, Question 1
A patient with heart failure with reduced ejection fraction (HFrEF) and an
eGFR of 28 mL/min/1.73 m² is being optimized on guideline-directed medical
therapy. Which combination reflects current ACC/AHA/HFSA and KDIGO
concordant practice?
A. Initiate sacubitril/valsartan plus spironolactone and discontinue the
ACE inhibitor immediately.
B. Add an SGLT2 inhibitor and a mineralocorticoid receptor antagonist
while continuing the ARNI or ACEi/ARB.
C. Withhold all RAAS agents because eGFR is below 30 and start a loop
diuretic alone.
D. Switch to ivabradine monotherapy and defer all RAAS and SGLT2
therapies.
Correct Answer: B - Add an SGLT2 inhibitor and a
mineralocorticoid receptor antagonist while continuing the ARNI
or ACEi/ARB.
RATIONALE
Current HFrEF guidance supports four pillars: ARNI/ACEi/ARB,
beta-blocker, MRA, and SGLT2 inhibitor; SGLT2 inhibitors and
MRAs retain benefit at reduced eGFR with appropriate monitoring.
Sacubitril/valsartan requires a 36-hour washout from ACE inhibitors,
so immediate simultaneous initiation is unsafe. Withholding RAAS
agents solely for eGFR <30 contradicts KDIGO/HF guidance.
Question 2
A postpartum patient at 6 weeks reports intrusive ego-dystonic thoughts of
harming the infant, without delusions or hallucinations. Which statement best
reflects current clinical consensus and management?
A. These thoughts indicate postpartum psychosis and require immediate
involuntary hospitalization.
Page 2
, B. Unwanted intrusive thoughts are common in postpartum OCD and
warrant SSRI therapy plus CBT, not antipsychotics.
C. Symptoms are expected and require no intervention unless the patient
acts on them.
D. First-line treatment is a benzodiazepine to reduce anxiety.
Correct Answer: B - Unwanted intrusive thoughts are common in
postpartum OCD and warrant SSRI therapy plus CBT, not
antipsychotics.
RATIONALE
Ego-dystonic intrusive thoughts of infant harm are characteristic of
postpartum OCD and are distinct from postpartum psychosis (which
features ego-syntonic commands, delusions, or hallucinations). SSRIs
plus CBT are first-line; antipsychotics are not indicated without
psychotic features. Benzodiazepines are not first-line and pose infant
safety concerns.
Question 3
A 55-year-old with type 2 diabetes has an A1c of 8.4% on metformin, an eGFR
of 55, and established ASCVD. Which add-on best aligns with ADA 2024
Standards of Care?
A. Add a DPP-4 inhibitor for its cardiovascular neutrality.
B. Add a GLP-1 receptor agonist with proven CV benefit (e.g.,
semaglutide or dulaglutide).
C. Add a sulfonylurea to achieve rapid glycemic control.
D. Add pioglitazone to improve insulin sensitivity.
Correct Answer: B - Add a GLP-1 receptor agonist with proven
CV benefit (e.g., semaglutide or dulaglutide).
Page 3
, RATIONALE
ADA 2024 recommends a GLP-1 RA or SGLT2 inhibitor with proven
CV benefit for patients with T2DM and established ASCVD,
independent of A1c. DPP-4 inhibitors are CV-neutral and less potent
for MACE reduction. Sulfonylureas and pioglitazone lack robust
MACE benefit and carry weight/hypoglycemia or HF/edema risks.
Question 4
A 62-year-old presents with sudden painless monocular vision loss described
as a 'curtain' over the eye; fundoscopy shows a pale retina with a cherry-red
macula. Which immediate action is most appropriate?
A. Refer routinely to ophthalmology within one week.
B. Start high-dose oral prednisone and follow up in 48 hours.
C. Activate emergency retinal artery occlusion protocol: immediate
ophthalmology/ED referral and stroke workup.
D. Prescribe topical timolol and reassess in 24 hours.
Correct Answer: C - Activate emergency retinal artery occlusion
protocol: immediate ophthalmology/ED referral and stroke
workup.
RATIONALE
Central retinal artery occlusion is an ocular stroke with a narrow
treatment window; emergent referral and concurrent stroke evaluation
(carotid imaging, ECG, echocardiogram) are indicated because of high
concurrent cerebrovascular risk. Routine referral, steroids, or topical
beta-blockers delay definitive care and miss the stroke workup.
Question 5
A 34-year-old G2P1 at 26 weeks reports a painless, firm, immobile mass in the
left breast. Which next step best balances diagnostic accuracy with obstetric
safety?
A. Defer evaluation until after delivery.
Page 4
A patient with heart failure with reduced ejection fraction (HFrEF) and an
eGFR of 28 mL/min/1.73 m² is being optimized on guideline-directed medical
therapy. Which combination reflects current ACC/AHA/HFSA and KDIGO
concordant practice?
A. Initiate sacubitril/valsartan plus spironolactone and discontinue the
ACE inhibitor immediately.
B. Add an SGLT2 inhibitor and a mineralocorticoid receptor antagonist
while continuing the ARNI or ACEi/ARB.
C. Withhold all RAAS agents because eGFR is below 30 and start a loop
diuretic alone.
D. Switch to ivabradine monotherapy and defer all RAAS and SGLT2
therapies.
Correct Answer: B - Add an SGLT2 inhibitor and a
mineralocorticoid receptor antagonist while continuing the ARNI
or ACEi/ARB.
RATIONALE
Current HFrEF guidance supports four pillars: ARNI/ACEi/ARB,
beta-blocker, MRA, and SGLT2 inhibitor; SGLT2 inhibitors and
MRAs retain benefit at reduced eGFR with appropriate monitoring.
Sacubitril/valsartan requires a 36-hour washout from ACE inhibitors,
so immediate simultaneous initiation is unsafe. Withholding RAAS
agents solely for eGFR <30 contradicts KDIGO/HF guidance.
Question 2
A postpartum patient at 6 weeks reports intrusive ego-dystonic thoughts of
harming the infant, without delusions or hallucinations. Which statement best
reflects current clinical consensus and management?
A. These thoughts indicate postpartum psychosis and require immediate
involuntary hospitalization.
Page 2
, B. Unwanted intrusive thoughts are common in postpartum OCD and
warrant SSRI therapy plus CBT, not antipsychotics.
C. Symptoms are expected and require no intervention unless the patient
acts on them.
D. First-line treatment is a benzodiazepine to reduce anxiety.
Correct Answer: B - Unwanted intrusive thoughts are common in
postpartum OCD and warrant SSRI therapy plus CBT, not
antipsychotics.
RATIONALE
Ego-dystonic intrusive thoughts of infant harm are characteristic of
postpartum OCD and are distinct from postpartum psychosis (which
features ego-syntonic commands, delusions, or hallucinations). SSRIs
plus CBT are first-line; antipsychotics are not indicated without
psychotic features. Benzodiazepines are not first-line and pose infant
safety concerns.
Question 3
A 55-year-old with type 2 diabetes has an A1c of 8.4% on metformin, an eGFR
of 55, and established ASCVD. Which add-on best aligns with ADA 2024
Standards of Care?
A. Add a DPP-4 inhibitor for its cardiovascular neutrality.
B. Add a GLP-1 receptor agonist with proven CV benefit (e.g.,
semaglutide or dulaglutide).
C. Add a sulfonylurea to achieve rapid glycemic control.
D. Add pioglitazone to improve insulin sensitivity.
Correct Answer: B - Add a GLP-1 receptor agonist with proven
CV benefit (e.g., semaglutide or dulaglutide).
Page 3
, RATIONALE
ADA 2024 recommends a GLP-1 RA or SGLT2 inhibitor with proven
CV benefit for patients with T2DM and established ASCVD,
independent of A1c. DPP-4 inhibitors are CV-neutral and less potent
for MACE reduction. Sulfonylureas and pioglitazone lack robust
MACE benefit and carry weight/hypoglycemia or HF/edema risks.
Question 4
A 62-year-old presents with sudden painless monocular vision loss described
as a 'curtain' over the eye; fundoscopy shows a pale retina with a cherry-red
macula. Which immediate action is most appropriate?
A. Refer routinely to ophthalmology within one week.
B. Start high-dose oral prednisone and follow up in 48 hours.
C. Activate emergency retinal artery occlusion protocol: immediate
ophthalmology/ED referral and stroke workup.
D. Prescribe topical timolol and reassess in 24 hours.
Correct Answer: C - Activate emergency retinal artery occlusion
protocol: immediate ophthalmology/ED referral and stroke
workup.
RATIONALE
Central retinal artery occlusion is an ocular stroke with a narrow
treatment window; emergent referral and concurrent stroke evaluation
(carotid imaging, ECG, echocardiogram) are indicated because of high
concurrent cerebrovascular risk. Routine referral, steroids, or topical
beta-blockers delay definitive care and miss the stroke workup.
Question 5
A 34-year-old G2P1 at 26 weeks reports a painless, firm, immobile mass in the
left breast. Which next step best balances diagnostic accuracy with obstetric
safety?
A. Defer evaluation until after delivery.
Page 4
