Question 1
A 72-year-old patient with heart failure and reduced ejection fraction develops a dry cough two
weeks after starting a new medication. Which drug class is most likely responsible?
A) Beta-blocker
B) Loop diuretic
C) ACE inhibitor
D) Hydralazine
Rationale: ACE inhibitors cause bradykinin-mediated dry cough in 5-20% of patients, unlike
ARBs which rarely cause cough.
Question 2
A patient on warfarin for atrial fibrillation has an INR of 4.5 without bleeding. What is the most
appropriate next step?
A) Administer vitamin K 10 mg orally
B) Hold warfarin for 1-2 days and monitor INR
C) Give fresh frozen plasma immediately
D) Increase warfarin dose
Rationale: INR 4.5 without bleeding requires withholding warfarin and rechecking; vitamin K
reserved for INR >10 or bleeding.
Question 3
A 28-year-old woman with recurrent genital herpes requests suppression therapy. Which
regimen is first-line?
A) Acyclovir 400 mg BID
B) Valacyclovir 500 mg daily
,C) Famciclovir 125 mg TID
D) Topical penciclovir
Rationale: Valacyclovir 500 mg daily is standard suppression; acyclovir requires more frequent
dosing reducing adherence.
Question 4
A patient with type 2 diabetes on metformin and glipizide presents with hypoglycemia. Which
SGLT2 inhibitor has the lowest risk of hypoglycemia as add-on?
A) Empagliflozin
B) Glyburide
C) Insulin glargine
D) Pioglitazone
Rationale: SGLT2 inhibitors cause hypoglycemia only when combined with sulfonylureas or
insulin, but empagliflozin alone rarely causes it.
Question 5
A 45-year-old with hypertension and gout has a BP of 152/94 mm Hg. Which antihypertensive
should be avoided?
A) Losartan
B) Amlodipine
C) Hydrochlorothiazide
D) Lisinopril
Rationale: Thiazide diuretics increase uric acid and can precipitate gout flares; losartan actually
lowers uric acid.
Question 6
A child with acute otitis media has a penicillin allergy (urticaria). Which antibiotic is safest?
A) Amoxicillin-clavulanate
B) Cefdinir
C) Doxycycline
D) Levofloxacin
,Rationale: Third-generation cephalosporins like cefdinir have low cross-reactivity (1-2%) with
penicillin allergy, safer than earlier cephalosporins.
Question 7
A patient on sertraline for 6 weeks reports no improvement. What is the best next step before
switching antidepressants?
A) Add buspirone
B) Increase to maximum tolerated dose
C) Change to phenelzine
D) Discontinue abruptly
Rationale: Full therapeutic trial requires 8-12 weeks at optimal dose; dose optimization
precedes augmentation or switch.
Question 8
A 30-year-old woman requests emergency contraception 48 hours after unprotected
intercourse. Which option is most effective?
A) Levonorgestrel 1.5 mg once
B) Ethinyl estradiol-norgestrel two doses
C) Copper IUD placement
D) Ulipristal acetate 30 mg
Rationale: Copper IUD is most effective (>99%) but ulipristal (given) is superior to levonorgestrel
up to 120 hours.
Question 9
A patient with COPD and frequent exacerbations has an FEV1 of 45% predicted. Which
maintenance therapy reduces mortality?
A) LAMA + LABA + ICS
B) Short-acting beta-agonist alone
C) Oral prednisone daily
D) Theophylline
Rationale: Triple therapy (LAMA/LABA/ICS) reduces exacerbations and mortality in severe
COPD versus dual therapy.
, Question 10
A 55-year-old with GERD symptoms despite omeprazole 20 mg daily for 8 weeks. What is the
next step?
A) Add ranitidine
B) Double omeprazole to 40 mg daily
C) Switch to famotidine
D) Refer for fundoplication
Rationale: Inadequate PPI response first requires dose optimization (BID or higher dose) before
adding H2RA or surgery.
Question 11
A patient on lithium develops tremor, nausea, and confusion. Lithium level is 2.1 mEq/L. What is
the priority action?
A) Add propranolol for tremor
B) Hold lithium and assess renal function
C) Increase fluids to 3 L/day
D) Give sodium polystyrene sulfonate
Rationale: Lithium toxicity (>1.5 mEq/L) requires discontinuation, hydration, and monitoring;
severe levels may need hemodialysis.
Question 12
A 68-year-old with osteoarthritis requests pain relief but has history of gastric ulcer. Which
NSAID is safest?
A) Naproxen
B) Ibuprofen
C) Celecoxib
D) Ketorolac
Rationale: COX-2 selective celecoxib reduces GI ulcer risk versus nonselective NSAIDs, but still
caution in high CV risk.
Question 13
A 72-year-old patient with heart failure and reduced ejection fraction develops a dry cough two
weeks after starting a new medication. Which drug class is most likely responsible?
A) Beta-blocker
B) Loop diuretic
C) ACE inhibitor
D) Hydralazine
Rationale: ACE inhibitors cause bradykinin-mediated dry cough in 5-20% of patients, unlike
ARBs which rarely cause cough.
Question 2
A patient on warfarin for atrial fibrillation has an INR of 4.5 without bleeding. What is the most
appropriate next step?
A) Administer vitamin K 10 mg orally
B) Hold warfarin for 1-2 days and monitor INR
C) Give fresh frozen plasma immediately
D) Increase warfarin dose
Rationale: INR 4.5 without bleeding requires withholding warfarin and rechecking; vitamin K
reserved for INR >10 or bleeding.
Question 3
A 28-year-old woman with recurrent genital herpes requests suppression therapy. Which
regimen is first-line?
A) Acyclovir 400 mg BID
B) Valacyclovir 500 mg daily
,C) Famciclovir 125 mg TID
D) Topical penciclovir
Rationale: Valacyclovir 500 mg daily is standard suppression; acyclovir requires more frequent
dosing reducing adherence.
Question 4
A patient with type 2 diabetes on metformin and glipizide presents with hypoglycemia. Which
SGLT2 inhibitor has the lowest risk of hypoglycemia as add-on?
A) Empagliflozin
B) Glyburide
C) Insulin glargine
D) Pioglitazone
Rationale: SGLT2 inhibitors cause hypoglycemia only when combined with sulfonylureas or
insulin, but empagliflozin alone rarely causes it.
Question 5
A 45-year-old with hypertension and gout has a BP of 152/94 mm Hg. Which antihypertensive
should be avoided?
A) Losartan
B) Amlodipine
C) Hydrochlorothiazide
D) Lisinopril
Rationale: Thiazide diuretics increase uric acid and can precipitate gout flares; losartan actually
lowers uric acid.
Question 6
A child with acute otitis media has a penicillin allergy (urticaria). Which antibiotic is safest?
A) Amoxicillin-clavulanate
B) Cefdinir
C) Doxycycline
D) Levofloxacin
,Rationale: Third-generation cephalosporins like cefdinir have low cross-reactivity (1-2%) with
penicillin allergy, safer than earlier cephalosporins.
Question 7
A patient on sertraline for 6 weeks reports no improvement. What is the best next step before
switching antidepressants?
A) Add buspirone
B) Increase to maximum tolerated dose
C) Change to phenelzine
D) Discontinue abruptly
Rationale: Full therapeutic trial requires 8-12 weeks at optimal dose; dose optimization
precedes augmentation or switch.
Question 8
A 30-year-old woman requests emergency contraception 48 hours after unprotected
intercourse. Which option is most effective?
A) Levonorgestrel 1.5 mg once
B) Ethinyl estradiol-norgestrel two doses
C) Copper IUD placement
D) Ulipristal acetate 30 mg
Rationale: Copper IUD is most effective (>99%) but ulipristal (given) is superior to levonorgestrel
up to 120 hours.
Question 9
A patient with COPD and frequent exacerbations has an FEV1 of 45% predicted. Which
maintenance therapy reduces mortality?
A) LAMA + LABA + ICS
B) Short-acting beta-agonist alone
C) Oral prednisone daily
D) Theophylline
Rationale: Triple therapy (LAMA/LABA/ICS) reduces exacerbations and mortality in severe
COPD versus dual therapy.
, Question 10
A 55-year-old with GERD symptoms despite omeprazole 20 mg daily for 8 weeks. What is the
next step?
A) Add ranitidine
B) Double omeprazole to 40 mg daily
C) Switch to famotidine
D) Refer for fundoplication
Rationale: Inadequate PPI response first requires dose optimization (BID or higher dose) before
adding H2RA or surgery.
Question 11
A patient on lithium develops tremor, nausea, and confusion. Lithium level is 2.1 mEq/L. What is
the priority action?
A) Add propranolol for tremor
B) Hold lithium and assess renal function
C) Increase fluids to 3 L/day
D) Give sodium polystyrene sulfonate
Rationale: Lithium toxicity (>1.5 mEq/L) requires discontinuation, hydration, and monitoring;
severe levels may need hemodialysis.
Question 12
A 68-year-old with osteoarthritis requests pain relief but has history of gastric ulcer. Which
NSAID is safest?
A) Naproxen
B) Ibuprofen
C) Celecoxib
D) Ketorolac
Rationale: COX-2 selective celecoxib reduces GI ulcer risk versus nonselective NSAIDs, but still
caution in high CV risk.
Question 13
