step is:
A. Start levothyroxine 25 mcg daily and recheck labs in 6
weeks
B. Start levothyroxine 75–100 mcg daily and recheck
labs in 6–8 weeks
C. Reassure the patient and repeat labs in 3 months
D. Order a thyroid ultrasound
Rationale: The patient presents with primary hypothyroidism.
Symptomatic adults without cardiac disease usually start 75–
100 mcg/day of levothyroxine, adjusting dose based on TSH
levels. Reassurance without treatment would worsen
symptoms. Ultrasound is not indicated unless there is
suspicion for nodules.
,2|P a g e
2. A 28-year-old male presents with dysuria, urethral
discharge, and a history of new sexual partners. Gram stain
shows intracellular Gram-negative diplococci. The
recommended treatment is:
A. Azithromycin 1 g orally single dose
B. Doxycycline 100 mg orally twice daily for 7 days
C. Ceftriaxone 500 mg IM single dose
D. Ciprofloxacin 500 mg orally twice daily for 3 days
Rationale: Intracellular Gram-negative diplococci indicate
gonorrhea. First-line therapy per CDC guidelines is
ceftriaxone 500 mg IM single dose. Azithromycin and
doxycycline are indicated for chlamydia.
3. A 65-year-old man with type 2 diabetes presents for routine
follow-up. His HbA1c is 8.5%. He is currently on
metformin 1000 mg twice daily. Which is the next best step
in management?
A. Continue metformin and reassess in 3 months
B. Add a GLP-1 receptor agonist or SGLT2 inhibitor
C. Switch metformin to insulin
D. Recommend lifestyle modification only
Rationale: For patients not at goal on metformin, guidelines
recommend adding a second agent with proven cardiovascular
or renal benefit, such as GLP-1 receptor agonists or SGLT2
inhibitors, alongside lifestyle changes.
4. A patient presents with acute onset dyspnea and pleuritic
chest pain. On examination: tachycardia, mild hypotension,
and decreased breath sounds at the right base. Chest X-ray
shows right-sided pleural effusion. The most likely
,3|P a g e
diagnosis is:
A. Pneumonia
B. Pulmonary embolism with pleural effusion
C. Congestive heart failure
D. Pneumothorax
Rationale: Acute dyspnea, pleuritic pain, and unilateral
pleural effusion suggest PE, which can cause small effusions.
Pneumonia typically presents with fever and consolidation.
CHF is usually bilateral. Pneumothorax presents with
hyperresonance and absent breath sounds.
5. A 34-year-old woman presents with a sudden severe
headache, photophobia, and neck stiffness. On
examination, she has a positive Brudzinski sign. What is
the most appropriate initial investigation?
A. Lumbar puncture
B. MRI brain
C. CT angiography
D. EEG
Rationale: The classic triad suggests meningitis. Lumbar
puncture is required to obtain CSF for definitive diagnosis.
Imaging is only indicated before LP if there are focal
neurologic deficits or risk of increased intracranial pressure.
6. A 72-year-old patient with chronic kidney disease stage 3 is
being considered for NSAID therapy for osteoarthritis.
Which is the best recommendation?
A. Start ibuprofen 400 mg daily
B. Avoid NSAIDs and consider acetaminophen
, 4|P a g e
C. Use naproxen as needed
D. Prescribe a COX-2 selective NSAID
Rationale: NSAIDs can worsen renal function in CKD.
Acetaminophen is safer. COX-2 inhibitors still carry renal
risk.
7. A 25-year-old male presents with fever, cough, and
pleuritic chest pain. He returned from a camping trip 10
days ago. Chest X-ray shows patchy infiltrates. Which
empiric therapy is most appropriate?
A. Amoxicillin
B. Ceftriaxone
C. Doxycycline
D. Azithromycin
Rationale: Given history of outdoor exposure and atypical
pneumonia signs, doxycycline covers atypical organisms
including Rickettsia and Mycoplasma. Macrolides may also be
used, but doxycycline is first-line in certain endemic
exposures.
8. A 45-year-old patient with hypertension is on lisinopril 20
mg daily. Lab results reveal potassium 5.8 mEq/L. Which
action is most appropriate?
A. Increase lisinopril
B. Hold lisinopril and check for contributing factors
C. Start a loop diuretic
D. Start potassium supplement
Rationale: ACE inhibitors can cause hyperkalemia. The drug
should be held, and contributing factors evaluated. Increasing
