I85PREP
⌘ K
AOBIM Internal Medicine study materials
AOBIM Internal Medicine study resources

AOBIM Internal Medicine practice questions

One question at a time. Build your AOBIM Internal Medicine understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Internal Medicine (initial certification)

A 58-year-old man with type 2 diabetes has an eGFR of 38 mL/min/1.73 m² and an albumin-to-creatinine ratio of 450 mg/g. Which medication most reliably slows progression of his kidney disease?

  1. Dapagliflozin Correct answer.
  2. Furosemide
  3. Amlodipine
  4. Atorvastatin

Explanation

SGLT2 inhibitors reduce progression of chronic kidney disease and are recommended in diabetic kidney disease with albuminuria, even at reduced eGFR. Their benefit is independent of glycemic control.

Question 2Internal Medicine (initial certification)

Which finding on urinalysis most strongly suggests acute interstitial nephritis rather than acute tubular necrosis?

  1. Broad waxy casts
  2. Muddy brown casts
  3. Dysmorphic red blood cells
  4. White blood cell casts Correct answer.

Explanation

White blood cell casts indicate tubulointerstitial inflammation and support a diagnosis of acute interstitial nephritis. Eosinophiluria is neither sensitive nor specific.

Question 3Internal Medicine (initial certification)

A 34-year-old woman has palpitations and a resting heart rate of 130 bpm. ECG shows an irregularly irregular rhythm with no discernible P waves. She is hemodynamically stable. Which is the most appropriate initial management?

  1. Vagal maneuvers
  2. Intravenous amiodarone
  3. Rate control with a beta-blocker Correct answer.
  4. Immediate synchronized cardioversion

Explanation

In stable atrial fibrillation, rate control is the initial priority; beta-blockers or nondihydropyridine calcium channel blockers are first-line. Cardioversion is reserved for instability or after adequate anticoagulation.

Question 4Internal Medicine (initial certification)

Which physical examination finding is most specific for cardiac tamponade?

  1. Pulsus parvus et tardus
  2. Pulsus paradoxus Correct answer.
  3. Pulsus alternans
  4. Pulsus bisferiens

Explanation

Pulsus paradoxus, an exaggerated inspiratory fall in systolic pressure greater than 10 mm Hg, reflects impaired ventricular filling and is characteristic of tamponade.

Question 5Internal Medicine (initial certification)

A 62-year-old smoker presents with sudden painless loss of vision in one eye described as a curtain descending. Fundoscopy shows a pale retina with a cherry-red spot. Which vessel is most likely occluded?

  1. Ophthalmic artery
  2. Central retinal vein
  3. Posterior ciliary artery
  4. Central retinal artery Correct answer.

Explanation

Central retinal artery occlusion produces sudden painless monocular vision loss with a pale, opaque retina and a cherry-red fovea. It is an ophthalmologic emergency associated with embolic disease.

Question 6Internal Medicine (initial certification)

A 70-year-old woman has fatigue, macrocytic anemia, and a serum B12 level of 110 pg/mL. Which additional finding would best confirm pernicious anemia?

  1. Elevated methylmalonic acid
  2. Positive intrinsic factor antibodies Correct answer.
  3. Hypersegmented neutrophils
  4. Elevated homocysteine

Explanation

Intrinsic factor antibodies are highly specific for pernicious anemia, the autoimmune cause of B12 deficiency from loss of intrinsic factor. Other tests confirm B12 deficiency but not its autoimmune etiology.

Question 7Internal Medicine (initial certification)

Which laboratory pattern is most consistent with iron deficiency anemia?

  1. Normal ferritin, normal total iron-binding capacity, low transferrin saturation
  2. High ferritin, high total iron-binding capacity, high transferrin saturation
  3. Low ferritin, high total iron-binding capacity, low transferrin saturation Correct answer.
  4. High ferritin, low total iron-binding capacity, high transferrin saturation

Explanation

Iron deficiency lowers ferritin and raises total iron-binding capacity, producing a low transferrin saturation. Ferritin is the most useful single test because it reflects iron stores.

Question 8Internal Medicine (initial certification)

A 45-year-old man has recurrent calcium oxalate kidney stones. Which dietary measure most effectively reduces recurrence?

  1. Increasing dietary calcium and fluid intake Correct answer.
  2. Increasing dietary protein
  3. Restricting dietary oxalate alone
  4. Restricting dietary calcium

Explanation

Adequate dietary calcium binds intestinal oxalate and reduces absorption, while high fluid intake dilutes urine. Calcium restriction paradoxically increases stone risk.

Question 9Internal Medicine (initial certification)

Which electrocardiographic finding is the earliest manifestation of acute ST-elevation myocardial infarction?

  1. T-wave inversion
  2. ST-segment depression
  3. Pathologic Q waves
  4. Hyperacute T waves Correct answer.

Explanation

Hyperacute, tall peaked T waves are the earliest ECG change in acute transmural ischemia, preceding ST elevation and Q-wave formation.

Question 10Internal Medicine (initial certification)

A 24-year-old woman has a positive pregnancy test and sudden severe pelvic pain with syncope. She is tachycardic and hypotensive with cervical motion tenderness and an adnexal mass. What is the next best step?

  1. Transvaginal ultrasound
  2. Immediate exploratory laparoscopy Correct answer.
  3. Methotrexate administration
  4. Serial beta-hCG measurements

Explanation

Hemodynamic instability with suspected ruptured ectopic pregnancy is a surgical emergency requiring immediate operative management. Diagnostic imaging should not delay surgery in an unstable patient.

Question 11Internal Medicine (initial certification)

Which organism is the most common cause of community-acquired pneumonia requiring hospitalization in adults?

  1. Streptococcus pneumoniae Correct answer.
  2. Haemophilus influenzae
  3. Mycoplasma pneumoniae
  4. Legionella pneumophila

Explanation

Streptococcus pneumoniae remains the most frequently identified cause of community-acquired pneumonia across all severity levels. Empiric therapy is therefore directed at this organism.

Question 12Internal Medicine (initial certification)

A 60-year-old with COPD has a resting PaO2 of 52 mm Hg on room air. Which intervention improves survival?

  1. Inhaled corticosteroids
  2. Oral theophylline
  3. Regular albuterol nebulization
  4. Long-term continuous oxygen therapy Correct answer.

Explanation

Long-term oxygen therapy improves survival in COPD patients with resting hypoxemia (PaO2 ≤55 mm Hg or ≤59 mm Hg with cor pulmonale or polycythemia). It is the only intervention shown to reduce mortality in this setting.

Question 13Internal Medicine (initial certification)

A 28-year-old woman has episodic palpitations, headache, and diaphoresis with severe hypertension. Which test is the most appropriate initial screen for pheochromocytoma?

  1. Renal artery Doppler
  2. 24-hour urinary cortisol
  3. Plasma free metanephrines Correct answer.
  4. Serum aldosterone-to-renin ratio

Explanation

Plasma free metanephrines are the most sensitive initial test for pheochromocytoma, particularly in high-suspicion cases. Biochemical confirmation precedes imaging.

Question 14Internal Medicine (initial certification)

Which finding is most characteristic of primary hypothyroidism?

  1. High TSH, low free T4 Correct answer.
  2. Low TSH, low free T4
  3. High TSH, high free T4
  4. Low TSH, high free T4

Explanation

Primary hypothyroidism results from thyroid gland failure, producing low free T4 with a compensatory rise in TSH. The elevated TSH distinguishes primary from central hypothyroidism.

Question 15Internal Medicine (initial certification)

A 55-year-old man has a fasting glucose of 138 mg/dL on two occasions. Which is the most appropriate first-line pharmacologic therapy?

  1. Pioglitazone
  2. Glipizide
  3. Metformin Correct answer.
  4. Insulin glargine

Explanation

Metformin is the preferred initial agent for type 2 diabetes because of its efficacy, weight neutrality, low hypoglycemia risk, and low cost. Lifestyle modification should accompany therapy.

Question 16Internal Medicine (initial certification)

A 68-year-old man has a sudden painless loss of vision in one eye lasting 10 minutes, followed by complete recovery. Which structure is most likely involved?

  1. Optic nerve
  2. Carotid artery Correct answer.
  3. Central retinal vein
  4. Ciliary body

Explanation

Amaurosis fugax is transient monocular vision loss caused by emboli from ipsilateral carotid atherosclerotic disease. It is a warning sign for stroke and warrants urgent evaluation.

Question 17Internal Medicine (initial certification)

Which is the most common cause of community-acquired meningitis in adults?

  1. Listeria monocytogenes
  2. Haemophilus influenzae
  3. Neisseria meningitidis
  4. Streptococcus pneumoniae Correct answer.

Explanation

Streptococcus pneumoniae is the leading cause of bacterial meningitis in adults, which is why empiric therapy includes vancomycin plus a third-generation cephalosporin.

Question 18Internal Medicine (initial certification)

A 72-year-old woman has new atrial fibrillation and a CHA2DS2-VASc score of 4. Which is the most appropriate management?

  1. Aspirin alone
  2. No antithrombotic therapy
  3. Long-term oral anticoagulation Correct answer.
  4. Dual antiplatelet therapy

Explanation

A CHA2DS2-VASc score of 2 or higher in women (or 1 in men) warrants oral anticoagulation to reduce stroke risk. Direct oral anticoagulants or warfarin are appropriate.

Question 19Internal Medicine (initial certification)

Which finding on joint aspiration most strongly suggests septic arthritis?

  1. Gram-positive cocci on Gram stain Correct answer.
  2. Needle-shaped negatively birefringent crystals
  3. Positive rheumatoid factor
  4. Joint fluid leukocyte count of 2,000/µL

Explanation

A positive Gram stain or culture from synovial fluid confirms septic arthritis. A synovial white cell count above 50,000/µL supports the diagnosis but is not definitive.

Question 20Internal Medicine (initial certification)

A 40-year-old woman has symmetric small-joint polyarthritis, morning stiffness lasting over an hour, and positive anti-CCP antibodies. Which is the most appropriate initial disease-modifying therapy?

  1. Prednisone monotherapy
  2. Colchicine
  3. Hydroxychloroquine
  4. Methotrexate Correct answer.

Explanation

Methotrexate is the anchor disease-modifying antirheumatic drug for rheumatoid arthritis and should be started early. Glucocorticoids may bridge symptoms but are not disease-modifying monotherapy.

Question 21Internal Medicine (initial certification)

Which electrolyte abnormality is most characteristic of primary hyperaldosteronism?

  1. Hypocalcemia and respiratory alkalosis
  2. Hypernatremia and metabolic acidosis
  3. Hypokalemia and metabolic alkalosis Correct answer.
  4. Hyperkalemia and metabolic acidosis

Explanation

Aldosterone excess promotes renal sodium retention and potassium excretion, producing hypertension with hypokalemia and metabolic alkalosis. Hypokalemia is present in only a minority of patients, however.

Question 22Internal Medicine (initial certification)

A 55-year-old man has ascites, a serum-ascites albumin gradient of 1.5 g/dL, and a history of alcohol use. Which is the most likely cause?

  1. Peritoneal carcinomatosis
  2. Pancreatic ascites
  3. Tuberculous peritonitis
  4. Portal hypertension Correct answer.

Explanation

A serum-ascites albumin gradient of 1.1 g/dL or greater indicates portal hypertension, most commonly from cirrhosis. Low-gradient ascites suggests peritoneal disease.

Question 23Internal Medicine (initial certification)

Which is the most common cause of upper gastrointestinal bleeding in hospitalized patients?

  1. Peptic ulcer disease Correct answer.
  2. Mallory-Weiss tear
  3. Gastric cancer
  4. Esophageal varices

Explanation

Peptic ulcer disease is the most frequent cause of upper GI bleeding overall. Varices are important but less common and occur in patients with portal hypertension.

Question 24Internal Medicine (initial certification)

A 30-year-old woman has a malar rash, photosensitivity, oral ulcers, and proteinuria. Which autoantibody is most specific for systemic lupus erythematosus?

  1. Anti-double-stranded DNA Correct answer.
  2. Rheumatoid factor
  3. Antinuclear antibody
  4. Anti-histone antibody

Explanation

Anti-double-stranded DNA is highly specific for SLE and correlates with disease activity and lupus nephritis. ANA is sensitive but not specific.

Question 25Internal Medicine (initial certification)

Which is the most appropriate treatment for a patient with symptomatic bradycardia and hypotension unresponsive to atropine?

  1. Intravenous adenosine
  2. Synchronized cardioversion
  3. Transcutaneous pacing Correct answer.
  4. Carotid sinus massage

Explanation

Transcutaneous pacing is indicated for symptomatic bradycardia refractory to atropine. It provides temporary electrical support until definitive management is available.

Question 26Internal Medicine (initial certification)

A 58-year-old man with a 40-pack-year smoking history presents with a 3-cm right upper lobe lung mass and ipsilateral mediastinal lymph node involvement but no distant metastases. Which stage best describes this cancer?

  1. Stage IV
  2. Stage IB
  3. Stage IIB
  4. Stage IIIA Correct answer.

Explanation

Ipsilateral mediastinal (N2) nodal involvement with a resectable primary tumor without distant spread corresponds to stage IIIA non-small cell lung cancer. Nodal stage N2 alone moves disease beyond early-stage categories. Distant metastasis would be required for stage IV.

Question 27Internal Medicine (initial certification)

Which finding on urinalysis is most suggestive of acute interstitial nephritis?

  1. Broad waxy casts
  2. Dysmorphic red blood cells with red cell casts
  3. Muddy brown granular casts
  4. White blood cell casts with eosinophiluria Correct answer.

Explanation

Acute interstitial nephritis produces an inflammatory tubulointerstitial picture with white blood cell casts, and eosinophiluria supports a drug-induced allergic etiology. The other casts reflect different compartments of renal injury.

Question 28Internal Medicine (initial certification)

A 34-year-old woman has a blood pressure of 168/104 mm Hg, a systolic murmur at the left sternal border, and a history of recurrent miscarriages. Which underlying diagnosis should be suspected?

  1. Pheochromocytoma
  2. Antiphospholipid syndrome Correct answer.
  3. Coarctation of the aorta
  4. Fibromuscular dysplasia

Explanation

Hypertension in a young woman with recurrent pregnancy loss and a cardiac murmur suggests antiphospholipid syndrome with renal or valvular involvement. Recurrent miscarriage is a defining clinical criterion for the syndrome.

Question 29Internal Medicine (initial certification)

Which vaccine is recommended for all adults aged 50 years and older to prevent herpes zoster and postherpetic neuralgia?

  1. Pneumococcal conjugate vaccine
  2. Tetanus-diphtheria booster
  3. Recombinant zoster vaccine Correct answer.
  4. Live attenuated zoster vaccine

Explanation

The recombinant adjuvanted zoster vaccine is preferred for adults 50 years and older because it is effective and safe in immunocompromised patients. The live vaccine is no longer recommended for general use.

Question 30Internal Medicine (initial certification)

A 62-year-old man has resting tremor, bradykinesia, and rigidity. Which medication is most appropriate to initiate for motor symptom control?

  1. Haloperidol
  2. Levodopa-carbidopa Correct answer.
  3. Propranolol
  4. Metoclopramide

Explanation

Levodopa combined with carbidopa is the most effective dopaminergic therapy for motor symptoms of Parkinson disease. Carbidopa prevents peripheral decarboxylation and reduces nausea.

Question 31Internal Medicine (initial certification)

Which laboratory abnormality is most characteristic of syndrome of inappropriate antidiuretic hormone secretion?

  1. Hyperkalemia with metabolic acidosis
  2. Hypercalcemia with shortened QT interval
  3. Hypernatremia with low urine osmolality
  4. Hyponatremia with urine osmolality greater than serum osmolality Correct answer.

Explanation

SIADH causes euvolemic hyponatremia with inappropriately concentrated urine, so urine osmolality exceeds serum osmolality. The dilutional hyponatremia results from continued water reabsorption despite low serum osmolality.

Question 32Internal Medicine (initial certification)

A 45-year-old man has sudden-onset severe epigastric pain radiating to the back with elevated lipase. Which intervention is most important early in management?

  1. Urgent endoscopic retrograde cholangiopancreatography
  2. Immediate CT-guided drainage
  3. Aggressive intravenous fluid resuscitation Correct answer.
  4. Prophylactic broad-spectrum antibiotics

Explanation

Early goal-directed intravenous fluid resuscitation is the cornerstone of acute pancreatitis management and reduces pancreatic necrosis. Antibiotics and drainage are reserved for infected necrosis, and ERCP is reserved for concurrent cholangitis or persistent biliary obstruction.

Question 33Internal Medicine (initial certification)

Which finding is most consistent with nephrotic syndrome?

  1. Hypokalemia with metabolic alkalosis
  2. Elevated serum creatinine with oliguria
  3. Active urine sediment with red cell casts
  4. Urine protein excretion greater than 3.5 g per day Correct answer.

Explanation

Nephrotic syndrome is defined by heavy proteinuria exceeding 3.5 g per day, hypoalbuminemia, edema, and hyperlipidemia. The urine sediment is typically bland, distinguishing it from nephritic syndromes.

Question 34Internal Medicine (initial certification)

A 70-year-old man has chronic atrial fibrillation, an ejection fraction of 30%, and no prior stroke. Which anticoagulant strategy is most appropriate?

  1. Dual antiplatelet therapy
  2. A direct oral anticoagulant such as apixaban Correct answer.
  3. No antithrombotic therapy
  4. Aspirin alone

Explanation

Anticoagulation is indicated for stroke prevention in atrial fibrillation when the stroke risk score is elevated. Apixaban is preferred in heart failure with reduced ejection fraction because it has favorable bleeding outcomes compared with warfarin.

Question 35Internal Medicine (initial certification)

Which organism is the most common cause of infective endocarditis in patients with prosthetic valves within the first year after surgery?

  1. Streptococcus bovis
  2. Viridans group streptococci
  3. Enterococcus faecalis
  4. Staphylococcus epidermidis Correct answer.

Explanation

Coagulase-negative staphylococci, particularly Staphylococcus epidermidis, are the leading cause of early prosthetic valve endocarditis. These organisms adhere to prosthetic material and are often methicillin resistant.

Question 36Internal Medicine (initial certification)

A 26-year-old man has a fasting serum calcium of 11.2 mg/dL, a low phosphate, and an elevated parathyroid hormone level. Which is the most likely diagnosis?

  1. Malignancy-associated hypercalcemia
  2. Familial hypocalciuric hypercalcemia
  3. Primary hyperparathyroidism Correct answer.
  4. Secondary hyperparathyroidism from chronic kidney disease

Explanation

Elevated calcium with inappropriately elevated parathyroid hormone and low phosphate characterizes primary hyperparathyroidism, usually from a solitary adenoma. Malignancy-associated hypercalcemia typically suppresses parathyroid hormone.

Question 37Internal Medicine (initial certification)

Which finding most strongly suggests a diagnosis of systemic mastocytosis?

  1. Elevated serum tryptase with urticaria pigmentosa Correct answer.
  2. Positive antinuclear antibody with photosensitivity
  3. Elevated angiotensin-converting enzyme level
  4. Low complement C3 with hematuria

Explanation

Systemic mastocytosis is characterized by mast cell infiltration and elevated serum tryptase, often with the characteristic urticaria pigmentosa skin lesions. Tryptase is a relatively specific marker of mast cell burden.

Question 38Internal Medicine (initial certification)

A 55-year-old woman has proximal muscle weakness, a heliotrope rash, and elevated creatine kinase. Which malignancy screening is most appropriate at diagnosis?

  1. Age-appropriate cancer screening including chest imaging Correct answer.
  2. Colonoscopy alone
  3. No screening is needed
  4. Bone marrow biopsy

Explanation

Dermatomyositis in adults carries an increased risk of underlying malignancy, so age-appropriate cancer screening with chest imaging is recommended at diagnosis. The risk is highest in the first few years after diagnosis.

Question 39Internal Medicine (initial certification)

Which finding on spirometry is most consistent with a restrictive lung defect?

  1. Positive bronchodilator response with normalization of FEV1
  2. Reduced FEV1 with a reduced FEV1/FVC ratio
  3. Increased residual volume with air trapping
  4. Reduced total lung capacity with a normal or increased FEV1/FVC ratio Correct answer.

Explanation

Restrictive disease reduces total lung capacity, and the FEV1/FVC ratio is preserved or elevated because both volumes fall proportionally. Obstructive disease instead lowers the ratio.

Question 40Internal Medicine (initial certification)

A 68-year-old man with decompensated heart failure has a serum sodium of 128 mEq/L despite fluid restriction. Which additional measure is most appropriate for hypervolemic hyponatremia?

  1. Tolvaptan Correct answer.
  2. Normal saline infusion
  3. Hypertonic saline infusion
  4. Free water restriction alone

Explanation

Tolvaptan, a vasopressin receptor antagonist, raises serum sodium in hypervolemic hyponatremia from heart failure by promoting aquaresis. Hypertonic saline is reserved for severe symptomatic hyponatremia or seizures.

Question 41Internal Medicine (initial certification)

Which electrocardiographic abnormality is most characteristic of hyperkalemia?

  1. Peaked T waves with a widened QRS Correct answer.
  2. Prominent U waves
  3. Prolonged QT interval
  4. ST-segment elevation in contiguous leads

Explanation

Hyperkalemia initially produces tall peaked T waves and, as potassium rises, QRS widening and sine-wave morphology. These changes reflect impaired myocardial conduction.

Question 42Internal Medicine (initial certification)

A 30-year-old woman has a first episode of unprovoked deep vein thrombosis. Which duration of anticoagulation is recommended after the initial treatment period?

  1. Lifelong therapy for all patients
  2. At least 3 months with consideration of extended therapy Correct answer.
  3. 6 weeks
  4. 3 months

Explanation

For unprovoked venous thromboembolism, anticoagulation for at least 3 months is standard, and extended therapy is considered based on bleeding risk and patient preference. Lifelong therapy is not mandated for every patient.

Question 43Internal Medicine (initial certification)

Which clinical feature most strongly suggests a diagnosis of giant cell arteritis rather than polymyalgia rheumatica?

  1. Bilateral shoulder pain
  2. Jaw claudication Correct answer.
  3. Elevated erythrocyte sedimentation rate
  4. Morning stiffness

Explanation

Jaw claudication reflects ischemia of the masticatory muscles from temporal artery involvement and is highly specific for giant cell arteritis. Polymyalgia rheumatica causes proximal pain and stiffness without vascular ischemia.

Question 44Internal Medicine (initial certification)

A 40-year-old man has recurrent peptic ulcers and watery diarrhea. Fasting serum gastrin is markedly elevated and does not suppress with a secretin challenge. Which is the most likely diagnosis?

  1. Helicobacter pylori gastritis
  2. Celiac disease
  3. Zollinger-Ellison syndrome Correct answer.
  4. Chronic atrophic gastritis

Explanation

Markedly elevated fasting gastrin that paradoxically rises with secretin stimulation indicates a gastrinoma, defining Zollinger-Ellison syndrome. Recurrent ulcers with diarrhea reflect acid hypersecretion.

Question 45Internal Medicine (initial certification)

Which finding is most consistent with acute tumor lysis syndrome?

  1. Hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia Correct answer.
  2. Hypokalemia, hypophosphatemia, and hypercalcemia
  3. Hyperkalemia, hyperphosphatemia, hyperuricemia, and hypercalcemia
  4. Hypernatremia with hyperchloremic acidosis

Explanation

Tumor lysis releases intracellular contents, producing hyperkalemia, hyperphosphatemia, and hyperuricemia, with secondary hypocalcemia from phosphate binding. This constellation can precipitate acute kidney injury and arrhythmias.

Question 46Internal Medicine (initial certification)

A 22-year-old college student has a sore throat, fever, and exudative pharyngitis. Rapid strep testing is positive. Which is the most appropriate treatment?

  1. No antibiotics needed
  2. Levofloxacin for 7 days
  3. Azithromycin for 5 days
  4. Amoxicillin for 10 days Correct answer.

Explanation

Penicillin or amoxicillin is first-line therapy for group A streptococcal pharyngitis, and a 10-day course eradicates the organism and prevents rheumatic fever. Macrolides are reserved for penicillin allergy.

Question 47Internal Medicine (initial certification)

A 50-year-old man has chronic hepatitis C infection with cirrhosis. Which complication is most strongly associated with hepatocellular carcinoma surveillance?

  1. Hepatocellular carcinoma Correct answer.
  2. Hepatic encephalopathy
  3. Spontaneous bacterial peritonitis
  4. Portal hypertension with varices

Explanation

Cirrhosis from chronic hepatitis C carries a high risk of hepatocellular carcinoma, so surveillance with abdominal ultrasound every six months is recommended. Early detection enables curative therapy.

Question 48Internal Medicine (initial certification)

Which finding is most consistent with a diagnosis of myasthenia gravis?

  1. Ascending symmetric paralysis with areflexia
  2. Fatigable weakness that worsens with repetitive use Correct answer.
  3. Distal sensory loss with a stocking-glove pattern
  4. Proximal muscle pain with elevated creatine kinase

Explanation

Myasthenia gravis causes fatigable weakness that worsens with activity and improves with rest, from antibodies against the acetylcholine receptor. The other patterns reflect different neuromuscular disorders.

Question 49Internal Medicine (initial certification)

A 60-year-old woman has a serum calcium of 9.0 mg/dL, a phosphate of 2.0 mg/dL, and an elevated alkaline phosphatase. Which additional feature would most strongly suggest Paget disease of bone?

  1. Elevated serum creatinine with anemia
  2. Positive antinuclear antibody with rash
  3. Isolated elevation of alkaline phosphatase with normal calcium and phosphate Correct answer.
  4. Low parathyroid hormone with hypercalcemia

Explanation

Paget disease of bone typically shows an isolated elevation of alkaline phosphatase with normal calcium and phosphate because bone turnover is increased without disturbing mineral homeostasis. The other findings point to different disorders.

Question 50Internal Medicine (initial certification)

Which is the most appropriate initial therapy for a patient with symptomatic bradycardia and hypotension unresponsive to atropine?

  1. Intravenous diltiazem
  2. Transcutaneous pacing Correct answer.
  3. Synchronized cardioversion
  4. Adenosine administration

Explanation

When atropine fails in symptomatic bradycardia with hypotension, transcutaneous pacing is the next step while preparing for definitive pacing. Chronotropic agents such as dopamine may be used as a bridge.