I85PREP
⌘ K
TECM Clínica Médica study materials
TECM Clínica Médica study resources

TECM Clínica Médica practice questions

One question at a time. Build your TECM Clínica Médica 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 1Clínica Médica

A 58-year-old man with type 2 diabetes has a fasting plasma glucose of 132 mg/dL on two separate occasions. Which finding alone is sufficient to establish the diagnosis of diabetes mellitus?

  1. A 2-hour plasma glucose of 150 mg/dL during an oral glucose tolerance test
  2. A random plasma glucose of 145 mg/dL
  3. A fasting plasma glucose of 126 mg/dL or higher Correct answer.
  4. A glycated hemoglobin of 5.9%

Explanation

Diabetes is diagnosed when fasting plasma glucose reaches 126 mg/dL or more, when 2-hour OGTT glucose reaches 200 mg/dL or more, when HbA1c reaches 6.5% or more, or when random glucose is 200 mg/dL or more with classic symptoms. Each criterion generally requires confirmation on a second sample in an asymptomatic patient. Values below these thresholds define prediabetes rather than diabetes.

Question 2Clínica Médica

Which electrocardiographic finding is most characteristic of acute transmural myocardial infarction in its earliest phase?

  1. Diffuse ST depression with PR elevation
  2. Peaked T waves with a shortened QT interval
  3. New left bundle branch block with left axis deviation
  4. ST-segment elevation in anatomically contiguous leads Correct answer.

Explanation

Acute transmural injury produces ST-segment elevation in leads facing the infarcted territory, often with reciprocal depression in opposite leads. Hyperacute T waves may precede this but are not specific. ST elevation in contiguous leads is the finding that triggers urgent reperfusion therapy.

Question 3Clínica Médica

A 70-year-old woman has a blood pressure of 168/94 mmHg confirmed on three visits. She has no diabetes, kidney disease, or other comorbidity. According to standard staging, how is her hypertension classified?

  1. White-coat hypertension
  2. Stage 1 hypertension
  3. Elevated blood pressure
  4. Stage 2 hypertension Correct answer.

Explanation

Stage 2 hypertension is defined as systolic pressure of 140 mmHg or higher or diastolic pressure of 90 mmHg or higher. Stage 1 covers systolic 130–139 or diastolic 80–89 mmHg. Her confirmed readings on repeated visits place her clearly in stage 2.

Question 4Clínica Médica

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

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

Explanation

Streptococcus pneumoniae remains the single most frequent pathogen isolated in adults hospitalized with community-acquired pneumonia. Atypical organisms such as Mycoplasma and Legionella are important but less common overall. Empiric therapy therefore always covers pneumococcus.

Question 5Clínica Médica

A patient presents with polyuria, polydipsia, and a plasma glucose of 480 mg/dL. Which finding best indicates diabetic ketoacidosis rather than hyperosmolar hyperglycemic state?

  1. Mild confusion without dehydration
  2. Glucose above 600 mg/dL
  3. Serum osmolality above 320 mOsm/kg
  4. Serum bicarbonate of 12 mEq/L with ketonemia Correct answer.

Explanation

Diabetic ketoacidosis is defined by the triad of hyperglycemia, ketonemia, and high-anion-gap metabolic acidosis, reflected in a low bicarbonate. Hyperosmolar hyperglycemic state typically shows extreme hyperosmolality with minimal ketosis and preserved bicarbonate. The acidotic picture with ketones is the discriminator.

Question 6Clínica Médica

A 45-year-old man has a serum creatinine of 2.4 mg/dL, a urine sodium of 12 mEq/L, and a fractional excretion of sodium of 0.4%. Which cause of acute kidney injury is most likely?

  1. Postrenal obstruction
  2. Prerenal azotemia from volume depletion Correct answer.
  3. Acute tubular necrosis
  4. Acute interstitial nephritis

Explanation

A low fractional excretion of sodium below 1% with low urine sodium indicates avid tubular sodium reabsorption, characteristic of prerenal states such as volume depletion. Acute tubular necrosis typically yields a fractional excretion above 2%. The preserved tubular function supports a prerenal cause.

Question 7Clínica Médica

Which finding is most suggestive of nephrotic syndrome rather than nephritic syndrome?

  1. Proteinuria greater than 3.5 g per day with hypoalbuminemia Correct answer.
  2. Hypertension with oliguria
  3. Red blood cell casts in the urine
  4. Gross hematuria with a rising creatinine

Explanation

Nephrotic syndrome is characterized by heavy proteinuria above 3.5 g daily, hypoalbuminemia, edema, and hyperlipidemia, reflecting podocyte injury. Nephritic syndrome instead features hematuria, red cell casts, hypertension, and oliguria from glomerular inflammation. The two patterns can overlap but heavy proteinuria defines the nephrotic picture.

Question 8Clínica Médica

A 62-year-old smoker presents with a cough and hyponatremia of 118 mEq/L. Serum osmolality is low, urine osmolality is high, and urine sodium is elevated while the patient is euvolemic. Which mechanism best explains the sodium disturbance?

  1. Excess secretion of antidiuretic hormone Correct answer.
  2. Diuretic use with volume contraction
  3. Adrenal insufficiency with sodium wasting
  4. Primary polydipsia with free water excess

Explanation

Euvolemic hypotonic hyponatremia with concentrated urine and high urine sodium indicates the syndrome of inappropriate antidiuretic hormone, often paraneoplastic in small cell lung cancer. Inappropriate ADH secretion causes water retention and dilutional hyponatremia. Treatment includes fluid restriction and addressing the underlying cause.

Question 9Clínica Médica

A 30-year-old woman has fatigue, weight gain, cold intolerance, and a thyroid-stimulating hormone level of 12 mIU/L with a low free thyroxine. Which is the most appropriate initial treatment?

  1. Methimazole
  2. Levothyroxine Correct answer.
  3. Propranolol alone
  4. Radioactive iodine

Explanation

Primary hypothyroidism with an elevated TSH and low free thyroxine is treated with levothyroxine replacement, titrated to normalize TSH. Dosing is weight-based and lower in older patients or those with coronary disease. Thyroid hormone replacement reverses the symptoms over weeks.

Question 10Clínica Médica

Which feature best distinguishes an exudative pleural effusion from a transudative one?

  1. Clear straw-colored appearance
  2. Pleural fluid glucose equal to serum glucose
  3. Pleural fluid pH of 7.45
  4. Pleural fluid protein to serum protein ratio above 0.5 Correct answer.

Explanation

Light's criteria classify an effusion as exudative when the pleural to serum protein ratio exceeds 0.5, the pleural to serum lactate dehydrogenase ratio exceeds 0.6, or pleural LDH exceeds two-thirds of the upper normal serum limit. Exudates reflect increased capillary permeability or impaired lymphatic drainage from infection, malignancy, or inflammation. Transudates result from hydrostatic or oncotic imbalance.

Question 11Clínica Médica

A 24-year-old man has sudden-onset pleuritic chest pain and dyspnea after a long flight. He is tachycardic and hypoxic, and the chest radiograph is normal. Which is the most appropriate next diagnostic step?

  1. Computed tomography pulmonary angiography Correct answer.
  2. D-dimer assay
  3. Serial troponin measurements
  4. Ventilation-perfusion scan

Explanation

In a patient with high pretest probability of pulmonary embolism, CT pulmonary angiography is the confirmatory test of choice because it directly visualizes thrombus in the pulmonary arteries. D-dimer is useful mainly to exclude embolism in low-probability patients. A normal radiograph does not exclude embolism.

Question 12Clínica Médica

A 55-year-old woman has epigastric pain that wakes her at night and is relieved by food. She takes ibuprofen regularly for arthritis. Which is the most likely diagnosis?

  1. Gastric ulcer
  2. Duodenal ulcer Correct answer.
  3. Acute pancreatitis
  4. Gastroesophageal reflux disease

Explanation

Duodenal ulcer pain classically occurs when the stomach is empty, waking patients at night, and is relieved by food or antacids. Nonsteroidal anti-inflammatory drugs are a major cause by impairing mucosal prostaglandin synthesis. Gastric ulcer pain tends to worsen with eating.

Question 13Clínica Médica

Which laboratory pattern is most consistent with iron deficiency anemia?

  1. Low ferritin with high total iron-binding capacity Correct answer.
  2. High ferritin with normal mean corpuscular volume
  3. High ferritin with low total iron-binding capacity
  4. Normal ferritin with low reticulocyte count

Explanation

Iron deficiency produces low serum ferritin reflecting depleted stores, low serum iron, and elevated total iron-binding capacity as transferrin rises. The result is a microcytic hypochromic anemia. Ferritin is the most specific single test for iron deficiency.

Question 14Clínica Médica

A 68-year-old man has fatigue and a hemoglobin of 8.2 g/dL with a mean corpuscular volume of 118 fL. Which cause should be considered first?

  1. Thalassemia trait
  2. Sideroblastic anemia
  3. Vitamin B12 deficiency Correct answer.
  4. Acute blood loss

Explanation

Macrocytosis with anemia most commonly reflects vitamin B12 or folate deficiency, which impair DNA synthesis and cause nuclear-cytoplasmic asynchrony. Vitamin B12 deficiency may also produce neurologic signs and elevated methylmalonic acid. Thalassemia and blood loss instead cause microcytic anemia.

Question 15Clínica Médica

A patient with atrial fibrillation has a CHA2DS2-VASc score of 4. Which therapy is most appropriate for stroke prevention?

  1. Dual antiplatelet therapy
  2. No antithrombotic therapy
  3. Aspirin alone
  4. Oral anticoagulation Correct answer.

Explanation

A CHA2DS2-VASc score of 2 or higher in men, or 3 or higher in women, warrants oral anticoagulation to reduce cardioembolic stroke risk. Antiplatelet therapy is inferior to anticoagulation for atrial fibrillation. The choice between direct oral anticoagulants and warfarin depends on renal function and valve status.

Question 16Clínica Médica

A 72-year-old man has exertional dyspnea and a systolic ejection murmur at the right upper sternal border radiating to the carotids. Which valvular lesion is most likely?

  1. Aortic stenosis Correct answer.
  2. Mitral stenosis
  3. Mitral regurgitation
  4. Tricuspid regurgitation

Explanation

Aortic stenosis produces a crescendo-decrescendo systolic murmur at the right second intercostal space that radiates to the carotid arteries. Symptoms of angina, syncope, and dyspnea indicate severe disease requiring intervention. The carotid radiation reflects transmission of the murmur through the neck vessels.

Question 17Clínica Médica

A 40-year-old woman has a blood pressure of 158/96 mmHg, episodic headache, palpitations, and sweating. Which test is most appropriate for initial screening for pheochromocytoma?

  1. Renal artery Doppler ultrasound
  2. Overnight dexamethasone suppression test
  3. Serum aldosterone to renin ratio
  4. Plasma metanephrines Correct answer.

Explanation

Pheochromocytoma is screened with plasma free metanephrines or 24-hour urinary fractionated metanephrines, which have high sensitivity. The classic triad of episodic headache, palpitations, and diaphoresis with hypertension raises suspicion. Biochemical confirmation precedes imaging.

Question 18Clínica Médica

Which finding most strongly suggests a diagnosis of systemic lupus erythematosus in a patient with arthritis and rash?

  1. Elevated erythrocyte sedimentation rate
  2. Positive rheumatoid factor
  3. Positive antinuclear antibody alone
  4. Anti-double-stranded DNA antibodies Correct answer.

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity and lupus nephritis. Antinuclear antibody is sensitive but not specific and occurs in many conditions and healthy people. Rheumatoid factor is nonspecific and can appear in lupus and other diseases.

Question 19Clínica Médica

A 20-year-old woman has a symmetric ascending weakness with areflexia two weeks after a diarrheal illness. Which is the most likely diagnosis?

  1. Multiple sclerosis
  2. Myasthenia gravis
  3. Guillain-Barré syndrome Correct answer.
  4. Polymyositis

Explanation

Guillain-Barré syndrome is an acute inflammatory demyelinating polyneuropathy that classically presents with symmetric ascending flaccid weakness and areflexia after an infection such as Campylobacter jejuni. Cerebrospinal fluid shows albuminocytologic dissociation. Respiratory monitoring is critical because of potential neuromuscular respiratory failure.

Question 20Clínica Médica

A 65-year-old man with chronic obstructive pulmonary disease has a PaO2 of 52 mmHg on room air and a hematocrit of 56%. Which intervention improves survival?

  1. Oral corticosteroids indefinitely
  2. Routine mucolytics
  3. Long-term continuous oxygen therapy Correct answer.
  4. Prophylactic antibiotics

Explanation

Long-term oxygen therapy improves survival in patients with chronic obstructive pulmonary disease and severe resting hypoxemia, defined as PaO2 of 55 mmHg or less or 59 mmHg or less with cor pulmonale or polycythemia. The benefit stems from reducing pulmonary hypertension and cardiac workload. Oxygen is titrated to maintain saturation near 90%.

Question 21Clínica Médica

A 50-year-old man has a serum calcium of 11.8 mg/dL with a low phosphate and an elevated parathyroid hormone level. Which is the most likely cause?

  1. Primary hyperparathyroidism Correct answer.
  2. Vitamin D deficiency
  3. Hypoparathyroidism
  4. Chronic kidney disease

Explanation

Primary hyperparathyroidism causes hypercalcemia with inappropriately elevated parathyroid hormone and often hypophosphatemia, most commonly from a solitary parathyroid adenoma. It is the leading cause of outpatient hypercalcemia. Surgery is indicated for symptomatic disease or complications.

Question 22Clínica Médica

A 28-year-old man has sudden severe abdominal pain with rigidity and free air under the diaphragm on an upright radiograph. Which is the most appropriate immediate management?

  1. Intravenous proton pump inhibitor and observation
  2. Nasogastric decompression alone
  3. Urgent surgical consultation for perforation Correct answer.
  4. Oral contrast study to localize the site

Explanation

Pneumoperitoneum with a rigid abdomen indicates a perforated hollow viscus, a surgical emergency requiring urgent operative repair. Resuscitation with intravenous fluids and broad-spectrum antibiotics should accompany surgical consultation. Delay increases mortality from peritonitis and sepsis.

Question 23Clínica Médica

A 34-year-old woman has a platelet count of 18,000/µL with petechiae but no anemia or splenomegaly. Which diagnosis is most likely?

  1. Disseminated intravascular coagulation
  2. Thrombotic thrombocytopenic purpura
  3. Aplastic anemia
  4. Immune thrombocytopenic purpura Correct answer.

Explanation

Immune thrombocytopenic purpura causes isolated thrombocytopenia with mucocutaneous bleeding and an otherwise normal blood count and physical examination. It results from autoantibody-mediated platelet destruction. The absence of anemia, schistocytes, or coagulopathy helps exclude other causes.

Question 24Clínica Médica

A 60-year-old woman has fatigue, hyperpigmentation of the skin, hypotension, and hyponatremia with hyperkalemia. Which test is most appropriate to confirm the diagnosis?

  1. Plasma renin activity
  2. Serum aldosterone concentration
  3. Overnight dexamethasone suppression test
  4. Morning cortisol and adrenocorticotropic hormone stimulation test Correct answer.

Explanation

Primary adrenal insufficiency presents with fatigue, hyperpigmentation from elevated adrenocorticotropic hormone, hypotension, hyponatremia, and hyperkalemia. Diagnosis is confirmed with a low morning cortisol and a blunted response to synthetic adrenocorticotropic hormone stimulation. Treatment requires glucocorticoid and mineralocorticoid replacement.

Question 25Clínica Médica

A 48-year-old man with alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be given immediately?

  1. Oral folate
  2. Intravenous glucose alone
  3. Intravenous naloxone
  4. Intravenous thiamine Correct answer.

Explanation

The triad of confusion, ataxia, and ophthalmoplegia indicates Wernicke encephalopathy from thiamine deficiency, a medical emergency requiring immediate parenteral thiamine. Thiamine should be given before or with glucose to avoid precipitating or worsening the encephalopathy. Untreated disease can progress to irreversible Korsakoff syndrome.

Question 26Clínica Médica

A 58-year-old man with a history of myocardial infarction presents with sudden-onset severe epigastric pain radiating to the back. He is diaphoretic and hypotensive. Bedside ultrasound shows a distended gallbladder with a thickened wall but no stones. Which diagnosis is most likely?

  1. Acute myocardial infarction Correct answer.
  2. Acute mesenteric ischemia
  3. Perforated peptic ulcer
  4. Acute calculous cholecystitis

Explanation

In a patient with known coronary artery disease, acute epigastric pain and hypotension can be an atypical presentation of myocardial infarction, especially in diabetics or the elderly. The ultrasound findings of a distended gallbladder with wall thickening without stones may be secondary to acute illness rather than primary biliary disease. An electrocardiogram and cardiac troponin should be obtained urgently. The other options are less likely given the presentation and ultrasound findings.

Question 27Clínica Médica

A 45-year-old woman is admitted with confusion and a serum sodium of 118 mEq/L. She has a history of schizophrenia and polydipsia. Her urine osmolality is 80 mOsm/kg and urine sodium is 10 mEq/L. Which is the most appropriate initial management?

  1. Intravenous isotonic saline
  2. Demeclocycline
  3. Fluid restriction Correct answer.
  4. Intravenous hypertonic saline

Explanation

The patient has hyponatremia with low urine osmolality, consistent with primary polydipsia. Fluid restriction is the treatment of choice. Hypertonic saline is reserved for severe symptomatic hyponatremia with seizures or coma, and isotonic saline would worsen the hyponatremia by increasing free water intake. Demeclocycline is used for SIADH, not for primary polydipsia.

Question 28Clínica Médica

Which finding is most characteristic of diabetic ketoacidosis compared with hyperosmolar hyperglycemic state?

  1. Mild ketonuria
  2. Arterial pH <7.30 Correct answer.
  3. Serum osmolality >320 mOsm/kg
  4. Serum glucose >600 mg/dL

Explanation

Diabetic ketoacidosis is defined by the triad of hyperglycemia, ketosis, and high anion gap metabolic acidosis, typically with arterial pH <7.30. Hyperosmolar hyperglycemic state usually presents with much higher glucose and osmolality but minimal ketosis and pH >7.30. Therefore, a pH <7.30 is more characteristic of DKA.

Question 29Clínica Médica

A 30-year-old man presents with fever, arthralgia, and a new systolic murmur. Blood cultures grow Streptococcus viridans. Which is the most appropriate next step in management?

  1. Obtain an echocardiogram and start antibiotics after results
  2. Start intravenous antibiotics and obtain an echocardiogram Correct answer.
  3. Obtain a transesophageal echocardiogram only if fever persists
  4. Start oral antibiotics and discharge with follow-up

Explanation

Infective endocarditis is suspected based on fever, arthralgia, new murmur, and positive blood cultures. Blood cultures should be drawn before antibiotics, but once cultures are positive, intravenous antibiotics should be started promptly and an echocardiogram obtained to assess for vegetations. Delay in antibiotics increases morbidity and mortality.

Question 30Clínica Médica

A 62-year-old woman with a history of hypertension presents with sudden severe headache and neck stiffness. CT scan shows subarachnoid hemorrhage. Which finding is most likely on lumbar puncture if performed?

  1. Low glucose and high protein
  2. Polymorphonuclear pleocytosis
  3. Elevated opening pressure with clear fluid
  4. Xanthochromia Correct answer.

Explanation

Xanthochromia, a yellow discoloration of cerebrospinal fluid due to bilirubin from red blood cell breakdown, is a hallmark of subarachnoid hemorrhage and can be detected by spectrophotometry. It helps distinguish true hemorrhage from traumatic tap. Elevated opening pressure with clear fluid is nonspecific, and low glucose with high protein suggests bacterial meningitis.

Question 31Clínica Médica

A 55-year-old man with cirrhosis presents with hematemesis and melena. He is tachycardic and hypotensive. After initial resuscitation, which medication should be started to reduce the risk of rebleeding?

  1. Vitamin K
  2. Propranolol
  3. Fresh frozen plasma
  4. Octreotide Correct answer.

Explanation

Octreotide, a somatostatin analog, is used in acute variceal hemorrhage to reduce portal pressure and decrease bleeding. Propranolol is used for prophylaxis, not acute bleeding. Vitamin K and fresh frozen plasma are used to correct coagulopathy but do not directly reduce portal pressure.

Question 32Clínica Médica

Which is the most common cause of nephrotic syndrome in adults?

  1. Focal segmental glomerulosclerosis
  2. Minimal change disease
  3. Membranous nephropathy Correct answer.
  4. IgA nephropathy

Explanation

Membranous nephropathy is the most common cause of nephrotic syndrome in adults, especially in whites. Minimal change disease is more common in children, and focal segmental glomerulosclerosis is more common in blacks and those with HIV. IgA nephropathy typically causes nephritic syndrome.

Question 33Clínica Médica

A 70-year-old man is found to have a hemoglobin of 10 g/dL and a mean corpuscular volume of 105 fL. His reticulocyte count is low. Which is the most likely cause?

  1. Vitamin B12 deficiency Correct answer.
  2. Iron deficiency
  3. Thalassemia trait
  4. Anemia of chronic disease

Explanation

Macrocytic anemia with a low reticulocyte count suggests decreased production, often due to vitamin B12 or folate deficiency. Iron deficiency and thalassemia trait cause microcytic anemia. Anemia of chronic disease is typically normocytic, though it can be microcytic.

Question 34Clínica Médica

A 40-year-old woman presents with fatigue, weight gain, and cold intolerance. Her TSH is elevated and free T4 is low. Which antibody is most specific for the underlying cause?

  1. TSH receptor antibodies
  2. Anti-thyroglobulin
  3. Anti-thyroid peroxidase Correct answer.
  4. Anti-nuclear antibodies

Explanation

The patient has primary hypothyroidism, most commonly due to Hashimoto's thyroiditis. Anti-thyroid peroxidase antibodies are the most sensitive and specific marker for Hashimoto's thyroiditis. TSH receptor antibodies are seen in Graves' disease, and anti-thyroglobulin antibodies are less specific.

Question 35Clínica Médica

A 25-year-old man presents with sudden onset of severe chest pain and dyspnea. He is tall and thin. Chest X-ray shows a tracheal deviation to the left and absent lung markings on the right. Which is the immediate management?

  1. CT scan of the chest
  2. Bronchoscopy
  3. Needle decompression Correct answer.
  4. Chest tube insertion

Explanation

The presentation is classic for tension pneumothorax, which is a clinical diagnosis requiring immediate needle decompression followed by chest tube insertion. Waiting for imaging can be fatal. Bronchoscopy is not indicated.

Question 36Clínica Médica

A 50-year-old woman presents with polyuria, polydipsia, and weight loss. Her random glucose is 250 mg/dL. Which is the most appropriate initial pharmacologic therapy?

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

Explanation

Metformin is the first-line therapy for type 2 diabetes mellitus unless contraindicated. It improves insulin sensitivity and lowers hepatic glucose production. Insulin is reserved for type 1 diabetes or severe hyperglycemia, and sulfonylureas and thiazolidinediones are second-line agents.

Question 37Clínica Médica

A 60-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be given immediately?

  1. Naloxone
  2. Thiamine Correct answer.
  3. Flumazenil
  4. Glucose

Explanation

The triad of confusion, ataxia, and ophthalmoplegia is characteristic of Wernicke encephalopathy, a thiamine deficiency syndrome. Immediate thiamine administration is crucial to prevent progression to Korsakoff syndrome. Glucose should be given after thiamine to avoid precipitating Wernicke encephalopathy.

Question 38Clínica Médica

A 35-year-old woman presents with a butterfly rash, arthralgia, and oral ulcers. Which laboratory test is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity, particularly lupus nephritis. Anti-nuclear antibodies are sensitive but not specific. Rheumatoid factor is seen in rheumatoid arthritis and other conditions, and anti-histone antibodies are associated with drug-induced lupus.

Question 39Clínica Médica

A 28-year-old woman presents with palpitations and heat intolerance. Her TSH is suppressed and free T4 is elevated. She has a diffuse goiter and mild exophthalmos. Which is the most appropriate initial treatment?

  1. Radioactive iodine
  2. Methimazole Correct answer.
  3. Propranolol alone
  4. Levothyroxine

Explanation

The patient has Graves' disease, and methimazole is the first-line treatment for hyperthyroidism. Radioactive iodine is an alternative but is contraindicated in pregnancy and may worsen ophthalmopathy. Levothyroxine would worsen hyperthyroidism, and propranolol alone is only for symptom control.

Question 40Clínica Médica

A 70-year-old man presents with a sudden painless loss of vision in his right eye. Fundoscopy shows a pale retina with a cherry-red spot at the macula. Which is the most likely diagnosis?

  1. Vitreous hemorrhage
  2. Retinal detachment
  3. Central retinal artery occlusion Correct answer.
  4. Central retinal vein occlusion

Explanation

Central retinal artery occlusion presents with sudden painless monocular vision loss and a pale retina with a cherry-red spot at the fovea due to ischemia. Central retinal vein occlusion typically shows a blood-and-thunder appearance with retinal hemorrhages. Retinal detachment causes flashes and floaters, and vitreous hemorrhage causes sudden vision loss with hazy view.

Question 41Clínica Médica

A 55-year-old man with a history of gout presents with acute monoarthritis of the first metatarsophalangeal joint. Joint aspiration shows needle-shaped negatively birefringent crystals. Which medication is most appropriate for acute treatment?

  1. Allopurinol
  2. Probenecid
  3. Colchicine Correct answer.
  4. Febuxostat

Explanation

Colchicine is an anti-inflammatory agent used for acute gout flares. Allopurinol and febuxostat are xanthine oxidase inhibitors used for chronic urate-lowering therapy, not acute flares. Probenecid is a uricosuric agent used for chronic management.

Question 42Clínica Médica

A 40-year-old woman presents with episodic palpitations, diaphoresis, and headache. She has a blood pressure of 210/120 mmHg during an episode. Which test is most appropriate for diagnosis?

  1. Serum cortisol
  2. Plasma metanephrines Correct answer.
  3. Renal artery Doppler
  4. Thyroid function tests

Explanation

The presentation suggests pheochromocytoma, a catecholamine-secreting tumor. Plasma free metanephrines are the most sensitive test for diagnosis. Serum cortisol is used for Cushing syndrome, renal artery Doppler for renovascular hypertension, and thyroid function tests for hyperthyroidism.

Question 43Clínica Médica

A 65-year-old man with a history of smoking presents with hemoptysis and weight loss. Chest X-ray shows a hilar mass. Which is the most likely type of lung cancer?

  1. Squamous cell carcinoma Correct answer.
  2. Large cell carcinoma
  3. Adenocarcinoma
  4. Small cell carcinoma

Explanation

Squamous cell carcinoma is strongly associated with smoking and typically presents as a central hilar mass that can cavitate and cause hemoptysis. Adenocarcinoma is more common in nonsmokers and tends to be peripheral. Small cell carcinoma also occurs centrally but is characterized by rapid growth and early metastasis.

Question 44Clínica Médica

A 30-year-old woman presents with recurrent kidney stones and bone pain. Serum calcium is elevated, phosphate is low, and PTH is elevated. Which is the most likely diagnosis?

  1. Secondary hyperparathyroidism
  2. Tertiary hyperparathyroidism
  3. Familial hypocalciuric hypercalcemia
  4. Primary hyperparathyroidism Correct answer.

Explanation

Primary hyperparathyroidism is characterized by hypercalcemia, hypophosphatemia, and elevated PTH. It often presents with recurrent kidney stones and bone pain. Secondary hyperparathyroidism occurs in chronic kidney disease with hypocalcemia, and tertiary hyperparathyroidism occurs after long-standing secondary hyperparathyroidism.

Question 45Clínica Médica

A 50-year-old man presents with a sudden severe headache, nausea, and photophobia. CT scan is normal. Lumbar puncture shows xanthochromia. Which is the most appropriate next step?

  1. Start antibiotics
  2. Start antiviral therapy
  3. Obtain magnetic resonance angiography Correct answer.
  4. Discharge with analgesics

Explanation

The diagnosis is subarachnoid hemorrhage, and the most common cause is a ruptured berry aneurysm. Magnetic resonance angiography or CT angiography should be performed to identify the aneurysm. Antibiotics and antivirals are not indicated for subarachnoid hemorrhage.

Question 46Clínica Médica

A 45-year-old man is found to have a blood pressure of 160/100 mmHg on three separate occasions. He has no symptoms. Which is the most appropriate initial management?

  1. Start lifestyle modifications alone
  2. Start an ACE inhibitor and a beta-blocker
  3. Start lifestyle modifications and a thiazide diuretic Correct answer.
  4. Refer for renal denervation

Explanation

According to guidelines, stage 2 hypertension (≥160/100 mmHg) should be treated with lifestyle modifications and two antihypertensive agents, often a thiazide diuretic plus an ACE inhibitor or ARB. Lifestyle modifications alone are insufficient for stage 2 hypertension. Renal denervation is reserved for resistant hypertension.

Question 47Clínica Médica

A 60-year-old woman presents with fatigue, hyperpigmentation, and hypotension. Laboratory tests show hyponatremia and hyperkalemia. Which is the most likely diagnosis?

  1. Syndrome of inappropriate antidiuretic hormone
  2. Secondary adrenal insufficiency
  3. Conn syndrome
  4. Primary adrenal insufficiency Correct answer.

Explanation

Primary adrenal insufficiency (Addison's disease) is characterized by deficiency of both cortisol and aldosterone, leading to hyponatremia, hyperkalemia, hypotension, and hyperpigmentation due to elevated ACTH. Secondary adrenal insufficiency typically lacks hyperkalemia and hyperpigmentation because aldosterone is preserved. SIADH causes hyponatremia but not hyperkalemia, and Conn syndrome causes hypertension and hypokalemia.

Question 48Clínica Médica

A 70-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. He has a history of falls. Which is the most appropriate anticoagulation strategy?

  1. Aspirin
  2. Warfarin
  3. No anticoagulation
  4. Apixaban Correct answer.

Explanation

For patients with atrial fibrillation and a CHA2DS2-VASc score ≥2, oral anticoagulation is recommended. Direct oral anticoagulants like apixaban are preferred over warfarin due to lower risk of bleeding, especially in patients with fall risk. Aspirin is not effective for stroke prevention in atrial fibrillation.

Question 49Clínica Médica

A 35-year-old woman presents with recurrent episodes of severe abdominal pain, dark urine, and muscle weakness. During an attack, her urine turns dark on standing. Which is the most likely diagnosis?

  1. Wilson disease
  2. Acute intermittent porphyria Correct answer.
  3. Alpha-1 antitrypsin deficiency
  4. Hereditary hemochromatosis

Explanation

Acute intermittent porphyria presents with neurovisceral symptoms including severe abdominal pain, dark urine due to porphobilinogen oxidation, and muscle weakness. Hereditary hemochromatosis causes liver disease, diabetes, and skin bronzing. Wilson disease causes liver and neurologic symptoms, and alpha-1 antitrypsin deficiency causes lung and liver disease.

Question 50Clínica Médica

A 50-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which is the most likely diagnosis?

  1. Wernicke encephalopathy Correct answer.
  2. Korsakoff syndrome
  3. Delirium tremens
  4. Hepatic encephalopathy

Explanation

Wernicke encephalopathy is characterized by the triad of confusion, ataxia, and ophthalmoplegia due to thiamine deficiency. Korsakoff syndrome is a chronic sequela with memory impairment and confabulation. Hepatic encephalopathy presents with confusion and asterixis, and delirium tremens occurs with alcohol withdrawal.