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a, ee, ee, Enh fin EE ee, aaia— i oh BS) ee ee Ly bk lo-——)_ Lo ) ee, ee ee, Eh he —ieneies “2 i ee ess | a-ha Gi Bie | BH © es e, Co my Ls Wb bh} WI ba Ld stede de APEA PREDICTOR EXAM ke aie oe l 15@ PRACTICE QUESTIONS | | WITH ANSWERS & DETAILED RATIONALES | 2026 EDITION | 100% PASS RATE | | || DESIGNED TO MIRROR THE ACTUAL APEA PREDICTOR EXAM | | || FORMAT: A-D OPTIONS, CORRECT ANSWER, DETAILED RATIONALE || PAGE 1 - QUESTIONS 1-5 Question 1 A 32-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. Physical exam reveals bradycardia and a firm, non-tender goiter. Which laboratory finding is expected? A. Elevated T4 and decreased TSH B. Decreased T4 and elevated TSH C. Elevated T3 and decreased TSH D. Decreased TSH and normal T4 Answer: B Rationale: Primary hypothyroidism is characterized by low free T4 and elevated TSH due to lack of negative feedback. Question 2 A 25-year-old male presents with sudden onset of severe testicular pain, nausea, and vomiting. Physical exam shows a high-riding, tender testis with absent cremasteric reflex. What is the most appropriate next step? A. Emergency surgical consultation B. Scrotal ultrasound Question 5 A 28-year-old female with systemic lupus erythematosus (SLE) presents with new-onset seizure. Blood pressure is 180/110 mmHg. Urinalysis shows red cell casts and proteinuria. What is the most likely diagnosis? A. Hypertensive emergency B. Lupus cerebritis C. Posterior reversible encephalopathy syndrome (PRES) D. Thrombotic thrombocytopenic purpura Answer: B Rationale: Lupus cerebritis (CNS lupus) can present with seizures, hypertension, and renal involvement (active nephritis). PAGE 2 - QUESTIONS 6-10 Question 6 A 55-year-old diabetic male reports a non-healing ulcer on the plantar surface of his foot. The ulcer is 2 cm in diameter, deep with exposed tendon, but no signs of infection. Which of the following is the most appropriate initial treatment? A. Oral antibiotics and dry dressing B. Offloading with a total contact cast C. Surgical debridement and skin graft D. Hyperbaric oxygen therapy Answer: B Rationale: Offloading is the cornerstone of neuropathic ulcer management. Total contact cast or removable cast walker relieves pressure, promoting healing. Question 7 A 45-year-old male presents with episodic burning epigastric pain that worsens when his stomach is empty and improves after eating. Which of the following is the most likely diagnosis? A. Gastric ulcer B. Duodenal ulcer C. GERD D. Pancreatitis Answer: B Rationale: Duodenal ulcers typically present with epigastric pain that occurs when the stomach is empty (between meals or at night) and is relieved by food or antacids. Question 8 A 25-year-old woman presents with episodes of palpitations, sweating, tremor, and anxiety that occur before lunch and resolve after eating. Fingerstick glucose is 45 mg/dL. Which of the following is the most appropriate next step? A. Oral glucose tolerance test B. Abdominal CT scan C. Fasting insulin and C-peptide levels D. Thyroid function tests Answer: C Rationale: To evaluate for insulinoma, obtain fasting insulin and C-peptide levels along with glucose. High insulin and C-peptide in the setting of low glucose indicate endogenous hyperinsulinism. Question 9 A 70-year-old female presents with acute onset of severe left flank pain radiating to the groin, accompanied by nausea and vomiting. She is afebrile. Urinalysis shows microscopic hematuria. What is the most likely diagnosis? A. Pyelonephritis B. Nephrolithiasis C. Diverticulitis D. Abdominal aortic aneurysm Answer: B Rationale: Nephrolithiasis (kidney stone) presents with acute, colicky flank pain radiating to the groin, nausea, vomiting, and microscopic hematuria B. Admit for magnesium sulfate and delivery planning C. Schedule outpatient blood pressure monitoring D. Prescribe bed rest at home Answer: B Rationale: This patient has severe preeclampsia (BP 2160/110, symptoms, proteinuria). Magnesium sulfate is indicated for seizure prophylaxis, and delivery is the definitive treatment. Question 13 A 35-year-old female presents with fatigue, joint pain, and a malar rash. Laboratory tests show ANA positive, anti-dsDNA positive, and low C3/C4. Which of the following is the most specific finding for SLE? A. ANA positive B. Anti-dsDNA positive Cc. Low C3 D. Rheumatoid factor positive Answer: B Rationale: Anti-dsDNA is highly specific for systemic lupus erythematosus (SLE). ANA is sensitive but not specific. Question 14 A 55-year-old female presents with a recent diagnosis of osteoporosis on DEXA scan (T-score -2.8). She has no prior fractures. She takes calcium and vitamin D but is postmenopausal and not on hormone therapy. Which of the following is the most appropriate pharmacologic treatment? A. Alendronate B. Raloxifene C. Teriparatide D. Calcitonin Answer: A Rationale: Alendronate, a bisphosphonate, is first-line for osteoporosis to reduce fracture risk. Raloxifene is used but less potent. Question 15 A 5@-year-old male with chronic alcoholism presents with confusion, ataxia, and ophthalmoplegia. Which vitamin deficiency is most likely? A. Vitamin A B. Vitamin B12 C. Thiamine (B1) D. Niacin Answer: C Rationale: Wernicke's encephalopathy (confusion, ataxia, ophthalmoplegia) is caused by thiamine deficiency, common in alcoholism. PAGE 4 - QUESTIONS 16-20 Question 16 A 72-year-old male with a history of atrial fibrillation on warfarin presents with sudden onset of left arm weakness and facial droop. Symptoms began 9@ minutes ago. CT head is negative for hemorrhage. What is the most appropriate next step? A. Administer IV alteplase (tPA) B. Start aspirin 325 mg daily C. Start heparin drip D. Transfer for mechanical thrombectomy Answer: A Rationale: Within 3-hour window for ischemic stroke, tPA is indicated if no contraindications. CT negative for hemorrhage supports ischemic stroke. Question 17 A 20-year-old college student presents with fever, sore throat, and fatigue. Physical exam reveals posterior cervical lymphadenopathy and splenomegaly. Which test is most appropriate to confirm the diagnosis? Question 20 A 65-year-old male with a history of COPD presents with increased dyspnea and purulent sputum. On exam, he has wheezing and prolonged expiratory phase. Which medication is most appropriate for acute exacerbation? A. Inhaled corticosteroids B. Inhaled short-acting beta-agonist (albuterol) C. Oral prednisone alone D. Oral antibiotics alone Answer: B Rationale: In acute COPD exacerbation, short-acting bronchodilators (albuterol) are first-line to relieve bronchospasm. PAGE 5 - QUESTIONS 21-25 Question 21 A 40-year-old female presents with a firm, non-tender nodule in the right thyroid lobe. TSH is normal. Ultrasound shows a 2.5 cm solid, hypoechoic nodule with microcalcifications. What is the most appropriate next step? A. Repeat TSH in 6 months B. Levothyroxine suppression therapy C. Fine needle aspiration biopsy D. Thyroid scan Answer: C Rationale: Nodules >1 cm with suspicious features (hypoechoic, microcalcifications) should undergo FNA biopsy to rule out malignancy. Question 22 A 75-year-old male presents with acute urinary retention. Digital rectal exam reveals a smooth, enlarged prostate. What is the most appropriate initial intervention? A. Insert a Foley catheter B. Alpha-blocker therapy C. Transurethral resection of prostate D. Finasteride Answer: A Rationale: Acute urinary retention requires immediate bladder decompression with catheterization. Definitive treatment can follow. Question 23 A 28-year-old pregnant woman at 36 weeks gestation presents with painless vaginal bleeding. Ultrasound shows placenta previa. What is the most appropriate management? A. Cesarean delivery B. Vaginal delivery C. Bed rest at home D. Induction of labor Answer: A Rationale: Complete placenta previa requires cesarean delivery to prevent massive hemorrhage. Vaginal delivery is contraindicated. Question 24 A 50-year-old female presents with episodic headaches, palpitations, and sweating. During an episode, blood pressure is 200/110 mmHg. Which test is most appropriate to diagnose the underlying cause? A. Thyroid function tests B. Renal artery duplex ultrasound C. Plasma metanephrines D. 24-hour urine cortisol Answer: C Rationale: Paroxysmal hypertension with headache, palpitations, sweating suggests pheochromocytoma. Plasma metanephrines is the initial test. C. Anti-SSA (Ro) and anti-SSB (La) D. ESR Answer: C Rationale: Anti-SSA and anti-SSB are highly specific for Sjégren's syndrome in a patient with sicca symptoms. Question 28 A 35-year-old male presents with acute-onset shortness of breath and pleuritic chest pain after a long flight. He has tachycardia and hypoxemia. Which test is most appropriate to confirm the diagnosis? A. D-dimer B. CT pulmonary angiography C. Chest X-ray D. Ventilation-perfusion scan Answer: B Rationale: CT pulmonary angiography is the gold standard for diagnosing pulmonary embolism in a high-risk patient. Question 29 A 2-week-old newborn presents with projectile vomiting after feeds. The infant is hungry and appears dehydrated. On exam, a palpable olive-shaped mass is noted in the epigastrium. What is the most likely diagnosis? A. Hypertrophic pyloric stenosis B. GERD C. Malrotation with volvulus D. Intussusception Answer: A Rationale: Projectile vomiting, olive-shaped mass, and dehydration in a 2-week-old are classic for hypertrophic pyloric stenosis. Question 30 A 70-year-old female presents with acute-onset severe headache, nausea, and vomiting. She has a history of hypertension. Neurologic exam is non-focal. CT head shows hyperdense material in the subarachnoid space. What is the most appropriate next step? A. Lumbar puncture B. CT angiography of head C. MRI brain D. Carotid ultrasound Answer: B Rationale: CT findings of subarachnoid hemorrhage require confirmation of aneurysmal source; CT angiography is next to identify aneurysm. PAGE 7 - QUESTIONS 31-35 Question 31 A 55-year-old diabetic male presents with painless red urine. He denies fever or dysuria. Urinalysis shows hematuria but no protein or casts. What is the most appropriate next step? A. Repeat urinalysis in 1 month B. CT urography C. Cystoscopy D. Renal ultrasound Answer: B Rationale: Painless hematuria in an adult with risk factors (diabetes, age) requires upper tract imaging (CT urography) to rule out malignancy. Question 32 A 28-year-old female presents with goiter and symptoms of hyperthyroidism. TSH is undetectable. Thyroid scan shows diffuse uptake. Which treatment is most appropriate for a woman planning pregnancy? A. Radioactive iodine B. Propylthiouracil (PTU) C. Methimazole Question 35 A 45-year-old female presents with a blood pressure of 145/9@ mmHg on three separate occasions. She has no comorbidities. Which of the following is the most appropriate initial treatment? A. Hydrochlorothiazide B. Lifestyle modification (diet, exercise, sodium restriction) C. Lisinopril D. Amlodipine Answer: B Rationale: For stage 1 hypertension without other risk factors, lifestyle modification is first-line for 3-6 months before pharmacologic therapy. PAGE 8 - QUESTIONS 36-40 Question 36 A 60-year-old male presents with progressive weakness in his lower extremities and urinary incontinence. He has a history of smoking. MRI shows a spinal cord lesion at T4. What is the most likely diagnosis? A. Multiple sclerosis B. Metastatic lung cancer C. Amyotrophic lateral sclerosis D. Guillain-Barré syndrome Answer: B Rationale: Progressive myelopathy with smoking history suggests metastatic disease (lung cancer) compressing the spinal cord. Question 37 A 25-year-old female with a history of migraines presents with a sudden-onset “thunderclap" headache that is the worst of her life. Neurologic exam is normal. CT head is negative. What is the most appropriate next step? A. Discharge with triptan prescription B. Lumbar puncture C. MRI brain D. Transcranial Doppler Answer: B Rationale: Thunderclap headache with negative CT requires lumbar puncture to rule out subarachnoid hemorrhage (xanthochromia). Question 38 A 5@-year-old female presents with fatigue, easy bruising, and bleeding gums. CBC shows pancytopenia. Bone marrow biopsy reveals hypocellularity with <5% cellularity. What is the most likely diagnosis? A. Acute leukemia B. Aplastic anemia C. Myelodysplastic syndrome D. Vitamin B12 deficiency Answer: B Rationale: Pancytopenia with markedly hypocellular marrow without malignant cells is aplastic anemia. Question 39 A 32-year-old male presents with 2 weeks of watery diarrhea, abdominal cramping, and weight loss. He recently returned from a camping trip. Stool studies are negative for ova and parasites. Colonoscopy shows erythematous, friable mucosa with continuous involvement starting at the rectum. What is the most likely diagnosis? A. Crohn's disease B. Ulcerative colitis C. Irritable bowel syndrome D. C difficile colitis Answer: B Rationale: Continuous mucosal inflammation starting at the rectum is characteristic of ulcerative colitis. D. Serum calcitonin Answer: B Rationale: Carcinoid syndrome (flushing, diarrhea, right-sided heart disease) is diagnosed with urinary 5-HIAA. Question 43 A 28-year-old female with no medical history presents with acute-onset shortness of breath and chest tightness. She has a history of seasonal allergies. On exam, she has diffuse wheezing. What is the most appropriate initial treatment? A. Albuterol via nebulizer B. Oral prednisone C. Montelukast D. Oxygen alone Answer: A Rationale: Acute asthma exacerbation requires inhaled short-acting beta-agonist (albuterol) as first-line bronchodilator. Question 44 A 70-year-old male presents with a 3-day history of gradually worsening abdominal pain, fever, and chills. He has a history of diverticulosis. Exam shows left lower quadrant tenderness and guarding. CT shows sigmoid diverticula with pericolic stranding and a small abscess. What is the most appropriate management? A. Oral antibiotics and discharge B. IV antibiotics and observation C. Percutaneous drainage of abscess D. Emergent sigmoid colectomy Answer: B Rationale: Small abscess associated with diverticulitis can be managed with IV antibiotics; large abscess (>4 cm) may need drainage. Question 45 A 45-year-old female presents with proximal muscle weakness, difficulty rising from a chair, and a heliotrope rash on her eyelids. Which lab finding is most likely? A. Positive ANA B. Elevated creatine kinase C. Anti-Jo-1 antibodies D. Low complement levels Answer: B Rationale: Heliotrope rash and proximal weakness suggest dermatomyositis. Elevated CK indicates muscle inflammation. PAGE 10 - QUESTIONS 46-50 Question 46 A 30-year-old male presents with recurrent episodes of abdominal pain, jaundice, and dark urine. Between episodes, he is asymptomatic. During an episode, liver enzymes are elevated. Ultrasound shows gallstones. What is the most likely diagnosis? A. Choledocholithiasis B. Acute cholecystitis C. Pancreatitis D. Hepatitis Answer: A Rationale: Intermittent jaundice and pain with gallstones suggest common bile duct stones (choledocholithiasis). Question 47 A 55-year-old female with a history of breast cancer presents with new-onset back pain. She has point tenderness over the lumbar spine. X-ray shows a compression fracture of L2. What is the most likely cause? A. Metastatic bone disease B. Osteoporosis C. Traumatic fracture 
