LG LO Questions

Learning Objective B9LG1.1

"Given a patient scenario with historical, physical and diagnostic information,
distinguish between acute renal failure and chronic kidney disease."

Question 1

A 72-year-old man presents with fatigue and generalized pruritus for 3 months. His past medical
history includes hypertension and type 2 diabetes mellitus. He takes lisinopril, metformin, and
aspirin. Physical examination reveals bilateral ankle edema and asterixis. Lab results show:

●​ BUN: 68 mg/dL​

●​ Creatinine: 5.6 mg/dL​

●​ Hemoglobin: 8.9 g/dL​

●​ Calcium: 8.1 mg/dL​

●​ Phosphorus: 5.8 mg/dL​

●​ eGFR: 10 mL/min/1.73m²​
Ultrasound shows small, echogenic kidneys bilaterally.​

Which of the following most likely describes this patient’s renal condition?

A) Acute tubular necrosis​

B) Pre-renal azotemia​
C) Chronic kidney disease​
D) Acute interstitial nephritis​
E) Post-renal obstruction

Question 2

A 55-year-old woman presents with sudden-onset oliguria and nausea after a week of high-dose
NSAID use for back pain. She has no prior kidney disease. Vitals are normal. Urinalysis reveals
muddy brown casts, and ultrasound shows normal-sized kidneys with no hydronephrosis. Labs:
 ●​ Creatinine: 3.5 mg/dL (baseline unknown)​

●​ BUN: 52 mg/dL​

●​ Urine sodium: 42 mEq/L​

Which of the following best distinguishes this condition from chronic kidney disease?

A) Presence of proteinuria​
B) History of hypertension​
C) Urine sodium concentration​
D) Kidney size on imaging​
E) Level of creatinine elevation

Question 3

A 65-year-old man with poorly controlled hypertension presents with fatigue and decreased
urine output. Labs:

●​ BUN: 90 mg/dL​

●​ Creatinine: 7.0 mg/dL​

●​ Urinalysis: Broad waxy casts​

●​ Hemoglobin: 9.0 g/dL​

Ultrasound reveals small, shrunken kidneys bilaterally.​

Which of the following findings most strongly supports a chronic rather than acute etiology?

A) Sudden onset of symptoms​

B) Broad waxy casts​
C) Elevated BUN​
D) Decreased urine output​
E) Presence of hypertension

Question 4

A 48-year-old woman is hospitalized for acute pancreatitis. On day 4, she develops decreased
urine output. Labs show:
 ●​ BUN: 68 mg/dL​

●​ Creatinine: 4.2 mg/dL​

●​ Urinalysis: Normal​
Renal ultrasound shows normal-sized kidneys with no hydronephrosis. Prior labs from 2
months ago were normal.​

What is the most likely diagnosis?

A) Acute kidney injury​

B) Chronic kidney disease​
C) Obstructive uropathy​
D) Nephrotic syndrome​
E) Renovascular hypertension

Question 5

A 59-year-old woman presents for routine follow-up. She has long-standing diabetes and
hypertension. She reports mild fatigue. Labs:

●​ BUN: 55 mg/dL​

●​ Creatinine: 4.8 mg/dL​

●​ Hemoglobin: 9.2 g/dL​

●​ Urinalysis: Proteinuria, no casts​

●​ Ultrasound: Kidneys measure 8.4 cm bilaterally​

Which feature best supports the diagnosis of chronic kidney disease?

A) Low hemoglobin​
B) Degree of proteinuria​
C) Bilateral kidney atrophy​
D) Presence of fatigue​
E) Elevated BUN and creatinine
Learning Objective B9LG1.2
"Discuss the metabolic and systemic consequences seen in patients who have
significant reductions in renal function, both in the acute and chronic phases."

Question 6

A 63-year-old man with known stage 4 CKD presents with nausea, pruritus, and confusion. Labs
show:

●​ BUN: 95 mg/dL​

●​ Creatinine: 6.3 mg/dL​

●​ Calcium: 7.6 mg/dL​

●​ Phosphate: 6.2 mg/dL​

●​ PTH: 480 pg/mL​

Which of the following best explains the patient’s metabolic abnormalities?​

A) Metabolic alkalosis from vomiting​

B) Secondary hyperparathyroidism due to phosphate retention​
C) Primary hypoparathyroidism due to low calcium​
D) Hyperphosphatemia due to increased GI absorption​
E) Vitamin D toxicity

Question 7

A 40-year-old woman is admitted with confusion and seizures. She had been receiving
gentamicin for a complicated UTI. Labs:

●​ Sodium: 138 mEq/L​

●​ Potassium: 6.9 mEq/L​

●​ BUN: 60 mg/dL​

●​ Creatinine: 5.2 mg/dL​

 ●​ ECG: Peaked T waves​
Which of the following metabolic abnormalities most likely accounts for her neurologic
symptoms?​

A) Hyponatremia​
B) Hypernatremia​
C) Hyperkalemia​
D) Hypocalcemia​
E) Hypermagnesemia

Question 8

A 71-year-old woman with CKD presents with bone pain and proximal muscle weakness. Labs:

●​ Calcium: 7.5 mg/dL​

●​ Phosphate: 5.6 mg/dL​

●​ PTH: 560 pg/mL​

●​ 25-hydroxyvitamin D: Low​
Which of the following long-term complications is most likely responsible for her
symptoms?​

A) Renal osteodystrophy​
B) Multiple myeloma​
C) Diabetic neuropathy​
D) Polymyalgia rheumatica​
E) Osteoarthritis

Question 9

A 58-year-old man with acute glomerulonephritis is hospitalized with oliguria and fluid overload.
Labs show:

●​ BUN: 84 mg/dL​

●​ Creatinine: 6.0 mg/dL​

 ●​ Sodium: 133 mEq/L​

●​ Potassium: 6.8 mEq/L​

●​ Arterial pH: 7.20​

Which of the following best describes his current metabolic state?​

A) Metabolic alkalosis with hypokalemia​

B) Respiratory acidosis with hyperkalemia​
C) High anion gap metabolic acidosis​
D) Normal anion gap metabolic acidosis​
E) Mixed metabolic and respiratory alkalosis

Question 10

A 67-year-old man with long-standing CKD is noted to have fatigue and exertional dyspnea.
Labs:

●​ Hemoglobin: 8.1 g/dL​

●​ MCV: 85 fL​

●​ Iron studies: Normal​

●​ Reticulocyte count: Low​

Which of the following is the most likely cause of this patient’s anemia?​

A) Folate deficiency​
B) Iron deficiency​
C) Erythropoietin deficiency​
D) Hemolysis due to uremia​
E) Gastrointestinal bleeding

Learning Objective B9LG1.3

"Describe the general approach to management of patients with acute renal failure and
chronic kidney disease, including non-pharmaceutical lifestyle approaches (e.g.,
avoidance of nephrotoxic agents, hydration, diet, etc.), basic pharmacologic
interventions, and renoprotective factors."
Question 11

A 58-year-old man with CKD stage 3 due to diabetic nephropathy presents for routine follow-up.
His BP is 144/86 mmHg, and he has mild peripheral edema. Labs show:

●​ Creatinine: 2.1 mg/dL​

●​ eGFR: 38 mL/min/1.73 m²​

●​ Urinalysis: Moderate proteinuria​

Which of the following interventions is most appropriate to slow progression of his
kidney disease?​

A) Begin thiazide diuretic therapy​

B) Start sodium bicarbonate supplementation​
C) Initiate ACE inhibitor therapy​
D) Restrict dietary potassium intake​
E) Start calcium channel blocker

Question 12

A 65-year-old woman with hypertension and osteoarthritis presents with rising creatinine over 2
weeks. She started using ibuprofen daily for joint pain 3 weeks ago. Labs show:

●​ BUN: 52 mg/dL​

●​ Creatinine: 3.8 mg/dL (baseline: 1.2)​

●​ Urinalysis: Bland sediment​

Which of the following is the most appropriate next step in management?​

A) Begin IV fluids and broad-spectrum antibiotics​

B) Switch from ibuprofen to acetaminophen​
C) Start prednisone for interstitial nephritis​
D) Order kidney biopsy​
E) Begin hemodialysis

Question 13
A 75-year-old man with CKD stage 4 due to hypertensive nephrosclerosis is counseled about
lifestyle changes. Which of the following dietary changes is most appropriate to reduce disease
progression?

A) Increase protein intake to prevent muscle loss​

B) Liberalize sodium to maintain blood pressure​
C) Restrict phosphorus-rich foods​
D) Increase fluid intake to 4 liters per day​
E) Avoid all dairy products

Question 14

A 70-year-old woman is admitted for community-acquired pneumonia. She has CKD stage 3
and is being treated with IV fluids and ceftriaxone. On day 2, vancomycin is added. What is the
most important step in preventing acute kidney injury?

A) Administer furosemide before vancomycin​

B) Add an ACE inhibitor to enhance renal perfusion​
C) Monitor vancomycin trough levels closely​
D) Increase protein intake during illness​
E) Discontinue ceftriaxone

Question 15

A 60-year-old man is evaluated for CKD management. He has proteinuria and an eGFR of 45
mL/min/1.73 m². Which of the following pharmacologic therapies has the greatest renoprotective
effect?

A) Statin​
B) Beta-blocker​
C) ACE inhibitor​
D) Loop diuretic​
E) Nitrate

Learning Objective B9LG1.4

"List the indications for urgent renal replacement therapy in the setting of acute renal
failure (AEIOU – acidosis, electrolytes, intoxications, overload, uremia)."
Question 16

A 68-year-old man is hospitalized with acute tubular necrosis following contrast exposure during
coronary angiography. On day 3 of admission, he becomes confused. Labs show:

●​ BUN: 105 mg/dL​

●​ Creatinine: 7.0 mg/dL​

●​ Serum bicarbonate: 13 mEq/L​

●​ Potassium: 6.5 mEq/L​

Despite IV fluids and medical management, his mental status worsens. What is the next
best step?​

A) Increase bicarbonate infusion​

B) Begin loop diuretic therapy​
C) Initiate urgent hemodialysis​
D) Administer calcium gluconate​
E) Perform kidney biopsy

Question 17

A 43-year-old woman is admitted for treatment of methanol ingestion. She is obtunded and
intubated. Labs show:

●​ pH: 7.01​

●​ Anion gap: 26​

●​ Osmolar gap: Elevated​

Which of the following is the most appropriate next step in management?​

A) Administer IV insulin​
B) Begin aggressive IV hydration​
C) Initiate emergent dialysis​
D) Administer oral bicarbonate​
E) Wait for methanol to be metabolized
Question 18

A 59-year-old man presents with progressive weakness and confusion. He has a history of CKD
and missed follow-up visits. Labs:

●​ Potassium: 7.2 mEq/L​

●​ ECG: Widened QRS and sine wave pattern​

●​ BUN: 96 mg/dL​

●​ Creatinine: 6.1 mg/dL​

Despite calcium gluconate, insulin, and glucose, potassium remains elevated. Which is
the next best step?​

A) Repeat insulin/glucose therapy​

B) Begin urgent dialysis​
C) Administer sodium bicarbonate​
D) Order a renal biopsy​
E) Increase oral sodium polystyrene sulfonate

Question 19

A 50-year-old man is admitted with rapidly progressive glomerulonephritis. Despite

corticosteroid therapy, he becomes oliguric and develops pulmonary edema and metabolic
acidosis. Which of the following is the most appropriate next step?

A) Increase diuretic dose​

B) Add IV cyclophosphamide​
C) Start urgent renal replacement therapy​
D) Administer albumin​
E) Order a bronchoscopy

Question 20

A 67-year-old woman with no prior history of kidney disease presents with severe nausea,
pericardial friction rub, and confusion. Labs show:

●​ BUN: 120 mg/dL​

 ●​ Creatinine: 6.5 mg/dL​

●​ pH: 7.12​

●​ Potassium: 6.6 mEq/L​

Which of the following best justifies initiation of dialysis in this patient?​

A) Severe volume overload​

B) High BUN alone​
C) Acidosis and uremic symptoms​
D) Hyperkalemia without ECG changes​
E) Stage 3 AKI diagnosis

Learning Objective B9LG1.5

"Briefly discuss the indications for renal replacement therapy in the setting of chronic
kidney disease."

Question 21

A 65-year-old woman with a history of diabetes and hypertension presents for evaluation of
worsening fatigue and poor appetite. She has CKD stage 5 and has not yet started dialysis.
Labs:

●​ BUN: 108 mg/dL​

●​ Creatinine: 7.3 mg/dL​

●​ Hemoglobin: 7.8 g/dL​

●​ Serum bicarbonate: 17 mEq/L​

●​ Potassium: 5.4 mEq/L​

She reports pruritus and trouble sleeping due to restless legs. Which of the following is
the most appropriate next step?​

A) Begin IV bicarbonate​
B) Start recombinant erythropoietin​
C) Initiate renal replacement therapy​
D) Administer phosphate binder​
E) Prescribe iron supplementation
Question 22

A 70-year-old man with long-standing CKD is seen for routine follow-up. He has not yet started
dialysis. Over the past month, he has developed worsening dyspnea and lower extremity
edema. Diuretics are no longer effective. CXR reveals pulmonary edema.​
Which of the following is the best next step?

A) Add thiazide diuretic​

B) Restrict dietary sodium and fluid​
C) Begin dialysis​
D) Increase loop diuretic dose​
E) Administer IV albumin

Question 23

A 63-year-old man with ESRD due to polycystic kidney disease has been managed medically.
Over the past several weeks, he has had poor appetite, weight loss, and increasing difficulty
concentrating. Labs show:

●​ BUN: 99 mg/dL​

●​ Creatinine: 6.8 mg/dL​

●​ Sodium: 140 mEq/L​

●​ Bicarbonate: 18 mEq/L​
Which of the following findings would most strongly indicate the need to initiate renal
replacement therapy?​

A) BUN > 80 mg/dL​

B) Symptomatic uremia​
C) Hypernatremia​
D) Low bicarbonate​
E) Polyuria

Question 24

A 52-year-old woman with stage 5 CKD due to lupus nephritis is evaluated for dialysis initiation.
She currently feels well, has no volume overload, and is normokalemic. Her labs show:
 ●​ BUN: 96 mg/dL​

●​ Creatinine: 8.0 mg/dL​

●​ eGFR: 9 mL/min/1.73 m²​

Which of the following best describes the timing of dialysis initiation in this patient?​

A) Start now due to eGFR < 10​

B) Wait until potassium is elevated​
C) Wait until creatinine > 10​
D) Start if she develops signs of uremia​
E) Initiate due to high BUN alone

Question 25

A 59-year-old man with ESRD managed conservatively presents with new-onset pericardial
chest pain and low-grade fever. He is tachycardic, and a friction rub is heard. Labs:

●​ BUN: 114 mg/dL​

●​ Creatinine: 8.2 mg/dL​

●​ Potassium: 5.8 mEq/L​

EKG: Normal sinus rhythm, low voltage.​
Which of the following is the most appropriate next step?​

A) NSAIDs for pericarditis​

B) Urgent pericardiocentesis​
C) Begin hemodialysis​
D) Repeat creatinine in 48 hours​
E) Steroids for autoimmune disease

Learning Objective B9LG2.1

"Identify, describe, and characterize each of the following genetic terms and be able to
predict how each can affect inheritance patterns: A) New mutations, B) Germline
mosaicism, C) Variable expression, D) Pleiotropy, E) Reduced penetrance, F)
Consanguinity, G) Epigenetics."
Question 26

A 2-year-old boy is diagnosed with achondroplasia. His parents are phenotypically normal, and
there is no family history of skeletal disorders. Genetic testing confirms a FGFR3 mutation.
Which of the following best explains the inheritance pattern in this patient?

A) Germline mosaicism​
B) Variable expression​
C) Pleiotropy​
D) De novo mutation​
E) Reduced penetrance

Question 27

A 4-year-old girl is diagnosed with a rare autosomal dominant syndrome affecting bone and skin
development. Her older brother died of the same disorder. Genetic testing of both parents is
negative. Which of the following best explains recurrence risk in future pregnancies?

A) Paternal uniparental disomy​

B) Reduced penetrance in the parents​
C) Germline mosaicism in a parent​
D) Somatic mosaicism in the child​
E) Epigenetic silencing of the gene

Question 28

A father and daughter are both diagnosed with neurofibromatosis type 1. The father has mild
café-au-lait spots only, while the daughter has multiple neurofibromas and optic gliomas. Which
of the following best explains this clinical observation?

A) Incomplete penetrance​
B) Variable expression​
C) Epigenetic modification​
D) Pleiotropy​
E) New mutation in daughter

Question 29
A mutation in the FBN1 gene causes Marfan syndrome, which is associated with tall stature,
lens dislocation, and aortic root dilation. Which genetic principle does this illustrate?

A) Germline mosaicism​
B) Epigenetics​
C) Variable expressivity​
D) Pleiotropy​
E) Consanguinity

Question 30

A couple has two children with an autosomal recessive disorder. They are first cousins. Genetic
counseling should emphasize which of the following concepts?

A) Epigenetic silencing​
B) Imprinting​
C) Pleiotropy​
D) Consanguinity​
E) Germline mosaicism

Learning Objective B9LG2.2

"Compare and contrast genetic heterogeneity and phenotypic diversity; and distinguish
between locus heterogeneity, double heterozygosity, allelic heterogeneity, and compound
heterozygosity."

Question 31

A 6-year-old boy is evaluated for developmental delay, ataxia, and muscle weakness. Genetic
testing reveals two different mutations in the same gene, one inherited from each parent. Which
of the following best describes this finding?

A) Allelic heterogeneity​
B) Locus heterogeneity​
C) Compound heterozygosity​
D) Variable penetrance​
E) Double heterozygosity

Question 32
Two unrelated families have children diagnosed with autosomal recessive hearing loss. In
Family A, mutations are found in the GJB2 gene, while in Family B, mutations are found in
SLC26A4. This best illustrates which of the following?

A) Allelic heterogeneity​
B) Compound heterozygosity​
C) Locus heterogeneity​
D) Phenotypic diversity​
E) Epigenetic regulation

Question 33

A patient with cystic fibrosis has one copy of the ΔF508 mutation and one copy of a different
mutation in the CFTR gene. Which of the following terms best describes this situation?

A) Double heterozygosity​
B) Locus heterogeneity​
C) Compound heterozygosity​
D) Genetic anticipation​
E) Epistasis

Question 34

A 4-year-old child is diagnosed with Leigh syndrome, a mitochondrial disorder. Genetic testing
reveals different causative mutations in two unrelated patients, one in a nuclear gene and one in
a mitochondrial gene. Which concept is best demonstrated?

A) Allelic heterogeneity​
B) Compound heterozygosity​
C) Locus heterogeneity​
D) Reduced penetrance​
E) Epigenetic modification

Question 35

Two siblings both have mutations in the NF1 gene but display vastly different phenotypes: one
has only skin findings while the other has CNS tumors and learning disability. What is the best
explanation for this variability?
A) Locus heterogeneity​
B) Incomplete penetrance​
C) Variable expression​
D) Epigenetic silencing​
E) Compound heterozygosity

Learning Objective B9LG2.3

"Describe the effects of imprinting and other contributing factors in diseases such as
Prader-Willi and Angelman syndromes, and differentiate between these two syndromes."

Question 36

A 2-year-old boy presents with hypotonia, poor feeding in infancy, delayed milestones, and now
shows signs of hyperphagia and obesity. Genetic testing reveals a deletion on chromosome 15
of paternal origin. What is the most likely diagnosis?

A) Angelman syndrome​
B) Fragile X syndrome​
C) Prader-Willi syndrome​
D) Rett syndrome​
E) Beckwith-Wiedemann syndrome

Question 37

A 5-year-old girl is evaluated for seizures, ataxia, and severe intellectual disability. She exhibits
frequent laughter and an unusually happy demeanor. Genetic testing reveals a maternal
deletion of 15q11–13. Which of the following best explains this condition?

A) Maternal uniparental disomy​

B) Paternal gene imprinting​
C) Maternal gene imprinting​
D) Paternal deletion​
E) Random X-inactivation

Question 38
Which of the following mechanisms can result in both Prader-Willi syndrome and Angelman
syndrome depending on the parent of origin?

A) Trisomy rescue​
B) Random mutation in mitochondrial DNA​
C) Maternal X-inactivation​
D) Chromosomal translocation​
E) Autosomal dominant inheritance

Question 39

A newborn is found to have Prader-Willi syndrome. Genetic studies show both copies of
chromosome 15 were inherited from the mother. Which of the following is the most likely
mechanism?

A) Paternal deletion​
B) Angelman gene mutation​
C) Uniparental disomy​
D) Epigenetic silencing of maternal genes​
E) Random X-inactivation

Question 40

Angelman syndrome most commonly results from deletion of a region of chromosome 15

inherited from the mother. What gene is typically involved in this deletion?

A) MECP2​
B) FMR1​
C) TSC1​
D) UBE3A​
E) GNAS

Learning Objective B9LG2.4

"Describe the genetic mechanisms which result in uniparental disomy and how
uniparental disomy can be associated with clinically relevant phenotypes."

Question 41
A newborn with hypotonia and poor feeding is diagnosed with Prader-Willi syndrome. Genetic
testing reveals two maternal copies of chromosome 15 and no paternal copy. What is the most
likely mechanism responsible for this finding?

A) Paternal deletion​
B) Trisomy rescue leading to maternal uniparental disomy​
C) Meiotic nondisjunction of chromosome X​
D) Mutation in UBE3A​
E) Genomic imprinting of maternal genes

Question 42

A 3-year-old boy presents with developmental delay and behavioral issues. Genetic testing
shows that he has two paternal copies of chromosome 15. What syndrome is most likely to
result from this genetic pattern?

A) Angelman syndrome​
B) Prader-Willi syndrome​
C) Beckwith-Wiedemann syndrome​
D) Rett syndrome​
E) Smith-Magenis syndrome

Question 43

Which of the following best describes the molecular mechanism underlying most cases of
uniparental disomy?

A) Robertsonian translocation during meiosis I​

B) Chromosomal nondisjunction during mitosis​
C) Rescue of a trisomic zygote resulting in isodisomy or heterodisomy​
D) De novo mutation in imprinted gene​
E) Epigenetic reprogramming after fertilization

Question 44

Uniparental disomy of chromosome 11p15 has been implicated in which of the following
congenital disorders?

A) Angelman syndrome​
B) Prader-Willi syndrome​
C) Silver-Russell syndrome​
D) Beckwith-Wiedemann syndrome​
E) Williams syndrome

Question 45

Which of the following best explains why uniparental disomy may lead to a genetic disorder?

A) It increases the number of sex chromosomes​

B) It activates oncogenes​
C) It unmasks autosomal recessive mutations or disrupts imprinting​
D) It introduces additional methylation sites​
E) It alters nuclear-cytoplasmic signaling

Learning Objective B9LG2.5

"Characterize trinucleotide repeat expansions and how this dynamic mutation relates to
delayed age of onset and anticipation in diseases such as Huntington Disease, Friedreich
Ataxia, Myotonic Dystrophy, and Fragile-X."

Question 46

A 42-year-old man presents with progressive choreiform movements and personality changes.
His father died of a similar condition in his 60s. Genetic testing reveals >40 CAG repeats in the
HTT gene. Which of the following terms best explains the earlier onset in the son?

A) Genomic imprinting​
B) Allelic heterogeneity​
C) Anticipation​
D) Mosaicism​
E) Variable penetrance

Question 47

A child with developmental delay and autistic behaviors is found to have large ears,
macroorchidism, and a long face. Genetic testing shows CGG trinucleotide repeat expansion on
the X chromosome. What is the most likely diagnosis?
A) Rett syndrome​
B) Fragile X syndrome​
C) Angelman syndrome​
D) Myotonic dystrophy​
E) Huntington disease

Question 48

Which of the following trinucleotide repeat disorders is inherited in an autosomal dominant

fashion and typically presents with muscle weakness, cataracts, and myotonia?

A) Friedreich ataxia​
B) Fragile X syndrome​
C) Myotonic dystrophy​
D) Rett syndrome​
E) Huntington disease

Question 49

A 10-year-old girl is diagnosed with Friedreich ataxia. She has progressive gait ataxia,
dysarthria, and scoliosis. Which of the following trinucleotide repeat expansions is most likely
present?

A) CAG​
B) CGG​
C) GAA​
D) CTG​
E) CCG

Question 50

Which of the following best describes why disorders caused by trinucleotide repeat expansions
often show increasing severity and earlier onset in successive generations?

A) Accumulation of DNA methylation​

B) Gradual decrease in protein levels​
C) Expansion of unstable repeats during gametogenesis​
D) Increasing homozygosity with inbreeding​
E) Deletion of regulatory gene sequences
LG LO Answers

B9LG1.1: Distinguishing AKI vs CKD

1.​ C. Chronic kidney disease​
Chronic symptoms, anemia, small echogenic kidneys.​

2.​ D. Kidney size on imaging​

CKD → small kidneys; AKI → normal size.​

3.​ B. Broad waxy casts​

Typical of CKD (tubular atrophy).​

4.​ A. Acute kidney injury​

Sudden rise in creatinine during hospitalization.​

5.​ C. Bilateral kidney atrophy​

Suggests chronic, irreversible damage.​

B9LG1.2: Metabolic/Systemic Effects of ↓ Renal Function

6.​ B. Secondary hyperparathyroidism due to phosphate retention​
CKD → hyperphosphatemia → ↑ PTH.​

7.​ C. Hyperkalemia​
Can cause seizures, ECG changes.​

8.​ A. Renal osteodystrophy​

Low Ca²⁺, high PO₄³⁻, ↑ PTH → bone disease.​

9.​ C. High anion gap metabolic acidosis​

From uremia (retained organic acids).​
 10.​C. Erythropoietin deficiency​
CKD → normocytic anemia.​

B9LG1.3: General CKD/AKI Management

11.​C. Initiate ACE inhibitor therapy​
Slows CKD progression, reduces proteinuria.​

12.​B. Switch from ibuprofen to acetaminophen​

NSAIDs → pre-renal or ATN.​

13.​C. Restrict phosphorus-rich foods​

To prevent mineral bone disease.​

14.​C. Monitor vancomycin trough levels closely​

Avoid nephrotoxicity in CKD.​

15.​C. ACE inhibitor​

Most renoprotective, especially with proteinuria.​

B9LG1.4: Urgent RRT (AEIOU)

16.​C. Initiate urgent hemodialysis​
Uremia + acidosis + hyperkalemia.​

17.​C. Initiate emergent dialysis​

Methanol → dialysis indicated.​

18.​B. Begin urgent dialysis​

Refractory hyperkalemia with ECG changes.​

19.​C. Start urgent renal replacement therapy​

Volume overload, acidosis despite therapy.​

20.​C. Acidosis and uremic symptoms​

Classic indications for dialysis.​
B9LG1.5: RRT in CKD
21.​C. Initiate renal replacement therapy​
Uremic symptoms = start dialysis.​

22.​C. Begin dialysis​

Volume overload refractory to diuretics.​

23.​B. Symptomatic uremia​

Indication for RRT even if labs not extreme.​

24.​D. Start if she develops signs of uremia​

eGFR alone is not sufficient.​

25.​C. Begin hemodialysis​

Uremic pericarditis = dialysis.​

B9LG2.1: Genetic Terms

26.​D. De novo mutation​
Classic in achondroplasia (FGFR3).​

27.​C. Germline mosaicism in a parent​

Explains recurrence without parental phenotype.​

28.​B. Variable expression​

Different severity with same mutation.​

29.​D. Pleiotropy​
One gene → multiple effects (FBN1 → skeletal, ocular, cardiac).​

30.​D. Consanguinity​
Increased risk of autosomal recessive disorders.​

B9LG2.2: Genetic Heterogeneity

 31.​C. Compound heterozygosity​
Two different mutations in the same gene.​

32.​C. Locus heterogeneity​

Same disease from different genes.​

33.​C. Compound heterozygosity​

Common in CFTR-related disorders.​

34.​C. Locus heterogeneity​

Same phenotype, mutations in nuclear vs mitochondrial genes.​

35.​C. Variable expression​

Different phenotypes from the same NF1 gene.​

B9LG2.3: Imprinting — PWS & AS

36.​C. Prader-Willi syndrome​
Paternal deletion on chr15.​

37.​B. Paternal gene imprinting​

Maternal deletion = Angelman.​

38.​A. Trisomy rescue​

Can lead to uniparental disomy (maternal or paternal).​

39.​C. Uniparental disomy​

Two maternal copies → PWS.​

40.​D. UBE3A​
Loss of maternal UBE3A = Angelman.​

B9LG2.4: Uniparental Disomy

41.​B. Trisomy rescue leading to maternal uniparental disomy​
Mechanism in PWS.​
 42.​A. Angelman syndrome​
Loss of maternal expression.​

43.​C. Rescue of a trisomic zygote resulting in isodisomy or heterodisomy​

Most common mechanism.​

44.​D. Beckwith-Wiedemann syndrome​

Paternal uniparental disomy of 11p15.​

45.​C. It unmasks autosomal recessive mutations or disrupts imprinting​

Pathogenic basis of UPD.​

B9LG2.5: Trinucleotide Repeats

46.​C. Anticipation​
Earlier onset due to more repeats in each generation.​

47.​B. Fragile X syndrome​

CGG expansion on FMR1.​

48.​C. Myotonic dystrophy​

Autosomal dominant; CTG repeat.​

49.​C. GAA​
Friedreich ataxia = GAA repeat.​

50.​C. Expansion of unstable repeats during gametogenesis​

Mechanism of anticipation.​

Structure LO Questions

B9S.1 – Histopathologic changes in myocarditis

Question 1

A 22-year-old previously healthy man presents with acute-onset chest pain, dyspnea, and
palpitations. He reports having a "bad cold" with fever and myalgias 10 days ago. ECG shows
nonspecific ST-T wave changes, and cardiac biomarkers are mildly elevated. A myocardial
biopsy is performed. Which of the following histopathologic findings is most likely present?
A) Coagulative necrosis with wavy myocardial fibers and neutrophilic infiltration​
B) Fibrinoid necrosis with eosinophilic infiltration and granuloma formation​
C) Interstitial lymphocytic infiltrates with focal myocyte necrosis​
D) Neutrophilic infiltrates with hypercontraction of myofibrils​
E) Noncaseating granulomas with multinucleated giant cells

Question 2

A 17-year-old male is hospitalized for heart failure symptoms following a viral illness. Cardiac
MRI shows myocardial edema and late gadolinium enhancement. Endomyocardial biopsy
confirms the diagnosis. Which of the following best correlates the histopathologic findings to his
clinical condition?

A) Fibrosis of the conduction system leading to bradyarrhythmias​

B) Myocyte disarray and concentric hypertrophy causing impaired relaxation​
C) Lymphocytic infiltrate causing direct cytotoxic injury to myocytes​
D) Neutrophilic infiltration triggering extensive coagulative necrosis​
E) Subendocardial ischemia causing contraction band necrosis

Question 3

A 25-year-old woman with no past medical history presents with fatigue, orthopnea, and lower
extremity edema. Cardiac workup reveals dilated cardiomyopathy with reduced ejection fraction.
Endomyocardial biopsy shows extensive interstitial lymphocytic infiltration and myocyte
necrosis. Which of the following pathogens is most commonly associated with this condition?

A) Coxsackievirus B​
B) Epstein-Barr virus​
C) Corynebacterium diphtheriae​
D) Parvovirus B19​
E) Trypanosoma cruzi

Question 4

A 32-year-old male dies suddenly after reporting chest discomfort and palpitations for several
days. Autopsy reveals patchy myocardial necrosis with mononuclear infiltrates, predominantly
lymphocytes. There is no evidence of coronary artery disease. Which of the following is the
most likely cause of death?
A) Ventricular arrhythmia due to myocardial inflammation​
B) Aortic dissection due to medial degeneration​
C) Pulmonary embolism secondary to deep vein thrombosis​
D) Cardiac tamponade from a ruptured myocardial wall​
E) Myocardial infarction from thrombotic coronary occlusion

Question 5

A 16-year-old boy with recent influenza-like symptoms presents with syncope. ECG reveals a
high-grade AV block. Echocardiogram shows reduced ejection fraction with global hypokinesis.
Which of the following histological changes most likely explains the conduction abnormality?

A) Neutrophilic infiltration of the AV node with myocyte necrosis​

B) Myocyte hypertrophy with concentric fibrosis​
C) Lymphocytic infiltration targeting conduction tissue​
D) Focal granulomatous inflammation with Langhans giant cells​
E) Interstitial amyloid deposits in the septal myocardium

Learning Objective B9S.2: Discuss pericarditis and

pericardial effusion concerning the anatomy of the
pericardium and heart.

B9S.2 – Pericarditis, pericardial effusion, and pericardial

anatomy
Question 6

A 48-year-old man presents to the ED with sharp, pleuritic chest pain that improves when sitting
forward. On auscultation, a friction rub is heard. ECG shows widespread ST-segment
elevations. Which of the following anatomic structures is most directly inflamed?

A) Parietal layer of the serous pericardium​

B) Visceral layer of the fibrous pericardium​
C) Myocardial interstitium​
D) Endocardium of the left ventricle​
E) Adventitia of the great vessels
Question 7

A 65-year-old man with metastatic lung cancer presents with dyspnea and hypotension. He has
jugular venous distension, muffled heart sounds, and pulsus paradoxus. Echocardiography
shows a large pericardial effusion. Which of the following best explains the pathophysiology of
his current condition?

A) External compression of the coronary arteries causing myocardial ischemia​

B) Excessive preload causing biventricular volume overload​
C) Equalization of diastolic pressures due to pericardial pressure elevation​
D) Right ventricular hypertrophy impairing left-sided filling​
E) Obstruction of pulmonary venous return leading to pulmonary edema

Question 8

A 55-year-old woman is undergoing pericardiocentesis for a large pericardial effusion. The

physician inserts the needle below the xiphoid process and advances it toward the left shoulder.
Which of the following anatomical relationships is most important in avoiding injury during this
procedure?

A) The pericardial cavity lies posterior to the parietal pleura​

B) The phrenic nerve runs posterior to the fibrous pericardium​
C) The pericardial space lies between the myocardium and endocardium​
D) The internal thoracic artery runs lateral to the pericardial sac​
E) The pericardial cavity lies between the visceral and parietal serous layers

Question 9

A 60-year-old man is diagnosed with uremic pericarditis. He reports chest pain and low-grade
fever. On exam, a pericardial rub is auscultated. Which of the following best explains why this
condition produces referred pain to the neck and shoulder?

A) Involvement of the vagus nerve supplying the epicardium​

B) Compression of the brachial plexus by the pericardial sac​
C) Inflammation of the fibrous pericardium innervated by the phrenic nerve​
D) Direct extension of inflammation to the cervical spinal nerves​
E) Myocardial ischemia involving sensory nerves in the endocardium

Question 10
A 70-year-old man with known hypothyroidism presents with progressive fatigue and shortness
of breath. Examination reveals distant heart sounds. Echocardiography shows a large
pericardial effusion without signs of tamponade. Which anatomical feature allows chronic
pericardial effusions to remain asymptomatic longer than acute ones?

A) Visceral pericardium dilates to accommodate fluid accumulation​

B) Parietal pleura absorbs excess pericardial fluid​
C) Fibrous pericardium stretches slowly over time​
D) Myocardial compliance increases with slow fluid accumulation​
E) Pericardial sinuses drain excess fluid to thoracic duct

B9S.3 – Roles of Pneumocytes in Normal Lungs and

ARDS
Question 11

A 33-year-old man develops acute respiratory failure following severe sepsis. Imaging reveals
bilateral pulmonary infiltrates. Histopathologic examination of alveolar tissue shows diffuse
alveolar damage with hyaline membrane formation. Which of the following best explains the
impaired gas exchange in this patient?

A) Destruction of alveolar macrophages leading to impaired ventilation​

B) Inactivation of club cells leading to mucous hypersecretion​
C) Injury to type I pneumocytes reducing surface area for diffusion​
D) Increased elastase activity leading to emphysematous destruction​
E) Overproduction of surfactant by type II pneumocytes causing alveolar flooding

Question 12

A 40-year-old man presents with progressive dyspnea and hypoxemia after aspiration
pneumonia. CT reveals bilateral ground-glass opacities. Biopsy shows type II pneumocyte
hyperplasia. What is the most likely role of these cells in the repair process?

A) Phagocytosis of alveolar debris​

B) Reepithelialization of damaged alveolar surfaces​
C) Vasodilation of alveolar capillaries​
D) Activation of fibroblasts for collagen deposition​
E) Mediation of pulmonary vasoconstriction

Question 13
A 58-year-old woman with pancreatitis develops severe hypoxemia. ABG shows PaO₂/FiO₂ =
110 mm Hg. Bronchoalveolar lavage reveals proteinaceous fluid and necrotic epithelial cells.
Which of the following best explains her decreased lung compliance?

A) Enhanced mucociliary clearance​

B) Surfactant deficiency from damaged type II pneumocytes​
C) Decreased tight junction integrity in bronchial epithelium​
D) Reduced blood-air barrier thickness​
E) Compensatory hyperplasia of type I pneumocytes

Question 14

A 19-year-old man with ARDS is undergoing mechanical ventilation. Alveolar biopsies show
protein-rich exudate and cellular debris within the alveoli, impairing oxygen diffusion. Which of
the following cellular components of the alveolar wall is most directly disrupted in this condition?

A) Ciliated epithelial cells​

B) Club cells​
C) Type I pneumocytes​
D) Pulmonary capillary pericytes​
E) Goblet cells

Question 15

A 45-year-old man has ARDS following a massive transfusion after trauma. He remains
hypoxemic despite supplemental oxygen. Which of the following best explains the persistence
of hypoxemia?

A) Pulmonary embolism from blood products​

B) Increased dead space ventilation​
C) High-output cardiac failure​
D) Right-to-left intrapulmonary shunting​
E) Hemoglobin dissociation curve shift

B9S.4 – Radiographic Appearance of Pulmonary and

Cardiac Pathologies
Question 16
A 72-year-old man presents with worsening dyspnea and orthopnea. Chest x-ray reveals an
enlarged cardiac silhouette, bilateral pleural effusions, and Kerley B lines. What is the most
likely diagnosis?

A) Acute respiratory distress syndrome​

B) Pulmonary embolism​
C) Cardiogenic pulmonary edema​
D) Noncardiogenic pulmonary edema​
E) Pneumothorax

Question 17

A 60-year-old woman presents with hypoxemia after recent sepsis. Chest x-ray reveals diffuse
bilateral ground-glass opacities, predominantly in the peripheral lung fields, without
cardiomegaly or pleural effusions. Which of the following best explains the findings?

A) Pulmonary edema due to congestive heart failure​

B) Diffuse alveolar damage consistent with ARDS​
C) Bronchopneumonia from aspiration​
D) Massive pulmonary embolism​
E) Interstitial fibrosis

Question 18

A 50-year-old man presents with acute dyspnea. Chest x-ray shows bilateral alveolar infiltrates
with a central “bat-wing” distribution and an enlarged cardiac silhouette. BNP is 950 pg/mL.
Which radiographic feature best supports a diagnosis of cardiogenic pulmonary edema?

A) Patchy peripheral opacities​

B) Cephalization of pulmonary vessels​
C) Absence of pleural effusions​
D) Hyperinflation with flattened diaphragms​
E) Reticulonodular infiltrates in upper lobes

Question 19

A 38-year-old man with blunt chest trauma develops acute dyspnea and hypoxemia. Chest
imaging reveals bilateral pulmonary infiltrates and normal heart size. What radiographic pattern
most reliably distinguishes ARDS from cardiogenic pulmonary edema?
A) Presence of cardiomegaly​
B) Symmetrical interstitial thickening​
C) Peripheral rather than central infiltrates​
D) Prominent pulmonary vessels​
E) Bilateral pleural effusions

Question 20

A 66-year-old woman is admitted with fever and productive cough. Chest x-ray shows a lobar
consolidation with air bronchograms. Which of the following findings would most clearly
distinguish this condition from congestive heart failure?

A) Enlarged heart silhouette​

B) Ground-glass opacities​
C) Kerley B lines​
D) Focal opacity limited to a single lobe​
E) Bilateral perihilar haze

B9S.5 – Histopathologic Changes in ARDS, COPD,

Pulmonary Hypertension, and Restrictive Lung Disease
Question 21

A 36-year-old man develops progressive dyspnea following pancreatitis. Lung biopsy shows
alveolar septal thickening, interstitial edema, and eosinophilic hyaline membranes lining alveolar
spaces. Which of the following best describes the histopathologic process?

A) Interstitial lymphocytic infiltration with fibroblast proliferation​

B) Diffuse alveolar damage with exudative phase changes​
C) Necrotizing granulomatous inflammation with vasculitis​
D) Emphysematous destruction of alveolar walls​
E) Mucous gland hyperplasia with goblet cell metaplasia

Question 22

A 65-year-old man with a 40-pack-year smoking history presents with chronic cough and
dyspnea. Lung biopsy shows dilated airspaces, destruction of alveolar septa, and reduced
capillary bed density. Which of the following is the most likely diagnosis?
A) ARDS​
B) Chronic bronchitis​
C) Idiopathic pulmonary fibrosis​
D) Centriacinar emphysema​
E) Pulmonary hypertension

Question 23

A 70-year-old woman with progressive dyspnea and dry cough undergoes lung biopsy.
Histology reveals fibroblastic foci and patchy interstitial fibrosis with honeycombing. Which of the
following is the most likely diagnosis?

A) Hypersensitivity pneumonitis​
B) Usual interstitial pneumonia (UIP)​
C) Chronic bronchitis​
D) Diffuse alveolar damage​
E) Pulmonary alveolar proteinosis

Question 24

A 52-year-old man presents with signs of right heart failure. A lung biopsy reveals medial
hypertrophy and intimal proliferation of pulmonary arteries without evidence of thrombosis.
Which of the following conditions most likely explains these findings?

A) Idiopathic pulmonary hypertension​

B) ARDS​
C) Emphysema​
D) Chronic thromboembolic disease​
E) Bronchiectasis

Question 25

A 30-year-old man presents with progressive exertional dyspnea. High-resolution CT shows

reticulonodular infiltrates, and biopsy reveals chronic inflammation with noncaseating
granulomas and interstitial fibrosis. Which of the following is the most likely diagnosis?

A) Sarcoidosis​
B) ARDS​
C) Emphysema​
D) Diffuse alveolar hemorrhage​
E) Bronchial asthma

Structure LO Answers

B9S.1 – Myocarditis: Histopathologic Changes

1.​ C – Interstitial lymphocytic infiltrates with focal myocyte necrosis​
→ Hallmark of viral myocarditis.​

2.​ C – Lymphocytic infiltrate causing direct cytotoxic injury to myocytes​

→ Explains heart failure and arrhythmias due to inflammation.​

3.​ A – Coxsackievirus B​
→ Most common viral cause of myocarditis.​

4.​ A – Ventricular arrhythmia due to myocardial inflammation​

→ Common cause of sudden death in young adults with myocarditis.​

5.​ C – Lymphocytic infiltration targeting conduction tissue​

→ Explains high-grade AV block in myocarditis.​

B9S.2 – Pericarditis and Pericardial Effusion Anatomy

6.​ A – Parietal layer of the serous pericardium​
→ Pain-sensitive layer inflamed in pericarditis.​

7.​ C – Equalization of diastolic pressures due to pericardial pressure elevation​

→ Defines cardiac tamponade pathophysiology.​

8.​ E – The pericardial cavity lies between the visceral and parietal serous layers​
→ Anatomical space accessed during pericardiocentesis.​

9.​ C – Inflammation of the fibrous pericardium innervated by the phrenic nerve​

→ Explains referred shoulder pain.​

10.​C – Fibrous pericardium stretches slowly over time​

→ Allows large chronic effusions to remain asymptomatic.​
B9S.3 – Pneumocytes in Gas Exchange and ARDS
11.​C – Injury to type I pneumocytes reducing surface area for diffusion​
→ Major mechanism of impaired gas exchange in ARDS.​

12.​B – Reepithelialization of damaged alveolar surfaces​

→ Type II pneumocytes regenerate alveolar lining.​

13.​B – Surfactant deficiency from damaged type II pneumocytes​

→ Leads to decreased lung compliance in ARDS.​

14.​C – Type I pneumocytes​

→ Flattened cells responsible for gas exchange, damaged in ARDS.​

15.​D – Right-to-left intrapulmonary shunting​

→ Oxygen cannot reach alveoli, causing refractory hypoxemia.​

B9S.4 – Radiographic Findings: Pulmonary vs. Cardiac

16.​C – Cardiogenic pulmonary edema​
→ Kerley B lines, cardiomegaly, and pleural effusions are classic findings.​

17.​B – Diffuse alveolar damage consistent with ARDS​

→ Bilateral peripheral opacities with normal heart size.​

18.​B – Cephalization of pulmonary vessels​

→ Sign of elevated left heart pressures in cardiogenic edema.​

19.​C – Peripheral rather than central infiltrates​

→ Helps differentiate ARDS (peripheral) from cardiogenic causes.​

20.​D – Focal opacity limited to a single lobe​

→ Lobar pneumonia is localized, unlike CHF which is diffuse.​
B9S.5 – Histopathology of ARDS, COPD, PH, Restrictive
Lung Disease
21.​B – Diffuse alveolar damage with exudative phase changes​
→ Hyaline membranes and interstitial edema = ARDS.​

22.​D – Centriacinar emphysema​

→ Smoking-related, upper lobe–predominant alveolar destruction.​

23.​B – Usual interstitial pneumonia (UIP)​

→ Patchy fibrosis, fibroblastic foci, and honeycombing = IPF.​

24.​A – Idiopathic pulmonary hypertension​

→ Shows vascular remodeling (medial hypertrophy, intimal proliferation).​

25.​A – Sarcoidosis​
→ Noncaseating granulomas with interstitial fibrosis.

CBL LO Questions

LO B9A1: Explain the pathophysiology of type 1 and 2

diabetes

Question 1

A 12-year-old boy is brought to the ED with 2 weeks of polyuria, polydipsia, and unintentional
weight loss. On exam, he is thin, lethargic, and tachypneic. His labs reveal:

●​ Glucose: 432 mg/dL​

●​ pH: 7.22​

●​ HCO₃⁻: 13 mEq/L​

●​ Positive urine ketones​

Which of the following best explains the underlying pathophysiology of this patient's condition?

A. Autoimmune destruction of pancreatic β-cells leading to absolute insulin deficiency​

B. Peripheral insulin resistance due to adipokine dysregulation​
C. Excess glucagon secretion due to α-cell hyperplasia​
D. Impaired GLUT4 translocation in muscle and adipose tissue​
E. Decreased incretin effect in the gastrointestinal tract

Question 2

A 52-year-old obese woman is diagnosed with type 2 diabetes mellitus. Fasting glucose is 168
mg/dL, and HbA1c is 8.2%. Which of the following most accurately describes the initial
abnormality in glucose metabolism in this condition?

A. Autoimmune lymphocytic infiltration of the pancreas​

B. Inappropriate hepatic glucose production​
C. Deficiency of insulin production​
D. Resistance of peripheral tissues to insulin​
E. Loss of pancreatic α-cell function

Question 3

A 16-year-old boy is found unresponsive at home. He has no past medical history but was
recently experiencing excessive thirst and frequent urination. Vitals: T 36.9°C, HR 118, RR 30,
BP 100/65. Labs:

●​ Glucose: 510 mg/dL​

●​ Serum bicarbonate: 9 mEq/L​

●​ Serum ketones: positive​

●​ Anion gap: 25​

Which of the following immune processes is most directly implicated in this patient’s
disease?​

A. CD4+ T-cell mediated destruction of pancreatic α-cells​

B. Antibody-mediated inhibition of insulin receptor signaling​
C. CD8+ T-cell destruction of β-cells in pancreatic islets​
D. Formation of islet amyloid polypeptide deposits​
E. Molecular mimicry involving thyroid and pancreatic antigens
Question 4

A 60-year-old man with a BMI of 33 kg/m² has a fasting blood glucose of 142 mg/dL and an
HbA1c of 7.5%. He has no ketones in urine. Which of the following mechanisms contributes
most to hyperglycemia in this patient?

A. Destruction of pancreatic β-cells via islet autoantibodies​

B. Increased hepatic glucose output and reduced insulin sensitivity​
C. Decreased renal glucose reabsorption​
D. Mutations in insulin receptor gene​
E. Overactivity of GLUT2 transporters in hepatocytes

Question 5

A 10-year-old girl with type 1 diabetes is started on insulin therapy. Her parents ask what
caused her condition. Which of the following best describes the role of genetic and
environmental factors in this disease?

A. It results solely from environmental triggers such as diet​

B. Genetic defects in the insulin gene are the primary cause​
C. It is due to autoimmunity influenced by HLA genotypes and environmental factors​
D. It is caused by chromosomal deletion affecting pancreatic development​
E. It arises from inherited mutations in the glucokinase gene

LO B9A2: Explain the pathophysiologic basis of

metabolic syndrome and insulin resistance and the
progression from pre-diabetes to diabetes and finally end
stage diabetes

Question 6

A 47-year-old woman presents for a wellness exam. She has abdominal obesity, hypertension,
and a fasting glucose of 110 mg/dL. Labs show triglycerides of 210 mg/dL and HDL of 35
mg/dL. Which of the following pathophysiologic processes best explains the metabolic changes
in this patient?
A. Excess hepatic glycogen storage​
B. Enhanced sensitivity to insulin at adipose tissue​
C. Increased free fatty acid release leading to insulin resistance​
D. Activation of the TCA cycle in skeletal muscle​
E. Defective leptin production in the hypothalamus

Question 7

A 55-year-old man with long-standing type 2 diabetes presents with worsening neuropathy and
retinopathy. Despite insulin therapy, his HbA1c remains 9.2%. Which of the following most likely
contributed to progression from insulin resistance to β-cell failure?

A. Chronic ketosis due to hepatic lipogenesis​

B. Loss of incretin-mediated insulin release​
C. Lipotoxicity and glucotoxicity impairing β-cell function​
D. Recurrent pancreatitis causing islet necrosis​
E. Autoimmune destruction of pancreatic islets

Question 8

A 50-year-old woman with a BMI of 36 kg/m² and sedentary lifestyle has fasting glucose of 120
mg/dL and 2-hour postprandial glucose of 165 mg/dL. Which of the following best characterizes
this stage of her disease?

A. Normal glucose tolerance​

B. Impaired glucose tolerance consistent with prediabetes​
C. Early type 2 diabetes mellitus​
D. Ketoacidosis​
E. Euglycemic hyperinsulinemia

Question 9

A 60-year-old man with poorly controlled type 2 diabetes has increasing proteinuria and an
eGFR of 28 mL/min/1.73m². Which of the following best describes the pathophysiology of this
patient’s progression to end-stage diabetes?

A. Autoimmune β-cell destruction and islet fibrosis​

B. Progressive insulin resistance with hepatic steatosis​
C. Advanced glycation end-product (AGE) accumulation causing end-organ damage​
D. Increased renal ammoniagenesis leading to acidosis​
E. Lipid-mediated inhibition of insulin secretion

Question 10

A 45-year-old woman with central obesity, hypertension, and elevated fasting insulin is found to
have elevated serum triglycerides and low HDL. Which of the following best describes the
primary defect leading to her metabolic syndrome?

A. Primary pancreatic β-cell apoptosis​

B. Central leptin overexpression​
C. Systemic inflammation and impaired insulin signaling​
D. Autoimmune attack on adipocytes​
E. Decreased hepatic glucose production

LO B9A3: Explain how chronic hyperglycemia leads to

micro and macrovascular complications in patients with
diabetes and describe recommended screenings to help
mitigate them

Question 11

A 61-year-old man with a 12-year history of type 2 diabetes presents for routine follow-up. He
reports no visual complaints or foot pain. Blood pressure is 142/88 mmHg. His last HbA1c was
8.3%. Which of the following screening tests should be performed annually to evaluate for
diabetic microvascular complications?

A. BNP measurement​
B. Ankle-brachial index​
C. Retinal examination​
D. Coronary calcium scoring​
E. Liver ultrasound

Question 12
A 56-year-old woman with poorly controlled diabetes presents with gradual vision loss.
Fundoscopic exam reveals microaneurysms and cotton wool spots. Which of the following best
describes the underlying pathophysiology of this complication?

A. Osmotic injury from glucose-induced lens swelling​

B. Non-enzymatic glycation causing basement membrane thickening​
C. Amyloid deposition in retinal vessels​
D. Chronic hypertension causing retinal detachment​
E. Arteriolar vasospasm leading to ischemia

Question 13

A 45-year-old man with type 2 diabetes and no known cardiovascular disease has a normal
physical exam. Which of the following is recommended for cardiovascular screening in this
asymptomatic patient?

A. Annual echocardiogram​
B. Cardiac stress testing every 2 years​
C. Lipid panel at diagnosis and every 5 years if < 40​
D. Coronary angiography​
E. BNP level every 6 months

Question 14

A 65-year-old man with long-standing diabetes, diabetic foot ulcers, and CKD presents for
evaluation. Which of the following vascular tests is recommended to assess for macrovascular
complications?

A. Troponin I level​
B. Carotid duplex ultrasound​
C. Ankle-brachial index​
D. Coronary calcium score​
E. 24-hour ambulatory blood pressure monitoring

Question 15

A 58-year-old woman with type 2 diabetes presents for follow-up. Urinalysis shows a spot
albumin-to-creatinine ratio of 75 mg/g. Serum creatinine is mildly elevated. Which of the
following best explains the mechanism of this diabetic complication?
A. Podocyte apoptosis due to immune complex deposition​
B. Progressive afferent arteriole vasoconstriction​
C. Non-enzymatic glycation of the glomerular basement membrane​
D. Acute tubular necrosis due to ischemia​
E. Immune-mediated destruction of the nephron

LO B9A5: Describe the pathophysiology of nodular

glomerulosclerosis (Kimmelstiel-Wilson lesion)

Question 16

A 63-year-old man with a 15-year history of poorly controlled type 2 diabetes is found to have
proteinuria and declining renal function. Kidney biopsy reveals nodular mesangial matrix
expansion. Which of the following is most consistent with the underlying mechanism of this
lesion?

A. Amyloid deposition in the glomeruli​

B. Lipid accumulation due to hypertriglyceridemia​
C. Non-enzymatic glycation of mesangial proteins​
D. Immune complex deposition in the mesangium​
E. Direct toxic effect of insulin on mesangial cells

Question 17

A kidney biopsy from a diabetic patient reveals nodular glomerulosclerosis. Which of the
following best describes this histopathologic finding?

A. Hyaline arteriosclerosis of efferent arterioles​

B. Sclerosis of juxtaglomerular cells​
C. PAS-positive spherical lesions in the mesangium​
D. Fibrinoid necrosis of glomerular capillaries​
E. Subepithelial immune complex deposits

Question 18

In the development of diabetic nephropathy, Kimmelstiel-Wilson nodules result primarily from

which of the following processes?
A. Glomerular basement membrane thinning​
B. Podocyte loss and epithelial proliferation​
C. Mesangial matrix accumulation secondary to chronic hyperglycemia​
D. Inflammatory destruction of capillary loops​
E. Endothelial hyperplasia and capillary occlusion

Question 19

A 60-year-old man with diabetes undergoes kidney biopsy for evaluation of nephrotic-range
proteinuria. The biopsy shows sclerosis in the glomeruli, including nodular lesions. Which of the
following additional findings is most likely?

A. Normal GFR​
B. Microhematuria​
C. Thickening of the glomerular basement membrane​
D. Interstitial lymphocytic infiltrates​
E. Extensive foot process effacement without sclerosis

Question 20

A 62-year-old woman with long-standing diabetes has progressive renal insufficiency. Kidney
biopsy shows Kimmelstiel-Wilson nodules. Which of the following clinical findings is most likely
to be present?

A. Urinary casts with eosinophils​

B. Hematuria with red blood cell casts​
C. Nephrotic-range proteinuria​
D. Polyuria with dilute urine​
E. Bence Jones proteinuria

LO B9A6: Describe the pathophysiology of the common

pathway of chronic renal disease

Question 21

A 58-year-old man with long-standing hypertension and type 2 diabetes presents for evaluation
of progressive renal dysfunction. Labs show elevated serum creatinine and reduced GFR.
Biopsy shows glomerular sclerosis, arteriolar hyalinization, and interstitial fibrosis. Which of the
following best describes the common final pathway of chronic kidney disease?

A. Autoimmune T-cell mediated tubular destruction​

B. Progressive nephron loss leading to hyperfiltration in remaining nephrons​
C. Obstruction of renal tubules by proteinaceous casts​
D. Renal vein thrombosis with back pressure injury​
E. Activation of complement system leading to necrosis

Question 22

A 66-year-old man with a history of hypertension and diabetic nephropathy has stage 4 chronic
kidney disease. Which of the following metabolic changes is most directly caused by the
decreased glomerular filtration rate?

A. Hypercalcemia​
B. Hyperuricemia​
C. Hypophosphatemia​
D. Hyperinsulinemia​
E. Decreased aldosterone

Question 23

In chronic kidney disease, reduced production of erythropoietin results in which of the following
hematologic findings?

A. Macrocytic anemia due to folate deficiency​

B. Microcytic anemia due to iron loss​
C. Normocytic, normochromic anemia due to reduced RBC production​
D. Pancytopenia due to bone marrow suppression​
E. Thrombocytopenia due to uremia-induced platelet destruction

Question 24

A patient with CKD has normal serum phosphate despite reduced renal phosphate clearance.
This is most likely due to the compensatory effect of which of the following mediators?

A. Parathyroid hormone (PTH)​

B. Vitamin D​
C. Renin​
D. Fibroblast growth factor 23 (FGF23)​
E. Aldosterone

Question 25

A 55-year-old woman with stage 5 chronic kidney disease develops severe bone pain and
increased fracture risk. Labs show hypocalcemia, hyperphosphatemia, and elevated PTH.
Which of the following best explains this patient's findings?

A. Reduced renal reabsorption of calcium​

B. Loss of vitamin D receptors in bone​
C. Impaired renal hydroxylation of vitamin D​
D. Increased tubular sodium reabsorption​
E. Hyperplasia of thyroid parafollicular cells

LO B9A7: Describe the pharmacologic approach in

treating chronic renal disease

Question 26

A 64-year-old man with diabetic nephropathy and proteinuria is started on lisinopril. Which of the
following is the primary benefit of ACE inhibitors in the setting of CKD?

A. Promotes diuresis by blocking aldosterone​

B. Enhances bicarbonate retention to prevent acidosis​
C. Reduces intraglomerular pressure to slow nephron damage​
D. Increases GFR via efferent arteriolar dilation​
E. Prevents nephrocalcinosis through phosphate binding

Question 27

A patient with stage 3 chronic kidney disease is found to have anemia with a hemoglobin of 9.0
g/dL. Ferritin is 420 ng/mL, and transferrin saturation (TSAT) is 18%. Which of the following is
the most appropriate initial therapy?
A. Oral ferrous sulfate​
B. Erythropoietin-stimulating agent (ESA)​
C. Red blood cell transfusion​
D. Parenteral vitamin B12​
E. Folic acid

Question 28

A 60-year-old man with CKD is found to have secondary hyperparathyroidism. Labs show
elevated phosphate and low 1,25-dihydroxyvitamin D. Which of the following medications is
most appropriate to control phosphate levels?

A. Ergocalciferol​
B. Calcium carbonate​
C. Cinacalcet​
D. Sevelamer​
E. Sodium bicarbonate

Question 29

A 70-year-old woman with CKD is started on erythropoietin-stimulating therapy for anemia. After
3 months, her hemoglobin has increased to 13.8 g/dL. Which of the following is the most
appropriate next step?

A. Increase the erythropoietin dose​

B. Continue the current dose​
C. Discontinue erythropoietin therapy​
D. Add intravenous iron​
E. Administer a blood transfusion

Question 30

A 61-year-old man with stage 4 CKD and refractory secondary hyperparathyroidism is found to
have persistently elevated PTH despite vitamin D analog and phosphate binder therapy. Which
of the following is the next most appropriate step?

A. Initiate sodium bicarbonate therapy​

B. Administer high-dose oral calcium​
C. Start loop diuretic therapy​
D. Refer for surgical parathyroidectomy​
E. Initiate glucocorticoid therapy

LO B9A8: Describe the indications for transitioning from

pharmacological treatment to dialysis

Question 31

A 63-year-old man with stage 5 chronic kidney disease is evaluated in the nephrology clinic. He
reports increasing fatigue, nausea, and pruritus over the past month. Labs:

●​ Creatinine: 7.5 mg/dL​

●​ BUN: 98 mg/dL​

●​ Bicarbonate: 17 mmol/L​

●​ Potassium: 6.1 mmol/L​

Despite medical therapy, his symptoms persist. Which of the following is the most
appropriate next step?​

A. Increase sodium bicarbonate dose​

B. Initiate erythropoietin therapy​
C. Begin phosphate binder therapy​
D. Initiate hemodialysis​
E. Prescribe loop diuretic for potassium excretion

Question 32

A 67-year-old woman with advanced chronic kidney disease presents with dyspnea and bilateral
leg swelling. Despite maximal diuretic therapy, she has persistent volume overload. Which of the
following is the best next step?

A. Increase sodium restriction​

B. Begin statin therapy​
C. Initiate dialysis​
D. Add thiazide diuretic​
E. Prescribe calcium channel blocker
Question 33

A 59-year-old man with end-stage renal disease presents with altered mental status. He was
noted to have lethargy and confusion. Labs show a BUN of 120 mg/dL. Which of the following
findings would most strongly indicate the need for emergent dialysis?

A. Creatinine of 9.5 mg/dL​

B. Mild metabolic acidosis​
C. Signs of uremic encephalopathy​
D. Hypertension​
E. Elevated phosphorus level

Question 34

A 65-year-old man with CKD presents with recurrent vomiting and weight loss. Despite
nutritional counseling, his BMI continues to decline. He reports poor appetite and a metallic
taste in his mouth. Which of the following is the most appropriate next step?

A. Initiate appetite stimulant​

B. Begin enteral feeding​
C. Initiate renal replacement therapy​
D. Increase protein intake to 1.5 g/kg/day​
E. Start low-dose corticosteroids

Question 35

A 58-year-old woman with CKD develops pericardial friction rub, hypotension, and shortness of
breath. Echocardiography confirms a moderate pericardial effusion. Which of the following best
explains the pathophysiologic indication for initiating dialysis?

A. Cardiac tamponade due to pericardial fat deposition​

B. Uremic pericarditis refractory to medical therapy​
C. Metastatic calcification of the pericardium​
D. Volume overload due to hypoalbuminemia​
E. Pericarditis due to viral reactivation in immunocompromised state

LO B9A9: Review acid-base and compensation as it

relates to chronic kidney disease
Question 36

A 62-year-old man with advanced CKD presents for follow-up. Labs show:

●​ pH: 7.29​

●​ pCO₂: 30 mmHg​

●​ HCO₃⁻: 14 mEq/L​
Which of the following best characterizes the acid-base disorder?​

A. Metabolic acidosis with respiratory compensation​

B. Respiratory acidosis with metabolic compensation​
C. Metabolic alkalosis due to vomiting​
D. Respiratory alkalosis due to hyperventilation​
E. Mixed metabolic and respiratory alkalosis

Question 37

A 70-year-old woman with CKD presents with confusion and Kussmaul breathing. ABG reveals:

●​ pH: 7.15​

●​ pCO₂: 23 mmHg​

●​ HCO₃⁻: 8 mEq/L​
What is the most likely cause of her acid-base disturbance?​

A. Excessive diuretic use​

B. Acute uremic acidosis​
C. Primary hyperaldosteronism​
D. Chronic obstructive pulmonary disease​
E. Vomiting-induced alkalosis

Question 38

A 55-year-old man with stage 4 CKD is evaluated for fatigue. Labs show:
 ●​ pH: 7.32​

●​ HCO₃⁻: 16 mEq/L​

●​ Anion gap: 20​

Which of the following mechanisms most likely contributes to his metabolic
derangement?​

A. Increased generation of lactic acid​

B. Increased phosphate buffering​
C. Decreased renal excretion of hydrogen ions​
D. Impaired respiratory drive​
E. Overuse of bicarbonate

Question 39

A 59-year-old man with end-stage renal disease misses multiple dialysis sessions. He presents
with deep rapid breathing. ABG:

●​ pH: 7.10​

●​ pCO₂: 22 mmHg​

●​ HCO₃⁻: 7 mEq/L​
Which of the following respiratory changes is expected in this patient?​

A. Hypoventilation as compensation​
B. Increased CO₂ retention​
C. Hyperventilation to lower pCO₂​
D. Increased dead space ventilation​
E. Decreased respiratory rate due to fatigue

Question 40

A 68-year-old woman with CKD is found to have a low serum bicarbonate level. Which of the
following best explains the metabolic acidosis observed in chronic kidney disease?

A. Increased hydrogen ion generation in the lungs​

B. Increased aldosterone activity​
C. Accumulation of sulfuric and phosphoric acids​
D. Increased bicarbonate absorption in the colon​
E. Reduced carbonic anhydrase activity

B9B1. REVIEW the factors that govern gas exchange at the

alveolar–capillary interface

Question 41​
A 72-year-old man with a 50-pack-year smoking history presents with progressive dyspnea on
exertion and reduced exercise tolerance. Pulmonary function testing reveals an increased total
lung capacity and decreased diffusing capacity of the lung for carbon monoxide (DLCO). Which
of the following changes at the alveolar–capillary interface is most likely responsible for this
patient's symptoms?

A) Increased capillary blood flow​

B) Decreased oxygen solubility​
C) Decreased alveolar surface area​
D) Increased oxygen partial pressure​
E) Decreased alveolar ventilation

Question 42​
A 36-year-old man climbs Mount Kilimanjaro and experiences acute shortness of breath. His
arterial blood gas shows decreased PaO₂ with normal A-a gradient. Which of the following best
explains his hypoxemia?

A) Right-to-left shunt​
B) Alveolar hypoventilation​
C) Diffusion impairment​
D) Decreased inspired oxygen tension​
E) Ventilation-perfusion mismatch

Question 43​
A 58-year-old woman is diagnosed with idiopathic pulmonary fibrosis. Her primary symptom is
exertional dyspnea. Which of the following pathophysiologic changes at the alveolar-capillary
interface most likely contributes to her hypoxemia?

A) Reduced solubility of oxygen​

B) Increased capillary perfusion pressure​
C) Decreased surface area for gas exchange​
D) Increased thickness of the alveolar membrane​
E) Decreased hemoglobin affinity for oxygen

Question 44​
During a physiology experiment, a subject exercises on a treadmill at increasing intensities. At
maximal exertion, his arterial PaO₂ slightly decreases. Which of the following best explains this
phenomenon?

A) Decreased alveolar PO₂​

B) Decreased cardiac output​
C) Diffusion-limited oxygen transport​
D) Increased oxygen extraction by muscles​
E) Decreased ventilation-perfusion ratio

Question 45​
A patient with long-standing pulmonary hypertension develops worsening dyspnea. His
diffusing capacity is reduced on pulmonary function testing. Which of the following best explains
the reduced gas exchange?

A) Decreased partial pressure gradient​

B) Increased red blood cell transit time​
C) Increased membrane thickness​
D) Increased alveolar PO₂​
E) Increased pulmonary venous pressure

B9B2. REVIEW the role of various pneumocytes in supporting alveolar gas

exchange

Question 46​
A 29-year-old woman presents with respiratory distress following a viral illness.
Bronchoalveolar lavage shows damage to type II pneumocytes. Which of the following functions
is most likely impaired as a result?

A) Gas exchange via diffusion​

B) Clearance of particulate matter​
C) Maintenance of alveolar structure​
D) Surfactant production​
E) Phagocytosis of pathogens
Question 47​
A preterm neonate is delivered at 28 weeks gestation and develops severe respiratory distress
shortly after birth. Chest X-ray reveals diffuse reticulogranular pattern with air bronchograms.
Deficiency of which cell type is primarily responsible for this condition?

A) Type I pneumocyte​
B) Type II pneumocyte​
C) Clara cells​
D) Alveolar macrophages​
E) Goblet cells

Question 48​
A 40-year-old man with a history of asbestos exposure presents with progressive dyspnea.
Lung biopsy reveals fibrosis and a reduction in alveolar type I pneumocytes. Which of the
following changes is most directly related to this cellular loss?

A) Reduced surfactant production​

B) Decreased alveolar elasticity​
C) Increased airway resistance​
D) Impaired gas exchange​
E) Reduced mucociliary clearance

Question 49​
An experimental drug selectively enhances proliferation of type II pneumocytes in a mouse
model of lung injury. What would be the most likely downstream effect of this cellular
regeneration?

A) Increased goblet cell number​

B) Increased mucus production​
C) Restoration of alveolar surface area​
D) Enhanced phagocytic capacity​
E) Decreased airway resistance

Question 50​
A 65-year-old man with chronic obstructive pulmonary disease undergoes histologic analysis of
lung tissue. There is an observed imbalance in type I and type II pneumocyte populations, with
destruction of alveolar walls. Which of the following is the most likely consequence of this
cellular imbalance?
A) Decreased alveolar recoil​
B) Increased surfactant synthesis​
C) Enhanced capillary recruitment​
D) Improved oxygen diffusion​
E) Reduced dead space ventilation

B9B3: REVIEW the relationship between surfactant and

surface tension in maintaining alveolar function

Question 51

A 27-week preterm infant develops respiratory distress shortly after birth. Which of the following
is the primary pathophysiologic mechanism leading to alveolar collapse in this condition?

A) Excess surfactant leading to alveolar flooding​

B) Defective alveolar macrophages preventing ventilation​
C) Immature type I pneumocytes impeding oxygen diffusion​
D) Increased alveolar surface tension due to surfactant deficiency​
E) Hyperplasia of smooth muscle in the bronchioles

Question 52

A 32-year-old woman gives birth to a preterm infant at 30 weeks gestation. The neonate
requires oxygen support. Which of the following best describes the role of pulmonary surfactant
in this infant?

A) Enhances mucociliary clearance​

B) Prevents alveolar edema by increasing interstitial pressure​
C) Reduces alveolar surface tension and prevents atelectasis​
D) Neutralizes alveolar macrophages and reduces inflammation​
E) Increases diffusion of gases through the alveolar wall

Question 53

Surfactant is primarily composed of which of the following molecules responsible for reducing
alveolar surface tension?

A) Phosphatidylcholine​
B) Albumin​
C) Ceramide​
D) Cholesterol​
E) Hemoglobin

Question 54

Which of the following best explains why pulmonary compliance increases with the presence of
surfactant?

A) Surfactant increases alveolar hydrostatic pressure​

B) Surfactant reduces elastic recoil of alveoli​
C) Surfactant decreases the work of breathing by reducing surface tension​
D) Surfactant promotes vasodilation of pulmonary capillaries​
E) Surfactant increases respiratory rate via stretch receptors

Question 55

A neonate with respiratory distress has histologic evidence of hyaline membranes lining alveoli.
Which of the following is the most likely cause?

A) Increased surfactant activity causing fibrosis​

B) Defective type I pneumocytes producing insufficient mucus​
C) Surfactant deficiency causing alveolar collapse and inflammation​
D) Excessive alveolar capillary perfusion​
E) Overactivation of alveolar macrophages

B9B4: Describe the use and interpretation of arterial

blood gases in evaluating respiratory function

Question 56

A 67-year-old man with COPD presents with worsening dyspnea. ABG:

●​ pH: 7.34​

●​ pCO₂: 60 mmHg​
 ●​ HCO₃⁻: 32 mEq/L​
Which of the following best characterizes this acid-base disorder?​

A) Acute respiratory acidosis​

B) Chronic respiratory acidosis with metabolic compensation​
C) Acute metabolic alkalosis​
D) Chronic metabolic acidosis​
E) Respiratory alkalosis with renal compensation

Question 57

A patient presents with fever, tachypnea, and dyspnea. ABG reveals:

●​ pH: 7.48​

●​ pCO₂: 28 mmHg​

●​ HCO₃⁻: 21 mEq/L​
What is the most likely acid-base disturbance?​

A) Metabolic alkalosis​
B) Respiratory alkalosis​
C) Mixed alkalosis​
D) Metabolic acidosis with respiratory compensation​
E) Chronic respiratory acidosis

Question 58

A patient with known interstitial lung disease has the following ABG:

●​ pH: 7.38​

●​ PaO₂: 58 mmHg​

●​ PaCO₂: 38 mmHg​
Which of the following best explains the discrepancy between oxygenation and
acid-base status?​
A) Increased CO₂ production​
B) High diffusion gradient for CO₂​
C) CO₂ retention due to hypoventilation​
D) Oxygen diffuses more slowly across thickened alveolar membrane​
E) Hyperventilation with lactic acidosis

Question 59

A 58-year-old woman with a history of opioid overdose presents with shallow breathing. ABG
shows:

●​ pH: 7.22​

●​ PaCO₂: 60 mmHg​

●​ HCO₃⁻: 24 mEq/L​
Which of the following best characterizes the acid-base disturbance?​

A) Chronic respiratory acidosis with compensation​

B) Acute respiratory acidosis without compensation​
C) Metabolic acidosis with respiratory compensation​
D) Mixed respiratory and metabolic acidosis​
E) Respiratory alkalosis

Question 60

A patient with sepsis is found to have a lactate level of 8 mmol/L. ABG shows:

●​ pH: 7.30​

●​ PaCO₂: 30 mmHg​

●​ HCO₃⁻: 15 mEq/L​
Which of the following best describes this acid-base disturbance?​

A) Non-anion gap metabolic acidosis​

B) Respiratory acidosis with renal compensation​
C) Anion gap metabolic acidosis with respiratory compensation​
D) Primary respiratory alkalosis​
E) Mixed respiratory alkalosis and metabolic alkalosis

B9B5: Relate O₂ saturation (SaO₂) to arterial oxygen

partial pressure (PaO₂) based on the oxygen-hemoglobin
dissociation curve

Question 61

A 45-year-old mountain climber ascends to 4,500 meters altitude and develops headaches and
fatigue. His ABG shows:

●​ PaO₂: 58 mmHg​

●​ SaO₂: 88%​

Which of the following best explains the reduction in SaO₂ at this altitude?

A) Rightward shift of the oxygen-hemoglobin dissociation curve​

B) Leftward shift due to decreased 2,3-BPG​
C) Linear decline of oxygen saturation with decreased PaO₂​
D) Increased oxygen solubility at low temperatures​
E) Inhibition of hemoglobin cooperativity

Question 62

A patient with chronic obstructive pulmonary disease (COPD) has the following blood gas:

●​ PaO₂: 55 mmHg​

●​ SaO₂: 85%​

Which of the following best accounts for the nonlinear relationship between PaO₂ and SaO₂?

A) Low solubility of oxygen in plasma​

B) Decreased production of erythropoietin​
C) Positive cooperativity among hemoglobin subunits​
D) Competitive inhibition by carbon dioxide​
E) Absence of myoglobin in erythrocytes

Question 63

A 65-year-old man is exposed to carbon monoxide. His pulse oximeter reads 98%, but he is
hypoxic. Which of the following explains why his measured PaO₂ is normal despite impaired
oxygen delivery?

A) Increased oxygen content due to elevated hemoglobin levels​

B) Carbon monoxide shifts the oxygen dissociation curve to the right​
C) PaO₂ reflects dissolved O₂, not O₂ bound to hemoglobin​
D) PaO₂ is falsely elevated in methemoglobinemia​
E) SaO₂ compensates to maintain PaO₂

Question 64

A 29-year-old pregnant woman has increased levels of fetal hemoglobin. Which of the following
best explains the relationship of fetal hemoglobin (HbF) to the oxygen-hemoglobin dissociation
curve?

A) HbF increases oxygen offloading by shifting the curve to the right​

B) HbF increases hemoglobin affinity for oxygen by shifting the curve to the left​
C) HbF increases PaO₂ and reduces SaO₂​
D) HbF prevents carbon monoxide binding, stabilizing SaO₂​
E) HbF eliminates cooperativity of oxygen binding

Question 65

A 56-year-old man with sepsis and metabolic acidosis is found to have increased tissue oxygen
delivery. Which of the following explains this finding in relation to the oxygen-hemoglobin
dissociation curve?

A) Left shift due to acidosis​

B) Increased affinity of hemoglobin for oxygen​
C) Right shift facilitating oxygen release in tissues​
D) Increased PaO₂ due to hyperventilation​
E) Decreased 2,3-BPG production in erythrocytes
B9B6: Calculate the alveolar-arterial (A-a) gradient and
explain its application

Question 66

A 50-year-old man presents with hypoxemia. ABG on room air shows:

●​ PaO₂: 60 mmHg​

●​ PaCO₂: 40 mmHg​
Assuming FiO₂ = 0.21 and barometric pressure = 760 mmHg, what is the calculated A-a
gradient?​
(Use: PAO₂ = FiO₂ × [Patm − PH₂O] − PaCO₂ / 0.8; PH₂O = 47 mmHg)​

A) 3 mmHg​
B) 7 mmHg​
C) 15 mmHg​
D) 25 mmHg​
E) 40 mmHg

Question 67

A 35-year-old man presents with acute shortness of breath. ABG:

●​ PaO₂: 55 mmHg​

●​ PaCO₂: 38 mmHg​

●​ FiO₂: 0.21​
Calculated A-a gradient is elevated. Which of the following mechanisms most likely
explains this finding?​

A) Decreased inspired oxygen​

B) Hypoventilation​
C) Right-to-left shunt​
D) Anemia​
E) Reduced respiratory rate
Question 68

A 64-year-old woman presents with gradual-onset dyspnea. A-a gradient is normal. Which of
the following is the most likely cause of her hypoxemia?

A) Pulmonary embolism​
B) Interstitial lung disease​
C) High altitude​
D) Pneumonia​
E) AV malformation

Question 69

A patient presents with hypoxemia and an increased A-a gradient. Which of the following is the
most likely to cause this?

A) Decreased PaCO₂​
B) Increased PaCO₂​
C) Ventilation-perfusion mismatch​
D) Decreased oxygen consumption​
E) Increased hemoglobin concentration

Question 70

A 72-year-old man with emphysema has a PaO₂ of 52 mmHg and a calculated A-a gradient of
30 mmHg. What does this finding most likely indicate?

A) Decreased alveolar ventilation​

B) Alveolar hypoventilation​
C) Diffusion impairment or V/Q mismatch​
D) Normal age-related decline​
E) Increased mixed venous oxygen content

B9B7: Explain the mechanism of respiratory adaptation

to excess acid
Question 71

A 55-year-old man presents with diabetic ketoacidosis. He is tachypneic and exhibits Kussmaul
breathing. Which of the following is the most likely reason for his respiratory pattern?

A) Increased bicarbonate reabsorption by the kidney​

B) Central chemoreceptor stimulation by low serum pH​
C) Peripheral chemoreceptor inhibition due to hypoxia​
D) Hyperosmolar state leading to CNS depression​
E) Increased CO₂ production by tissues

Question 72

A patient with chronic metabolic acidosis due to renal failure presents for follow-up. Which of the
following best describes the respiratory compensatory mechanism in this condition?

A) Decreased respiratory rate due to medullary inhibition​

B) Increased respiratory rate to blow off CO₂​
C) Activation of peripheral stretch receptors​
D) Stimulation of renal ammonium excretion​
E) Decreased diaphragmatic compliance

Question 73

A patient with lactic acidosis is found to have a pH of 7.15 and a PaCO₂ of 25 mmHg. What
mechanism primarily accounts for this change in PaCO₂?

A) Pulmonary edema reducing CO₂ diffusion​

B) Alveolar hypoventilation due to hypoxia​
C) Hyperventilation triggered by central chemoreceptors​
D) Decreased metabolic rate lowering CO₂ production​
E) Hepatic compensation via urea cycle activation

Question 74

Which of the following best characterizes respiratory compensation in metabolic acidosis?

A) It occurs after renal compensation​

B) It takes several days to achieve full effect​
C) It involves increased alveolar ventilation to decrease PaCO₂​
D) It raises the plasma bicarbonate concentration​
E) It decreases 2,3-BPG levels in red blood cells

Question 75

A 67-year-old man is recovering from a large bowel resection and develops sepsis. He is
tachypneic with an arterial blood gas showing:

●​ pH: 7.25​

●​ PaCO₂: 23 mmHg​

●​ HCO₃⁻: 12 mEq/L​
Which of the following best explains the low PaCO₂?​

A) Decreased serum bicarbonate buffering​

B) Metabolic alkalosis due to nasogastric suction​
C) Compensatory hyperventilation due to metabolic acidosis​
D) CO₂ retention due to alveolar collapse​
E) Pulmonary embolism causing V/Q mismatch

B9B8: Compare and contrast the pathophysiology of

cardiogenic and non-cardiogenic pulmonary edema,
including the forces governing fluid exchange in the
pulmonary capillaries

Question 76

A 72-year-old man with long-standing hypertension and ischemic heart disease presents with
dyspnea and orthopnea. Chest X-ray shows bilateral pulmonary infiltrates. BNP is elevated.
Which of the following mechanisms best explains the development of pulmonary edema in this
patient?

A) Increased alveolar permeability​

B) Decreased oncotic pressure in capillaries​
C) Increased hydrostatic pressure in pulmonary capillaries​
D) Disruption of epithelial sodium channels​
E) Excess surfactant production

Question 77

A 36-year-old woman presents with acute respiratory distress 24 hours after trauma. She has
hypoxemia unresponsive to oxygen therapy. Chest X-ray reveals bilateral fluffy infiltrates.
Pulmonary capillary wedge pressure is normal. Which of the following is the most likely
mechanism of her pulmonary edema?

A) Left ventricular failure​

B) Increased capillary hydrostatic pressure​
C) Decreased lymphatic drainage​
D) Inflammation-induced alveolar-capillary barrier disruption​
E) Decreased serum albumin

Question 78

Which of the following distinguishes non-cardiogenic pulmonary edema from cardiogenic

pulmonary edema on hemodynamic evaluation?

A) Elevated central venous pressure​

B) Normal pulmonary capillary wedge pressure​
C) Reduced pulmonary compliance​
D) Decreased alveolar ventilation​
E) Increased left atrial pressure

Question 79

A patient with pneumonia develops respiratory distress and pulmonary infiltrates. Pulmonary
capillary wedge pressure remains within the normal range. Which of the following findings
supports non-cardiogenic pulmonary edema?

A) Presence of Kerley B lines on imaging​

B) Evidence of left atrial enlargement​
C) Reduced oncotic pressure in pulmonary vessels​
D) Disruption of tight junctions in alveolar epithelium​
E) Increased preload on echocardiogram
Question 80

A patient with decompensated congestive heart failure is found to have bilateral pulmonary
rales. Which of the following pressures is most likely elevated in this form of pulmonary edema?

A) Intra-alveolar pressure​
B) Pulmonary artery systolic pressure​
C) Pulmonary capillary hydrostatic pressure​
D) Interstitial oncotic pressure​
E) Alveolar air pressure

B9B10: Explain the pertinent positive and negative

findings on history and physical examination in a patient
with ARDS

Question 81

A 60-year-old man presents to the ICU with severe shortness of breath after developing sepsis
from pneumonia. He is intubated and mechanically ventilated. Chest X-ray shows bilateral
pulmonary infiltrates. His PaO₂/FiO₂ ratio is 150. Which of the following findings is most
consistent with ARDS?

A) Pulmonary capillary wedge pressure >18 mmHg​

B) Unilateral focal consolidation​
C) Acute onset hypoxemia with diffuse crackles​
D) Productive cough with wheezing​
E) Left ventricular hypertrophy on echocardiography

Question 82

A 42-year-old woman with a history of pancreatitis is admitted with respiratory distress. She is
tachypneic and hypoxic, and auscultation reveals bilateral crackles. Which of the following
findings would most strongly support a diagnosis of ARDS over cardiogenic pulmonary edema?

A) Pulmonary edema on imaging​

B) Elevated BNP levels​
C) Normal pulmonary capillary wedge pressure​
D) Presence of orthopnea​
E) S3 gallop on cardiac exam

Question 83

A 55-year-old man is admitted after a near-drowning incident. He later develops dyspnea and
cyanosis despite oxygen therapy. Chest auscultation reveals diffuse rales, and ABG shows
severe hypoxemia. Which of the following features would be expected on physical
examination?

A) Inspiratory stridor​
B) Decreased tactile fremitus and dullness to percussion​
C) Diffuse bilateral crackles without cardiac findings​
D) Loud S1 and diastolic murmur​
E) Pleural friction rub

Question 84

A 68-year-old woman is hospitalized for acute pancreatitis and develops worsening oxygen
saturation on day 3. Chest imaging shows bilateral opacities. Her lung examination reveals
diffuse crackles. Which of the following historical or clinical findings would exclude a diagnosis
of ARDS?

A) Sudden onset of dyspnea​

B) Bilateral infiltrates on chest X-ray​
C) PCWP of 12 mmHg​
D) Severe hypoxemia (PaO₂/FiO₂ ratio < 300)​
E) Echocardiographic evidence of isolated left ventricular failure

Question 85

A 70-year-old man develops severe ARDS following septic shock. On physical examination, he
is tachypneic with cyanotic lips and diffuse inspiratory crackles. Which of the following additional
findings would be most expected on auscultation?

A) Unilateral wheezing​
B) Localized rhonchi​
C) Diffuse fine rales without signs of fluid overload​
D) Mid-systolic click​
E) Bronchial breath sounds

CBL LO Answers

B9A1: Pathophysiology of Type 1 and 2 Diabetes

1.​ C – T1DM involves autoimmune beta-cell destruction.​

2.​ A – Insulin resistance in T2DM is largely post-receptor.​

3.​ D – DKA is due to insulin deficiency → lipolysis → ketones.​

4.​ C – T2DM: increased insulin, hepatic gluconeogenesis, and insulin resistance.​

5.​ A – T1DM: HLA-DR3/DR4, CD8+ T-cell–mediated destruction.​

B9A2: Metabolic Syndrome, Insulin Resistance, Progression to Diabetes

6.​ D – Visceral adiposity causes insulin resistance via adipokines.​

7.​ A – Hyperinsulinemia compensates for insulin resistance.​

8.​ C – IFG and IGT represent intermediate steps toward diabetes.​

9.​ E – Low HDL, high triglycerides → metabolic syndrome.​

10.​B – Chronic beta-cell exhaustion leads to overt diabetes.​

B9A3: Hyperglycemia & Complications; Screening

11.​C – Glycation of proteins (e.g., basement membranes) causes microvascular damage.​

12.​D – Hypertension → macrovascular disease in diabetes.​

13.​B – Retinal microaneurysms = diabetic retinopathy → annual screening.​

14.​E – Monofilament detects peripheral neuropathy.​

 15.​A – LDL control reduces macrovascular risk.​

B9A5: Nodular Glomerulosclerosis

16.​C – KW lesions = mesangial expansion + sclerosis.​

17.​B – Proteinuria is common in diabetic nephropathy.​

18.​A – PAS-positive nodules = classic KW lesion.​

19.​E – ACEi/ARB reduce glomerular pressure.​

20.​D – Diabetic nephropathy often progresses to ESRD.​

B9A6: Chronic Renal Disease – Common Pathway

21.​B – Hyperfiltration causes nephron loss.​

22.​B – Hyperuricemia from reduced excretion.​

23.​C – ↓ EPO → normocytic normochromic anemia.​

24.​D – FGF23 regulates phosphate in CKD.​

25.​C – Loss of 1α-hydroxylation → ↓ vitamin D → ↑ PTH.​

B9A7: Pharmacologic CKD Treatment

26.​C – ACEi reduce intraglomerular pressure.​

27.​B – ESA is appropriate with normal iron stores.​

28.​D – Sevelamer = non-calcium phosphate binder.​

29.​C – Target Hgb ~10–11.5; avoid overshooting.​

 30.​D – Refractory SHPT may need parathyroidectomy.​

B9A8: Dialysis Indications

31.​D – Uremia, electrolyte imbalance → dialysis.​

32.​C – Refractory volume overload = dialysis indication.​

33.​C – Uremic encephalopathy = urgent dialysis.​

34.​C – Uremic symptoms with malnutrition → initiate dialysis.​

35.​B – Uremic pericarditis is a dialysis indication.​

B9A9: Acid-Base in CKD

36.​A – Low HCO₃⁻, low pCO₂ = metabolic acidosis with compensation.​

37.​B – Uremia → metabolic acidosis.​

38.​C – CKD = ↓ H⁺ excretion.​

39.​C – Respiratory compensation = hyperventilation.​

40.​C – Phosphoric/sulfuric acid accumulation in CKD.​

B9B1: Gas Exchange at Alveolar–Capillary Interface

41.​C – Emphysema: ↓ surface area for diffusion.​

42.​D – High altitude = low inspired O₂.​

43.​D – Fibrosis thickens alveolar membrane.​

44.​C – Fast blood flow → diffusion-limited O₂ transport.​

 45.​C – Capillary remodeling → ↑ membrane thickness.​

B9B2: Pneumocyte Roles

46.​D – Type II cells produce surfactant.​

47.​B – Type II deficiency → neonatal RDS.​

48.​D – Type I cells = gas exchange; their loss → ↓ diffusion.​

49.​C – Type II → Type I regeneration restores surface area.​

50.​A – Alveolar wall loss → ↓ recoil → air trapping.​

B9B3: Surfactant & Surface Tension

51.​D – Surfactant ↓ surface tension; deficiency = atelectasis.​

52.​C – Surfactant prevents collapse.​

53.​A – Phosphatidylcholine (DPPC) = key surfactant lipid.​

54.​C – Lower surface tension → ↑ compliance.​

55.​C – Surfactant deficiency → hyaline membranes.​

B9B4: ABG Interpretation

56.​B – High pCO₂ + high HCO₃⁻ = compensated chronic resp acidosis.​

57.​B – Low pCO₂, high pH = respiratory alkalosis.​

58.​D – Thickened membrane impairs O₂ but not CO₂ diffusion.​

59.​B – Acute opioid overdose = acute respiratory acidosis.​

 60.​C – AG metabolic acidosis with resp compensation.​

B9B5: O₂ Dissociation Curve

61.​A – High altitude: right shift = ↓ SaO₂ at given PaO₂.​

62.​C – Cooperativity = sigmoidal O₂ curve.​

63.​C – PaO₂ = dissolved O₂; CO competes for Hb.​

64.​B – HbF → left shift → ↑ affinity for O₂.​

65.​C – Acidosis → right shift → ↑ tissue O₂ release.​

B9B6: A-a Gradient

66.​D – PAO₂ = ~85 → A–a = 85 – 60 = 25 mmHg.​

67.​C – Shunt → ↑ A–a gradient.​

68.​C – High altitude: low PAO₂, normal A–a.​

69.​C – V/Q mismatch = ↑ A–a gradient.​

70.​C – Emphysema → V/Q mismatch, diffusion defect.​

B9B7: Respiratory Compensation to Acidosis

71.​B – Central chemoreceptors → ↑ ventilation.​

72.​B – Lungs compensate by ↓ CO₂.​

73.​C – Acidosis → central drive → hyperventilation.​

74.​C – Resp comp: fast, ↓ PaCO₂.​

 75.​C – Metabolic acidosis → hyperventilation.​

B9B8: Cardiogenic vs Non-Cardiogenic Pulmonary Edema

76.​C – CHF → ↑ hydrostatic pressure → cardiogenic edema.​

77.​D – ARDS → ↑ permeability = non-cardiogenic.​

78.​B – Normal wedge pressure = non-cardiogenic.​

79.​D – Alveolar injury in ARDS → barrier breakdown.​

80.​C – CHF → ↑ pulmonary capillary hydrostatic pressure.​

B9B10: ARDS H&P Findings

81.​C – ARDS = acute hypoxemia + bilateral crackles.​

82.​C – Normal wedge pressure rules out cardiogenic edema.​

83.​C – ARDS: bilateral crackles without volume overload.​

84.​E – LV failure = cardiogenic edema, not ARDS.​

85.​C – ARDS: fine crackles, cyanosis, no cardiac signs.