APEA 3P HIGH STAKES EXAM (2026
EDITION) 200 Questions | Answers &
Rationales
Instructions
Simulated time: 4 hours (1.2 minutes per question)
Passing score: 70% (140/200)
Domains: Advanced Physical Assessment (25%), Pharmacotherapeutics
(25%), Pathophysiology (25%), Differential Diagnosis (20%), Professional
Issues (5%)
Questions 1–50: Advanced Physical Assessment & Differential Diagnosis
1. A 58-year-old male with DM type 2 reports burning foot pain worse at
night. Exam: diminished pinprick sensation distal to ankles, absent Achilles
reflexes. Most likely diagnosis?
A) Peripheral artery disease
B) Lumbar radiculopathy
C) Diabetic peripheral neuropathy
D) Vitamin B12 deficiency
Answer: C
Rationale: Distal symmetric polyneuropathy in diabetes presents with
burning pain, nocturnal exacerbation, loss of sensation, and areflexia. PAD
causes claudication, not burning dysesthesia.
2. A 45-year-old woman has BP 152/96 mmHg on two visits. No
comorbidities. According to 2024 ACC/AHA guidelines, what is the first
step?
,A) Start amlodipine 5 mg daily
B) Start lisinopril 10 mg daily
C) Recommend DASH diet and exercise for 4–6 months
D) Order renal artery duplex ultrasound
Answer: C
Rationale: Stage 2 hypertension without comorbidities or target organ
damage first receives therapeutic lifestyle changes for 4–6 months before
pharmacotherapy.
3. A 32-year-old man has sudden onset of severe, tearing chest pain radiating
to the back. BP 160/90 in right arm, 100/60 in left arm. Most likely diagnosis?
A) Myocardial infarction
B) Pulmonary embolism
C) Aortic dissection
D) Pericarditis
Answer: C
Rationale: Aortic dissection presents with tearing chest pain and asymmetric
blood pressures between arms.
4. A 70-year-old woman reports progressive forgetfulness over 2 years. Exam:
difficulty with word finding, apraxia, agnosia. MMSE 22/30. No fluctuation in
cognition. Most likely?
A) Alzheimer’s disease
B) Lewy body dementia
C) Frontotemporal dementia
D) Vascular dementia
Answer: A
Rationale: Gradual onset of memory loss with cortical signs (aphasia,
,apraxia, agnosia) points to Alzheimer’s. Lewy body has fluctuations and
visual hallucinations.
5. A 28-year-old woman with palpitations, heat intolerance, weight loss
despite good appetite. Exam: fine tremor, brisk reflexes, lid lag. TSH <0.01,
free T4 elevated. Best initial pharmacotherapy?
A) Propylthiouracil
B) Methimazole
C) Levothyroxine
D) Radioactive iodine
Answer: B
Rationale: Methimazole is first-line for Graves’ disease in non-pregnant
adults because of lower hepatotoxicity risk than PTU.
6. A patient with COPD has worsening dyspnea, increased sputum purulence
and volume. No fever. Best initial treatment?
A) Oral prednisone alone
B) Azithromycin alone
C) Bronchodilators + antibiotics
D) Oxygen only
Answer: C
Rationale: Acute exacerbation of COPD with increased dyspnea, sputum
purulence, and volume (Anthonisen type I) requires antibiotics +
bronchodilators.
7. A 52-year-old man has a firm, painless nodule on the right lobe of the
thyroid. Ultrasound shows microcalcifications, irregular margins. Next best
step?
A) Repeat ultrasound in 1 year
B) Fine needle aspiration (FNA)
, C) TSH level
D) Thyroid scan
Answer: B
Rationale: Suspicious ultrasound features (microcalcifications, irregular
margins) in a thyroid nodule warrant FNA regardless of TSH.
8. A 24-year-old woman with fatigue, joint pain, malar rash, and oral ulcers.
Labs: ANA positive, anti-dsDNA positive, low C3/C4. Best initial
maintenance medication?
A) Hydroxychloroquine
B) Prednisone
C) Methotrexate
D) Cyclophosphamide
Answer: A
Rationale: Hydroxychloroquine is first-line for mild to moderate SLE to
reduce flares and prevent organ damage.
9. A 65-year-old man with Parkinson’s disease develops confusion,
hallucinations, and myoclonus after starting amantadine. Most likely
diagnosis?
A) Parkinson’s disease psychosis
B) Amantadine toxicity
C) UTI delirium
D) Neuroleptic malignant syndrome
Answer: B
Rationale: Amantadine toxicity in older adults causes confusion,
hallucinations, myoclonus, and livedo reticularis.
10. A newborn fails hearing screen. Family history: maternal first cousin with
profound hearing loss and childhood photosensitivity. Most likely genetic
cause?
EDITION) 200 Questions | Answers &
Rationales
Instructions
Simulated time: 4 hours (1.2 minutes per question)
Passing score: 70% (140/200)
Domains: Advanced Physical Assessment (25%), Pharmacotherapeutics
(25%), Pathophysiology (25%), Differential Diagnosis (20%), Professional
Issues (5%)
Questions 1–50: Advanced Physical Assessment & Differential Diagnosis
1. A 58-year-old male with DM type 2 reports burning foot pain worse at
night. Exam: diminished pinprick sensation distal to ankles, absent Achilles
reflexes. Most likely diagnosis?
A) Peripheral artery disease
B) Lumbar radiculopathy
C) Diabetic peripheral neuropathy
D) Vitamin B12 deficiency
Answer: C
Rationale: Distal symmetric polyneuropathy in diabetes presents with
burning pain, nocturnal exacerbation, loss of sensation, and areflexia. PAD
causes claudication, not burning dysesthesia.
2. A 45-year-old woman has BP 152/96 mmHg on two visits. No
comorbidities. According to 2024 ACC/AHA guidelines, what is the first
step?
,A) Start amlodipine 5 mg daily
B) Start lisinopril 10 mg daily
C) Recommend DASH diet and exercise for 4–6 months
D) Order renal artery duplex ultrasound
Answer: C
Rationale: Stage 2 hypertension without comorbidities or target organ
damage first receives therapeutic lifestyle changes for 4–6 months before
pharmacotherapy.
3. A 32-year-old man has sudden onset of severe, tearing chest pain radiating
to the back. BP 160/90 in right arm, 100/60 in left arm. Most likely diagnosis?
A) Myocardial infarction
B) Pulmonary embolism
C) Aortic dissection
D) Pericarditis
Answer: C
Rationale: Aortic dissection presents with tearing chest pain and asymmetric
blood pressures between arms.
4. A 70-year-old woman reports progressive forgetfulness over 2 years. Exam:
difficulty with word finding, apraxia, agnosia. MMSE 22/30. No fluctuation in
cognition. Most likely?
A) Alzheimer’s disease
B) Lewy body dementia
C) Frontotemporal dementia
D) Vascular dementia
Answer: A
Rationale: Gradual onset of memory loss with cortical signs (aphasia,
,apraxia, agnosia) points to Alzheimer’s. Lewy body has fluctuations and
visual hallucinations.
5. A 28-year-old woman with palpitations, heat intolerance, weight loss
despite good appetite. Exam: fine tremor, brisk reflexes, lid lag. TSH <0.01,
free T4 elevated. Best initial pharmacotherapy?
A) Propylthiouracil
B) Methimazole
C) Levothyroxine
D) Radioactive iodine
Answer: B
Rationale: Methimazole is first-line for Graves’ disease in non-pregnant
adults because of lower hepatotoxicity risk than PTU.
6. A patient with COPD has worsening dyspnea, increased sputum purulence
and volume. No fever. Best initial treatment?
A) Oral prednisone alone
B) Azithromycin alone
C) Bronchodilators + antibiotics
D) Oxygen only
Answer: C
Rationale: Acute exacerbation of COPD with increased dyspnea, sputum
purulence, and volume (Anthonisen type I) requires antibiotics +
bronchodilators.
7. A 52-year-old man has a firm, painless nodule on the right lobe of the
thyroid. Ultrasound shows microcalcifications, irregular margins. Next best
step?
A) Repeat ultrasound in 1 year
B) Fine needle aspiration (FNA)
, C) TSH level
D) Thyroid scan
Answer: B
Rationale: Suspicious ultrasound features (microcalcifications, irregular
margins) in a thyroid nodule warrant FNA regardless of TSH.
8. A 24-year-old woman with fatigue, joint pain, malar rash, and oral ulcers.
Labs: ANA positive, anti-dsDNA positive, low C3/C4. Best initial
maintenance medication?
A) Hydroxychloroquine
B) Prednisone
C) Methotrexate
D) Cyclophosphamide
Answer: A
Rationale: Hydroxychloroquine is first-line for mild to moderate SLE to
reduce flares and prevent organ damage.
9. A 65-year-old man with Parkinson’s disease develops confusion,
hallucinations, and myoclonus after starting amantadine. Most likely
diagnosis?
A) Parkinson’s disease psychosis
B) Amantadine toxicity
C) UTI delirium
D) Neuroleptic malignant syndrome
Answer: B
Rationale: Amantadine toxicity in older adults causes confusion,
hallucinations, myoclonus, and livedo reticularis.
10. A newborn fails hearing screen. Family history: maternal first cousin with
profound hearing loss and childhood photosensitivity. Most likely genetic
cause?
