ADVANCED CURRENT MEDICAL DIAGNOSIS AND
TREATMENT 2026, 65TH EDITION BY MAXINE PAPADAKIS.
With Questions and Answers/Plus a Rationale Updated
2026 A+/Instant Download PDF
Table of Contents - 1. Cardiovascular Diseases - 2. Pulmonary Disorders - 3. Gastrointestinal
& Liver Diseases - 4. Endocrinology & Diabetes - 5. Nephrology & Urology - 6. Infectious
Diseases & Antimicrobial Therapy - 7. Hematology & Oncology - 8. Rheumatology &
Immunology - 9. Neurology & Psychiatry - 10. Dermatologic & Common Outpatient
Conditions
1. A 67-year-old male with a history of heart failure with reduced ejection fraction
(HFrEF, EF 32%) presents for a routine follow-up. He is currently asymptomatic while
taking maximum-tolerated doses of sacubitril/valsartan, carvedilol, and
empagliflozin. His blood pressure is 114/72 mmHg, and his heart rate is 64 bpm.
Laboratory evaluation reveals an estimated glomerular filtration rate (eGFR) of 48
mL/min/1.73m² and a serum potassium of 4.2 mEq/L. Which of the following is the
most appropriate next step to optimize his guideline-directed medical therapy
(GDMT)? A. Initiation of ivabradine B. Initiation of spironolactone C. Initiation of
vericiguat) D. Initiation of hydralazine-isosorbide dinitrate Answer: B [Initiation of
spironolactone] Rationale: According to the current clinical guidelines referenced in
CMDT 2026, a mineralocorticoid receptor antagonist (MRA) such as spironolactone
should be added to the baseline regimen of an ARNI, beta-blocker, and SGLT2
inhibitor for patients with HFrEF (NYHA Class II-IV) provided the eGFR is greater than
30 mL/min/1.73m² and potassium is less than 5.0 mEq/L. Ivabradine is only indicated
if the resting heart rate remains 70 bpm or higher despite maximum-tolerated beta-
blockade. Vericiguat and hydralazine/isosorbide dinitrate are reserved for specific
populations or after baseline foundational therapies have failed.
2. A 54-year-old female presents to the emergency department with acute onset of
severe substernal chest pressure. Her electrocardiogram (ECG) shows 2-mm ST-
segment elevation in leads V1 through V4. While being prepared for immediate
cardiac catheterization, she becomes unresponsive, and the cardiac monitor reveals
ventricular fibrillation. Cardiopulmonary resuscitation is initiated, and she receives
one unsynchronized shock. The rhythm check shows persistent ventricular
fibrillation. After resuming chest compressions, what is the next most appropriate
pharmacologic intervention? A. Epinephrine 1 mg intravenously B. Amiodarone 300
mg intravenously bolus C. Lidocaine 100 mg intravenously bolus D. Magnesium
sulfate 2 g intravenously Answer: A [Epinephrine 1 mg intravenously] Rationale:
Standard ACLS algorithms embedded in CMDT guidelines require administration of
epinephrine 1 mg IV after the second unsuccessful shock during cardiac arrest
management for non-shockable or persistent shockable rhythms. Antiarrhythmic
, therapy with amiodarone or lidocaine is indicated only after the third shock has failed
to restore a perfusing rhythm. Magnesium sulfate is utilized primarily if the rhythm is
identified specifically as Torsades de Pointes.
3. A 72-year-old male with a history of severe calcific aortic stenosis presents with
increasing dyspnea on exertion and two recent episodes of exertional syncope. On
physical examination, a harsh 4/6 late-peaking systolic crescendo-decrescendo
murmur is heard loudest at the right second intercostal space, radiating to the
carotids. Transthoracic echocardiography reveals a mean aortic valve gradient of 44
mmHg, an aortic valve area of 0.7 cm², and a preserved left ventricular ejection
fraction of 55%. What is the most definitive management strategy for this patient? A.
Strict blood pressure control with high-dose beta-blockers B. Aortic valve
replacement (surgical or transcatheter) C. Balloon aortic valvuloplasty as definitive
long-term therapy D. Initiation of heavy diuretic therapy to relieve pulmonary
congestion Answer: B [Aortic valve replacement (surgical or transcatheter)]
Rationale: Symptomatic severe aortic stenosis carries an exceptionally poor prognosis
without mechanical relief, making aortic valve replacement (SAVR or TAVR) the only
definitive long-term solution. Medical therapies such as high-dose beta-blockers can
worsen cardiac output by restricting heart rate in a stroke-volume-limited state.
Balloon valvuloplasty serves only as a temporary bridge to definitive replacement,
and aggressive diuresis risks sudden hemodynamic collapse by lowering necessary
preload.
4. A 43-year-old female is evaluated for a three-month history of progressive exertional
dyspnea, fatigue, and near-syncope. Physical examination reveals a loud pulmonic
component of the second heart sound () and a prominent prominent v-wave in the
jugular venous pulse. Echocardiography demonstrates marked right ventricular
hypertrophy and an estimated right ventricular systolic pressure of 65 mmHg, with
no left-sided valvular or structural disease. High-resolution chest CT shows no
parenchymal lung disease, and a ventilation-perfusion scan shows low probability for
thromboembolism. Right heart catheterization confirms a mean pulmonary artery
pressure of 42 mmHg and a pulmonary capillary wedge pressure of 10 mmHg. What
is the most appropriate initial diagnostic or therapeutic next step? A. Continuous
intravenous epoprostenol infusion B. Acute vasodilator testing during right heart
catheterization C. High-dose oral loop diuretic therapy D. Initiation of empiric lifelong
anticoagulation with warfarin Answer: B [Acute vasodilator testing during right heart
catheterization] Rationale: The patient meets diagnostic criteria for idiopathic
pulmonary arterial hypertension (Group 1 PAH), demonstrating an elevated mean
pulmonary artery pressure with a normal pulmonary capillary wedge pressure. Prior
to establishing long-term advanced vasodilator regimens, acute vasodilator testing
during right heart catheterization must be performed to identify the minority of
patients who respond to high-dose calcium channel blockers. Initiating powerful
, prostanoid infusions like epoprostenol without defining vasoreactivity is premature,
and empiric anticoagulation is no longer universally recommended for all Group 1
PAH patients unless alternate indications exist.
5. A 29-year-old male presents with sudden-onset, sharp, substernal chest pain that
worsens significantly when lying flat on his back and improves when leaning forward.
He reports having a mild upper respiratory illness two weeks ago. His temperature is
37.9°C. On auscultation, a scratchy, high-pitched three-phase sound is heard along
the left sternal border. An ECG demonstrates diffuse, upwardly concave ST-segment
elevations with associated PR-segment depressions in leads I, II, aVL, and V2-V6.
What is the first-line pharmacologic regimen for this condition? A. High-dose aspirin
combined with prednisone B. High-dose ibuprofen combined with colchicine C.
Acetaminophen combined with a 14-day course of amoxicillin D. Immediate systemic
anticoagulation with low-molecular-weight heparin Answer: B [High-dose ibuprofen
combined with colchicine] Rationale: The clinical scenario is highly characteristic of
acute viral or idiopathic pericarditis, confirmed by position-dependent chest pain, a
pericardial friction rub, and classic diffuse ST elevations with PR depressions.
Standard management requires a combination of a nonsteroidal anti-inflammatory
drug (NSAID) like ibuprofen or high-dose aspirin plus colchicine, which reduces
recurrence rates significantly. Corticosteroids like prednisone are avoided in initial
management because they are associated with an increased risk of recurrent
pericarditis, and anticoagulation is contraindicated due to the risk of precipitating
hemorrhagic pericardial effusion or tamponade.
6. A 68-year-old female with a long-standing history of hypertension and Type 2
diabetes presents with a 48-hour history of irregular palpitations and mild shortness
of breath. An ECG confirms atrial fibrillation with a ventricular response rate
fluctuating between 110 and 130 bpm. Her blood pressure is 132/84 mmHg.
Laboratory values, including serum thyroid-stimulating hormone (TSH) and
electrolytes, are within reference ranges. Echocardiography demonstrates a left
ventricular ejection fraction of 50% and mild left atrial enlargement. Which of the
following represents the most appropriate long-term stroke prevention strategy for
this patient? A. Aspirin 81 mg daily B. Dual antiplatelet therapy with aspirin and
clopidogrel C. Oral anticoagulation with a direct oral anticoagulant (DOAC) such as
apixaban D. Watchful waiting without antithrombotic therapy given her controlled
blood pressure Answer: C [Oral anticoagulation with a direct oral anticoagulant
(DOAC) such as apixaban] Rationale: The patient's risk of stroke must be quantified
using the scoring system; she scores 4 points (Age 65–74 = 1, Female sex = 1,
Hypertension = 1, Diabetes = 1). Current guidelines mandate oral anticoagulation for
any female patient with a score of 3 or higher to reduce thromboembolic risk. Direct
oral anticoagulants (DOACs) are preferred over warfarin unless mechanical heart
valves or moderate-to-severe mitral stenosis are present, while aspirin and dual
, antiplatelet therapies are vastly inferior and ineffective for stroke prevention in non-
valvular atrial fibrillation.
7. A 62-year-old male presents with a history of stable angina that has become
progressively more frequent and severe over the last 3 days, now occurring with
minimal exertion such as walking across the room. He denies any prolonged episodes
of rest pain. His blood pressure is 148/88 mmHg and his pulse is 76 bpm. Cardiac
troponin levels drawn at presentation and 3 hours later are completely normal. The
ECG shows 0.5-mm horizontal ST-segment depression in leads V5 and V6. How is this
patient's acute coronary syndrome classified? A. ST-elevation myocardial infarction
(STEMI) B. Non-ST-elevation myocardial infarction (NSTEMI) C. Unstable angina D.
Chronic stable angina pectoris Answer: C [Unstable angina] Rationale: This
presentation fits the classic definition of unstable angina, characterized by an
accelerating pattern of angina occurring with lower thresholds of exertion without
biomarker evidence of myocardial necrosis (negative troponins). If troponins were
elevated, the diagnosis would shift to NSTEMI. The lack of persistent ST-segment
elevations rules out STEMI, and the rapid crescendo pattern distinguishes it from
chronic stable angina.
8. A 35-year-old postpartum female presents to the clinic 4 weeks after an
uncomplicated vaginal delivery complaining of progressive orthopnea, paroxysmal
nocturnal dyspnea, and bilateral lower extremity edema. She had no prior cardiac
history. Physical examination reveals a third heart sound (), jugular venous distention
to the angle of the jaw, and bilateral pulmonary crackles. Transthoracic
echocardiography reveals global left ventricular hypokinesis with an ejection fraction
of 28%. Which of the following is the most likely diagnosis? A. Acute viral myocarditis
B. Peripartum cardiomyopathy C. High-output heart failure secondary to severe
anemia D. Severe preeclampsia with pulmonary edema Answer: B [Peripartum
cardiomyopathy] Rationale: Peripartum cardiomyopathy is defined as an idiopathic
cardiomyopathy presenting with heart failure secondary to left ventricular systolic
dysfunction (typically EF less than 45%) toward the end of pregnancy or in the
months following delivery, in the absence of any other identifiable cause. While viral
myocarditis presents similarly, the timing relative to delivery makes peripartum
cardiomyopathy the primary diagnostic entity. Her normal blood pressure and timing
postpartum make acute preeclampsia less likely, and an with depressed EF points to
systolic failure rather than a high-output state.
9. A 74-year-old male is admitted to the cardiac care unit following a large anterior wall
STEMI that was treated with primary percutaneous coronary intervention (PCI) and
deployment of a drug-eluting stent in the left anterior descending artery. On day 4 of
hospitalization, he suddenly develops severe shortness of breath, diaphoresis, and
hypotension (BP 82/50 mmHg). On examination, a new, harsh, loud 4/6 holosystolic
TREATMENT 2026, 65TH EDITION BY MAXINE PAPADAKIS.
With Questions and Answers/Plus a Rationale Updated
2026 A+/Instant Download PDF
Table of Contents - 1. Cardiovascular Diseases - 2. Pulmonary Disorders - 3. Gastrointestinal
& Liver Diseases - 4. Endocrinology & Diabetes - 5. Nephrology & Urology - 6. Infectious
Diseases & Antimicrobial Therapy - 7. Hematology & Oncology - 8. Rheumatology &
Immunology - 9. Neurology & Psychiatry - 10. Dermatologic & Common Outpatient
Conditions
1. A 67-year-old male with a history of heart failure with reduced ejection fraction
(HFrEF, EF 32%) presents for a routine follow-up. He is currently asymptomatic while
taking maximum-tolerated doses of sacubitril/valsartan, carvedilol, and
empagliflozin. His blood pressure is 114/72 mmHg, and his heart rate is 64 bpm.
Laboratory evaluation reveals an estimated glomerular filtration rate (eGFR) of 48
mL/min/1.73m² and a serum potassium of 4.2 mEq/L. Which of the following is the
most appropriate next step to optimize his guideline-directed medical therapy
(GDMT)? A. Initiation of ivabradine B. Initiation of spironolactone C. Initiation of
vericiguat) D. Initiation of hydralazine-isosorbide dinitrate Answer: B [Initiation of
spironolactone] Rationale: According to the current clinical guidelines referenced in
CMDT 2026, a mineralocorticoid receptor antagonist (MRA) such as spironolactone
should be added to the baseline regimen of an ARNI, beta-blocker, and SGLT2
inhibitor for patients with HFrEF (NYHA Class II-IV) provided the eGFR is greater than
30 mL/min/1.73m² and potassium is less than 5.0 mEq/L. Ivabradine is only indicated
if the resting heart rate remains 70 bpm or higher despite maximum-tolerated beta-
blockade. Vericiguat and hydralazine/isosorbide dinitrate are reserved for specific
populations or after baseline foundational therapies have failed.
2. A 54-year-old female presents to the emergency department with acute onset of
severe substernal chest pressure. Her electrocardiogram (ECG) shows 2-mm ST-
segment elevation in leads V1 through V4. While being prepared for immediate
cardiac catheterization, she becomes unresponsive, and the cardiac monitor reveals
ventricular fibrillation. Cardiopulmonary resuscitation is initiated, and she receives
one unsynchronized shock. The rhythm check shows persistent ventricular
fibrillation. After resuming chest compressions, what is the next most appropriate
pharmacologic intervention? A. Epinephrine 1 mg intravenously B. Amiodarone 300
mg intravenously bolus C. Lidocaine 100 mg intravenously bolus D. Magnesium
sulfate 2 g intravenously Answer: A [Epinephrine 1 mg intravenously] Rationale:
Standard ACLS algorithms embedded in CMDT guidelines require administration of
epinephrine 1 mg IV after the second unsuccessful shock during cardiac arrest
management for non-shockable or persistent shockable rhythms. Antiarrhythmic
, therapy with amiodarone or lidocaine is indicated only after the third shock has failed
to restore a perfusing rhythm. Magnesium sulfate is utilized primarily if the rhythm is
identified specifically as Torsades de Pointes.
3. A 72-year-old male with a history of severe calcific aortic stenosis presents with
increasing dyspnea on exertion and two recent episodes of exertional syncope. On
physical examination, a harsh 4/6 late-peaking systolic crescendo-decrescendo
murmur is heard loudest at the right second intercostal space, radiating to the
carotids. Transthoracic echocardiography reveals a mean aortic valve gradient of 44
mmHg, an aortic valve area of 0.7 cm², and a preserved left ventricular ejection
fraction of 55%. What is the most definitive management strategy for this patient? A.
Strict blood pressure control with high-dose beta-blockers B. Aortic valve
replacement (surgical or transcatheter) C. Balloon aortic valvuloplasty as definitive
long-term therapy D. Initiation of heavy diuretic therapy to relieve pulmonary
congestion Answer: B [Aortic valve replacement (surgical or transcatheter)]
Rationale: Symptomatic severe aortic stenosis carries an exceptionally poor prognosis
without mechanical relief, making aortic valve replacement (SAVR or TAVR) the only
definitive long-term solution. Medical therapies such as high-dose beta-blockers can
worsen cardiac output by restricting heart rate in a stroke-volume-limited state.
Balloon valvuloplasty serves only as a temporary bridge to definitive replacement,
and aggressive diuresis risks sudden hemodynamic collapse by lowering necessary
preload.
4. A 43-year-old female is evaluated for a three-month history of progressive exertional
dyspnea, fatigue, and near-syncope. Physical examination reveals a loud pulmonic
component of the second heart sound () and a prominent prominent v-wave in the
jugular venous pulse. Echocardiography demonstrates marked right ventricular
hypertrophy and an estimated right ventricular systolic pressure of 65 mmHg, with
no left-sided valvular or structural disease. High-resolution chest CT shows no
parenchymal lung disease, and a ventilation-perfusion scan shows low probability for
thromboembolism. Right heart catheterization confirms a mean pulmonary artery
pressure of 42 mmHg and a pulmonary capillary wedge pressure of 10 mmHg. What
is the most appropriate initial diagnostic or therapeutic next step? A. Continuous
intravenous epoprostenol infusion B. Acute vasodilator testing during right heart
catheterization C. High-dose oral loop diuretic therapy D. Initiation of empiric lifelong
anticoagulation with warfarin Answer: B [Acute vasodilator testing during right heart
catheterization] Rationale: The patient meets diagnostic criteria for idiopathic
pulmonary arterial hypertension (Group 1 PAH), demonstrating an elevated mean
pulmonary artery pressure with a normal pulmonary capillary wedge pressure. Prior
to establishing long-term advanced vasodilator regimens, acute vasodilator testing
during right heart catheterization must be performed to identify the minority of
patients who respond to high-dose calcium channel blockers. Initiating powerful
, prostanoid infusions like epoprostenol without defining vasoreactivity is premature,
and empiric anticoagulation is no longer universally recommended for all Group 1
PAH patients unless alternate indications exist.
5. A 29-year-old male presents with sudden-onset, sharp, substernal chest pain that
worsens significantly when lying flat on his back and improves when leaning forward.
He reports having a mild upper respiratory illness two weeks ago. His temperature is
37.9°C. On auscultation, a scratchy, high-pitched three-phase sound is heard along
the left sternal border. An ECG demonstrates diffuse, upwardly concave ST-segment
elevations with associated PR-segment depressions in leads I, II, aVL, and V2-V6.
What is the first-line pharmacologic regimen for this condition? A. High-dose aspirin
combined with prednisone B. High-dose ibuprofen combined with colchicine C.
Acetaminophen combined with a 14-day course of amoxicillin D. Immediate systemic
anticoagulation with low-molecular-weight heparin Answer: B [High-dose ibuprofen
combined with colchicine] Rationale: The clinical scenario is highly characteristic of
acute viral or idiopathic pericarditis, confirmed by position-dependent chest pain, a
pericardial friction rub, and classic diffuse ST elevations with PR depressions.
Standard management requires a combination of a nonsteroidal anti-inflammatory
drug (NSAID) like ibuprofen or high-dose aspirin plus colchicine, which reduces
recurrence rates significantly. Corticosteroids like prednisone are avoided in initial
management because they are associated with an increased risk of recurrent
pericarditis, and anticoagulation is contraindicated due to the risk of precipitating
hemorrhagic pericardial effusion or tamponade.
6. A 68-year-old female with a long-standing history of hypertension and Type 2
diabetes presents with a 48-hour history of irregular palpitations and mild shortness
of breath. An ECG confirms atrial fibrillation with a ventricular response rate
fluctuating between 110 and 130 bpm. Her blood pressure is 132/84 mmHg.
Laboratory values, including serum thyroid-stimulating hormone (TSH) and
electrolytes, are within reference ranges. Echocardiography demonstrates a left
ventricular ejection fraction of 50% and mild left atrial enlargement. Which of the
following represents the most appropriate long-term stroke prevention strategy for
this patient? A. Aspirin 81 mg daily B. Dual antiplatelet therapy with aspirin and
clopidogrel C. Oral anticoagulation with a direct oral anticoagulant (DOAC) such as
apixaban D. Watchful waiting without antithrombotic therapy given her controlled
blood pressure Answer: C [Oral anticoagulation with a direct oral anticoagulant
(DOAC) such as apixaban] Rationale: The patient's risk of stroke must be quantified
using the scoring system; she scores 4 points (Age 65–74 = 1, Female sex = 1,
Hypertension = 1, Diabetes = 1). Current guidelines mandate oral anticoagulation for
any female patient with a score of 3 or higher to reduce thromboembolic risk. Direct
oral anticoagulants (DOACs) are preferred over warfarin unless mechanical heart
valves or moderate-to-severe mitral stenosis are present, while aspirin and dual
, antiplatelet therapies are vastly inferior and ineffective for stroke prevention in non-
valvular atrial fibrillation.
7. A 62-year-old male presents with a history of stable angina that has become
progressively more frequent and severe over the last 3 days, now occurring with
minimal exertion such as walking across the room. He denies any prolonged episodes
of rest pain. His blood pressure is 148/88 mmHg and his pulse is 76 bpm. Cardiac
troponin levels drawn at presentation and 3 hours later are completely normal. The
ECG shows 0.5-mm horizontal ST-segment depression in leads V5 and V6. How is this
patient's acute coronary syndrome classified? A. ST-elevation myocardial infarction
(STEMI) B. Non-ST-elevation myocardial infarction (NSTEMI) C. Unstable angina D.
Chronic stable angina pectoris Answer: C [Unstable angina] Rationale: This
presentation fits the classic definition of unstable angina, characterized by an
accelerating pattern of angina occurring with lower thresholds of exertion without
biomarker evidence of myocardial necrosis (negative troponins). If troponins were
elevated, the diagnosis would shift to NSTEMI. The lack of persistent ST-segment
elevations rules out STEMI, and the rapid crescendo pattern distinguishes it from
chronic stable angina.
8. A 35-year-old postpartum female presents to the clinic 4 weeks after an
uncomplicated vaginal delivery complaining of progressive orthopnea, paroxysmal
nocturnal dyspnea, and bilateral lower extremity edema. She had no prior cardiac
history. Physical examination reveals a third heart sound (), jugular venous distention
to the angle of the jaw, and bilateral pulmonary crackles. Transthoracic
echocardiography reveals global left ventricular hypokinesis with an ejection fraction
of 28%. Which of the following is the most likely diagnosis? A. Acute viral myocarditis
B. Peripartum cardiomyopathy C. High-output heart failure secondary to severe
anemia D. Severe preeclampsia with pulmonary edema Answer: B [Peripartum
cardiomyopathy] Rationale: Peripartum cardiomyopathy is defined as an idiopathic
cardiomyopathy presenting with heart failure secondary to left ventricular systolic
dysfunction (typically EF less than 45%) toward the end of pregnancy or in the
months following delivery, in the absence of any other identifiable cause. While viral
myocarditis presents similarly, the timing relative to delivery makes peripartum
cardiomyopathy the primary diagnostic entity. Her normal blood pressure and timing
postpartum make acute preeclampsia less likely, and an with depressed EF points to
systolic failure rather than a high-output state.
9. A 74-year-old male is admitted to the cardiac care unit following a large anterior wall
STEMI that was treated with primary percutaneous coronary intervention (PCI) and
deployment of a drug-eluting stent in the left anterior descending artery. On day 4 of
hospitalization, he suddenly develops severe shortness of breath, diaphoresis, and
hypotension (BP 82/50 mmHg). On examination, a new, harsh, loud 4/6 holosystolic
