SARAH MICHELLE LIVE REVIEW EXAM 2026/2027 |
High-Yield Board Certification Prep | Questions &
Answers | Pass Guaranteed - A+ Graded
SECTION 1: CARDIOVASCULAR & RESPIRATORY (35 Questions)
Q1: A 58-year-old African American male presents for a follow-up visit. His blood
pressure readings over the past three visits have averaged 152/94 mmHg. He has no
history of diabetes or chronic kidney disease. According to the 2017 ACC/AHA
hypertension guidelines, what is the most appropriate initial pharmacologic
management?
A. Initiate lisinopril 10 mg daily as monotherapy
B. Initiate hydrochlorothiazide 25 mg daily as monotherapy
C. Initiate amlodipine 5 mg daily or a thiazide diuretic as monotherapy, with
consideration for two-drug combination if BP is ≥20/10 mmHg above goal
D. Initiate metoprolol 50 mg twice daily as first-line therapy
Correct Answer: C
Rationale: The 2017 ACC/AHA guidelines classify BP 130-139/80-89 as Stage 1 and
≥140/90 as Stage 2 hypertension. For Stage 2 hypertension (≥140/90 mmHg) or BP
≥20/10 mmHg above goal, initiating two antihypertensive agents of different classes is
recommended. In Black patients without CKD or diabetes, thiazide diuretics or calcium
channel blockers are preferred initial agents. ACE inhibitors are less effective as
monotherapy in Black patients. Beta-blockers are not first-line unless compelling
indications exist (per 2017 ACC/AHA).
,Q2: A 45-year-old female with a 20-pack-year smoking history presents with progressive
dyspnea on exertion and a chronic productive cough. Her FEV1/FVC ratio is 0.62 and
FEV1 is 55% predicted. According to the 2023 GOLD guidelines, what is her COPD
classification and recommended initial pharmacotherapy?
A. GOLD Grade 2, Group B; initiate LAMA monotherapy
B. GOLD Grade 2, Group B; initiate LABA monotherapy
C. GOLD Grade 2, Group A; initiate SABA prn only
D. GOLD Grade 3, Group B; initiate LABA/LAMA combination
Correct Answer: A
Rationale: FEV1 50-80% predicted = GOLD Grade 2 (moderate). With dyspnea and
exacerbation history determining Group B (mMRC ≥2 or CAT ≥10, or ≥1 moderate
exacerbation), initial therapy is a long-acting muscarinic antagonist (LAMA) or
long-acting beta-agonist (LABA). LAMA is preferred first-line in Group B per 2023 GOLD.
FEV1 55% is Grade 2, not Grade 3 (30-49%). Group A requires no exacerbations and
mMRC 0-1/CAT <10.
Q3: A 62-year-old male with hypertension and hyperlipidemia presents with acute chest
pain. His EKG shows ST-segment elevation in leads V1-V4. He is given aspirin 325 mg,
clopidogrel 600 mg loading dose, and taken for emergent PCI. Which anticoagulant is
contraindicated in this patient undergoing primary PCI?
A. Unfractionated heparin
B. Enoxaparin
C. Bivalirudin
D. Fondaparinux
Correct Answer: D
Rationale: Fondaparinux is contraindicated in patients undergoing primary PCI for
STEMI due to an increased risk of catheter thrombosis. Unfractionated heparin,
enoxaparin, and bivalirudin are all acceptable anticoagulant options during primary PCI.
,Fondaparinux can be used conservatively in NSTEMI but not when PCI is planned (per
2022 ACC/AHA STEMI guidelines).
Q4: A 55-year-old female presents with worsening shortness of breath and lower
extremity edema. Her BNP is 850 pg/mL. Echocardiogram reveals an ejection fraction
of 30%. Which medication combination represents the current evidence-based
foundational therapy for HFrEF (heart failure with reduced ejection fraction)?
A. ACE inhibitor + beta-blocker + loop diuretic
B. ACE inhibitor + beta-blocker + SGLT2 inhibitor + MRA
C. ARB + beta-blocker + digoxin
D. ACE inhibitor + calcium channel blocker + hydralazine/isosorbide
Correct Answer: B
Rationale: The 2022 ACC/AHA/HFSA heart failure guidelines recommend the "four
pillars" of HFrEF therapy: ARNI (or ACEI/ARB), evidence-based beta-blocker,
mineralocorticoid receptor antagonist (MRA), and SGLT2 inhibitor. Loop diuretics are
used for congestion but do not reduce mortality. Digoxin is for symptom control only.
CCBs are generally avoided in HFrEF except amlodipine.
Q5: A 38-year-old male with asthma reports using his albuterol inhaler more than twice
weekly for rescue symptoms. His ACT score is 18. According to the 2020 GINA
guidelines, what is the most appropriate next step in management?
A. Continue SABA as needed and add a daily leukotriene receptor antagonist
B. Initiate low-dose ICS-formoterol as both maintenance and reliever therapy
C. Initiate high-dose ICS monotherapy
D. Add a long-acting muscarinic antagonist to current SABA therapy
Correct Answer: B
Rationale: GINA 2020 and subsequent updates recommend against SABA-only
treatment. For adults with asthma not controlled on as-needed SABA (Step 2), low-dose
ICS-formoterol as maintenance and reliever (MART) is preferred. This approach reduces
, severe exacerbations compared to SABA + separate ICS maintenance. LTRA is less
effective than ICS. LAMA is add-on therapy at Step 4-5.
Q6: A 70-year-old male with atrial fibrillation has a CHA2DS2-VASc score of 4. His renal
function is normal. He is started on apixaban. What is the primary mechanism of action
of this anticoagulant?
A. Direct inhibition of thrombin (Factor IIa)
B. Direct inhibition of Factor Xa
C. Indirect inhibition of Factor Xa via antithrombin III
D. Inhibition of vitamin K-dependent clotting factors
Correct Answer: B
Rationale: Apixaban is a direct oral anticoagulant (DOAC) that directly inhibits Factor Xa.
Direct thrombin inhibitors include dabigatran. Heparins work indirectly via antithrombin
III. Warfarin inhibits vitamin K epoxide reductase. Apixaban is preferred over warfarin in
non-valvular AF with CHA2DS2-VASc ≥2 (men) or ≥3 (women) per 2023
ACC/AHA/ACCP/HRS guidelines.
Q7: A 48-year-old female presents with a blood pressure of 168/102 mmHg. Laboratory
studies reveal potassium of 2.8 mEq/L and metabolic alkalosis. Plasma renin activity is
suppressed, and aldosterone is elevated. What is the most likely diagnosis and initial
treatment?
A. Pheochromocytoma; initiate phenoxybenzamine
B. Primary hyperaldosteronism; initiate spironolactone
C. Renal artery stenosis; initiate angioplasty
D. Cushing syndrome; initiate ketoconazole
Correct Answer: B
Rationale: Hypertension with hypokalemia and metabolic alkalosis in the setting of
suppressed renin and elevated aldosterone is classic for primary hyperaldosteronism
(Conn syndrome). Spironolactone (or eplerenone) is the initial medical therapy.
High-Yield Board Certification Prep | Questions &
Answers | Pass Guaranteed - A+ Graded
SECTION 1: CARDIOVASCULAR & RESPIRATORY (35 Questions)
Q1: A 58-year-old African American male presents for a follow-up visit. His blood
pressure readings over the past three visits have averaged 152/94 mmHg. He has no
history of diabetes or chronic kidney disease. According to the 2017 ACC/AHA
hypertension guidelines, what is the most appropriate initial pharmacologic
management?
A. Initiate lisinopril 10 mg daily as monotherapy
B. Initiate hydrochlorothiazide 25 mg daily as monotherapy
C. Initiate amlodipine 5 mg daily or a thiazide diuretic as monotherapy, with
consideration for two-drug combination if BP is ≥20/10 mmHg above goal
D. Initiate metoprolol 50 mg twice daily as first-line therapy
Correct Answer: C
Rationale: The 2017 ACC/AHA guidelines classify BP 130-139/80-89 as Stage 1 and
≥140/90 as Stage 2 hypertension. For Stage 2 hypertension (≥140/90 mmHg) or BP
≥20/10 mmHg above goal, initiating two antihypertensive agents of different classes is
recommended. In Black patients without CKD or diabetes, thiazide diuretics or calcium
channel blockers are preferred initial agents. ACE inhibitors are less effective as
monotherapy in Black patients. Beta-blockers are not first-line unless compelling
indications exist (per 2017 ACC/AHA).
,Q2: A 45-year-old female with a 20-pack-year smoking history presents with progressive
dyspnea on exertion and a chronic productive cough. Her FEV1/FVC ratio is 0.62 and
FEV1 is 55% predicted. According to the 2023 GOLD guidelines, what is her COPD
classification and recommended initial pharmacotherapy?
A. GOLD Grade 2, Group B; initiate LAMA monotherapy
B. GOLD Grade 2, Group B; initiate LABA monotherapy
C. GOLD Grade 2, Group A; initiate SABA prn only
D. GOLD Grade 3, Group B; initiate LABA/LAMA combination
Correct Answer: A
Rationale: FEV1 50-80% predicted = GOLD Grade 2 (moderate). With dyspnea and
exacerbation history determining Group B (mMRC ≥2 or CAT ≥10, or ≥1 moderate
exacerbation), initial therapy is a long-acting muscarinic antagonist (LAMA) or
long-acting beta-agonist (LABA). LAMA is preferred first-line in Group B per 2023 GOLD.
FEV1 55% is Grade 2, not Grade 3 (30-49%). Group A requires no exacerbations and
mMRC 0-1/CAT <10.
Q3: A 62-year-old male with hypertension and hyperlipidemia presents with acute chest
pain. His EKG shows ST-segment elevation in leads V1-V4. He is given aspirin 325 mg,
clopidogrel 600 mg loading dose, and taken for emergent PCI. Which anticoagulant is
contraindicated in this patient undergoing primary PCI?
A. Unfractionated heparin
B. Enoxaparin
C. Bivalirudin
D. Fondaparinux
Correct Answer: D
Rationale: Fondaparinux is contraindicated in patients undergoing primary PCI for
STEMI due to an increased risk of catheter thrombosis. Unfractionated heparin,
enoxaparin, and bivalirudin are all acceptable anticoagulant options during primary PCI.
,Fondaparinux can be used conservatively in NSTEMI but not when PCI is planned (per
2022 ACC/AHA STEMI guidelines).
Q4: A 55-year-old female presents with worsening shortness of breath and lower
extremity edema. Her BNP is 850 pg/mL. Echocardiogram reveals an ejection fraction
of 30%. Which medication combination represents the current evidence-based
foundational therapy for HFrEF (heart failure with reduced ejection fraction)?
A. ACE inhibitor + beta-blocker + loop diuretic
B. ACE inhibitor + beta-blocker + SGLT2 inhibitor + MRA
C. ARB + beta-blocker + digoxin
D. ACE inhibitor + calcium channel blocker + hydralazine/isosorbide
Correct Answer: B
Rationale: The 2022 ACC/AHA/HFSA heart failure guidelines recommend the "four
pillars" of HFrEF therapy: ARNI (or ACEI/ARB), evidence-based beta-blocker,
mineralocorticoid receptor antagonist (MRA), and SGLT2 inhibitor. Loop diuretics are
used for congestion but do not reduce mortality. Digoxin is for symptom control only.
CCBs are generally avoided in HFrEF except amlodipine.
Q5: A 38-year-old male with asthma reports using his albuterol inhaler more than twice
weekly for rescue symptoms. His ACT score is 18. According to the 2020 GINA
guidelines, what is the most appropriate next step in management?
A. Continue SABA as needed and add a daily leukotriene receptor antagonist
B. Initiate low-dose ICS-formoterol as both maintenance and reliever therapy
C. Initiate high-dose ICS monotherapy
D. Add a long-acting muscarinic antagonist to current SABA therapy
Correct Answer: B
Rationale: GINA 2020 and subsequent updates recommend against SABA-only
treatment. For adults with asthma not controlled on as-needed SABA (Step 2), low-dose
ICS-formoterol as maintenance and reliever (MART) is preferred. This approach reduces
, severe exacerbations compared to SABA + separate ICS maintenance. LTRA is less
effective than ICS. LAMA is add-on therapy at Step 4-5.
Q6: A 70-year-old male with atrial fibrillation has a CHA2DS2-VASc score of 4. His renal
function is normal. He is started on apixaban. What is the primary mechanism of action
of this anticoagulant?
A. Direct inhibition of thrombin (Factor IIa)
B. Direct inhibition of Factor Xa
C. Indirect inhibition of Factor Xa via antithrombin III
D. Inhibition of vitamin K-dependent clotting factors
Correct Answer: B
Rationale: Apixaban is a direct oral anticoagulant (DOAC) that directly inhibits Factor Xa.
Direct thrombin inhibitors include dabigatran. Heparins work indirectly via antithrombin
III. Warfarin inhibits vitamin K epoxide reductase. Apixaban is preferred over warfarin in
non-valvular AF with CHA2DS2-VASc ≥2 (men) or ≥3 (women) per 2023
ACC/AHA/ACCP/HRS guidelines.
Q7: A 48-year-old female presents with a blood pressure of 168/102 mmHg. Laboratory
studies reveal potassium of 2.8 mEq/L and metabolic alkalosis. Plasma renin activity is
suppressed, and aldosterone is elevated. What is the most likely diagnosis and initial
treatment?
A. Pheochromocytoma; initiate phenoxybenzamine
B. Primary hyperaldosteronism; initiate spironolactone
C. Renal artery stenosis; initiate angioplasty
D. Cushing syndrome; initiate ketoconazole
Correct Answer: B
Rationale: Hypertension with hypokalemia and metabolic alkalosis in the setting of
suppressed renin and elevated aldosterone is classic for primary hyperaldosteronism
(Conn syndrome). Spironolactone (or eplerenone) is the initial medical therapy.
