, Question 1
A patient with a history of systolic heart failure presents with a new dry,
persistent cough and mild bronchospasm after starting a new antihypertensive.
Which mechanism best explains this adverse effect, and what is the most
appropriate management?
A. Bradykinin accumulation from ACE inhibition; discontinue ACE
inhibitor and switch to an ARB
B. Beta-2 receptor blockade causing bronchoconstriction; add an inhaled
beta-agonist and continue therapy
C. Calcium channel blockade causing airway smooth muscle relaxation;
reduce the dose
D. Angiotensin II receptor blockade causing cough; switch to a direct
renin inhibitor
Correct Answer: A - Bradykinin accumulation from ACE
inhibition; discontinue ACE inhibitor and switch to an ARB
RATIONALE
ACE inhibitors reduce bradykinin degradation, causing cough and
bronchospasm; switching to an ARB avoids this because ARBs do not
affect bradykinin metabolism. Beta-blockers cause bronchospasm but
are not first-line for systolic HF cough, and ARBs are not typically
associated with cough.
Question 2
A patient presents with sudden-onset unilateral vision loss described as a
'curtain' over one eye, resolving within minutes. Which diagnostic study is
most appropriate to identify the underlying cause?
A. Carotid duplex ultrasound
B. Echocardiogram
C. MRI of the brain
D. EEG
Page 2
,Correct Answer: A - Carotid duplex ultrasound
RATIONALE
Transient monocular vision loss (amaurosis fugax) often results from
emboli originating from carotid artery stenosis; carotid duplex is the
first-line noninvasive test. Echocardiography evaluates cardiac sources
but is not the initial test for suspected carotid stenosis.
Question 3
A patient with type 2 diabetes has an A1c of 8.2% on metformin monotherapy.
Which add-on therapy provides the greatest cardiovascular risk reduction based
on current evidence?
A. Sulfonylurea
B. SGLT2 inhibitor
C. DPP-4 inhibitor
D. Insulin
Correct Answer: B - SGLT2 inhibitor
RATIONALE
SGLT2 inhibitors have demonstrated significant reductions in major
adverse cardiovascular events and heart failure hospitalization in
patients with type 2 diabetes and established cardiovascular disease.
Sulfonylureas and DPP-4 inhibitors do not confer comparable
cardiovascular benefit.
Question 4
A patient reports a headache that awakens them from sleep, is worse in the
morning, and is accompanied by projectile vomiting. Which finding on
fundoscopic exam is most consistent with this presentation?
A. Papilledema
B. Cupping of the optic disc
C. Retinal hemorrhages
Page 3
, D. Cotton-wool spots
Correct Answer: A - Papilledema
RATIONALE
Morning headache worsened by recumbency and projectile vomiting
suggest increased intracranial pressure; papilledema is the classic
fundoscopic finding. Cupping suggests glaucoma, while hemorrhages
and cotton-wool spots are more typical of hypertensive or diabetic
retinopathy.
Question 5
A patient presents with acute onset of severe unilateral flank pain radiating to
the groin, with microscopic hematuria. Which imaging modality is the most
appropriate initial diagnostic study?
A. Non-contrast CT of the abdomen and pelvis
B. Abdominal ultrasound
C. Intravenous pyelogram
D. MRI of the abdomen
Correct Answer: A - Non-contrast CT of the abdomen and pelvis
RATIONALE
Non-contrast CT is the gold standard for suspected nephrolithiasis,
with high sensitivity and specificity for detecting stones and
alternative diagnoses. Ultrasound is preferred in pregnancy or to avoid
radiation but is less sensitive for small stones.
Question 6
A patient with a history of peptic ulcer disease reports new onset of black, tarry
stools. Which finding on physical exam is most concerning for hemodynamic
compromise?
A. Orthostatic hypotension
B. Epigastric tenderness
Page 4
A patient with a history of systolic heart failure presents with a new dry,
persistent cough and mild bronchospasm after starting a new antihypertensive.
Which mechanism best explains this adverse effect, and what is the most
appropriate management?
A. Bradykinin accumulation from ACE inhibition; discontinue ACE
inhibitor and switch to an ARB
B. Beta-2 receptor blockade causing bronchoconstriction; add an inhaled
beta-agonist and continue therapy
C. Calcium channel blockade causing airway smooth muscle relaxation;
reduce the dose
D. Angiotensin II receptor blockade causing cough; switch to a direct
renin inhibitor
Correct Answer: A - Bradykinin accumulation from ACE
inhibition; discontinue ACE inhibitor and switch to an ARB
RATIONALE
ACE inhibitors reduce bradykinin degradation, causing cough and
bronchospasm; switching to an ARB avoids this because ARBs do not
affect bradykinin metabolism. Beta-blockers cause bronchospasm but
are not first-line for systolic HF cough, and ARBs are not typically
associated with cough.
Question 2
A patient presents with sudden-onset unilateral vision loss described as a
'curtain' over one eye, resolving within minutes. Which diagnostic study is
most appropriate to identify the underlying cause?
A. Carotid duplex ultrasound
B. Echocardiogram
C. MRI of the brain
D. EEG
Page 2
,Correct Answer: A - Carotid duplex ultrasound
RATIONALE
Transient monocular vision loss (amaurosis fugax) often results from
emboli originating from carotid artery stenosis; carotid duplex is the
first-line noninvasive test. Echocardiography evaluates cardiac sources
but is not the initial test for suspected carotid stenosis.
Question 3
A patient with type 2 diabetes has an A1c of 8.2% on metformin monotherapy.
Which add-on therapy provides the greatest cardiovascular risk reduction based
on current evidence?
A. Sulfonylurea
B. SGLT2 inhibitor
C. DPP-4 inhibitor
D. Insulin
Correct Answer: B - SGLT2 inhibitor
RATIONALE
SGLT2 inhibitors have demonstrated significant reductions in major
adverse cardiovascular events and heart failure hospitalization in
patients with type 2 diabetes and established cardiovascular disease.
Sulfonylureas and DPP-4 inhibitors do not confer comparable
cardiovascular benefit.
Question 4
A patient reports a headache that awakens them from sleep, is worse in the
morning, and is accompanied by projectile vomiting. Which finding on
fundoscopic exam is most consistent with this presentation?
A. Papilledema
B. Cupping of the optic disc
C. Retinal hemorrhages
Page 3
, D. Cotton-wool spots
Correct Answer: A - Papilledema
RATIONALE
Morning headache worsened by recumbency and projectile vomiting
suggest increased intracranial pressure; papilledema is the classic
fundoscopic finding. Cupping suggests glaucoma, while hemorrhages
and cotton-wool spots are more typical of hypertensive or diabetic
retinopathy.
Question 5
A patient presents with acute onset of severe unilateral flank pain radiating to
the groin, with microscopic hematuria. Which imaging modality is the most
appropriate initial diagnostic study?
A. Non-contrast CT of the abdomen and pelvis
B. Abdominal ultrasound
C. Intravenous pyelogram
D. MRI of the abdomen
Correct Answer: A - Non-contrast CT of the abdomen and pelvis
RATIONALE
Non-contrast CT is the gold standard for suspected nephrolithiasis,
with high sensitivity and specificity for detecting stones and
alternative diagnoses. Ultrasound is preferred in pregnancy or to avoid
radiation but is less sensitive for small stones.
Question 6
A patient with a history of peptic ulcer disease reports new onset of black, tarry
stools. Which finding on physical exam is most concerning for hemodynamic
compromise?
A. Orthostatic hypotension
B. Epigastric tenderness
Page 4
