Geriatrics midterm

High-Yield Cumulative Practice Exam

CUMULATIVE — Intro & Assessment • Sensory/Derm/Gait • Cardiology • Endo & Pulm — clinical vignettes

50 vignette-style questions  |  Choose the single best answer  |  Answer key and rationales begin after Question 50

Name: ______________________________     Date: ____________     Score: ______ / 50

1.  A 76-year-old smoker notices that straight lines on door frames look wavy and has a dark spot in the center of his vision in one eye over 2 weeks. Peripheral vision is intact. Fundoscopy shows subretinal hemorrhage and fluid near the macula. What is the treatment of choice?

A.  Topical timolol

B.  Cataract surgery

C.  Observation only, since nothing slows progression

D.  Intravitreal anti-VEGF injections (e.g., bevacizumab, ranibizumab, aflibercept)

E.  Oral prednisone

2.  A 77-year-old with COPD (FEV1 38% predicted, FEV1/FVC 0.55) lives in a long-term care facility. He has an exacerbation with increased sputum purulence. What is his GOLD stage, and what antibiotic coverage is needed?

A.  GOLD 2; amoxicillin

B.  GOLD 4; no antibiotics

C.  GOLD 3; cover Pseudomonas (e.g., levofloxacin) because of LTC residence

D.  GOLD 1; azithromycin only

E.  Not COPD; no antibiotics

3.  Which organ systems are the FIRST to show reduced ability to maintain homeostasis under stress with aging?

A.  Skin, hair, and nails

B.  Musculoskeletal and integumentary

C.  Cardiovascular, renal, and central nervous systems

D.  GI and hepatic

E.  Endocrine and reproductive

4.  An 86-year-old from home presents with confusion. BUN is 28, RR 32, BP 100/58, and there is a new RLL infiltrate. What is his CURB-65 score, and what is the disposition?

A.  2; outpatient treatment

B.  3; outpatient treatment

C.  1; outpatient treatment

D.  4; discharge with follow-up

E.  5; admit and consider ICU

5.  A 77-year-old has a gait with difficulty initiating steps ('magnetic' gait), urinary incontinence, and progressive memory decline. Which category of sensorimotor deficit, and which diagnosis, fit best?

A.  Peripheral motor; Trendelenburg gait from hip abductor weakness

B.  Peripheral sensory; vestibular disorder

C.  Subcortical; B12 myelopathy

D.  Peripheral motor; steppage gait from foot drop

E.  Cortical (frontal) gait disorder; normal pressure hydrocephalus

6.  An 80-year-old with AF of unknown duration is stable with mild palpitations. Cardioversion is planned for symptom control. He is not anticoagulated. What is required first?

A.  Anticoagulation for 4 weeks before cardioversion, or a TEE to exclude atrial thrombus

B.  Immediate electrical cardioversion

C.  Cardioversion is never done after 75

D.  Ablation before any cardioversion

E.  IV adenosine

7.  A 69-year-old woman's routine CMP shows a calcium of 11.4 mg/dL. She has osteoporosis and a history of a kidney stone. What is the most important next step?

A.  Check intact PTH

B.  Start calcium and vitamin D supplements

C.  Start hydrochlorothiazide

D.  Repeat calcium in 2 years

E.  Order a thyroid uptake scan

8.  An asymptomatic 80-year-old has a TSH of 8.4 with normal free T4. He has stable CAD. What is the best management per the lecture?

A.  Monitor only, since TSH <26

B.  Start levothyroxine at full weight-based dose

C.  Start levothyroxine 25 mcg daily and titrate slowly

D.  Start Armour Thyroid

E.  Start methimazole

9.  At an initial geriatric visit, which approach to the medication history is recommended?

A.  Ask the patient to list medications from memory

B.  Recommend putting all pills into one container for simplicity

C.  Have the patient bring ALL prescriptions, OTCs, supplements, and herbals (a 'brown bag'), and assess the ability to read labels, open containers, and use devices such as inhalers

D.  Record only prescription medications

E.  Rely on the most recent hospital discharge summary

10.  A stable 79-year-old with COPD has a resting PaO2 of 53 mmHg on room air. Which intervention improves survival?

A.  Oxygen only during exercise

B.  Inhaled corticosteroid monotherapy

C.  Long-term oxygen therapy worn >16 hours/day

D.  Chronic oral prednisone

E.  Theophylline

11.  An 87-year-old with dementia, CHF, and CKD stage 4 who lives in a nursing home has an A1c of 6.2% on glipizide, with recurrent lows. What is the best plan?

A.  Add basal insulin to keep A1c under 6.5%

B.  Continue the current regimen

C.  Switch to glyburide

D.  Add a sulfonylurea at bedtime

E.  Deintensify: stop glipizide and target an A1c of about 8.0–8.5%

12.  A 71-year-old fair-skinned retired golfer has several rough, pink, scaly papules on his scalp and dorsal hands that are 'easier to feel than see.' What is the recommended treatment per the AAD?

A.  Wide local excision with 2 cm margins

B.  Cryosurgery (liquid nitrogen) for these actinic keratoses

C.  Mohs surgery for every lesion

D.  Observation; they never progress

E.  Oral isotretinoin

13.  A 79-year-old with slowly worsening blurred vision, glare and halos around headlights when driving at night, and frequent eyeglass prescription changes has a diminished red reflex. What is the definitive treatment?

A.  Topical latanoprost

B.  Intravitreal anti-VEGF injections

C.  AREDS vitamins

D.  Surgical removal of the lens with intraocular lens placement

E.  Laser photocoagulation

14.  A 66-year-old with a 15-year history of poorly controlled T2DM has no visual complaints. Fundoscopy shows microaneurysms, dot-blot hemorrhages, hard exudates, and cotton-wool spots, with no neovascularization. What is the diagnosis and the recommended screening?

A.  Proliferative diabetic retinopathy; immediate vitrectomy

B.  Dry AMD; AREDS vitamins

C.  Hypertensive retinopathy only; no follow-up needed

D.  Nonproliferative diabetic retinopathy; annual dilated eye exam with glucose and BP control

E.  Central retinal artery occlusion

15.  A 74-year-old man asks why he has become frail. Per the lecture's 'Rule of Fourths,' changes attributed to normal aging or progressive frailty come from which four sources?

A.  Genetics, diet, income, and education

B.  Cardiac, renal, CNS, and pulmonary decline

C.  Medications, falls, infection, and depression

D.  Disease, disuse, misuse, and physiologic aging, about one-fourth each

E.  Telomeres, senescence, inflammation, and glycation

16.  An 84-year-old widow can bathe, dress, toilet, transfer, feed herself, and is continent. Her son now manages her finances, and she has missed several doses of her medications. Which statement is correct?

A.  She is impaired in basic ADLs

B.  She is independent in basic ADLs but has impairment in IADLs (finances, medication management)

C.  Managing finances is a basic ADL

D.  IADLs include bathing and transferring

E.  She has no functional impairment

17.  A 70-year-old on chronic inhaled fluticasone for COPD has white patches on her tongue and buccal mucosa that scrape off easily, leaving erythema. What is the best initial treatment?

A.  IV amphotericin B

B.  Oral fluconazole 400 mg daily for 6 weeks

C.  Biopsy to rule out leukoplakia

D.  Stop all inhaled therapy permanently

E.  Topical antifungal, e.g., clotrimazole troches 10 mg five times daily or nystatin swish-and-swallow, for 7–14 days, and rinse after inhaler use

18.  An 84-year-old on amlodipine, lisinopril, and chlorthalidone remains at 156/88. Her refill history shows 60-day gaps. What is the #1 cause of her resistant HTN?

A.  Primary aldosteronism

B.  Poor medication adherence

C.  Renal artery stenosis

D.  Obstructive sleep apnea

E.  Pheochromocytoma

19.  A 76-year-old has sudden vertigo, vomiting, diplopia, nystagmus, and ataxia. What vascular territory is involved, and what is the most significant modifiable stroke risk factor to address afterward?

A.  Anterior cerebral artery; age

B.  Middle cerebral artery; family history

C.  Posterior (vertebrobasilar) circulation; hypertension

D.  Ophthalmic artery; sex

E.  Lenticulostriate arteries; sedentary lifestyle

20.  A 76-year-old man with mild cognitive impairment comes to his first visit with his son. He is fully able to communicate. How should the interview be conducted?

A.  Interview only the son, since he is the more reliable historian

B.  Skip the medication history and request pharmacy records

C.  Interview the patient alone for at least part of the visit, unless his mental status is significantly impaired

D.  Use only yes/no questions to save time

E.  Defer the history until the son can complete forms at home

21.  A 78-year-old woman's daughter says she 'just isn't herself.' Over 2 days she has been sleepy, inattentive, and intermittently confused. She has no fever and no cough. UA shows pyuria and bacteriuria. Which concept best explains this presentation?

A.  Normal aging-related cognitive decline

B.  Rule of fourths: disuse

C.  Expected decline in renal perfusion

D.  A geriatric syndrome: a disease in one organ (UTI) shows up as dysfunction in another (delirium)

E.  Chronic dementia progression

22.  Which pattern of pulmonary function changes is expected with NORMAL aging?

A.  ↑FEV1/FVC ratio and ↓TLC

B.  ↓FEV1/FVC ratio, relatively stable TLC, ↑residual volume, and ↓DLCO

C.  ↑DLCO and ↑vital capacity

D.  ↓TLC with a normal ratio (restriction)

E.  No change in any PFT parameter

23.  An 82-year-old woman of normal weight is started on a water-soluble drug at the standard adult dose and develops toxicity. Her serum creatinine is 0.8 mg/dL. Which age-related change best explains this?

A.  Increased total body water diluting the drug

B.  Decreased total body water and lean mass, plus reduced GFR masked by low creatinine production

C.  Increased hepatic CYP450 activity

D.  Increased renal tubular secretion

E.  Increased lean body mass

24.  An 83-year-old has a BP of 168/62 on repeated readings. Which pair of age-related changes best explains this widened pulse pressure?

A.  Increased plasma renin and increased vessel elasticity

B.  Increased beta-receptor responsiveness and more SA node cells

C.  Decreased sympathetic activity and enhanced NO response

D.  Arterial stiffening with early reflected pulse waves, plus decreased baroreceptor sensitivity

E.  Increased sodium excretion and low insulin resistance

25.  An 80-year-old with HTN is switched to oxybutynin for urge incontinence. Within a week she is confused, constipated, and in urinary retention. Which age-related change explains her heightened sensitivity?

A.  Exaggerated response to anticholinergic medications from reduced muscarinic parasympathetic responses

B.  Increased beta-adrenergic responsiveness

C.  Increased dopamine receptors

D.  Increased hepatic blood flow

E.  Enhanced baroreflex responses

26.  A 76-year-old with HFrEF (EF 30%) is on lisinopril, carvedilol, and furosemide. You consider adding spironolactone. Labs: Cr 1.4, K 4.4. Which statement about his regimen is correct?

A.  Furosemide provides the largest mortality benefit

B.  Spironolactone is contraindicated because he is over 75

C.  Carvedilol should be stopped because it worsens HFrEF mortality

D.  Diltiazem should be added for rate control

E.  Spironolactone can be added (Cr <2.5, K <5.0) and adds mortality benefit; furosemide relieves symptoms only

27.  A geriatric clinic is considering a Comprehensive Geriatric Assessment (CGA) program. Which statement about CGA is correct?

A.  It is performed by the physician alone in the ED

B.  It is most successful when done by an interdisciplinary team and is associated with reduced mortality and fewer nursing home and hospital admissions

C.  It evaluates physical health only

D.  It increases nursing home placement

E.  It is recommended for every adult at age 65 regardless of risk or cost

28.  A 78-year-old woman with HTN and diabetes is newly found to have nonvalvular AF. CrCl is 58. What is her CHA2DS2-VASc score, and what is the preferred therapy?

A.  3; aspirin alone

B.  5; a DOAC such as apixaban

C.  4; no anticoagulation because of age

D.  5; warfarin is required

E.  2; observation

29.  A 72-year-old has sudden right-sided hearing loss that began 2 days ago. Exam suggests sensorineural loss. What is the most appropriate next step?

A.  Reassure him that this is presbycusis

B.  Recommend OTC hearing aids

C.  Recheck at his annual visit

D.  Urgent ENT (otolaryngology) referral

E.  Ear irrigation

30.  A 75-year-old had 15 minutes of left arm weakness that fully resolved. MRI shows no infarct. Carotid ultrasound shows 80% right ICA stenosis. He is fit, with a life expectancy greater than 5 years. What is the best management?

A.  Carotid endarterectomy plus antiplatelet, statin, BP control, and smoking cessation

B.  Medical management alone, since the deficit resolved

C.  Repeat ultrasound in 1 year

D.  Warfarin

E.  Carotid stenting preferred for all patients

31.  A 73-year-old with early cognitive impairment wants her wishes about CPR and intubation honored if she becomes seriously ill. She wants a portable medical ORDER that EMS will follow. What is the most appropriate document?

A.  Living will only

B.  Durable power of attorney for finances

C.  HIPAA release form

D.  Last will and testament

E.  POLST (Physician Orders for Life-Sustaining Treatment)

32.  An 81-year-old with dyspnea and leg swelling has COPD that makes the exam hard to interpret. BNP is normal. Which exam finding best assesses her volume status, and what does the BNP imply?

A.  Pedal edema is the best volume assessment; a normal BNP confirms HF

B.  Skin turgor is best; BNP is useless in older adults

C.  Capillary refill is best; a normal BNP means low-output HF

D.  JVP is the best bedside volume assessment; a normal BNP essentially rules out HF

E.  Lung crackles are best; BNP is falsely low only in renal failure

33.  A 72-year-old weighing 200 lb needs basal-bolus insulin because his A1c is 11%. Using the lecture's formula (lbs × 0.23), what is his approximate basal dose?

A.  About 46 units of basal insulin daily

B.  About 23 units of basal insulin daily

C.  About 8 units of basal insulin daily

D.  About 15 units of basal insulin daily

E.  About 60 units of basal insulin daily

34.  During a wellness exam, a 79-year-old has an S4, a PR interval of 0.22 s, and left axis deviation on ECG. He is asymptomatic, exercises daily, and has a normal echo. What is the most appropriate interpretation?

A.  An S4 always means acute ischemia; obtain troponins

B.  A prolonged PR mandates a pacemaker

C.  Left axis deviation requires cardiac catheterization

D.  A diastolic murmur would also be expected with aging

E.  These can be age-related findings; interpret them in context of symptoms and evidence of disease rather than assuming pathology

35.  A 77-year-old man says, 'I can hear you talking, but I can't understand you,' especially in restaurants and with his granddaughters. Weber is midline, and Rinne shows AC > BC bilaterally. What is the most likely diagnosis?

A.  Bilateral cerumen impaction

B.  Presbycusis: bilateral, symmetric, high-frequency sensorineural hearing loss

C.  Otosclerosis

D.  Acoustic neuroma

E.  Meniere disease

36.  An 85-year-old woman has a resting HR of 32. She has had two syncopal episodes, and a Holter shows a 3.8-second pause. Her medication list has no AV-nodal blockers. What is the best management?

A.  Permanent pacemaker

B.  Start metoprolol

C.  Observation; bradycardia is normal with aging

D.  Start digoxin

E.  Start amiodarone

37.  An 87-year-old nursing home resident with pneumonia and SBP of 84 has a troponin rise and fall without chest pain or ST elevation. What is the most likely diagnosis?

A.  Type 2 MI from supply–demand mismatch

B.  Type 1 STEMI requiring emergent PCI

C.  Aortic dissection

D.  Pericarditis

E.  Lab error

38.  A daughter asks whether Medicare will pay for an aide to help her 85-year-old father with bathing and dressing. He has no skilled nursing or therapy needs. What is the correct answer?

A.  Yes; Medicare covers 24-hour in-home custodial care

B.  Yes; Medicare pays family caregivers for ADL help

C.  Yes; Medicare covers homemaker services like shopping

D.  Yes; ADL help is covered without any physician certification

E.  No; Medicare doesn't cover non-medical personal care (ADL help) when it's the only care needed

39.  A bed-bound 84-year-old has a sacral wound with full-thickness skin loss exposing subcutaneous fat, but no visible bone, tendon, or muscle. Which prevention and treatment measures are appropriate?

A.  Stage 1; massage the reddened area vigorously

B.  Stage 4; immediate amputation

C.  Stage 3 pressure injury; scheduled repositioning, pressure-relief surfaces, moisture management, high-protein nutrition, and wound care

D.  Stage 2; no repositioning needed

E.  Unstageable; nothing can be done

40.  An 83-year-old with T2DM, sepsis from pneumonia, and 5 days of confusion has glucose 1,040, serum osmolality 360, minimal ketones, and AKI. After fluids and IV insulin, glucose falls to 240. What is the next step?

A.  Stop all IV fluids

B.  Stop insulin and discharge

C.  Add 5% dextrose in 0.45% saline and continue insulin, checking glucose hourly

D.  Give IV bicarbonate

E.  Switch to oral metformin

41.  A 69-year-old man who smoked for 25 years (quit 15 years ago) asks about AAA screening. What does the USPSTF recommend?

A.  Annual CT (Grade A)

B.  No screening (Grade D)

C.  Insufficient evidence (Grade I)

D.  Screen only if he has a family history (Grade C)

E.  One-time abdominal ultrasound (Grade B)

42.  A 74-year-old with sudden left hemiparesis was last known well 2 hours ago. Glucose is 132. Noncontrast CT shows no hemorrhage. He takes no anticoagulants, and BP is 174/96. What is the best treatment?

A.  IV alteplase now (within 4.5 hours, ideally <3 hours), plus thrombectomy evaluation if there is a large vessel occlusion

B.  Withhold alteplase because he is over 70

C.  Aspirin only; MRI first

D.  Start heparin drip

E.  Wait for full labs (CBC, lipids, A1c) before deciding

43.  A 68-year-old Black man is found on routine exam to have an increased cup-to-disc ratio and elevated IOP. He has no complaints, but visual field testing shows peripheral defects. What is the first-line medical therapy?

A.  Topical prostaglandin analog (e.g., latanoprost) or topical beta-blocker

B.  Oral acetazolamide as first line

C.  Pilocarpine as first line

D.  Cataract extraction

E.  Intravitreal anti-VEGF

44.  An 81-year-old with dentures has redness confined to the palatal mucosa under her upper denture, plus fissures at both corners of her mouth. What is the diagnosis?

A.  Acute pseudomembranous candidiasis

B.  Hyperplastic candidiasis

C.  Geographic tongue

D.  Chronic atrophic candidiasis (denture stomatitis) with angular cheilitis

E.  Oral squamous cell carcinoma

45.  A 78-year-old woman takes 16 seconds to complete the Timed Up and Go test and cannot stand on one leg for 5 seconds. What do these results indicate?

A.  Normal results for her age

B.  Isolated cerebellar disease requiring MRI

C.  Peripheral neuropathy confirmed

D.  Increased fall risk; TUG ≥14 seconds and unipedal stance <5 seconds both predict falls

E.  Normal pressure hydrocephalus confirmed

46.  A 70-year-old with COPD asks in October which vaccine prevents a respiratory virus circulating from October to early spring that hospitalizes up to 16% of high-risk older adults. Care for this virus is mainly supportive. What should be offered?

A.  Live varicella vaccine

B.  RSV vaccine

C.  HPV vaccine

D.  MMR booster

E.  BCG vaccine

47.  A 70-year-old with T2DM on metformin has a history of acute pancreatitis and frequent UTIs. A1c is 8.1%. Which add-on is most appropriate?

A.  Semaglutide

B.  Sitagliptin

C.  Empagliflozin

D.  Glyburide

E.  Glipizide (a low-cost sulfonylurea, preferred over glyburide in older adults)

48.  A 75-year-old has decreased hearing in the left ear. Weber lateralizes to the LEFT, and Rinne on the left shows BC > AC. What type of hearing loss is this, and what is the likely cause?

A.  Left conductive hearing loss, e.g., cerumen impaction

B.  Left sensorineural hearing loss

C.  Right sensorineural hearing loss

D.  Right conductive hearing loss

E.  Normal hearing

49.  A 79-year-old woman has 6 weeks of worsening fatigue and dyspnea when walking to her car. She denies chest pain. ECG shows no acute changes. What is the most appropriate interpretation?

A.  Normal deconditioning; no workup needed

B.  Almost certainly anxiety

C.  Dyspnea on exertion may be an anginal equivalent; evaluate for coronary heart disease

D.  Only pulmonary causes need evaluation

E.  Older adults always report typical chest pain with ischemia

50.  An 82-year-old woman has weight loss, fatigue, and new AFib but no tremor or heat intolerance. TSH is suppressed. Which statement is correct?

A.  Older adults often have 'apathetic' hyperthyroidism; AF occurs in about 27%, and thyroid function should be checked with any new arrhythmia or CHF

B.  Heat intolerance and irritability are more prominent in older adults

C.  New AF never warrants thyroid testing

D.  This is hypothyroidism

E.  Radioactive iodine is contraindicated in Graves

Answer Key

Coverage: Wk 2 · Sensory/Derm/Gait 13  •  Wk 4 · Endo & Pulm 12  •  Wk 1 · Intro & Assessment 12  •  Wk 3 · Cardiology 13

Answers & Clinical Rationales

1.  Answer: D. Intravitreal anti-VEGF injections (e.g., bevacizumab, ranibizumab, aflibercept)   [Wk 2 · Sensory/Derm/Gait]

Rationale: Wet (neovascular) AMD: choroidal neovascularization with rapid, often unilateral central loss; metamorphopsia is the first symptom, and peripheral and color vision are spared. AMD is the most common cause of irreversible central vision loss in older adults; smokers have 4× the risk. ALL AMD starts dry (drusen, RPE changes, slow bilateral loss). Dry → AREDS supplements (vitamins C and E, lutein, zeaxanthin, zinc). Wet → add anti-VEGF.

Why not the others: Timolol treats glaucoma. Cataract surgery won't help. Anti-VEGF does preserve vision. Steroids are not the treatment.

2.  Answer: C. GOLD 3; cover Pseudomonas (e.g., levofloxacin) because of LTC residence   [Wk 4 · Endo & Pulm]

Rationale: GOLD with ratio <0.70: 1 ≥80%, 2 50–79%, 3 30–49%, 4 <30%. 38% = GOLD 3. Exacerbation: O2, bronchodilators, steroids, and antibiotics for increased sputum, severe obstruction, or LTC residence. Pseudomonas risk (LTC, recent hospitalization, FEV1 <30%) → levofloxacin (Zosyn if admitted).

Why not the others: Wrong stage or inadequate coverage in the other options.

3.  Answer: C. Cardiovascular, renal, and central nervous systems   [Wk 1 · Intro & Assessment]

Rationale: Aging is the inevitable, irreversible decline in organ function over time, even without injury, illness, or poor lifestyle. Early changes don't affect baseline function but reduce each organ's ability to maintain homeostasis under stress (diminished functional reserve). The first systems affected are cardiovascular, renal, and CNS. Mechanisms include telomere shortening leading to cellular senescence, advanced glycation end products, chronic inflammation, and fibrosis.

Why not the others: The other systems change with age but are not the first to lose homeostatic reserve.

4.  Answer: E. 5; admit and consider ICU   [Wk 4 · Endo & Pulm]

Rationale: CURB-65: Confusion (1) + BUN >20 (1) + RR ≥30 (1) + BP (SBP <90 or DBP ≤60: 58, so 1) + age ≥65 (1) = 5. 0–1: outpatient; 2: consider hospital; 3: admit; 4–5: admit and consider ICU (>40% mortality). Older adults often present atypically (falls, confusion, anorexia). The most common pathogen is S. pneumoniae; microaspiration is the main mechanism.

Why not the others: Each criterion is met, so the score is 5. Lower scores and outpatient care are wrong.

5.  Answer: E. Cortical (frontal) gait disorder; normal pressure hydrocephalus   [Wk 2 · Sensory/Derm/Gait]

Rationale: Gait disorders by level: Peripheral sensory (vestibular, neuropathy, proprioception, vision, fear of falling) and peripheral motor (Trendelenburg, antalgic, steppage, shuffle). Subcortical (midbrain, brainstem, cerebellum, cord: myelopathy, B12, stroke, spasticity) starts normally with abnormal stepping. Cortical (frontal) involves cognitive dysfunction, gait initiation failure, and frontal disequilibrium (cerebrovascular disease, dementia, NPH, frontal mass). NPH = wet, wobbly, wacky.

Why not the others: The other options don't explain initiation failure combined with dementia and incontinence.

6.  Answer: A. Anticoagulation for 4 weeks before cardioversion, or a TEE to exclude atrial thrombus   [Wk 3 · Cardiology]

Rationale: Cardioversion timing: immediate if hemodynamically unstable; OK if AF has lasted <48 hours; otherwise anticoagulate for 4 weeks or use a TEE to rule out thrombus. Rate control: BB (carvedilol, metoprolol) or CCB (diltiazem, verapamil). Rhythm: amiodarone, flecainide, propafenone, sotalol.

Why not the others: He's stable with unknown duration, so immediate cardioversion risks stroke. Age isn't a contraindication. Ablation is for persistent symptoms. Adenosine doesn't treat AF.

7.  Answer: A. Check intact PTH   [Wk 4 · Endo & Pulm]

Rationale: Don't overlook a high calcium; check PTH. Primary hyperparathyroidism (adenoma) peaks at ages 60–70 with vague symptoms ('bones, stones, groans, psychic moans'). Complications: osteoporosis and fractures, stones, renal failure, HTN, LVH, valvular calcification. Localize with a sestamibi scan. Treat with parathyroidectomy, or cinacalcet if surgical risk is high.

Why not the others: Supplements and thiazides worsen hypercalcemia. Delay and a thyroid scan miss the diagnosis.

8.  Answer: C. Start levothyroxine 25 mcg daily and titrate slowly   [Wk 4 · Endo & Pulm]

Rationale: TSH thresholds: 4.3–6.9 → monitor if asymptomatic; >7.0 → treat with levothyroxine to avoid cardiac issues; >26 → urgent. Start at 25 mcg (start low, go slow, especially with CAD). Avoid desiccated thyroid (cardiac risk). Myxedema coma: ICU, IV levothyroxine 300–500 mcg then 100 mcg.

Why not the others: TSH >7 warrants treatment. A full dose risks ischemia. Armour carries cardiac risk. Methimazole treats hyperthyroidism.

9.  Answer: C. Have the patient bring ALL prescriptions, OTCs, supplements, and herbals (a 'brown bag'), and assess the ability to read labels, open containers, and use devices such as inhalers   [Wk 1 · Intro & Assessment]

Rationale: Medication history: bring everything, including OTCs, supplements, and topicals. Evaluate the ability to read labels, open containers, recognize meds, and use inhalers. Advise against keeping all meds in one container. Record each med with dose, schedule, prescriber, reason, and allergies with reactions, and give a copy to the patient or caregiver. Also record alcohol, caffeine, and illicit substances.

Why not the others: Memory recall, a single combined container, prescription-only lists, and discharge summaries are incomplete or unsafe.

10.  Answer: C. Long-term oxygen therapy worn >16 hours/day   [Wk 4 · Endo & Pulm]

Rationale: LTOT for more than 16 hours a day improves survival in severe resting hypoxemia (PaO2 ≤55–60). Survival is also improved by smoking cessation (it returns FEV1 decline from 80–200 to 20–40 mL/yr) and pulmonary rehab within 90 days of hospitalization. Vaccinate against influenza, pneumococcus, COVID, and RSV. Use the palliative 'surprise question' for advanced disease.

Why not the others: Exertion-only O2, ICS, chronic steroids, and theophylline don't improve survival.

11.  Answer: E. Deintensify: stop glipizide and target an A1c of about 8.0–8.5%   [Wk 4 · Endo & Pulm]

Rationale: A1c goals: 7.0–7.5% for most older adults; 8.0–8.5% for those over 75 in moderate to severe decline or nursing home residents with comorbidities; never below 6% on medications; always avoid hypoglycemia. Sulfonylureas and CKD 3b–5 increase lows. Simplify regimens when cognition declines.

Why not the others: Tightening or adding hypoglycemic agents worsens lows. Glyburide is contraindicated over 65.

12.  Answer: B. Cryosurgery (liquid nitrogen) for these actinic keratoses   [Wk 2 · Sensory/Derm/Gait]

Rationale: Actinic keratoses are precancerous keratinocyte changes that can progress to SCC. Risk: age, immunosuppression, fair skin (types I–II), light hair and eyes, sun exposure. They're pink or red with adherent scale and often more easily felt than seen. Diagnosis is clinical. The AAD strongly recommends cryosurgery (field therapy such as 5-FU is an option).

Why not the others: Excision and Mohs are for cancers. AKs CAN progress to SCC. Isotretinoin is not the treatment.

13.  Answer: D. Surgical removal of the lens with intraocular lens placement   [Wk 2 · Sensory/Derm/Gait]

Rationale: Cataracts: lens opacity causing blur, glare, halos, diplopia or polyopia, color disturbance, and frequent refraction changes. Risk factors: age, smoking, alcohol, UV, steroids, DM, trauma. They affect about half of people over 80 and increase falls and medication errors. Diagnosis is by fundoscopy and slit lamp. Treatment: extraction with an IOL, the most common surgery (about 15 minutes, >95% success).

Why not the others: Latanoprost treats glaucoma. Anti-VEGF treats wet AMD or DME. AREDS slows AMD. Laser is for DR.

14.  Answer: D. Nonproliferative diabetic retinopathy; annual dilated eye exam with glucose and BP control   [Wk 2 · Sensory/Derm/Gait]

Rationale: Diabetic retinopathy: nonproliferative (first and most common) shows microaneurysms, hemorrhages, hard exudates, cotton-wool spots, and later macular edema. Proliferative adds neovascularization with vitreous hemorrhage and traction detachment. Prevalence correlates with DM duration, glycemic control, and BP. Screen with an annual dilated exam. Treat with glucose and BP control; for macular edema, anti-VEGF, steroid implants, laser, or vitrectomy.

Why not the others: There's no neovascularization, so it isn't proliferative. Drusen indicate AMD. A CRAO causes sudden painless vision loss with a cherry-red spot.

15.  Answer: D. Disease, disuse, misuse, and physiologic aging, about one-fourth each   [Wk 1 · Intro & Assessment]

Rationale: Rule of fourths: about ¼ disease, ¼ disuse (sedentary, little mental stimulation), ¼ misuse (smoking, poor lifestyle, injuries), and ¼ physiologic aging. Three-fourths are potentially modifiable, so treatment includes medical therapy and an activity regimen to prevent deterioration, preserve function, and adapt or compensate for disability.

Why not the others: Telomeres, senescence, inflammation, and AGEs are mechanisms of aging, not the rule of fourths. The other lists are not the lecture's framework.

16.  Answer: B. She is independent in basic ADLs but has impairment in IADLs (finances, medication management)   [Wk 1 · Intro & Assessment]

Rationale: Basic ADLs: eating, dressing, bathing, transferring, toileting, continence. IADLs: preparing meals, housework, taking medications, errands or shopping, managing finances, using the telephone. IADL decline is often an early sign of cognitive impairment and is part of the Comprehensive Geriatric Assessment.

Why not the others: Her basic ADLs are intact. Finances and medications are IADLs. Bathing and transferring are basic ADLs.

17.  Answer: E. Topical antifungal, e.g., clotrimazole troches 10 mg five times daily or nystatin swish-and-swallow, for 7–14 days, and rinse after inhaler use   [Wk 2 · Sensory/Derm/Gait]

Rationale: Acute pseudomembranous candidiasis (thrush) is the most common form, with white patches that are easily removed. Risk factors: inhaled or systemic steroids, antibiotics, decreased saliva, diabetes, dentures, immunosuppression. Mild disease → topical first line: clotrimazole 10 mg 5×/day or nystatin 5 mL QID for 7–14 days. Moderate to severe → fluconazole. Rinse the mouth after ICS use.

Why not the others: Amphotericin and prolonged high-dose fluconazole are excessive. Leukoplakia doesn't scrape off. Inhaled therapy shouldn't be stopped.

18.  Answer: B. Poor medication adherence   [Wk 3 · Cardiology]

Rationale: The lecture: the #1 cause of resistant HTN is poor adherence (polypharmacy, cost, side effects, cognition). Geriatric HTN: stage 1 starts at 130/80; confirm with multiple readings; orthostatic vitals always; first line thiazide, ACEI, ARB, or CCB, started low; goal 130/80 (120/80 for high stroke risk).

Why not the others: Secondary causes are considered after adherence is addressed.

19.  Answer: C. Posterior (vertebrobasilar) circulation; hypertension   [Wk 3 · Cardiology]

Rationale: Posterior circulation causes the 'V's': vomiting, visual change, vertigo, plus nystagmus, ataxia, coma, and crossed findings. Anterior (ACA/MCA) causes contralateral weakness, aphasia, and hemianopsia. HTN is the most significant modifiable stroke risk factor. Secondary prevention: BP control, antiplatelet (DAPT within 24 hours for 21 days for minor stroke or TIA), statin, and anticoagulation for AF.

Why not the others: Age, family history, and sex aren't modifiable. The other territories don't produce this syndrome.

20.  Answer: C. Interview the patient alone for at least part of the visit, unless his mental status is significantly impaired   [Wk 1 · Intro & Assessment]

Rationale: Interviewing older adults: unless mental status is impaired, interview the patient alone (this also allows screening for abuse or neglect). Start with rapport and ask 'Tell me about a typical day' to learn baseline function and what has changed. Assess mental status early to determine reliability. Watch nonverbal cues. Ask about formerly common diseases (rheumatic fever, polio), outdated treatments, vaccine reactions, and advance directives.

Why not the others: Bypassing the patient, skipping the med history, and closed questions all miss key information.

21.  Answer: D. A geriatric syndrome: a disease in one organ (UTI) shows up as dysfunction in another (delirium)   [Wk 1 · Intro & Assessment]

Rationale: Disease interacts with normal aging to produce 'geriatric syndromes.' These affect organs that are not the primary site of disease; delirium complicating pneumonia or a UTI is the classic example. Don't mistake disease for aging or aging for disease. Unusual manifestations, or functional decline as the only sign, are common.

Why not the others: Acute fluctuating inattention is not normal aging or dementia progression (dementia is chronic and insidious). The rule of fourths and renal perfusion don't explain acute delirium.

22.  Answer: B. ↓FEV1/FVC ratio, relatively stable TLC, ↑residual volume, and ↓DLCO   [Wk 4 · Endo & Pulm]

Rationale: Aging: loss of elastic recoil (air trapping, ↑RV, ↓FEV1), weaker diaphragm (↓FVC). FEV1 falls more than FVC, so the ratio falls. TLC is stable (bigger lungs, smaller chest wall). Capillary loss and V/Q mismatch lower DLCO. A fixed 0.70 GOLD cutoff overdiagnoses COPD in older adults.

Why not the others: The ratio and DLCO fall, VC falls, TLC is stable, and changes definitely occur.

23.  Answer: B. Decreased total body water and lean mass, plus reduced GFR masked by low creatinine production   [Wk 1 · Intro & Assessment]

Rationale: Aging lowers lean body mass, muscle mass, and total body water, and raises the percentage of fat. Water-soluble drugs therefore reach higher concentrations, and fat-soluble drugs have longer half-lives. Lower muscle mass means less creatinine production, so a 'normal' creatinine can hide a reduced GFR. Kidneys lose mass, blood flow, and GFR, raising adverse drug effects. Liver mass, blood flow, and CYP450 activity also fall. Start low and avoid high initial doses.

Why not the others: Body water, CYP450 activity, tubular secretion, and lean mass all DECREASE with age.

24.  Answer: D. Arterial stiffening with early reflected pulse waves, plus decreased baroreceptor sensitivity   [Wk 3 · Cardiology]

Rationale: Aging → stiff arteries → higher pulse wave velocity → reflected waves arrive during systole → higher SBP and lower DBP (isolated systolic HTN). Also: decreased baroreceptor sensitivity (orthostatic hypotension, BP variability), more sympathetic activity, lower alpha/beta responsiveness, endothelial dysfunction, sodium sensitivity, LOW renin, insulin resistance, and central adiposity.

Why not the others: Renin is low and elasticity is reduced. Beta responsiveness and pacemaker cells decline. Sympathetic tone is increased. Sodium excretion is decreased.

25.  Answer: A. Exaggerated response to anticholinergic medications from reduced muscarinic parasympathetic responses   [Wk 1 · Intro & Assessment]

Rationale: Peripheral nervous system aging: decreased baroreflex (syncope), decreased beta-adrenergic responsiveness (weaker response to beta-blockers), decreased muscarinic parasympathetic responses (EXAGGERATED response to anticholinergics), and preserved alpha responses. CNS: fewer dopamine receptors (stiffness, impaired balance).

Why not the others: Beta responsiveness, dopamine receptors, hepatic flow, and baroreflexes all DECREASE with age.

26.  Answer: E. Spironolactone can be added (Cr <2.5, K <5.0) and adds mortality benefit; furosemide relieves symptoms only   [Wk 3 · Cardiology]

Rationale: HFrEF mortality-benefit drugs: ACEI/ARB/ARNI, beta-blocker (metoprolol, carvedilol, bisoprolol), and MRA (avoid if Cr >2.5 or K >5.0; monitor K and watch for gynecomastia). Loops: symptoms only, no survival benefit. Devices: ICD for EF <35%; CRT for EF <35% with QRS >150. Sodium <3 g/day.

Why not the others: Loops don't improve survival. Age isn't an MRA contraindication. BBs reduce mortality. Non-DHP CCBs harm HFrEF.

27.  Answer: B. It is most successful when done by an interdisciplinary team and is associated with reduced mortality and fewer nursing home and hospital admissions   [Wk 1 · Intro & Assessment]

Rationale: CGA evaluates functional and cognitive abilities, social support, finances, environment, and physical and mental health. Domains: functional ability, physical health, cognition and mental health, and socioenvironmental situation. Benefits: more conditions identified, better functional and mental status, LOWER mortality, less nursing home and acute care use, and greater satisfaction. It works best with an interdisciplinary team (geriatrician, nurse, social worker, pharmacist), is typically outpatient, and because of cost may be reserved for high-risk patients.

Why not the others: It is team-based, multidomain, DECREASES institutionalization, and is often targeted to high-risk patients.

28.  Answer: B. 5; a DOAC such as apixaban   [Wk 3 · Cardiology]

Rationale: CHA2DS2-VASc: age ≥75 (2) + HTN (1) + DM (1) + female (1) = 5, about 7% annual stroke risk. Nonvalvular → DOAC (apixaban, rivaroxaban, dabigatran). Valvular (mechanical valve or moderate–severe MS) → warfarin. Age is a reason TO anticoagulate. If she can't take long-term anticoagulation, consider LAA closure.

Why not the others: The miscalculated scores omit the 2 points for age or the female point. Warfarin is only required for valvular AF.

29.  Answer: D. Urgent ENT (otolaryngology) referral   [Wk 2 · Sensory/Derm/Gait]

Rationale: Refer to ENT for: sudden loss <72 hours, unilateral loss >15 dB, pulsatile tinnitus, head trauma at onset, ototoxic drug use, chronic ear infections, otosclerosis, acute or chronic dizziness, ear deformity, blood, pus, or a foreign body, and bilateral speech discrimination loss. Sudden SNHL is time-sensitive (steroids).

Why not the others: Presbycusis is gradual and bilateral. OTC aids are for mild to moderate chronic loss. Delay and irrigation are inappropriate.

30.  Answer: A. Carotid endarterectomy plus antiplatelet, statin, BP control, and smoking cessation   [Wk 3 · Cardiology]

Rationale: This is a TIA (deficit <24 hours, no infarct) in the right ICA territory with high-grade SYMPTOMATIC stenosis, so revascularize. CEA is the gold standard; CAS is for hostile neck, prior radiation, or high cardiac risk. Intervention requires a life expectancy over 5 years. Asymptomatic <50% → medical therapy (aspirin, statin, BP <120/80).

Why not the others: Medical therapy alone or surveillance undertreats. Warfarin isn't indicated. CEA is preferred over CAS.

31.  Answer: E. POLST (Physician Orders for Life-Sustaining Treatment)   [Wk 1 · Intro & Assessment]

Rationale: Advance care planning makes sure care matches the patient's values when she can't speak for herself. A living will states wishes. A durable POA for HEALTH CARE names a surrogate. POLST (or MOST) is an actionable medical order for life-sustaining treatment that travels with seriously ill patients.

Why not the others: A living will isn't a medical order. A financial POA doesn't address medical decisions. A HIPAA release and a last will are unrelated.

32.  Answer: D. JVP is the best bedside volume assessment; a normal BNP essentially rules out HF   [Wk 3 · Cardiology]

Rationale: HF workup: elevated JVP is the best assessment of volume status; also S3, rales, edema. CXR shows cardiomegaly, cephalization, Kerley B lines, and effusions. A normal BNP essentially rules out HF. Echo assesses systolic and diastolic function and valves.

Why not the others: Edema, skin turgor, and capillary refill are unreliable. A normal BNP doesn't confirm HF. BNP is useful in older adults (it runs higher with age and CKD).

33.  Answer: B. About 23 units of basal insulin daily   [Wk 4 · Endo & Pulm]

Rationale: 200 × 0.23 = 46 units TDD. 50% basal = 23 units. The remaining 23 ÷ 3 ≈ 8 units before each meal. Correction factor = 1800 ÷ 46 ≈ 39 mg/dL per unit. A1c >10.5% → metformin plus insulin. Stop sulfonylureas with prandial insulin. Premixed insulin is only for patients who eat breakfast and supper.

Why not the others: 46 is the TDD. 8 is the pre-meal dose. The others are miscalculations.

34.  Answer: E. These can be age-related findings; interpret them in context of symptoms and evidence of disease rather than assuming pathology   [Wk 1 · Intro & Assessment]

Rationale: Age-related CV changes: lower peak exercise capacity, cardiac output, HR, and EF; increased LV stiffness; possible valvular regurgitation; PR, QRS, and QT prolongation; left axis deviation; and S4 commonly heard. Ask: does the patient have symptoms or evidence of pathology? Diastolic murmurs are abnormal at ANY age. A basal systolic murmur is most often aortic sclerosis, but consider AS, MR, and HOCM.

Why not the others: Each of the other options overcalls an expected finding. Diastolic murmurs are never normal.

35.  Answer: B. Presbycusis: bilateral, symmetric, high-frequency sensorineural hearing loss   [Wk 2 · Sensory/Derm/Gait]

Rationale: Presbycusis (age-related hearing loss) is sensorineural, bilateral, symmetric, insidious, and high-frequency. Consonants (p, w, f, sh) and women's and children's voices are hard to hear, causing poor speech discrimination. It affects about 44% at 60, 66% at 70, and 90% over 80. It's linked to social withdrawal, depression, reduced safety, and up to 40% faster cognitive decline.

Why not the others: Cerumen and otosclerosis are conductive (Rinne BC > AC). Acoustic neuroma is unilateral. Meniere's is episodic vertigo with low-frequency loss.

36.  Answer: A. Permanent pacemaker   [Wk 3 · Cardiology]

Rationale: Bradycardia 'rule of 3': pacemaker for HR <30, HR <35 with symptoms, or a pause >3 seconds. Aging reduces SA node pacemaker cells (sick sinus syndrome).

Why not the others: Metoprolol, digoxin, and amiodarone slow the heart further. Symptomatic pauses are not normal aging.

37.  Answer: A. Type 2 MI from supply–demand mismatch   [Wk 3 · Cardiology]

Rationale: Type 2 MI is an O2 supply/demand imbalance from acute illness: sepsis, blood loss, anemia, pneumonia, PE, COPD, CHF, dysrhythmia, or HTN urgency. Treat the cause. In older adults, NSTEMI is more common than STEMI, and the average age of first MI is 66 in men and 72 in women.

Why not the others: There's no ST elevation or plaque-rupture picture. The other diagnoses don't fit.

38.  Answer: E. No; Medicare doesn't cover non-medical personal care (ADL help) when it's the only care needed   [Wk 1 · Intro & Assessment]

Rationale: Medicare covers part-time skilled nursing and therapy at home if certified medically necessary and the patient is homebound, and a home health aide when it accompanies skilled care. Starting in 2025 it may cover caregiver training. It does NOT cover ADL help alone, homemaker services, 24-hour care, or (in most cases) family caregivers.

Why not the others: Each of the other options states a service Medicare does not cover.

39.  Answer: C. Stage 3 pressure injury; scheduled repositioning, pressure-relief surfaces, moisture management, high-protein nutrition, and wound care   [Wk 2 · Sensory/Derm/Gait]

Rationale: Pressure injuries come from unrelieved pressure plus friction, shear, and moisture. Staging: 1 = non-blanchable erythema, intact skin; 2 = partial thickness or blister; 3 = full thickness into fat; 4 = exposed bone, tendon, or muscle; unstageable = base obscured by slough or eschar. Prevention: repositioning, pressure-relief surfaces, trapeze or draw sheets for friction and shear, toileting and barrier creams for moisture, and high-protein nutrition. AVOID massaging reddened areas.

Why not the others: The depth defines stage 3. Massage is contraindicated. Repositioning is always needed.

40.  Answer: C. Add 5% dextrose in 0.45% saline and continue insulin, checking glucose hourly   [Wk 4 · Endo & Pulm]

Rationale: HHS: glucose >600, AMS, renal failure, severe dehydration, days of symptoms, triggered by infection, CVA, or MI. Treatment: ICU and airway, vigorous IV fluids, IV insulin, hourly glucose, slow the insulin drip near 300, and add D5 ½NS once glucose is below 250. Treat the trigger.

Why not the others: Stopping fluids or insulin is premature. Bicarbonate isn't indicated. Metformin is contraindicated with AKI.

41.  Answer: E. One-time abdominal ultrasound (Grade B)   [Wk 3 · Cardiology]

Rationale: USPSTF: men 65–75 who EVER smoked → one-time ultrasound (B). Men who never smoked → selective (C). Women who never smoked with no family history → against (D). Women who ever smoked or have a family history → I. Surveillance: 3.0–3.9 cm every 3 years; 4.0–4.9 cm yearly; 5.0–5.4 cm every 6 months. Refer if >4.0 cm or growing ≥0.5 cm in 6 months.

Why not the others: The other grades apply to other populations, and CT is not the screening test.

42.  Answer: A. IV alteplase now (within 4.5 hours, ideally <3 hours), plus thrombectomy evaluation if there is a large vessel occlusion   [Wk 3 · Cardiology]

Rationale: Noncontrast CT first (goal within 20 minutes of arrival). Glucose is the only lab required before alteplase (unless anticoagulated). Alteplase works best <3 hours and is acceptable up to 4.5 hours. Mechanical thrombectomy is for terminal ICA or M1 occlusion. Age is NOT a contraindication. Contraindications include bleeding, stroke, intracranial surgery, or head trauma within 3 months; intracranial neoplasm, aneurysm, or AVM; and severe uncontrolled HTN.

Why not the others: Age, MRI, labs, or heparin should not delay lytics.

43.  Answer: A. Topical prostaglandin analog (e.g., latanoprost) or topical beta-blocker   [Wk 2 · Sensory/Derm/Gait]

Rationale: Primary open-angle glaucoma: increased resistance to aqueous outflow causing optic nerve damage with PERIPHERAL loss first. Patients are usually unaware until a routine exam. It's the leading cause of blindness in Black people and the second most common cause of legal blindness. Workup: tonometry, optic disc exam, visual fields, OCT, gonioscopy. First-line therapy per the lecture: topical beta-blockers or prostaglandin analogs; second line is CAIs or alpha-2 agonists. Watch for systemic beta-blocker absorption (bradycardia, bronchospasm).

Why not the others: Oral CAIs and pilocarpine are no longer first line. Cataract surgery and anti-VEGF treat other conditions.

44.  Answer: D. Chronic atrophic candidiasis (denture stomatitis) with angular cheilitis   [Wk 2 · Sensory/Derm/Gait]

Rationale: Chronic atrophic candidiasis (denture stomatitis) is localized erythema under dentures; risk factors are poorly fitting dentures, prolonged wear, and poor hygiene. Angular cheilitis is fissured patches at the commissures (dentures, lip licking, wrinkling). Hyperplastic candidiasis forms adherent white plaques that don't scrape off (smoking; can turn malignant).

Why not the others: Pseudomembranous candidiasis has removable white patches. Geographic tongue is a benign normal finding. Cancer would be a persistent mass or ulcer.

45.  Answer: D. Increased fall risk; TUG ≥14 seconds and unipedal stance <5 seconds both predict falls   [Wk 2 · Sensory/Derm/Gait]

Rationale: TUG: rise from a chair, walk 3 m (10 ft), turn, return, and sit. ≥14 seconds means increased fall risk; watching the gait is as important as the time. Unipedal stance <5 seconds indicates higher fall risk. Usual gait speed (optimal 0.8–1.0 m/s over 4 m) is the most valid and reliable measure and predicts survival. Contributors: decreased vestibular sensitivity, peripheral vision, proprioception, and strength; slower reaction; and medications.

Why not the others: These are abnormal results and they aren't diagnostic of a specific disease.

46.  Answer: B. RSV vaccine   [Wk 4 · Endo & Pulm]

Rationale: Three FDA-licensed RSV vaccines are available for adults 60 and older. RSV has a 3–5 day incubation and contributes significant morbidity in community-dwelling and LTC older adults. Also offer influenza, pneumococcal, and COVID-19 vaccines (81% of COVID deaths occur in people over 65; Paxlovid needs renal dosing if GFR <60).

Why not the others: The other vaccines aren't indicated here.

47.  Answer: E. Glipizide (a low-cost sulfonylurea, preferred over glyburide in older adults)   [Wk 4 · Endo & Pulm]

Rationale: After metformin plus lifestyle, consider adding a sulfonylurea (low cost), SGLT2i, or GLP-1 RA. He is excluded from: GLP-1 and DPP-4 (NEVER with a history of pancreatitis), SGLT2i (frequent UTIs and genital yeast infections), and glyburide (contraindicated over 65). Glipizide is the best fit; dose cautiously.

Why not the others: The GLP-1, DPP-4, and SGLT2 options are excluded by his history. Glyburide is contraindicated over 65.

48.  Answer: A. Left conductive hearing loss, e.g., cerumen impaction   [Wk 2 · Sensory/Derm/Gait]

Rationale: Weber: conductive loss lateralizes TOWARD the affected ear; sensorineural loss lateralizes to the BETTER ear. Rinne: normal or SNHL shows AC > BC; conductive loss shows BC > AC. Common conductive causes include cerumen, otitis externa or media, TM perforation, and otosclerosis. A 512 Hz fork is ideal.

Why not the others: With SNHL, Weber goes to the good ear and Rinne stays AC > BC.

49.  Answer: C. Dyspnea on exertion may be an anginal equivalent; evaluate for coronary heart disease   [Wk 3 · Cardiology]

Rationale: DOE is the most common initial presentation of CAD in older adults. Anginal equivalents: dyspnea, epigastric pain, fatigue, confusion, malaise. The 'ischemia warning system' is impaired (patients over 70 take more than twice as long to report angina). If the picture fits a supply/demand mismatch, work up CHD.

Why not the others: Older adults frequently LACK typical pain. The other answers miss ischemia.

50.  Answer: A. Older adults often have 'apathetic' hyperthyroidism; AF occurs in about 27%, and thyroid function should be checked with any new arrhythmia or CHF   [Wk 4 · Endo & Pulm]

Rationale: Hyperthyroidism in older adults: functional decline, fatigue, weakness, cognitive changes, tachycardia, weight loss, AF in 27% (may present as CHF), less irritability, rare heat intolerance. Causes: Graves, toxic MNG, over-replacement. Treatment: propranolol; methimazole or PTU trial for 4 weeks for toxic nodular goiter; RAI (preferred for Graves).

Why not the others: Adrenergic symptoms are LESS prominent. New AF warrants thyroid testing. A suppressed TSH means hyperthyroidism. RAI is preferred in Graves.