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CMMI Medicina Interna practice questions

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Question 1Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 58-year-old man with type 2 diabetes has an HbA1c of 8.9% after 3 months of metformin at maximally tolerated dose. He has no cardiovascular disease and an eGFR of 70 mL/min/1.73 m². Which addition is most appropriate next step in therapy?

  1. Switch metformin to a sulfonylurea
  2. Add a GLP-1 receptor agonist or SGLT2 inhibitor Correct answer.
  3. Discontinue metformin and start pioglitazone
  4. Add basal insulin immediately

Explanation

When metformin alone fails to reach glycemic goals, guidelines recommend adding an agent with proven cardiovascular and renal benefit, such as a GLP-1 receptor agonist or SGLT2 inhibitor. These are preferred over older agents when there is no contraindication.

Question 2Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which finding best supports a diagnosis of heart failure with reduced ejection fraction?

  1. Left ventricular ejection fraction of 35% with symptoms of dyspnea Correct answer.
  2. Elevated troponin with chest pain
  3. Isolated peripheral edema with normal echocardiogram
  4. Preserved ejection fraction with elevated natriuretic peptides

Explanation

HFrEF is defined by symptoms and signs of heart failure together with a left ventricular ejection fraction of 40% or less. The combination of symptoms and reduced EF establishes the diagnosis.

Question 3Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 70-year-old woman with atrial fibrillation has a CHA2DS2-VASc score of 4. Which therapy most reduces her risk of ischemic stroke?

  1. Aspirin 100 mg daily
  2. Clopidogrel 75 mg daily
  3. Oral anticoagulation with a DOAC or warfarin Correct answer.
  4. No antithrombotic therapy

Explanation

A CHA2DS2-VASc score of 2 or more in women (or 1 or more in men) warrants oral anticoagulation, which substantially reduces stroke risk compared with antiplatelet therapy. DOACs or warfarin are appropriate choices.

Question 4Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which spirometric finding is required to confirm persistent airflow obstruction consistent with COPD?

  1. Pre-bronchodilator FEV1/FVC greater than 0.80
  2. Reduced diffusion capacity alone
  3. Increased residual volume on plethysmography
  4. Post-bronchodilator FEV1/FVC less than 0.70 Correct answer.

Explanation

COPD is confirmed by a post-bronchodilator FEV1/FVC ratio below 0.70, demonstrating persistent airflow obstruction. Other measures support but do not establish the diagnosis.

Question 5Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 24-year-old with acute severe asthma has a peak expiratory flow of 40% predicted despite repeated bronchodilators. Which agent should be added early?

  1. Inhaled long-acting beta-agonist alone
  2. Oral antihistamine
  3. Systemic corticosteroids Correct answer.
  4. Prophylactic antibiotics

Explanation

Systemic corticosteroids are indicated early in acute severe asthma to reduce airway inflammation and prevent relapse. They complement inhaled bronchodilators.

Question 6Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which feature most strongly suggests community-acquired pneumonia rather than acute bronchitis in an adult with cough?

  1. Focal crackles and a new infiltrate on chest imaging Correct answer.
  2. Productive cough for 5 days
  3. Low-grade fever with rhinorrhea
  4. Wheezing with a recent cold

Explanation

Pneumonia is distinguished from bronchitis by evidence of pulmonary parenchymal involvement, typically a new infiltrate on imaging with focal auscultatory findings. Bronchitis lacks consolidation.

Question 7Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 65-year-old man presents with acute decompensated heart failure. Which finding on examination best indicates elevated left-sided filling pressures?

  1. Jugular venous distension at 45 degrees Correct answer.
  2. Hepatomegaly
  3. Bilateral ankle edema
  4. Ascites

Explanation

Jugular venous distension reflects elevated right atrial pressure, which correlates with elevated filling pressures and volume overload in decompensated heart failure. Edema has many causes and is less specific.

Question 8Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which is the most appropriate initial pharmacologic therapy for a patient with newly diagnosed uncomplicated hypertension and no comorbidities?

  1. A thiazide-type diuretic, ACE inhibitor, ARB, or calcium channel blocker Correct answer.
  2. Central alpha-2 agonist as first-line
  3. An alpha-blocker as first-line
  4. A loop diuretic as first-line

Explanation

First-line therapy for uncomplicated hypertension includes thiazide-type diuretics, ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers. These agents have outcome data supporting their use.

Question 9Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 55-year-old woman has an LDL cholesterol of 190 mg/dL and no other risk factors. What is the most appropriate management?

  1. Recommend dietary change alone
  2. Check LDL again in 5 years
  3. Start ezetimibe monotherapy
  4. Start a moderate- to high-intensity statin Correct answer.

Explanation

An LDL cholesterol of 190 mg/dL or higher is a risk-enhancing threshold that warrants statin therapy regardless of calculated risk. Lifestyle modification is added but not sufficient alone.

Question 10Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which ECG finding is most characteristic of acute ST-elevation myocardial infarction?

  1. Sinus tachycardia with normal ST segments
  2. Diffuse ST depression with PR depression
  3. First-degree AV block
  4. ST-segment elevation in contiguous leads Correct answer.

Explanation

STEMI is identified by ST-segment elevation in anatomically contiguous leads, reflecting transmural ischemia. Prompt reperfusion is required.

Question 11Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 30-year-old has a first unprovoked deep vein thrombosis. Which duration of anticoagulation is generally recommended?

  1. At least 3 months, with consideration of extended therapy Correct answer.
  2. Lifelong therapy in all patients
  3. Until symptoms resolve only
  4. 2 weeks

Explanation

For a first unprovoked VTE, anticoagulation is recommended for at least 3 months, and extended therapy is considered based on bleeding risk and patient preference. Shorter courses increase recurrence risk.

Question 12Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which laboratory pattern is typical of iron deficiency anemia?

  1. High ferritin with high MCV
  2. Low ferritin with low mean corpuscular volume Correct answer.
  3. Elevated ferritin with normal MCV
  4. Normal ferritin with macrocytosis

Explanation

Iron deficiency anemia produces microcytosis and low ferritin, reflecting depleted iron stores. Ferritin is the most specific initial test.

Question 13Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 72-year-old with chronic kidney disease has a hemoglobin of 9.5 g/dL. Which cause of anemia should be considered first?

  1. Hemolysis from G6PD deficiency
  2. Vitamin B12 toxicity
  3. Iron overload
  4. Erythropoietin deficiency Correct answer.

Explanation

CKD causes anemia primarily through reduced erythropoietin production. Evaluation should exclude other causes, but EPO deficiency is the leading mechanism.

Question 14Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which finding best distinguishes acute kidney injury from chronic kidney disease?

  1. Elevated creatinine alone
  2. Hematuria alone
  3. Proteinuria alone
  4. Small echogenic kidneys on ultrasound suggest chronic disease Correct answer.

Explanation

Small, echogenic kidneys indicate chronic scarring and support CKD, whereas normal or enlarged kidneys favor acute injury. A prior baseline creatinine is also helpful.

Question 15Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A patient with decompensated cirrhosis has ascites. Which initial therapy is most appropriate?

  1. Large-volume paracentesis as sole therapy
  2. Dietary sodium restriction plus spironolactone with or without furosemide Correct answer.
  3. High-dose furosemide alone
  4. NSAIDs for discomfort

Explanation

First-line management of cirrhotic ascites is sodium restriction combined with a potassium-sparing diuretic (spironolactone), often with furosemide. This addresses the aldosterone-mediated sodium retention.

Question 16Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which endoscopic finding is most consistent with peptic ulcer disease caused by Helicobacter pylori?

  1. A duodenal ulcer with a positive urea breath test Correct answer.
  2. Multiple colonic polyps
  3. Diffuse esophageal varices
  4. Erosive esophagitis alone

Explanation

H. pylori is a leading cause of duodenal and gastric ulcers, and noninvasive testing such as the urea breath test confirms infection. Eradication promotes ulcer healing.

Question 17Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 45-year-old has recurrent episodes of epigastric pain radiating to the back with elevated lipase. Which is the most likely diagnosis?

  1. Peptic ulcer perforation
  2. Acute pancreatitis Correct answer.
  3. Acute cholecystitis
  4. Myocardial infarction

Explanation

Epigastric pain radiating to the back with lipase elevation greater than three times the upper limit of normal is characteristic of acute pancreatitis. Gallstones and alcohol are common causes.

Question 18Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which finding is most consistent with hypothyroidism?

  1. Elevated TSH with low free T4 Correct answer.
  2. Normal TSH with low free T4
  3. Low TSH with high free T4
  4. Elevated TSH with high free T4

Explanation

Primary hypothyroidism shows an elevated TSH with low free T4, reflecting inadequate thyroid hormone production with intact pituitary feedback.

Question 19Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 60-year-old with type 2 diabetes and hypertension has an eGFR of 45 mL/min/1.73 m² and albuminuria. Which medication class slows progression of diabetic kidney disease?

  1. Loop diuretic
  2. Alpha-blocker
  3. Thiazolidinedione
  4. ACE inhibitor or ARB Correct answer.

Explanation

ACE inhibitors or ARBs reduce intraglomerular pressure and albuminuria, slowing progression of diabetic nephropathy. They are indicated in patients with albuminuria and hypertension.

Question 20Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which criterion supports the diagnosis of diabetic ketoacidosis?

  1. Hypoglycemia with metabolic alkalosis
  2. Hyperglycemia with respiratory alkalosis alone
  3. Hyperglycemia with ketonemia and metabolic acidosis Correct answer.
  4. Hyperglycemia with normal anion gap

Explanation

DKA is defined by hyperglycemia, ketonemia, and a high-anion-gap metabolic acidosis. Treatment includes fluids, insulin, and potassium management.

Question 21Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 28-year-old woman has a systolic murmur at the upper sternal border that increases with Valsalva and a midsystolic click. What is the most likely diagnosis?

  1. Ventricular septal defect
  2. Mitral stenosis
  3. Mitral valve prolapse Correct answer.
  4. Aortic stenosis

Explanation

A midsystolic click with a late systolic murmur that intensifies with maneuvers reducing preload (Valsalva) is characteristic of mitral valve prolapse.

Question 22Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which is the most appropriate first-line treatment for a patient with symptomatic bradycardia and hemodynamic instability?

  1. Amiodarone
  2. Beta-blocker
  3. Adenosine
  4. Atropine Correct answer.

Explanation

Atropine is first-line for symptomatic bradycardia with a pulse when vagal tone or AV nodal block is suspected. Pacing is used if atropine fails.

Question 23Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 50-year-old presents with sudden severe headache described as the worst of his life. Which imaging study should be obtained first?

  1. Carotid ultrasound
  2. Plain skull radiograph
  3. EEG
  4. Noncontrast head CT Correct answer.

Explanation

A thunderclap headache raises concern for subarachnoid hemorrhage, for which noncontrast head CT is the initial test. If CT is negative and suspicion persists, lumbar puncture is performed.

Question 24Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which feature most suggests a diagnosis of major depressive disorder rather than a brief adjustment reaction?

  1. Persistent depressed mood and anhedonia for at least 2 weeks with functional impairment Correct answer.
  2. Sadness lasting 2 days after a disappointment
  3. Irritability occurring once a month
  4. Anxiety only before exams

Explanation

Major depressive disorder requires depressed mood or anhedonia for at least 2 weeks, accompanied by other symptoms and functional impairment. Brief reactions to stressors do not meet duration or severity criteria.

Question 25Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 68-year-old with COPD has worsening dyspnea and purulent sputum. Which intervention is most likely to reduce mortality if his oxygen saturation is 85%?

  1. High-flow oxygen to 100% saturation
  2. Controlled supplemental oxygen targeting 88–92% Correct answer.
  3. Oral cough suppressant
  4. Chest physiotherapy alone

Explanation

Hypoxemia in acute COPD exacerbation is treated with controlled oxygen to a target saturation of 88–92%, which improves oxygenation while avoiding hypercapnia. This is a key mortality-reducing measure.

Question 26Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 58-year-old man with type 2 diabetes has a fasting plasma glucose of 132 mg/dL on two occasions and an HbA1c of 6.9%. He is asymptomatic. What is the correct interpretation?

  1. The results indicate impaired fasting glucose only
  2. The diagnosis cannot be made without symptoms
  3. A repeat HbA1c after 3 months is required before any diagnosis
  4. The results meet diagnostic criteria for diabetes mellitus Correct answer.

Explanation

Diabetes is diagnosed by fasting glucose ≥126 mg/dL, HbA1c ≥6.5%, 2-hour OGTT ≥200 mg/dL, or random glucose ≥200 mg/dL with symptoms. Two abnormal fasting values or an abnormal HbA1c confirm the diagnosis even in the absence of symptoms. Symptoms are only required when relying on a random glucose measurement.

Question 27Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which medication is first-line for a patient with newly diagnosed type 2 diabetes and no contraindications, in addition to lifestyle modification?

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

Explanation

Metformin is recommended as initial pharmacotherapy for most patients with type 2 diabetes because of its efficacy, weight neutrality, low hypoglycemia risk, and low cost. Sulfonylureas and insulin are generally reserved for specific situations or later intensification.

Question 28Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 70-year-old woman with heart failure with reduced ejection fraction (EF 30%) is on furosemide and lisinopril. Which additional drug class reduces mortality in this condition?

  1. Nitrate monotherapy
  2. Loop diuretic dose increase
  3. Calcium channel blocker
  4. Beta-blocker Correct answer.

Explanation

Beta-blockers, ACE inhibitors/ARBs/ARNI, mineralocorticoid receptor antagonists, and SGLT2 inhibitors all reduce mortality in HFrEF. Diuretics relieve congestion but do not improve survival. Non-dihydropyridine calcium channel blockers are generally avoided in HFrEF.

Question 29Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 64-year-old man has an anterior STEMI and is 2 hours from symptom onset at a hospital without PCI capability, with a door-to-balloon time estimated at 3 hours. What is the preferred reperfusion strategy?

  1. Observation with aspirin alone
  2. Transfer for primary PCI without fibrinolysis
  3. Elective coronary angiography the next day
  4. Immediate fibrinolysis followed by transfer for PCI Correct answer.

Explanation

When primary PCI cannot be achieved within 120 minutes of first medical contact, fibrinolysis should be given promptly (within 30 minutes of arrival) in eligible patients, followed by transfer for angiography. Delay to PCI beyond 120 minutes worsens outcomes.

Question 30Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which finding on physical examination is most characteristic of mitral stenosis?

  1. An opening snap followed by a rumbling diastolic murmur Correct answer.
  2. A harsh systolic crescendo-decrescendo murmur at the right upper sternal border
  3. A early diastolic decrescendo murmur at the left upper sternal border
  4. A blowing holosystolic murmur at the apex radiating to the axilla

Explanation

Mitral stenosis produces a loud S1, an opening snap, and a low-pitched rumbling mid-diastolic murmur heard best at the apex. The other described murmurs correspond to aortic stenosis, mitral regurgitation, and aortic regurgitation.

Question 31Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 72-year-old woman has a blood pressure of 168/92 mmHg confirmed on two visits despite lifestyle changes. She has no diabetes or kidney disease. What is the most appropriate initial antihypertensive regimen?

  1. A thiazide-type diuretic, ACE inhibitor, ARB, or calcium channel blocker as monotherapy Correct answer.
  2. Clonidine as first-line monotherapy
  3. A loop diuretic as first-line monotherapy
  4. An alpha-blocker as first-line monotherapy

Explanation

First-line agents for uncomplicated hypertension include thiazide-type diuretics, ACE inhibitors, ARBs, and dihydropyridine calcium channel blockers. Alpha-blockers, loop diuretics, and central alpha-2 agonists are not preferred initial therapy for uncomplicated hypertension.

Question 32Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 68-year-old man with COPD (FEV1 45% predicted) has had two moderate exacerbations in the past year. Which maintenance therapy reduces exacerbation frequency?

  1. Long-acting bronchodilator combination with an inhaled corticosteroid Correct answer.
  2. Regular oral corticosteroids
  3. Oral theophylline monotherapy
  4. Short-acting beta-agonist as needed only

Explanation

For patients with COPD and frequent exacerbations, long-acting muscarinic antagonist/long-acting beta-agonist combinations reduce exacerbations, and adding an inhaled corticosteroid further reduces exacerbations in those with an eosinophilic phenotype. Short-acting agents and theophylline do not reduce exacerbation frequency.

Question 33Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 24-year-old woman has episodic wheeze, chest tightness, and cough at night, with symptoms on 3 days per week and FEV1 of 85% predicted. What is the most appropriate initial controller therapy?

  1. Daily oral corticosteroid
  2. Low-dose inhaled corticosteroid Correct answer.
  3. Long-acting beta-agonist monotherapy
  4. Daily oral montelukast alone

Explanation

Asthma with symptoms more than twice weekly but not daily is mild persistent asthma, for which low-dose inhaled corticosteroids are the preferred controller. LABA monotherapy is contraindicated in asthma because of the risk of severe exacerbations.

Question 34Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 55-year-old man with a smoking history presents with hemoptysis and a 3-cm spiculated mass in the right upper lobe. Which next step is most appropriate?

  1. PET scan alone without tissue confirmation
  2. Tissue sampling with bronchoscopy or CT-guided biopsy Correct answer.
  3. Repeat chest radiograph in 3 months
  4. Empiric antibiotic therapy for 4 weeks

Explanation

A spiculated mass in a smoker with hemoptysis is highly suspicious for lung cancer, and tissue diagnosis is required before treatment. Imaging alone cannot confirm malignancy, and delay risks progression.

Question 35Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

Which finding is most characteristic of nephrotic syndrome?

  1. Hematuria with red blood cell casts and hypertension
  2. Proteinuria greater than 3.5 g/day with hypoalbuminemia and edema Correct answer.
  3. Hyperkalemia with metabolic acidosis and oliguria
  4. Sterile pyuria with eosinophiluria

Explanation

Nephrotic syndrome is defined by heavy proteinuria (>3.5 g/day), hypoalbuminemia, edema, and hyperlipidemia. The other patterns describe nephritic syndrome, acute interstitial nephritis, and acute kidney injury with tubular dysfunction.

Question 36Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 30-year-old man has colicky flank pain, gross hematuria, and a 5-mm radiopaque stone in the ureter. Which initial management is most appropriate if he is hemodynamically stable and has no infection?

  1. Open ureterolithotomy
  2. Immediate ureteral stent placement
  3. Percutaneous nephrolithotomy
  4. Analgesia with NSAIDs and hydration with observation for spontaneous passage Correct answer.

Explanation

Small ureteral stones (≤10 mm) often pass spontaneously, so initial management is analgesia and hydration with follow-up. NSAIDs are effective for renal colic. Intervention is reserved for obstruction with infection, refractory pain, or failure of passage.

Question 37Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 70-year-old woman has a hemoglobin of 9.8 g/dL, MCV of 72 fL, and a ferritin of 8 ng/mL. What is the most likely cause of her anemia?

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

Explanation

Microcytic anemia with a low ferritin (<30 ng/mL) is diagnostic of iron deficiency. Ferritin is an acute-phase reactant, so a low value is highly specific. B12 deficiency causes macrocytosis, and anemia of chronic disease usually has normal or elevated ferritin.

Question 38Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 35-year-old woman has fatigue, weight gain, cold intolerance, and a TSH of 12 mIU/L with a low free T4. What is the most appropriate treatment?

  1. Methimazole
  2. Levothyroxine replacement Correct answer.
  3. Observation without treatment
  4. Radioactive iodine

Explanation

Overt primary hypothyroidism (elevated TSH with low free T4) is treated with levothyroxine, titrated to normalize TSH. Methimazole and radioactive iodine are treatments for hyperthyroidism.

Question 39Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 28-year-old woman has a thyroid nodule, palpitations, weight loss, and a suppressed TSH with elevated free T4. Which finding on radioiodine uptake scan is most consistent with Graves disease?

  1. A single hot nodule with suppressed surrounding tissue
  2. Multiple hot nodules
  3. Absent uptake
  4. Diffuse increased uptake Correct answer.

Explanation

Graves disease causes diffuse hyperfunction of the gland, producing diffuse increased uptake on scintigraphy. A single hot nodule suggests a toxic adenoma, multiple hot nodules suggest toxic multinodular goiter, and absent uptake suggests thyroiditis or exogenous hormone.

Question 40Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 45-year-old man has central obesity, blood pressure 146/92 mmHg, fasting glucose 112 mg/dL, triglycerides 180 mg/dL, and HDL 32 mg/dL. Which diagnosis best fits?

  1. Familial hypercholesterolemia
  2. Cushing disease
  3. Metabolic syndrome Correct answer.
  4. Type 1 diabetes mellitus

Explanation

Metabolic syndrome requires at least three of the following: central obesity, elevated triglycerides, low HDL, elevated blood pressure, and impaired fasting glucose. This patient meets at least three criteria.

Question 41Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 62-year-old man has sudden painless loss of vision in one eye described as a curtain descending. Which diagnosis should be considered first?

  1. Acute angle-closure glaucoma
  2. Vitreous hemorrhage
  3. Central retinal artery occlusion Correct answer.
  4. Optic neuritis

Explanation

A painless curtain-like visual loss is characteristic of retinal artery occlusion, often from an embolus. Acute angle-closure glaucoma is painful, vitreous hemorrhage causes floaters and hazy vision, and optic neuritis causes painful visual loss with a relative afferent pupillary defect.

Question 42Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 70-year-old man has sudden onset of right-sided weakness and aphasia with a last known well time of 2 hours ago. Noncontrast head CT shows no hemorrhage. What is the most appropriate next step?

  1. Aspirin 325 mg only
  2. Immediate anticoagulation with heparin
  3. Observation with repeat CT in 24 hours
  4. Intravenous thrombolysis with alteplase or tenecteplase if no contraindications Correct answer.

Explanation

Acute ischemic stroke within 4.5 hours of last known well, without hemorrhage on CT and without contraindications, is an indication for intravenous thrombolysis. Aspirin is started after thrombolysis or when thrombolysis is not given.

Question 43Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 25-year-old woman has a first generalized tonic-clonic seizure. She has no history of seizures, and her neurologic examination is normal. What is the most appropriate initial evaluation?

  1. Brain imaging and EEG Correct answer.
  2. Start lifelong valproate without further testing
  3. No evaluation if the seizure was brief
  4. Lumbar puncture in all cases

Explanation

A first unprovoked seizure warrants brain imaging (CT or MRI) and EEG to identify structural lesions and epileptiform activity. Treatment decisions follow risk stratification for recurrence.

Question 44Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 68-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. He has no contraindication to anticoagulation. What is the most appropriate therapy to reduce stroke risk?

  1. No antithrombotic therapy
  2. Clopidogrel monotherapy
  3. Aspirin 81 mg daily
  4. Oral anticoagulation with a direct oral anticoagulant or warfarin Correct answer.

Explanation

A CHA2DS2-VASc score of 2 or more in men indicates a clear benefit from oral anticoagulation. Direct oral anticoagulants are preferred over warfarin in most patients without mechanical valves or severe mitral stenosis. Aspirin is less effective for stroke prevention in atrial fibrillation.

Question 45Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 34-year-old woman has a malar rash, photosensitivity, arthralgias, and a positive antinuclear antibody with anti-dsDNA. Which additional finding would most support active lupus nephritis?

  1. Positive rheumatoid factor
  2. Isolated microscopic hematuria without proteinuria
  3. Elevated ESR alone
  4. Proteinuria and active urinary sediment with red blood cell casts Correct answer.

Explanation

Lupus nephritis is suggested by proteinuria, hematuria, and cellular casts reflecting glomerular inflammation. Isolated hematuria or nonspecific inflammatory markers are less specific. Rheumatoid factor is not a marker of lupus nephritis.

Question 46Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 60-year-old man has acute monoarthritis of the first metatarsophalangeal joint with severe pain and swelling. Joint aspiration shows needle-shaped negatively birefringent crystals. What is the most appropriate acute treatment?

  1. NSAIDs, colchicine, or intra-articular glucocorticoids Correct answer.
  2. Antibiotics for presumed septic arthritis
  3. Probenecid during the acute attack
  4. Allopurinol at high dose during the acute attack

Explanation

Acute gout is treated with anti-inflammatory therapy: NSAIDs, colchicine, or glucocorticoids. Urate-lowering therapy is not started or adjusted during an acute flare without anti-inflammatory coverage, and antibiotics are unnecessary once crystals confirm gout.

Question 47Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 78-year-old woman has a hip fracture after a fall. Which intervention most reduces her risk of subsequent fragility fracture?

  1. Calcium supplementation alone
  2. Bisphosphonate therapy with calcium and vitamin D Correct answer.
  3. Annual vitamin D injection alone
  4. Bed rest and avoidance of weight-bearing

Explanation

After a fragility fracture, osteoporosis treatment with an antiresorptive agent plus calcium and vitamin D substantially reduces subsequent fracture risk. Calcium or vitamin D alone is insufficient for fracture prevention in established osteoporosis.

Question 48Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 50-year-old woman has a blood pressure of 168/100 mmHg, hypokalemia, and an elevated aldosterone-to-renin ratio. Which diagnosis is most likely?

  1. Primary aldosteronism Correct answer.
  2. Cushing syndrome
  3. Renovascular hypertension
  4. Pheochromocytoma

Explanation

Hypertension with spontaneous or diuretic-induced hypokalemia and a high aldosterone-to-renin ratio suggests primary aldosteronism. Pheochromocytoma causes paroxysmal symptoms with elevated metanephrines, and renovascular hypertension usually shows elevated renin.

Question 49Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 40-year-old man has fever, night sweats, weight loss, and painless cervical lymphadenopathy. Excisional biopsy shows Reed-Sternberg cells. Which statement about staging is most appropriate?

  1. Staging is unnecessary because treatment is the same for all stages
  2. Staging requires only a complete blood count
  3. Staging is based on the size of the largest node alone
  4. Staging requires CT or PET-CT imaging plus bone marrow evaluation Correct answer.

Explanation

Hodgkin lymphoma is staged with imaging (PET-CT or CT) and bone marrow assessment when indicated, since stage determines treatment. Node size alone or a CBC does not provide staging information.

Question 50Medicina Interna - atención integral del paciente adulto con enfermedades de alta prevalencia

A 66-year-old man with cirrhosis presents with hematemesis and melena. He is tachycardic and hypotensive. After initial resuscitation, which intervention is most appropriate?

  1. Oral iron supplementation
  2. Immediate beta-blocker initiation
  3. Intravenous octreotide and prophylactic antibiotics before endoscopy Correct answer.
  4. Elective endoscopy in 48 hours

Explanation

Acute variceal hemorrhage is managed with vasoactive therapy (octreotide) and prophylactic antibiotics, followed by urgent endoscopic therapy within 12 hours. Beta-blockers are for prophylaxis, not acute bleeding, and delay increases mortality.