BCPS mock exam: a timed 60-case set at exam pace

Preview — the first 10 cases of Timed set

1. Case 01Nephrology & urology

   A 59-year-old man with hypertension and CKD stage 3a (urine albumin-to-creatinine ratio 380 mg/g) started lisinopril 10 mg daily 2 weeks ago. Labs: SCr 1.40 mg/dL before starting and 1.65 mg/dL today; K 4.4 mEq/L before and 5.1 mEq/L today. BP is 132/80 mm Hg, and he feels well. Which action is most appropriate?

   1. AOption A: Reduce lisinopril to 2.5 mg daily
   2. BOption B: Discontinue lisinopril because of acute kidney injury
   3. COption C: Continue lisinopril; recheck SCr and K in 2–4 weeks
   4. DOption D: Switch lisinopril to losartan 50 mg daily
   Answer and option notes

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   An SCr rise of up to 30% after starting a RAS inhibitor reflects reduced intraglomerular pressure, not kidney injury, and KDIGO advises continuing therapy; here the rise is 18% and K is 5.1 mEq/L, so lisinopril should continue with repeat monitoring. Stopping the drug (the most tempting error) removes the antiproteinuric benefit he needs. Switching to losartan produces the same hemodynamic SCr and K effects, and cutting the dose sacrifices albuminuria reduction without a reason to do so.

   A

   Cutting to 2.5 mg gives up albuminuria reduction when the creatinine and potassium changes are expected.

   B

   An 18% creatinine rise after a RAS inhibitor reflects lower glomerular pressure, not acute kidney injury.

   C

   Correct: a rise under 30% with K of 5.1 is expected, so KDIGO advises continuing lisinopril and rechecking labs.

   D

   Losartan acts on the same pathway and causes the same creatinine and potassium shifts.

2. Case 02Pulmonology & GI

   A 32-year-old man with ileocolonic Crohn disease and a draining perianal fistula has needed three prednisone courses in the past year and flares each time the dose falls below 15 mg daily. Mesalamine was ineffective. TB testing and hepatitis B serologies are negative. Which maintenance therapy is most appropriate?

   1. AOption A: Azathioprine
   2. BOption B: Budesonide
   3. COption C: Adalimumab
   4. DOption D: Vedolizumab
   Answer and option notes

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   An anti-TNF agent such as adalimumab (or infliximab) induces and maintains steroid-free remission in moderate-to-severe Crohn disease and has the best evidence for closing perianal fistulas. Azathioprine is the tempting steroid-sparing drug, but it takes months to work and is weaker for fistulizing disease. Vedolizumab is gut-selective and less effective for perianal fistulas, and budesonide is still a corticosteroid that is not used for long-term maintenance.

   A

   Azathioprine is steroid-sparing but takes months to work and is weaker for fistulizing disease.

   B

   Budesonide is still a corticosteroid and is not used for long-term maintenance.

   C

   Correct: an anti-TNF agent maintains steroid-free remission and has the best evidence for closing perianal fistulas.

   D

   Vedolizumab is gut-selective and less effective for perianal fistulas than anti-TNF therapy.

3. Case 03Therapeutics & patient management

   A 29-year-old woman at 9 weeks of pregnancy has had well-controlled major depression on sertraline 100 mg daily for 2 years. An older drug reference she found online lists sertraline as ‘Category C,’ and she asks whether she should stop it. Which approach is most appropriate?

   1. AOption A: Continue sertraline, as Category C confirms no human risk was found
   2. BOption B: Stop sertraline, as Category C means fetal risk cannot be excluded
   3. COption C: Switch to bupropion, which was listed as a Category B antidepressant
   4. DOption D: Weigh the label’s risk summary and human data with her relapse risk
   Answer and option notes

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Under the 2015 Pregnancy and Lactation Labeling Rule the A/B/C/D/X letters were removed because they oversimplified risk; the label now gives a narrative risk summary and clinical considerations, which for sertraline support continuing therapy when relapse risk is high. Stopping because of a letter category exposes her to untreated depression, which carries its own maternal and fetal risk. Switching on the basis of an outdated letter adds a new exposure without evidence of benefit, and ‘Category C’ never meant human safety had been demonstrated.

   A

   Category C never confirmed human safety; it meant animal risk or missing data, which is why the letters were retired.

   B

   Stopping because of a letter exposes her to untreated depression, which carries its own maternal and fetal risk.

   C

   Switching because of an old letter adds a new exposure with no evidence of benefit.

   D

   Correct: the 2015 PLLR replaced letters with a narrative risk summary, to be weighed against her high relapse risk.

4. Case 04Infectious diseases

   A 44-year-old woman admitted with acute pyelonephritis has received piperacillin/tazobactam for 48 hours. She is now afebrile, eating, and hemodynamically stable. Blood and urine cultures grow E. coli susceptible to ampicillin/sulbactam, ceftriaxone, ciprofloxacin, and TMP-SMX. She has not received a fluoroquinolone in the past year. On stewardship audit, which recommendation is most appropriate?

   1. AOption A: Change to IV meropenem to cover resistant organisms
   2. BOption B: Change to oral nitrofurantoin to finish 5 days in total
   3. COption C: Continue piperacillin/tazobactam to complete 14 days
   4. DOption D: Change to oral ciprofloxacin to finish 7 days in total
   Answer and option notes

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   The 2025 IDSA complicated-UTI guideline supports oral step-down once the patient improves, even with bacteremia, and a fluoroquinolone course of 5–7 days total; ciprofloxacin is active against her isolate. Continuing broad IV therapy for 14 days adds no benefit, and escalating to meropenem ignores the susceptibility report. Nitrofurantoin does not reach therapeutic renal or blood concentrations and should not be used for pyelonephritis or bacteremia.

   A

   Meropenem escalates to a carbapenem despite a fully susceptible E. coli and adds resistance pressure.

   B

   Nitrofurantoin does not reach therapeutic kidney or blood levels and is not used for pyelonephritis.

   C

   She is stable and improving, so 14 days of broad IV therapy adds no benefit.

   D

   Correct: once stable, oral step-down to an active fluoroquinolone for a 7-day total course fits complicated UTI guidance.

5. Case 05Biostatistics

   A nurse asks whether IV vancomycin and IV meropenem can be co-administered through the same Y-site line in a patient with limited venous access. Which resource is most appropriate for answering this question?

   1. AOption A: FDA Orange Book
   2. BOption B: Natural Medicines Comprehensive Database
   3. COption C: Trissel’s Handbook on Injectable Drugs
   4. DOption D: Drugs and Lactation Database (LactMed)
   Answer and option notes

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   Trissel’s Handbook on Injectable Drugs (also available as the IV compatibility tool in Micromedex) is the standard reference for Y-site and admixture compatibility data. LactMed covers drugs in breastfeeding, and Natural Medicines covers herbals and supplements. The Orange Book lists therapeutic equivalence ratings for generic substitution, not compatibility.

   A

   The Orange Book lists therapeutic equivalence ratings for generics, not IV compatibility.

   B

   Natural Medicines covers herbals and supplements, not Y-site compatibility.

   C

   Correct: Trissel’s Handbook is the standard reference for Y-site and admixture compatibility of injectables.

   D

   LactMed covers drugs in breastfeeding and has no compatibility data.

6. Case 06Critical care

   A 72-year-old woman with septic shock from cholangitis remains hypotensive (MAP 56 mm Hg) after 30 mL/kg of balanced crystalloid. Piperacillin-tazobactam was given within the first hour. She has two peripheral IV catheters in the antecubital veins; central line placement is expected to take about 2 hours. Which vasopressor plan is most appropriate?

   1. AOption A: Dopamine via a peripheral IV now
   2. BOption B: Norepinephrine only after central access
   3. COption C: Norepinephrine via a peripheral IV now
   4. DOption D: Phenylephrine via a peripheral IV now
   Answer and option notes

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   Norepinephrine is the first-line vasopressor in septic shock, and the Surviving Sepsis Campaign supports starting it through a well-placed peripheral IV rather than delaying while a central line is placed, because time spent hypotensive worsens outcomes. Waiting for central access is the tempting safety choice, but short-term proximal peripheral infusion has a low extravasation risk. Dopamine causes more arrhythmias and higher mortality than norepinephrine, and phenylephrine is not first-line.

   A

   Dopamine causes more arrhythmias and higher mortality than norepinephrine in septic shock.

   B

   Waiting about 2 hours for central access prolongs hypotension; short-term peripheral norepinephrine is acceptable.

   C

   Correct: norepinephrine is first line, and starting it through a proximal peripheral IV avoids delay while the central line is placed.

   D

   Phenylephrine is not a first-line vasopressor in septic shock.

7. Case 07Therapeutics & patient management

   A pharmacist reconciles the discharge orders of a 68-year-old woman admitted for a hip fracture. Four discrepancies are found between her home list and the discharge orders. Which discrepancy must be resolved before she leaves?

   1. AOption A: Home docusate 100 mg twice daily not listed at discharge
   2. BOption B: Inpatient sliding-scale insulin stopped and home metformin resumed
   3. COption C: Home omeprazole 20 mg replaced by inpatient pantoprazole 40 mg
   4. DOption D: Home apixaban resumed with enoxaparin 40 mg daily also ordered
   Answer and option notes

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Resuming home apixaban while also prescribing enoxaparin duplicates anticoagulant therapy with high-alert drugs and carries an immediate risk of serious bleeding, so it takes priority. A formulary PPI interchange is a low-risk discrepancy that only needs clarification for home use. A missing stool softener and the planned return from sliding-scale insulin to home metformin are expected, low-harm changes.

   A

   Missing docusate is a low-harm omission that can be clarified without holding discharge.

   B

   Returning from sliding-scale insulin to home metformin is an expected, intended change.

   C

   A formulary PPI interchange is low-risk and needs only clarification for home use.

   D

   Correct: apixaban plus enoxaparin duplicates high-alert anticoagulants and creates an immediate bleeding risk.

8. Case 08Therapeutics & patient management

   A 76-year-old woman with osteoporosis and no swallowing problems is starting alendronate 70 mg once weekly. She also takes calcium carbonate 600 mg twice daily with meals. Which administration instruction is correct?

   1. AOption A: Take with orange juice, then lie down for 30 minutes
   2. BOption B: Take on waking with plain water, 30 minutes before food
   3. COption C: Take with breakfast and her morning calcium supplement
   4. DOption D: Take at bedtime with a small glass of milk to avoid upset
   Answer and option notes

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   Oral bisphosphonates are poorly absorbed (under 1%), so alendronate must be taken on an empty stomach with 6–8 oz of plain water at least 30 minutes before food, drink, or other medications, and she must stay upright to prevent esophagitis. Calcium binds alendronate and blocks absorption, as do milk and juice. Taking it at bedtime or lying down afterward allows reflux of the tablet into the esophagus.

   A

   Juice blocks absorption, and lying down afterward lets the tablet reflux and injure the esophagus.

   B

   Correct: alendronate is poorly absorbed, so it goes on waking with plain water, 30 minutes before food, and she stays upright.

   C

   Calcium binds alendronate in the gut, and food blocks its already tiny absorption.

   D

   Milk blocks absorption, and a bedtime dose leaves her lying down with reflux risk.

9. Case 09Therapeutics & patient management

   A 70-year-old hospice patient with metastatic esophageal cancer has had stable pain control for 3 weeks on morphine ER 30 mg every 12 hours, but progressive dysphagia now prevents him from swallowing tablets. Renal function is normal. Which long-acting regimen is most appropriate?

   1. AOption A: Fentanyl 25 mcg/hr patch every 72 hours
   2. BOption B: Crushed morphine ER tablets in applesauce
   3. COption C: Hydromorphone 2 mg IM every 4 hours
   4. DOption D: Fentanyl 50 mcg/hr patch every 72 hours
   Answer and option notes

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   He takes 60 mg/day of oral morphine and is opioid tolerant, so a transdermal route is appropriate; the label conversion for 60–134 mg/day oral morphine is fentanyl 25 mcg/hr, applied with the last ER morphine dose because the patch takes 12–24 hours to reach effect. The 50 mcg/hr patch roughly doubles his exposure and risks respiratory depression. Crushing an ER tablet dumps the whole 12-hour dose at once, and repeated IM injections are painful and unnecessary in hospice.

   A

   Correct: 60 mg/day of oral morphine converts to fentanyl 25 mcg/hr by the label table, and he is opioid tolerant.

   B

   Crushing an ER tablet releases the whole 12-hour dose at once and risks overdose.

   C

   Repeated IM injections are painful and unnecessary when a transdermal route is available.

   D

   A 50 mcg/hr patch roughly doubles his current exposure and risks respiratory depression.

10. Case 10Therapeutics & patient management

    A 70-year-old woman (80 kg) in the ICU is diagnosed with a proximal DVT. SCr is 2.1 mg/dL and her calculated CrCl is 25 mL/min; it has been stable for 3 days. Platelets are 210,000 cells/mm³, and she has no active bleeding. Which anticoagulant regimen is most appropriate to start?

    1. AOption A: Enoxaparin 40 mg SC every 24 hours
    2. BOption B: Enoxaparin 80 mg SC every 12 hours
    3. COption C: Fondaparinux 7.5 mg SC every 24 hours
    4. DOption D: Enoxaparin 80 mg SC every 24 hours
    Answer and option notes

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    For treatment-dose enoxaparin at CrCl below 30 mL/min, the 1 mg/kg dose is kept but the interval is extended from every 12 to every 24 hours, giving 80 mg once daily. Continuing 80 mg every 12 hours causes accumulation of this renally cleared drug and bleeding. 40 mg once daily is a prophylactic dose, and fondaparinux is contraindicated at CrCl below 30 mL/min.

    A

    40 mg once daily is a prophylactic dose and will not treat an acute DVT.

    B

    Keeping the every-12-hour interval at CrCl 25 lets this renally cleared drug accumulate and raises bleeding risk.

    C

    Fondaparinux is contraindicated at CrCl below 30 mL/min.

    D

    Correct: at CrCl below 30, the enoxaparin treatment dose stays 1 mg/kg but is given every 24 hours, so 80 mg once daily.