A 46-year-old woman is admitted with acute pancreatitis from gallstones. She has mild tachycardia (HR 104 beats/minute), BP 118/74 mm Hg, BUN 24 mg/dL and hematocrit 46%, and no signs of heart failure. She has epigastric pain of 8/10. Which initial management is most appropriate?

Lactated Ringer’s at a moderate, guided rate

Parenteral nutrition while kept NPO for 7 days

Meropenem 1 g IV every 8 hours as prophylaxis

Normal saline 20 mL/kg bolus, then 3 mL/kg/hour

A 45-year-old man has a duodenal ulcer and a positive H. pylori stool antigen test. He reports hives after amoxicillin as a child and took azithromycin for bronchitis 4 months ago. He takes no other medications. Which eradication regimen is most appropriate?

PPI, bismuth, tetracycline and metronidazole for 14 days

PPI, clarithromycin, amoxicillin and metronidazole for 14 days

PPI, clarithromycin and metronidazole for 14 days

Vonoprazan and amoxicillin for 14 days

A 56-year-old man with compensated cirrhosis from chronic hepatitis C completed 12 weeks of sofosbuvir/velpatasvir, and his HCV RNA is undetectable 12 weeks after treatment (SVR12). He asks what follow-up he needs. Which plan is most appropriate?

Liver ultrasound every 6 months, indefinitely

No further monitoring at all, since he is cured

HCV antibody yearly to confirm the cure

HCV RNA every 6 months for 5 years

A 68-year-old man with COPD on budesonide/glycopyrrolate/formoterol is being discharged after a 2-day admission for a moderate exacerbation. He is improving, and his sputum is no longer purulent after azithromycin. Which systemic corticosteroid regimen is most appropriate to complete at home?

Prednisone 40 mg daily for 5 days, no taper

Prednisone 40 mg for 5 days, then 10 mg daily

Prednisone 20 mg daily for 21 days

Prednisone 60 mg daily, tapered over 14 days

A 66-year-old man with COPD (post-bronchodilator FEV1 52% of predicted, mMRC 2) uses umeclidinium/vilanterol daily with good technique and adherence. He quit smoking 5 years ago. In the past 12 months he had one exacerbation, treated as an outpatient with prednisone and an antibiotic, and no hospital stays. Blood eosinophils are 340 cells/µL. Under GOLD 2026, how should he be classified and managed?

High exacerbation risk; add an ICS to LABA + LAMA

Low risk with only one event; keep LABA + LAMA

High exacerbation risk; add azithromycin to LABA + LAMA

High exacerbation risk; switch to an ICS + LABA inhaler

A 14-year-old girl (52 kg) with severe asthma has had three oral corticosteroid bursts in the past year despite good adherence to high-dose fluticasone/salmeterol plus tiotropium. Blood eosinophils are 480 cells/µL, total IgE is 22 IU/mL, and she has no aeroallergen sensitization. Which add-on therapy is most appropriate?

Mepolizumab 100 mg SC every 4 weeks

Omalizumab dosed by IgE and weight

Daily prednisone 10 mg as maintenance

Reslizumab 3 mg/kg IV every 4 weeks

A 58-year-old man with alcohol-associated cirrhosis has a second episode of overt hepatic encephalopathy despite adherence to lactulose titrated to 2–3 soft stools daily. Infection, GI bleeding, and electrolyte disorders have been excluded. CrCl is 70 mL/min. Which addition is most appropriate for preventing recurrence?

Rifaximin 550 mg twice daily with lactulose

Metronidazole 250 mg three times daily long term

Dietary protein restriction to 0.5 g/kg/day

Neomycin 1 g every 6 hours long term

A 22-year-old man with a severe asthma exacerbation has received continuous albuterol nebulization for 1 hour, ipratropium three times and methylprednisolone 125 mg IV. He is improving: peak flow rose from 30% to 55% of predicted and SpO2 is 95%. HR is 128 beats/minute in sinus rhythm (it was 132 on arrival), K 3.6 mEq/L. The nurse asks about the tachycardia. Which recommendation is most appropriate?

Continue albuterol; tachycardia is not a reason to stop

Switch albuterol to levalbuterol to lower the heart rate

Add IV metoprolol to slow the heart rate

Stop albuterol and start IV aminophylline

A 29-year-old man with ileal Crohn disease responded to infliximab 5 mg/kg every 8 weeks, but over the last 2 months his diarrhea and abdominal pain have returned. Stool studies for infection are negative, and fecal calprotectin is 650 mcg/g. His infliximab trough is 1.2 mcg/mL (target at least 5), and anti-infliximab antibodies are undetectable. Which action is most appropriate?

Increase the infliximab dose or shorten the interval

Continue infliximab unchanged; low troughs are expected

Add prednisone 10 mg daily long term

Switch to adalimumab because infliximab has failed

A 49-year-old man has taken omeprazole 40 mg daily for 3 years for heartburn and has had no symptoms for more than 2 years. Upper endoscopy before treatment showed no erosive esophagitis and no Barrett’s esophagus. He takes no NSAIDs, aspirin, or anticoagulants, and he asks whether he still needs the PPI. Which recommendation is most appropriate?

Try on-demand use, and warn that rebound heartburn may occur

Continue daily omeprazole, since GERD is a lifelong disease

Stop omeprazole and start daily sucralfate to protect the esophagus

Switch to esomeprazole, which carries less long-term risk

A 39-year-old woman with pulmonary arterial hypertension receives continuous IV epoprostenol through a tunneled central catheter with a home ambulatory pump. She calls because the pump alarmed and the infusion has been stopped for about 10 minutes; she is becoming short of breath and lightheaded. Which action is most appropriate?

Restart it now with her backup pump and cassette

Restart at twice the usual rate to replace the missed drug

Wait for the next scheduled cassette change to restart

Take her oral sildenafil and restart the pump tomorrow

A 71-year-old former smoker with COPD has had two moderate exacerbations in the past year despite tiotropium/olodaterol/budesonide triple therapy with good technique. Blood eosinophils are 80 cells/µL. Azithromycin 250 mg daily is planned to reduce exacerbations. He takes no other medications. Which assessment should be completed before starting azithromycin?

ECG for QTc and a hearing assessment

Repeat pulmonary function testing

Baseline liver enzymes and creatine kinase

A 62-year-old man with chronic hepatitis B has taken tenofovir disoproxil fumarate 300 mg daily for 6 years; HBV DNA has been undetectable for 5 years. His eGFR has declined from 85 to 52 mL/min/1.73 m², he has new hypophosphatemia, and DXA shows osteoporosis. Which action is most appropriate?

Switch to tenofovir alafenamide 25 mg daily

Change TDF to 300 mg every 48 hours

Stop antiviral therapy since HBV DNA is undetectable

Switch to lamivudine 100 mg daily

A 78-year-old man with COPD has an exacerbation with increased dyspnea, sputum volume and sputum purulence and is managed as an outpatient. He takes amiodarone for atrial fibrillation, and his QTc is 495 ms. He has no drug allergies, no Pseudomonas risk factors, and CrCl is 55 mL/min. Which antibiotic is most appropriate?

Amoxicillin-clavulanate 875/125 mg twice daily for 5 days

Moxifloxacin 400 mg daily for 5 days

Azithromycin 500 mg on day 1, then 250 mg daily for 4 days

Levofloxacin 750 mg daily for 5 days

A 70-year-old man with alcohol-related cirrhosis presents with hematemesis. BP is 94/58 mm Hg and HR 112 beats/minute after initial transfusion, hemoglobin 7.4 g/dL. Variceal bleeding is suspected, and endoscopy is planned within 12 hours. Which pharmacologic regimen should be started now?

Octreotide infusion plus ceftriaxone 1 g IV daily

Propranolol 20 mg orally twice daily plus ceftriaxone

BCPS Pulmonology and GI Review: COPD, Asthma, Liver

1GOLD 2026: what moved, and why old answer keys break

GOLD rewrites its report every year, and the 2026 edition redrew the line for the high-risk “exacerbator” group: it now takes fewer moderate or severe exacerbations in the past 12 months to land there than it did under the reports most review books were written against. The exact cutoff and how it changes escalation are laid out on our asthma vs COPD inhaler page. Read that before you trust a flashcard printed in 2023.

GOLD 2026 also names biologic options for selected COPD patients. You do not need a biologic decision tree for this exam. You do need to recognize that a COPD case may now offer a biologic as a defensible option, so you can no longer eliminate it on reflex.

2Two airway guidelines, two starting points

≠ marks rows where the two differ.

Where GINA 2026 and GOLD 2026 begin maintenance therapy, and the classic wrong answer each one rules out.
Question	Asthma (GINA 2026)	COPD (GOLD 2026)
Differs: Report year	GINA 2026, May 2026	GOLD 2026, November 2025
Differs: Anchor of maintenance therapy	Inhaled corticosteroid from the first step (Track 1: ICS-formoterol as reliever or maintenance and reliever)	Long-acting bronchodilators first
Differs: Wrong answer it rules out	SABA-only treatment; LABA without an ICS	ICS monotherapy
Differs: Where an ICS fits	Always, in every adult and adolescent step	As an add-on for selected patients
Differs: Risk label to know	Symptom control plus future exacerbation risk	The exacerbator definition, changed in 2026

Summarized from GINA 2026 (May 2026) and GOLD 2026 (November 2025), as of October 27, 2026. Check the reports themselves at ginasthma.org and goldcopd.org before you treat a patient.

3Gastroenterology: read the record first

GI cases usually hand you the diagnosis. What remains is which option this patient’s record allows, so the lines that look like background (allergies, kidney function, everything else on the medication list) carry the decision. Skim them and you can pick a sound regimen the patient cannot take.

3.1Acid suppression

Treat every acid suppressant as a drug that needs a current reason. A proton pump inhibitor started for stress ulcer prophylaxis in the ICU and carried through transfer and discharge is a reconciliation finding, not a home medication.

3.2Inflammatory bowel disease

Sort an IBD regimen into drugs meant to induce remission and drugs meant to keep it. A plan that leans on systemic corticosteroids for maintenance is a red flag in any chronic inflammatory disease.

3.3Liver disease

In advanced liver disease, ask what to avoid as often as what to give. Drugs that sedate, injure the kidneys or add to bleeding risk deserve a second look in any patient with cirrhosis, and the kidney function on the chart can change which alternative is safe.

4Underline these before you look at the options

The QTc and any other QT-prolonging drug already on the list
The allergy line, with what the reaction actually was
Exacerbation history over the past 12 months
Renal function, quoted as CrCl or eGFR (they are not interchangeable; see CrCl vs eGFR for dosing)
Over-the-counter drugs and supplements, which are easy to read past
Smoking status and inhaler technique, before any step-up in therapy
Pregnancy potential, for any drug with a teratogenic warning

5Airway and gut decisions

Work each case to a decision of your own, then read the note on every option, the wrong ones included.

Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.

Case 1 of 15 · 0 answered

How case rounds work

Pick an option to see the verdict and a note on every option. Keys while the round has focus: 1–5 or A–E answer, ← → move between cases. Nothing is saved or sent anywhere.

Case 01
A 46-year-old woman is admitted with acute pancreatitis from gallstones. She has mild tachycardia (HR 104 beats/minute), BP 118/74 mm Hg, BUN 24 mg/dL and hematocrit 46%, and no signs of heart failure. She has epigastric pain of 8/10. Which initial management is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
Current guidance (ACG 2024, after WATERFALL) favors moderate, goal-directed resuscitation with lactated Ringer’s, given as about 10 mL/kg if hypovolemic and then 1.5 mL/kg/hour with frequent reassessment. Aggressive normal saline was standard teaching, but it caused fluid overload without better outcomes, and saline adds hyperchloremic acidosis. Prophylactic antibiotics are not recommended without infected necrosis, and early oral or enteral feeding is preferred over parenteral nutrition.
A
Early oral or enteral feeding is preferred, and a 7-day NPO period with PN is outdated.
B
Correct: moderate, goal-directed lactated Ringer’s with frequent reassessment is the current approach after WATERFALL.
C
Prophylactic antibiotics are not recommended without infected necrosis.
D
Aggressive normal saline caused fluid overload without better outcomes and adds hyperchloremic acidosis.
Case 02
A 45-year-old man has a duodenal ulcer and a positive H. pylori stool antigen test. He reports hives after amoxicillin as a child and took azithromycin for bronchitis 4 months ago. He takes no other medications. Which eradication regimen is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
Bismuth quadruple therapy is the preferred first-line regimen in the ACG 2024 guideline and contains no penicillin, so it fits his amoxicillin allergy. PPI, clarithromycin and metronidazole is the tempting penicillin-free alternative, but his recent macrolide exposure predicts clarithromycin resistance, and clarithromycin triple therapy is no longer recommended empirically in the US. Both amoxicillin-containing regimens are inappropriate unless penicillin allergy is first delabeled.
A
This regimen contains amoxicillin, which is inappropriate with his hives history unless the allergy is delabeled.
B
Correct: bismuth quadruple therapy is the preferred first-line regimen and contains no penicillin.
C
Recent azithromycin predicts clarithromycin resistance, and empiric clarithromycin regimens are no longer recommended in the US.
D
Vonoprazan-amoxicillin dual therapy contains amoxicillin, which his allergy history rules out.
Case 03
A 56-year-old man with compensated cirrhosis from chronic hepatitis C completed 12 weeks of sofosbuvir/velpatasvir, and his HCV RNA is undetectable 12 weeks after treatment (SVR12). He asks what follow-up he needs. Which plan is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: D.
SVR12 defines virologic cure, but patients with cirrhosis keep a substantial risk of hepatocellular carcinoma, so AASLD/IDSA recommend continued HCC surveillance with ultrasound (with or without AFP) every 6 months indefinitely. Stopping all monitoring ignores that residual cancer risk. Late relapse after SVR12 is rare, so serial HCV RNA is unnecessary without new exposure, and the antibody remains positive for life and cannot confirm cure or detect reinfection.
A
Cure removes the virus, but cirrhosis leaves a substantial liver cancer risk that still needs surveillance.
B
The antibody stays positive for life and cannot confirm cure or detect reinfection.
C
Late relapse after SVR12 is rare, so serial HCV RNA is unnecessary without new exposure.
D
Correct: cirrhosis keeps the HCC risk after cure, so ultrasound surveillance every 6 months continues indefinitely.
Case 04
A 68-year-old man with COPD on budesonide/glycopyrrolate/formoterol is being discharged after a 2-day admission for a moderate exacerbation. He is improving, and his sputum is no longer purulent after azithromycin. Which systemic corticosteroid regimen is most appropriate to complete at home?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
GOLD recommends prednisone 40 mg daily for 5 days for an exacerbation; the REDUCE trial showed 5 days is as effective as 14 days with less steroid exposure, and a course this short needs no taper. A 14-day tapered course adds hyperglycemia, myopathy, and infection risk without benefit. Maintenance oral steroids are discouraged in COPD, and a lower dose for 21 days gives more cumulative exposure without better efficacy.
A
A tail of 10 mg daily adds steroid exposure, and maintenance oral steroids are discouraged in COPD.
B
A lower dose for 21 days gives more cumulative exposure without better efficacy.
C
Correct: prednisone 40 mg for 5 days is as effective as 14 days, and a course this short needs no taper.
D
A 14-day taper adds hyperglycemia, myopathy and infection risk without benefit.
Case 05
A 66-year-old man with COPD (post-bronchodilator FEV1 52% of predicted, mMRC 2) uses umeclidinium/vilanterol daily with good technique and adherence. He quit smoking 5 years ago. In the past 12 months he had one exacerbation, treated as an outpatient with prednisone and an antibiotic, and no hospital stays. Blood eosinophils are 340 cells/µL. Under GOLD 2026, how should he be classified and managed?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
GOLD 2026 now places anyone with at least one moderate or severe exacerbation in the past 12 months in the high-risk group E. The earlier threshold was two moderate exacerbations or one leading to hospitalization. For patients with further exacerbations on LABA + LAMA, GOLD suggests escalating to LABA + LAMA + ICS when blood eosinophils are at least 100 cells/µL. The benefit is largest at 300 or more, as here. Azithromycin or roflumilast are options mainly when eosinophils are low. An ICS + LABA combination is not encouraged in COPD; if an ICS is indicated, triple therapy is preferred.
A
Correct. GOLD 2026 counts one moderate exacerbation as high risk; with eosinophils of 340, the next step is LABA + LAMA + ICS.
B
This is the old rule (two moderate exacerbations or one hospitalization). GOLD 2026 lowered the threshold to one moderate or severe event.
C
Azithromycin is mainly for patients with eosinophils below 100. At 340, an ICS is the better-supported step.
D
GOLD does not encourage ICS + LABA in COPD. When an ICS is indicated, triple therapy is preferred over dropping the LAMA.
Case 06
A 14-year-old girl (52 kg) with severe asthma has had three oral corticosteroid bursts in the past year despite good adherence to high-dose fluticasone/salmeterol plus tiotropium. Blood eosinophils are 480 cells/µL, total IgE is 22 IU/mL, and she has no aeroallergen sensitization. Which add-on therapy is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
Severe eosinophilic asthma with frequent exacerbations on Step 5 therapy is an indication for an anti-IL-5 biologic, and mepolizumab 100 mg SC every 4 weeks is approved from age 6 and reduces exacerbations and steroid use. Omalizumab requires a total IgE of at least 30 IU/mL and allergic sensitization, and she has neither. Reslizumab is approved only for adults 18 and older, and GINA discourages maintenance oral corticosteroids because of cumulative toxicity.
A
Omalizumab needs a total IgE of at least 30 IU/mL and allergic sensitization, and she has neither.
B
Correct: severe eosinophilic asthma with frequent bursts calls for an anti-IL-5 biologic, and mepolizumab is labeled for her age.
C
Maintenance oral corticosteroids are discouraged because of cumulative toxicity, especially in an adolescent.
D
Reslizumab is labeled only for adults 18 and older and is given IV.
Case 07
A 58-year-old man with alcohol-associated cirrhosis has a second episode of overt hepatic encephalopathy despite adherence to lactulose titrated to 2–3 soft stools daily. Infection, GI bleeding, and electrolyte disorders have been excluded. CrCl is 70 mL/min. Which addition is most appropriate for preventing recurrence?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
AASLD/EASL guidance adds rifaximin to lactulose after a second episode of overt HE; the combination reduced recurrence and hospitalization in a randomized trial. Long-term neomycin causes ototoxicity and nephrotoxicity, and chronic metronidazole causes peripheral neuropathy. Protein restriction is outdated—it worsens malnutrition and sarcopenia—and patients with cirrhosis should receive 1.2–1.5 g/kg/day.
A
Chronic metronidazole causes peripheral neuropathy, so it is not used for long-term prevention.
B
Correct: rifaximin added to lactulose after a second overt episode reduced recurrence and hospitalization.
C
Protein restriction worsens malnutrition and sarcopenia; cirrhosis calls for 1.2–1.5 g/kg/day.
D
Long-term neomycin causes ototoxicity and nephrotoxicity.
Case 08
A 22-year-old man with a severe asthma exacerbation has received continuous albuterol nebulization for 1 hour, ipratropium three times and methylprednisolone 125 mg IV. He is improving: peak flow rose from 30% to 55% of predicted and SpO2 is 95%. HR is 128 beats/minute in sinus rhythm (it was 132 on arrival), K 3.6 mEq/L. The nurse asks about the tachycardia. Which recommendation is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
In acute asthma, sinus tachycardia usually reflects respiratory distress and often falls as bronchospasm resolves, and his improving peak flow shows the albuterol is working, so it should continue with potassium monitoring. Switching to levalbuterol is a common reflex, but trials show no meaningful difference in heart rate at equivalent bronchodilating doses. Aminophylline adds arrhythmia and seizure risk without more bronchodilation, and β-blockers can precipitate severe bronchospasm.
A
Correct: improving peak flow shows albuterol is working, and the tachycardia usually eases as bronchospasm resolves.
B
Levalbuterol shows no meaningful heart-rate difference at equivalent bronchodilating doses.
C
A beta-blocker can precipitate severe bronchospasm in acute asthma.
D
Aminophylline adds arrhythmia and seizure risk without more bronchodilation, and stopping albuterol removes the working drug.
Case 09
A 29-year-old man with ileal Crohn disease responded to infliximab 5 mg/kg every 8 weeks, but over the last 2 months his diarrhea and abdominal pain have returned. Stool studies for infection are negative, and fecal calprotectin is 650 mcg/g. His infliximab trough is 1.2 mcg/mL (target at least 5), and anti-infliximab antibodies are undetectable. Which action is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
A subtherapeutic trough without anti-drug antibodies indicates pharmacokinetic failure, which proactive drug monitoring corrects by dose intensification (10 mg/kg or every 4–6 weeks); calprotectin confirms active inflammation rather than functional symptoms. Switching within the TNF class is the preferred step when high antibody titers are present, not here. Long-term corticosteroids are not maintenance therapy, and leaving the low trough unaddressed allows ongoing inflammation.
A
A low trough with active inflammation is not expected; it is a correctable cause of lost response.
B
Correct: a subtherapeutic trough without antibodies is pharmacokinetic failure, corrected by dose intensification.
C
Long-term corticosteroids are not maintenance therapy for Crohn disease.
D
Switching within the class is the step when high antibody titers are present, which is not the case here.
Case 10
A 49-year-old man has taken omeprazole 40 mg daily for 3 years for heartburn and has had no symptoms for more than 2 years. Upper endoscopy before treatment showed no erosive esophagitis and no Barrett’s esophagus. He takes no NSAIDs, aspirin, or anticoagulants, and he asks whether he still needs the PPI. Which recommendation is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
The ACG 2022 GERD guideline advises that, for patients without erosive esophagitis or Barrett’s esophagus whose symptoms have resolved on a PPI, an attempt should be made to stop the PPI or switch to on-demand use (taking it only when symptoms occur). This patient has no ongoing indication: no erosive disease, no Barrett’s, and no NSAID or antiplatelet use. Stopping a PPI can cause rebound acid hypersecretion for a few weeks. Counseling him about this helps keep him from restarting daily therapy out of fear that the disease has returned.
A
Without erosive esophagitis, Barrett’s or another ongoing indication, indefinite daily PPI use is not needed.
B
Sucralfate is not a maintenance alternative for GERD and adds pill burden without a clear indication.
C
Correct. ACG 2022 advises trying to stop or switching to on-demand use; transient rebound acid symptoms do not mean the GERD is back.
D
Esomeprazole is a PPI too, with the same class concerns. Switching does not address the lack of an ongoing indication.
Case 11
A 39-year-old woman with pulmonary arterial hypertension receives continuous IV epoprostenol through a tunneled central catheter with a home ambulatory pump. She calls because the pump alarmed and the infusion has been stopped for about 10 minutes; she is becoming short of breath and lightheaded. Which action is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: D.
Epoprostenol has a half-life of only a few minutes, so any interruption causes rapid rebound pulmonary hypertension and possible right heart failure; patients are taught to switch to their backup pump and cassette immediately (or go to the emergency department if they cannot). Waiting for the next change or until tomorrow allows dangerous rebound. Oral sildenafil cannot replace the prostacyclin, and doubling the rate causes hypotension, flushing, and headache.
A
Doubling the rate causes hypotension, flushing and headache rather than replacing what was missed.
B
Epoprostenol’s half-life is minutes, so waiting for the next cassette allows dangerous rebound.
C
Oral sildenafil cannot replace the prostacyclin, and a day off the pump risks right heart failure.
D
Correct: with a half-life of minutes, any interruption causes rebound, so she restarts at once on the backup pump.
Case 12
A 71-year-old former smoker with COPD has had two moderate exacerbations in the past year despite tiotropium/olodaterol/budesonide triple therapy with good technique. Blood eosinophils are 80 cells/µL. Azithromycin 250 mg daily is planned to reduce exacerbations. He takes no other medications. Which assessment should be completed before starting azithromycin?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
Long-term azithromycin reduces COPD exacerbations in former smokers, but it can prolong the QT interval and cause hearing loss, so a baseline ECG (avoid if QTc is prolonged) and hearing assessment are recommended before starting; ruling out nontuberculous mycobacterial infection is also advised. Liver enzymes and CK are the monitoring tests for statins, not macrolides. Repeat spirometry does not change the decision, and azithromycin needs no renal dose adjustment.
A
Correct: azithromycin can prolong QT and cause hearing loss, so a baseline ECG and a hearing check come first.
B
Repeat spirometry does not change the decision to start azithromycin.
C
Liver enzymes and CK are monitoring tests for statins, not for macrolides.
D
Azithromycin needs no renal dose adjustment, so creatinine and potassium do not gate the start.
Case 13
A 62-year-old man with chronic hepatitis B has taken tenofovir disoproxil fumarate 300 mg daily for 6 years; HBV DNA has been undetectable for 5 years. His eGFR has declined from 85 to 52 mL/min/1.73 m², he has new hypophosphatemia, and DXA shows osteoporosis. Which action is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
Tenofovir alafenamide achieves the same antiviral effect with much lower plasma tenofovir, causing less renal tubular and bone toxicity, and AASLD recommends switching to it (or entecavir) when renal dysfunction or bone disease develops. Stopping therapy risks a severe hepatitis flare. Lamivudine has a high rate of resistance, and every-48-hour TDF dosing applies to CrCl 30–49 mL/min while still exposing him to the same toxicity.
A
Every-48-hour dosing applies to CrCl 30–49 mL/min and still exposes him to the same tubular and bone toxicity.
B
Correct: tenofovir alafenamide keeps viral suppression with lower plasma tenofovir and less renal and bone toxicity.
C
Stopping therapy risks a severe hepatitis flare even with undetectable DNA.
D
Lamivudine has a high resistance rate and is a poor long-term choice.
Case 14
A 78-year-old man with COPD has an exacerbation with increased dyspnea, sputum volume and sputum purulence and is managed as an outpatient. He takes amiodarone for atrial fibrillation, and his QTc is 495 ms. He has no drug allergies, no Pseudomonas risk factors, and CrCl is 55 mL/min. Which antibiotic is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
Increased sputum purulence plus another cardinal symptom warrants a 5-day antibiotic course for a COPD exacerbation, and amoxicillin-clavulanate covers H. influenzae, M. catarrhalis and S. pneumoniae without QT liability. With a QTc of 495 ms on amiodarone, every QT-prolonging option is a poor choice: moxifloxacin carries the highest QT risk among fluoroquinolones, levofloxacin also prolongs QT, and azithromycin, the tempting usual choice, has been linked to excess cardiac death in patients at risk.
A
Correct: amoxicillin-clavulanate covers the usual COPD exacerbation pathogens without adding QT risk.
B
Moxifloxacin carries the highest QT risk among fluoroquinolones, unsafe at 495 ms on amiodarone.
C
Azithromycin is the usual pick but prolongs QT and has been linked to cardiac death in at-risk patients.
D
Levofloxacin also prolongs QT, which matters with amiodarone and a QTc of 495 ms.
Case 15
A 70-year-old man with alcohol-related cirrhosis presents with hematemesis. BP is 94/58 mm Hg and HR 112 beats/minute after initial transfusion, hemoglobin 7.4 g/dL. Variceal bleeding is suspected, and endoscopy is planned within 12 hours. Which pharmacologic regimen should be started now?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
Suspected variceal bleeding in cirrhosis needs a splanchnic vasoconstrictor (octreotide bolus, then infusion for 2–5 days) to lower portal pressure plus short-term antibiotic prophylaxis with ceftriaxone, which reduces infection, rebleeding and mortality. Octreotide alone is the tempting answer, but omitting the antibiotic misses a proven mortality benefit. A PPI does not treat variceal bleeding, and a nonselective β-blocker is for secondary prevention and is harmful during active bleeding with hypotension.
A
A PPI does not treat variceal bleeding.
B
Correct: octreotide lowers portal pressure, and ceftriaxone prophylaxis reduces infection, rebleeding and mortality.
C
Octreotide alone omits the antibiotic prophylaxis that carries a proven mortality benefit.
D
A nonselective beta-blocker is for secondary prevention and is harmful during active bleeding with hypotension.

6Pulmonology and GI, briefly

Which GOLD report should I study for the BCPS exam?

Study GOLD 2026, released in November 2025, and learn what it changed from earlier reports. BPS does not say which guideline edition a form follows; its Candidate’s Guide (as of October 27, 2026) notes that forms are assembled months ahead and leave out rapidly evolving practice changes.

Is inhaler technique tested here or somewhere else?

Device use belongs to Domain 2 (medication delivery and patient education), so it can appear in any airway case. Our therapeutics and patient management guide covers how that domain is built.

Where is tuberculosis covered?

Under infectious diseases. Latent TB regimens from the CDC/NTCA 2020 guidelines sit with the other antimicrobial topics in the infectious diseases guide.

Where should I go after this domain?

Neurology and Psychiatry sit in the same secondary tier, so neurology and psychiatry is a natural next stop. To mix more airway and GI cases with other areas first, use the practice set filtered to pulmonology and GI.

7Concepts in this domain

Asthma vs COPD inhalers

Next step

Check yourself, then check the notes

Read the note on every option, then decide where the next session goes.

Get the app Practice free on this site

Pharmacotherapy Exam Prep 2026 is an app for iPhone and iPad only; there is no Android version. On any other phone or a computer, use the free practice set on this site in your browser.