Saudi Board Internal Medicine Final Written Exam (SCFHS)

A 58-year-old man presents to the emergency department with 2 hours of crushing substernal chest pain. The ECG reveals 3-mm ST-segment elevation in leads V2-V4. The nearest PCI-capable hospital is 90 minutes away, but transfer and door-to-balloon time is expected to exceed 120 minutes. What is the most appropriate reperfusion strategy?

• AImmediate fibrinolytic therapy with tenecteplase followed by transfer for coronary angiog…
• BTransfer for primary percutaneous coronary intervention (PCI) despite the expected delay
• CIntravenous heparin infusion and double antiplatelet therapy with delayed outpatient angi…
• DEmergency coronary artery bypass grafting (CABG) surgery

A 64-year-old woman with a history of chronic heart failure with reduced ejection fraction (HFrEF, EF 32%) presents for a routine follow-up. She is currently asymptomatic on bisoprolol 5 mg daily and lisinopril 10 mg daily. Her blood pressure is 118/76 mmHg and heart rate is 64 bpm. Which of the following is the most appropriate next step in optimizing her medical therapy?

• ASwitch lisinopril to sacubitril-valsartan, and add spironolactone and an SGLT2 inhibitor…
• BIncrease lisinopril to 20 mg daily and follow up in 3 months
• CAdd digoxin to improve left ventricular contractility
• DAdd amlodipine for additional blood pressure and heart rate control

A 71-year-old man with hypertension, type 2 diabetes, and chronic kidney disease (eGFR 42 mL/min/1.73 m²) is newly diagnosed with nonvalvular atrial fibrillation. What is the most appropriate management for stroke prevention in this patient?

• AOral anticoagulation with a direct oral anticoagulant (DOAC) such as apixaban
• BDual antiplatelet therapy with aspirin and clopidogrel
• COral anticoagulation with warfarin targeting an INR of 2.0-3.0
• DAspirin 81 mg daily monotherapy

A 28-year-old woman is referred for evaluation of resistant hypertension. She has been on three antihypertensive medications (amlodipine, lisinopril, hydrochlorothiazide) at optimal doses for 6 months. On physical examination, a bruit is heard over her right flank. Renal artery duplex ultrasound suggests stenosis of the mid-to-distal right renal artery. What is the most likely diagnosis and preferred management?

• AFibromuscular dysplasia (FMD); percutaneous transluminal angioplasty (PTA) without stenti…
• BAtherosclerotic renal artery stenosis (ARAS); renal artery stenting
• CPheochromocytoma; surgical resection of the adrenal gland
• DPrimary aldosteronism; spironolactone titration

A 34-year-old man presents with sharp, retrosternal chest pain that is worse when lying flat and improves when sitting forward. He reports having a mild upper respiratory tract infection 2 weeks ago. His ECG shows diffuse, concave-upward ST-segment elevation with PR-segment depression in lead II and PR-segment elevation in lead aVR. What is the first-line pharmacotherapy for this patient?

• AHigh-dose ibuprofen or aspirin combined with colchicine
• BIntravenous thrombolysis with alteplase
• CLow-dose oral prednisone monotherapy
• DImmediate coronary angiography and percutaneous coronary intervention

A 78-year-old man presents with progressive exertional dyspnea and lightheadedness. On physical examination, he has a harsh, late-peaking 3/6 systolic ejection murmur at the right upper sternal border that radiates to his carotids, along with a delayed and weak carotid pulse (pulsus parvus et tardus). Echocardiography reveals a calcified aortic valve with an area of 0.8 cm², a mean gradient of 44 mmHg, and a left ventricular ejection fraction of 55%. What is the most appropriate next step in management?

• AAortic valve replacement (either surgical or transcatheter)
• BMedical therapy with beta-blockers and loop diuretics, with close follow-up
• CBalloon aortic valvuloplasty as a definitive procedure
• DRepeat echocardiography in 6-12 months

A 22-year-old male athlete is evaluated after experiencing an episode of exertional syncope. His uncle died suddenly at age 26. On examination, a 3/6 systolic murmur is heard at the left sternal border. The murmur increases in intensity during the strain phase of a Valsalva maneuver and decreases with passive leg elevation. What is the most likely diagnosis?

• AHypertrophic obstructive cardiomyopathy (HOCM)
• BAortic valve stenosis
• CMitral regurgitation due to prolapse
• DPhysiological flow murmur of an athlete

A 45-year-old woman with a history of mitral valve prolapse with moderate regurgitation is scheduled for a dental extraction involving manipulation of the gingival tissue. She has no other medical history or drug allergies. What is the current AHA/ESC guideline recommendation regarding infective endocarditis (IE) prophylaxis for this patient?

• ANo antibiotic prophylaxis is indicated for this patient
• BAmoxicillin 2 g orally 1 hour prior to the procedure
• CClindamycin 600 mg orally 1 hour prior to the procedure
• DIntravenous ampicillin 2 g administered 30 minutes before the procedure

A 42-year-old man presents with generalized swelling, weight gain of 8 kg, and foamy urine over the last 3 weeks. Urinalysis shows 4+ protein, and a 24-hour urine collection reveals 6.8 g of protein. Serum albumin is 2.1 g/dL, total cholesterol is 310 mg/dL, and serum creatinine is 0.9 mg/dL. Serum serology for phospholipase A2 receptor (PLA2R) antibody is strongly positive. What is the most likely diagnosis?

• APrimary membranous nephropathy
• BMinimal change disease
• CFocal segmental glomerulosclerosis (FSGS)
• DDiabetic nephropathy

A 29-year-old woman with a history of systemic lupus erythematosus (SLE) presents with new-onset lower extremity edema and worsening proteinuria (uPCR 3.2 g/g). A renal biopsy shows diffuse segmental and global endocapillary proliferation involving 60% of glomeruli, with subendothelial immune complex deposits ('wire loops') and active inflammation. Which of the following is the most appropriate initial induction therapy?

• AMycophenolate mofetil (MMF) or intravenous cyclophosphamide, combined with high-dose cort…
• BHigh-dose oral prednisone monotherapy
• CRituximab monotherapy
• DHydroxychloroquine combined with low-dose prednisone

A 23-year-old man presents with recurrent episodes of gross hematuria. He reports that the blood in his urine typically occurs 1-2 days after an upper respiratory tract infection. His blood pressure is 132/84 mmHg, serum creatinine is 0.8 mg/dL, and urinalysis shows dysmorphic red blood cells and RBC casts with 1+ protein. What is the most likely diagnosis?

• AIgA nephropathy
• BPoststreptococcal glomerulonephritis (PSGN)
• CAlport syndrome
• DMinimal change disease

A 48-year-old woman is admitted for treatment of osteomyelitis and started on intravenous nafcillin. Ten days later, she develops a diffuse maculopapular rash, low-grade fever, and mild arthralgias. Laboratory studies show: serum creatinine increased from 0.8 mg/dL to 2.1 mg/dL, peripheral blood eosinophilia, and urinalysis showing white blood cell casts and eosinophiluria. What is the most likely diagnosis and initial management?

• AAcute interstitial nephritis (AIN); discontinuation of nafcillin
• BAcute tubular necrosis (ATN); intravenous fluid resuscitation
• CPoststreptococcal glomerulonephritis; high-dose methylprednisolone
• DRenal atheroembolization; systemic anticoagulation

A 68-year-old man with end-stage renal disease on hemodialysis presents to the emergency department after missing three consecutive dialysis sessions. He reports severe generalized muscle weakness. His ECG reveals tall, peaked T waves, prolonged PR interval, and widening of the QRS complex. His serum potassium is 7.2 mEq/L. Which of the following is the most urgent initial step in the management of this patient?

• AIntravenous calcium gluconate
• BIntravenous regular insulin and dextrose
• CIntravenous sodium bicarbonate
• DEmergent hemodialysis

A 45-year-old woman is evaluated for chronic muscle weakness and polyuria. Laboratory studies reveal: sodium 138 mEq/L, potassium 2.8 mEq/L, chloride 114 mEq/L, and bicarbonate 16 mEq/L (normal 22-28). Her arterial blood gas confirms a normal anion gap metabolic acidosis. Urinalysis shows a pH of 6.2 and a positive urine anion gap. What is the most likely diagnosis?

• AType 1 (distal) renal tubular acidosis (RTA)
• BType 2 (proximal) renal tubular acidosis (RTA)
• CType 4 (hyperkalemic) renal tubular acidosis (RTA)
• DChronic diarrhea

A 68-year-old man with a history of type 2 diabetes and stage 3b chronic kidney disease (eGFR 35 mL/min/1.73 m²) is scheduled for an elective contrast-enhanced CT scan of the abdomen. What is the most effective evidence-based strategy to prevent contrast-induced nephropathy (CIN)?

• AIntravenous volume expansion with isotonic saline (0.9% NaCl)
• BOral administration of high-dose N-acetylcysteine
• CProphylactic hemodialysis immediately following the procedure
• DIntravenous administration of loop diuretics during the scan

A 72-year-old man with severe HFrEF (EF 20%) is admitted with progressive shortness of breath, orthopnea, and marked peripheral edema. Over the first 48 hours of admission, he is treated with aggressive intravenous loop diuretics. His serum creatinine rises from 1.2 mg/dL to 2.4 mg/dL, while his blood pressure remains stable at 105/65 mmHg. This clinical scenario represents which of the following?

• ACardiorenal syndrome Type 1
• BCardiorenal syndrome Type 2
• CAcute tubular necrosis secondary to diuretic toxicity
• DPre-renal azotemia from over-diuresis

A 55-year-old woman is admitted for acute decompensated heart failure. She is noted to have cold extremities, weak pulses, altered mental status, and a low urine output (< 20 mL/hour). Her blood pressure is 82/50 mmHg and heart rate is 112 bpm. Auscultation reveals diffuse bilateral crackles and a loud S3. What is her hemodynamic profile and the most appropriate initial therapy?

• ACold and Wet; intravenous inotrope (e.g., dobutamine) and cautious loop diuretics
• BWarm and Wet; aggressive intravenous loop diuretics and vasodilators
• CCold and Dry; intravenous fluid bolus and vasopressors
• DWarm and Dry; oral beta-blocker titration and outpatient follow-up

A 43-year-old man is evaluated for resistant hypertension and persistent hypokalemia. His plasma aldosterone concentration (PAC) is 24 ng/dL, and his plasma renin activity (PRA) is 0.2 ng/mL/hour, giving a PAC/PRA ratio of 120. Which of the following is the most appropriate next step in confirming the diagnosis of primary aldosteronism?

• ASaline infusion test or oral sodium loading test
• BAdrenal venous sampling (AVS)
• CCT scan of the abdomen and pelvis
• DInitiation of spironolactone 50 mg daily

A 45-year-old woman presents with sinus pain, chronic purulent nasal discharge, and cough with hemoptysis. Laboratory evaluation reveals a creatinine of 2.4 mg/dL and active sediment in her urine (dysmorphic RBCs and RBC casts). Serum testing is positive for c-ANCA (PR3-ANCA). A renal biopsy shows crescentic glomerulonephritis with minimal immune deposits (pauci-immune). What is the most likely diagnosis?

• AGranulomatosis with polyangiitis (GPA)
• BMicroscopic polyangiitis (MPA)
• CAnti-glomerular basement membrane (GBM) disease
• DEosinophilic granulomatosis with polyangiitis (EGPA)

A 62-year-old woman with Stage 4 CKD (eGFR 22 mL/min/1.73 m²) is found to have a serum calcium of 8.2 mg/dL (normal 8.5-10.2), phosphate of 5.8 mg/dL (normal 2.5-4.5), and an intact parathyroid hormone (PTH) of 280 pg/mL (normal 15-65). What is the primary pathophysiological mechanism driving her secondary hyperparathyroidism?

• AHyperphosphatemia and decreased renal synthesis of 1,25-dihydroxyvitamin D (calcitriol)
• BAutonomous parathyroid gland hyperplasia independent of calcium levels
• CExcessive renal loss of calcium due to loop diuretic use
• DDecreased intestinal absorption of phosphate

A 66-year-old man with a 45 pack-year smoking history presents with progressive shortness of breath and a chronic cough. His post-bronchodilator spirometry shows an FEV1/FVC ratio of 0.62 and FEV1 of 52% of predicted. Over the past year, he has had two moderate exacerbations of COPD requiring oral corticosteroids. He reports an mMRC dyspnea score of 3. His blood eosinophil count is 350 cells/µL. According to the GOLD 2024 report, what is the preferred initial pharmacotherapy?

• ATriple therapy with LAMA + LABA + ICS
• BDual bronchodilation with LAMA + LABA
• CLAMA monotherapy
• DSABA as-needed monotherapy

A 28-year-old woman presents with intermittent wheezing and dry cough, occurring 3-4 times a week, especially at night. She has no history of severe asthma exacerbations or hospitalizations. Her FEV1 is 84% of predicted. According to GINA 2024 guidelines (Track 1, preferred), what is the recommended initial controller and reliever regimen?

• AAs-needed low-dose ICS-formoterol only
• BAs-needed short-acting beta-agonist (SABA) alone
• CDaily low-dose ICS plus as-needed SABA
• DDaily low-dose ICS-LABA plus as-needed SABA

A 45-year-old woman is admitted to the ICU with severe community-acquired pneumonia. Over the next 12 hours, she develops worsening hypoxemia refractory to oxygen therapy. Her chest radiograph shows bilateral alveolar infiltrates, and her PaO2/FiO2 ratio is 140 mmHg on a mechanical ventilator. Her plateau pressure is 28 cm H2O. What is the most appropriate lung-protective ventilation strategy for this patient?

• ALow tidal volumes of 6 mL/kg predicted body weight (PBW) and target plateau pressure <= 3…
• BHigh tidal volumes of 10-12 mL/kg predicted body weight (PBW) to recruit collapsed alveoli
• CHigh-frequency oscillatory ventilation
• DTidal volumes of 6 mL/kg actual body weight and target plateau pressure <= 40 cm H2O

A 62-year-old man presents with a 9-month history of dry cough and progressive shortness of breath on exertion. On examination, bilateral fine, late-inspiratory velcro crackles are heard at the lung bases, and digital clubbing is present. A high-resolution CT (HRCT) of the chest shows subpleural, basal-predominant reticular abnormalities, traction bronchiectasis, and honeycombing. What is the most likely diagnosis and first-line treatment?

• AIdiopathic pulmonary fibrosis (IPF); antifibrotic therapy (nintedanib or pirfenidone)
• BNonspecific interstitial pneumonia (NSIP); high-dose glucocorticoids
• CHypersensitivity pneumonitis; antigen avoidance and cyclosporine
• DCryptogenic organizing pneumonia (COP); oral prednisone

A 48-year-old obese man (BMI 36 kg/m²) is evaluated for severe daytime somnolence, morning headaches, and loud snoring with witnessed apneas. Polysomnography reveals an Apnea-Hypopnea Index (AHI) of 38 events per hour. His overnight oxygen saturation drops to a minimum of 76%. What is the most appropriate first-line therapy for this patient?

• AContinuous positive airway pressure (CPAP)
• BMandibular advancement device (MAD)
• CSurgical uvulopalatopharyngoplasty (UPPP)
• DOral modafinil

A 72-year-old woman is brought to the clinic by her daughter due to a 3-day history of fever, productive cough, and progressive confusion. Her vital signs are: BP 88/54 mmHg, HR 104 bpm, Temp 38.6°C, RR 32 breaths/min, and oxygen saturation 90% on room air. Crackles are heard in the right lower lung field. Laboratory studies show: BUN 32 mg/dL and creatinine 1.4 mg/dL. Based on the CURB-65 score, what is her score and recommended site of care?

• AScore of 4; urgent admission to the hospital (consider ICU)
• BScore of 1; outpatient management with oral macrolides
• CScore of 2; brief inpatient observation or close outpatient follow-up
• DScore of 5; immediate endotracheal intubation and mechanical ventilation

A 35-year-old woman presents with progressive dyspnea on exertion and atypical chest pain. On physical examination, she has a loud pulmonic component of the second heart sound (P2) and a tricuspid regurgitation murmur. Echocardiography shows right ventricular hypertrophy and dilation, with an estimated pulmonary artery systolic pressure of 65 mmHg. Right heart catheterization confirms a mean pulmonary artery pressure (mPAP) of 28 mmHg at rest, pulmonary capillary wedge pressure (PCWP) of 12 mmHg, and pulmonary vascular resistance (PVR) of 4 Wood units. What is the diagnosis and preferred initial screening step for identifying the etiology?

• APre-capillary pulmonary arterial hypertension (PAH); Ventilation-Perfusion (V/Q) lung scan
• BPost-capillary pulmonary hypertension; CT coronary angiography
• CChronic thromboembolic pulmonary hypertension (CTEPH); Pulmonary angiography
• DPulmonary hypertension due to lung disease; High-resolution CT chest

A 58-year-old man presents with progressive shortness of breath. A chest radiograph reveals a large right-sided pleural effusion. Thoracentesis is performed, and pleural fluid analysis shows: protein 4.2 g/dL, LDH 280 U/L. Serum laboratory values show: protein 6.8 g/dL, LDH 180 U/L. The upper limit of normal for serum LDH is 200 U/L. Based on Light's criteria, how is this effusion classified?

• AExudate, because the pleural fluid to serum protein ratio is > 0.5
• BTransudate, because the pleural fluid LDH is less than the upper limit of normal for serum
• CTransudate, because the pleural fluid to serum LDH ratio is < 0.6
• DExudate, because the pleural fluid protein is > 3.0 g/dL

A 32-year-old woman presents with painful red nodules on her shins, bilateral ankle pain, and a low-grade fever. A chest radiograph reveals bilateral hilar lymphadenopathy without lung parenchymal infiltrates. What is this clinical triad called, and what is the recommended next step?

• ALöfgren syndrome; clinical monitoring and symptomatic management with NSAIDs
• BHeerfordt syndrome; immediate initiation of high-dose prednisone
• CSjögren syndrome; salivary gland biopsy and pilocarpine
• DBerylliosis; occupational avoidance and methotrexate

A 64-year-old man is admitted to the ICU with severe abdominal pain and vomiting. He is found to have a perforated sigmoid diverticulum. His blood pressure is 82/40 mmHg despite 3 L of intravenous crystalloid resuscitation. His heart rate is 120 bpm, temperature is 39.1°C, and respiratory rate is 28 breaths/min. His blood lactate is 3.8 mmol/L. According to the Surviving Sepsis Campaign 2021 guidelines, what is the first-line vasopressor and the target mean arterial pressure (MAP)?

• ANorepinephrine; target MAP >= 65 mmHg
• BDopamine; target MAP >= 75 mmHg
• CEpinephrine; target MAP >= 60 mmHg
• DVasopressin; target MAP >= 70 mmHg

A 54-year-old man with a 10-year history of chronic gastroesophageal reflux disease (GERD) presents for evaluation. He has no alarm symptoms such as dysphagia, weight loss, or gastrointestinal bleeding. An upper endoscopy (EGD) is performed, revealing mucosal salmon-colored projections extending 2 cm above the gastroesophageal junction. Biopsies confirm specialized intestinal metaplasia (Barrett's esophagus) without dysplasia. What is the recommended surveillance strategy for this patient?

• ARepeat EGD every 3-5 years
• BRepeat EGD every 12 months
• CEndoscopic mucosal resection (EMR) or radiofrequency ablation (RFA) immediately
• DNo further surveillance is required since there is no dysplasia

A 45-year-old woman is diagnosed with Helicobacter pylori-associated duodenal ulcer disease. She has no drug allergies and has not previously been treated for H. pylori. She resides in an area where local clarithromycin resistance is known to be 22%. According to the ACG 2024 H. pylori guidelines, what is the most appropriate first-line eradication therapy?

• ABismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) for 14 days
• BClarithromycin triple therapy (PPI + clarithromycin + amoxicillin) for 10 days
• CSequential therapy (PPI + amoxicillin for 5 days, followed by PPI + clarithromycin + metr…
• DLevofloxacin triple therapy (PPI + levofloxacin + amoxicillin) for 14 days

A 34-year-old woman presents with a 6-month history of chronic diarrhea, abdominal bloating, and flatulence. She has lost 5 kg without dieting. Laboratory studies show: hemoglobin 10.4 g/dL, MCV 74 fL, and serum ferritin 8 ng/mL. Serum IgA tissue transglutaminase (tTG) antibody is elevated at 10 times the upper limit of normal. What is the most appropriate next step to confirm the diagnosis?

• AEGD with multiple duodenal biopsies while she continues a gluten-containing diet
• BImmediate initiation of a gluten-free diet and repeat antibody testing in 6 months
• CHLA-DQ2/DQ8 genetic testing to confirm the diagnosis
• DColonoscopy with random biopsies of the terminal ileum and colon

A 28-year-old man presents with chronic bloody diarrhea, lower abdominal cramping, and tenesmus. On colonoscopy, there is continuous, circumferential mucosal inflammation, erythema, and loss of vascular markings extending from the anal verge to the splenic flexure. Biopsies reveal crypt abscesses and crypt architectural distortion, with no granulomas. What is the diagnosis and preferred first-line induction and maintenance therapy?

• ALeft-sided ulcerative colitis; oral and topical 5-aminosalicylic acid (mesalamine)
• BCrohn's disease; oral budesonide
• CInfectious colitis; oral ciprofloxacin and metronidazole
• DMicroscopic colitis; oral budesonide

A 26-year-old woman is evaluated for a 1-year history of recurrent abdominal pain associated with defecation. She reports that her bowel habits fluctuate, with periods of hard, lumpy stools followed by loose, watery stools. The pain is relieved by defecation. She has no alarm features (no weight loss, no family history of colon cancer or IBD, normal hemoglobin). What is her most likely diagnosis and first-line dietary intervention?

• AIrritable bowel syndrome with mixed bowel habits (IBS-M); low-FODMAP diet trial
• BSmall intestinal bacterial overgrowth (SIBO); trial of rifaximin
• CLactose intolerance; elimination of all dairy products
• DExocrine pancreatic insufficiency; pancreatic enzyme replacement therapy

A 52-year-old man with a history of decompensated cirrhosis due to chronic hepatitis B presents with moderate ascites. He has normal renal function. What is the recommended first-line pharmacological regimen for managing his ascites?

• ASpironolactone 100 mg daily and furosemide 40 mg daily, combined with sodium restriction
• BFurosemide 80 mg daily monotherapy
• CTherapeutic large-volume paracentesis every 2 weeks
• DFluid restriction to < 1 L/day and spironolactone 50 mg daily

A 60-year-old woman with cirrhosis and a history of esophageal varices is brought to the emergency department by her family due to progressive confusion, sleep reversal, and a coarse flapping tremor of her outstretched hands (asterixis). There is no history of trauma or gastrointestinal bleeding. Which of the following is the preferred first-line therapy for her condition?

• ALactulose titrated to 3-4 soft stools per day
• BRifaximin 550 mg BID monotherapy
• CNeomycin and fluid restriction
• DFlumazenil injection

A 54-year-old man with alcoholic cirrhosis is admitted with abdominal pain, low-grade fever, and worsening confusion. Diagnostic paracentesis is performed, and pleural/peritoneal fluid analysis reveals a neutrophil (polymorphonuclear, PMN) count of 320 cells/mm³. What is the most appropriate management for this patient?

• AIntravenous cefotaxime (or another third-generation cephalosporin) and intravenous albumin
• BIntravenous vancomycin and metronidazole
• CRepeat paracentesis in 48 hours to confirm the diagnosis before starting antibiotics
• DImmediate surgical exploration for secondary bacterial peritonitis

A 38-year-old woman presents with severe epigastric pain radiating to her back, accompanied by nausea and persistent vomiting. Her serum lipase is 1,200 U/L (normal < 60). She is diagnosed with acute pancreatitis. An abdominal ultrasound shows gallstones in the gallbladder without common bile duct dilation. What is the most appropriate initial management?

• AAggressive intravenous hydration with lactated Ringer's solution, pain control, and early…
• BImmediate endoscopic retrograde cholangiopancreatography (ERCP)
• CNil per os (NPO) status for at least 5 days and total parenteral nutrition (TPN)
• DProphylactic intravenous imipenem to prevent pancreatic necrosis

A 76-year-old woman with a history of chronic atrial fibrillation presents with sudden-onset, severe diffuse abdominal pain. On physical examination, her abdomen is soft and non-distended, with minimal tenderness to palpation, which is completely out of proportion to her severe distress. Her blood pressure is 112/70 mmHg, heart rate is 108 bpm and irregular. What is the most likely diagnosis and preferred diagnostic imaging modality?

• AAcute mesenteric ischemia; CT angiography of the abdomen and pelvis
• BAcute diverticulitis; CT scan with oral contrast
• CPerforated peptic ulcer; Erect abdominal X-ray
• DRuptured abdominal aortic aneurysm; Abdominal duplex ultrasound

A 62-year-old man with type 2 diabetes mellitus, Stage 3a chronic kidney disease (eGFR 48 mL/min/1.73 m²), and a history of myocardial infarction 3 years ago presents for diabetes optimization. His current HbA1c is 8.2% on metformin 1,000 mg BID. Which of the following is the most appropriate next step in his glycemic management per the ADA 2024 standards?

• AAdd an SGLT2 inhibitor (e.g., empagliflozin) or a GLP-1 receptor agonist (e.g., semagluti…
• BAdd a sulfonylurea (e.g., glimepiride) to rapidly lower HbA1c
• CInitiate basal insulin glargine daily
• DAdd a DPP-4 inhibitor (e.g., sitagliptin)

A 24-year-old woman with type 1 diabetes is admitted to the emergency department with nausea, vomiting, and abdominal pain. Her vital signs are: BP 96/60 mmHg, HR 112 bpm, and RR 28 breaths/min. Laboratory studies show: serum glucose 380 mg/dL, arterial pH 7.15, bicarbonate 10 mEq/L, and serum potassium 4.8 mEq/L. Ketones are present in the urine. Fluid resuscitation is initiated. What is the most appropriate next step in her pharmacological management?

• AInitiate an intravenous regular insulin infusion, and hold potassium replacement for now
• BAdminister an intravenous bolus of regular insulin followed by subcutaneous basal insulin
• CInitiate an intravenous regular insulin infusion and administer intravenous potassium chl…
• DAdminister intravenous sodium bicarbonate to correct the severe acidosis

A 58-year-old asymptomatic woman is found to have a serum calcium of 10.8 mg/dL (normal 8.5-10.2) on routine screening. A repeat value is 10.9 mg/dL. Her serum albumin is normal. Further evaluation shows: intact parathyroid hormone (PTH) 94 pg/mL (normal 15-65), 24-hour urine calcium excretion 280 mg (normal < 250), and normal renal function. DEXA scan reveals a T-score of -1.8 at the lumbar spine. Which of the following is the most appropriate management?

• ASurgical parathyroidectomy
• BTreatment with cinacalcet to lower serum calcium
• CObservation with annual monitoring of calcium, renal function, and bone density
• DTreatment with oral alendronate for osteopenia

A 35-year-old woman presents with progressive weight gain, facial puffiness, easy bruising, and proximal muscle weakness. On physical examination, she has a round face ('moon facies'), truncal obesity, dorsocervical fat pad, and wide purple striae on her abdomen. What is the most appropriate initial diagnostic approach to screen for Cushing's syndrome?

• APerform two different first-line screening tests: 24-hour urinary free cortisol, late-nig…
• BPerform a CT scan of the abdomen to look for adrenal masses
• CMeasure random morning serum cortisol and ACTH levels
• DPerform a high-dose (8-mg) dexamethasone suppression test

A 32-year-old woman presents with fatigue, weight loss, anorexia, and hyperpigmentation of her skin, particularly in her palmar creases and oral mucosa. Her blood pressure is 92/56 mmHg with orthostatic drop. Laboratory studies show: sodium 128 mEq/L, potassium 5.6 mEq/L, and morning serum cortisol 3.2 µg/dL. A cosyntropin (ACTH) stimulation test is performed, and 30-minute cortisol is 4.8 µg/dL (normal response > 18). What is the diagnosis and preferred maintenance treatment?

• APrimary adrenal insufficiency (Addison's disease); oral hydrocortisone (or prednisone) an…
• BSecondary adrenal insufficiency; oral hydrocortisone monotherapy
• CCongenital adrenal hyperplasia; high-dose dexamethasone
• DACTH resistance syndrome; oral fludrocortisone monotherapy

A 36-year-old woman presents with palpitations, weight loss, heat intolerance, and a diffuse, non-tender goiter. Her thyroid function tests show: TSH < 0.01 mIU/L, free T4 2.8 ng/dL (normal 0.8-1.8). TSH-receptor antibody (TRAb) is positive. A radioactive iodine uptake (RAIU) scan is performed. What is the most likely diagnosis and typical RAIU pattern?

• AGraves' disease; diffuse, homogeneously increased radioactive iodine uptake
• BToxic multinodular goiter; patchy, heterogeneous uptake with multiple hot nodules
• CSubacute thyroiditis (de Quervain's); low or near-zero radioactive iodine uptake
• DHashimoto's thyroiditis; normal uptake with positive anti-TPO antibodies

A 42-year-old woman with a history of untreated Graves' disease is admitted to the hospital with high fever (39.8°C), severe agitation, delirium, vomiting, and tachycardia (HR 145 bpm) with atrial fibrillation. She underwent emergency appendectomy yesterday. Her Burch-Wartofsky Point Scale score is 65. In addition to supportive care, what is the most appropriate pharmacological combination and sequence for this emergency?

• APropylthiouracil (PTU), followed by saturated solution of potassium iodide (SSKI) 1 hour…
• BPotassium iodide (SSKI), followed by methimazole, and intravenous esmolol
• CMethimazole, followed by radioactive iodine therapy, and dexamethasone
• DThyroidectomy immediately without medical stabilization