CHRONIC DISEASES
A 57-year-old man with HTN and type 2 diabetes on metformin has persistent A1c 8.4%. BMI 31. eGFR 59. Which medication should be added for cardiovascular benefit?
SGLT2 inhibitor (ex: empagliflozin)
Explanation:
SGLT2 inhibitors reduce progression of diabetic kidney disease and offer proven cardiovascular mortality benefits, especially in patients with ASCVD or multiple risk factors. They can be added when eGFR ≥30. GLP-1 agonists also provide CV benefit, but SGLT2 inhibitors have stronger renal data.
A 24-year-old G1P0 presents for prenatal care. She is Rh-negative with a negative antibody screen. When should RhoGAM be given?
At 28 weeks and within 72 hours postpartum if infant Rh-positive.
A 3-year-old with barky cough, mild stridor only when agitated. No retractions. Management?
Single-dose dexamethasone
Explanation:
Mild croup = no stridor at rest. Steroids reduce airway inflammation, shorten illness, and reduce ED return rates. Nebulized epinephrine is for moderate-to-severe croup.
A 21-year-old with asthma presents with wheezing. Peak flow <50% of baseline. No improvement with albuterol ×3. Next step?
Add ipratropium + give systemic steroids.
Explanation:
Peak flow <50% = severe exacerbation. If albuterol alone is insufficient, add ipratropium (duonebs) and give systemic corticosteroids early to reduce airway inflammation and prevent relapse.
A patient on amiodarone develops tremor, weight loss, heat intolerance. Which test should be ordered?
TSH (check for amiodarone-induced thyrotoxicosis)
Explanation:
Amiodarone contains iodine and can cause hyper- or hypothyroidism. Symptoms suggest hyperthyroidism. Always check TSH in patients on chronic amiodarone.
A 68-year-old woman with stable angina has LDL 76 on moderate-dose statin. ASCVD 22%. What is the next step?
Increase to high-intensity statin (goal LDL <70).
Explanation:
Patients with established ASCVD (like stable angina) should be on high-intensity statins (atorvastatin 40–80 or rosuvastatin 20–40) regardless of LDL level unless contraindicated. LDL <70 is the goal for secondary prevention.
A 36-year-old at 33 weeks with new-onset hypertension and 1+ proteinuria. No symptoms. Platelets 198k. Next step?
Urine protein/creatinine ratio (to evaluate for preeclampsia).
Explanation:
New-onset hypertension + proteinuria after 20 weeks → evaluate for preeclampsia. A protein/creatinine ratio ≥0.3 or 24-hour urine protein ≥300 mg confirms the diagnosis.
A 6-week-old with non-bilious projectile vomiting, visible peristalsis, metabolic alkalosis. Diagnosis?
Pyloric stenosis
Explanation:
Projectile non-bilious vomiting + metabolic alkalosis + 4–8 weeks old → classic for pyloric stenosis. Diagnosis is confirmed with ultrasound. Treat with pyloromyotomy.
A 76-year-old falls and cannot externally rotate his leg. Shortened, externally rotated limb. Diagnosis?
Femoral neck fracture
Explanation:
Shortened, externally rotated leg = classic hip fracture presentation, especially femoral neck. Requires urgent orthopedic evaluation. Higher risk of AVN than intertrochanteric fractures.
An elderly man on digoxin has nausea, color vision changes, bradycardia. What electrolyte abnormality worsens digoxin toxicity?
Hypokalemia
Explanation:
Digoxin binds the Na/K ATPase. Low potassium increases digoxin binding, worsening toxicity. Classic signs: nausea, confusion, yellow vision (xanthopsia), arrhythmias.
A patient’s BP is 136/84 on lisinopril 20 mg. He has LVH on EKG. According to ACC/AHA guidelines, what is the BP goal?
<130/80 mmHg
Explanation:
ACC/AHA guidelines recommend <130/80 for patients with target-organ damage like LVH, diabetes, or CKD. LVH is a marker of chronic hypertension and higher CV risk
A 27-year-old with secondary amenorrhea, low FSH/LH, normal prolactin, and history of excessive exercise. What is the most likely diagnosis?
Functional hypothalamic amenorrhea
A 4-year-old with itchy papules in linear burrows in finger webs. Several family members itchy. Treatment?
Permethrin 5% cream for patient + household.
Explanation:
Scabies presents with burrows, papules, and intense nighttime pruritus. Treat close contacts because it spreads easily between household members. Wash bedding in hot water.
A patient presents with chest pain; EKG shows ST depressions in V2–V3 and elevation in aVR. Concern for what?
Left main coronary artery occlusion (or proximal LAD).
Explanation:
ST elevation in aVR + diffuse ST depressions = highly concerning for left main or proximal LAD disease, a cardiology emergency. Mortality is extremely high without urgent intervention.
A patient started on an ACE inhibitor develops a persistent dry cough. What is the mechanism?
Increased bradykinin levels
Explanation:
ACE inhibitors block bradykinin breakdown → dry cough. Switching to an ARB resolves the cough because ARBs do not affect bradykinin metabolism.
A 42-year-old obese woman with OSA presents with resistant HTN despite 3 meds. Labs show K+ 3.1. What test is indicated?
Aldosterone/renin ratio to evaluate for primary hyperaldosteronism.
Explanation:
Hypokalemia + hypertension resistant to ≥3 antihypertensives → primary hyperaldosteronism until proven otherwise. Screening is done with an aldosterone/renin ratio. OSA also increases suspicion.
A 34-year-old postpartum day 2 develops fever, uterine tenderness, foul lochia. Next step?
Broad-spectrum IV antibiotics (clindamycin + gentamicin)
Explanation:
Postpartum endometritis presents with fever + uterine tenderness + foul lochia, especially after C-section. Broad-spectrum coverage for anaerobes and polymicrobial flora is required.
A previously healthy 7-year-old now has proteinuria on UA after a URI. BP normal. No edema. Next step?
Repeat first-morning urine in 1–2 weeks (likely transient/orthostatic proteinuria)
Explanation:
After febrile illnesses, children commonly have transient proteinuria. If BP is normal and there are no symptoms, repeat evaluation is appropriate. Persistent proteinuria needs nephrology referral.
A 50-year-old with alcohol use presents with confusion, nystagmus, ataxia. Management?
IV thiamine BEFORE glucose
Explanation:
Giving glucose before thiamine can precipitate or worsen Wernicke encephalopathy. The triad: confusion, ophthalmoplegia/nystagmus, and ataxia.
A patient with diabetes on an SGLT2 inhibitor presents with nausea, abdominal pain, normal glucose, and high anion gap. Diagnosis?
Euglycemic DKA
Explanation:
SGLT2 inhibitors increase urinary glucose loss → decreased insulin → ketosis even at normal glucose levels. Anion gap metabolic acidosis with ketones confirms diagnosis.
A 60-year-old smoker with COPD presents with worsening dyspnea on exertion. CT shows centrilobular emphysema. What intervention improves mortality?
Smoking cessation
Explanation:
Smoking cessation is the only intervention proven to reduce mortality in COPD. Long-term oxygen only improves mortality if the patient has chronic resting hypoxemia (PaO2 ≤55 or O2 sat ≤88%).
A 31-year-old with PCOS trying to conceive. BMI 35. Irregular cycles. What is the first-line ovulation induction medication?
Letrozole
Explanation: Letrozole (aromatase inhibitor) is the first-line ovulation induction agent in PCOS because it offers higher live-birth rates compared to clomiphene.
A 2-year-old previously vaccinated develops fever and rash that begins on face → trunk → extremities. Koplik spots seen. What is the most likely complication?
Otitis media
Explanation:
Measles (rubeola) classically begins on face and spreads downward with Koplik spots. Otitis media is the most common complication. More severe complications include pneumonia and encephalitis.
A teen in a MVC has hypotension, jugular venous distention, muffled heart sounds. Diagnosis and immediate step?
Cardiac tamponade → perform pericardiocentesis.
Explanation:
Hypotension + JVD + muffled heart sounds = Beck’s triad. Emergent pericardiocentesis is lifesaving. FAST exam shows pericardial effusion.
A patient on warfarin has INR 8.2 with minor bleeding. Next step?
Hold warfarin + give oral vitamin K
Explanation:
INR > 8 with minor bleeding (or no bleeding) → give oral vitamin K. IV vitamin K is for serious bleeding. PCC/FFP is for life-threatening bleeding.