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OMSB Internal Medicine (OEIM) study materials
OMSB Internal Medicine (OEIM) study resources

OMSB Internal Medicine (OEIM) practice questions

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Question 1Internal Medicine (general / specialty content)

A 58-year-old man with type 2 diabetes has an eGFR of 28 mL/min/1.73 m². Which antihyperglycaemic agent should be avoided because of reduced clearance and risk of lactic acidosis?

  1. Empagliflozin
  2. Metformin Correct answer.
  3. Liraglutide
  4. Sitagliptin

Explanation

Metformin is cleared renally, and accumulation in advanced chronic kidney disease predisposes to lactic acidosis; most guidance advises stopping it when eGFR falls below 30 mL/min/1.73 m². The other agents listed do not carry a lactic acidosis risk and are used in renal impairment with appropriate dose adjustment.

Question 2Internal Medicine (general / specialty content)

A 24-year-old woman has palpitations and weight loss. TSH is suppressed and free T4 is elevated. Which finding on examination most specifically supports Graves disease over a toxic nodule?

  1. Tender thyroid gland
  2. Diffuse smooth goitre with a bruit Correct answer.
  3. A single palpable thyroid nodule
  4. Firm, fixed thyroid mass

Explanation

Graves disease produces a diffusely enlarged, vascular gland, and increased blood flow generates an audible bruit, which reflects the diffuse autoimmune stimulation of the whole gland. A single nodule suggests toxic adenoma, tenderness suggests subacute thyroiditis, and a fixed mass raises concern for malignancy.

Question 3Internal Medicine (general / specialty content)

Which arterial blood gas pattern is expected in a patient with an acute exacerbation of COPD retaining carbon dioxide?

  1. High pH, low PaCO2, low bicarbonate
  2. High pH, high PaCO2, high bicarbonate
  3. Low pH, high PaCO2, high bicarbonate Correct answer.
  4. Low pH, low PaCO2, low bicarbonate

Explanation

Acute respiratory acidosis from CO2 retention lowers pH while PaCO2 rises; bicarbonate is only modestly elevated because renal compensation takes days. The combination of low pH with high PaCO2 therefore identifies an acute respiratory acidosis.

Question 4Internal Medicine (general / specialty content)

A 70-year-old man has resting tremor, bradykinesia and rigidity. Which medication is the most effective initial dopaminergic therapy for motor symptoms of Parkinson disease?

  1. Amantadine
  2. Propranolol
  3. Trihexyphenidyl
  4. Levodopa combined with carbidopa Correct answer.

Explanation

Levodopa is the most effective dopamine replacement for motor symptoms of Parkinson disease, and carbidopa prevents its peripheral decarboxylation, reducing nausea and improving brain delivery. The other agents have narrower or adjunctive roles.

Question 5Internal Medicine (general / specialty content)

A 30-year-old woman has iron deficiency anaemia. Which finding best distinguishes iron deficiency from anaemia of chronic disease?

  1. Low serum ferritin Correct answer.
  2. Low serum iron
  3. Low total iron-binding capacity
  4. Normal bone marrow cellularity

Explanation

Ferritin reflects body iron stores and is low in iron deficiency, whereas it is normal or raised as an acute-phase reactant in anaemia of chronic disease. Serum iron and total iron-binding capacity can be low in both conditions, so they discriminate poorly.

Question 6Internal Medicine (general / specialty content)

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

  1. Mycoplasma pneumoniae
  2. Pneumocystis jirovecii
  3. Streptococcus pneumoniae Correct answer.
  4. Legionella pneumophila

Explanation

Streptococcus pneumoniae remains the most frequently identified cause of community-acquired pneumonia across all severity levels, including patients requiring admission. The other organisms cause pneumonia but are less common overall.

Question 7Internal Medicine (general / specialty content)

A 45-year-old man has a blood pressure of 168/104 mmHg on three visits. Which class of antihypertensive is most appropriate as first-line therapy in a patient without compelling comorbidities?

  1. Loop diuretic
  2. Central alpha-2 agonist
  3. Alpha-1 blocker
  4. Thiazide-type diuretic Correct answer.

Explanation

Thiazide-type diuretics are established first-line agents for uncomplicated hypertension, along with ACE inhibitors, ARBs and calcium channel blockers, because they reduce cardiovascular events. Alpha blockers, central agonists and loop diuretics are generally reserved for specific indications or resistant cases.

Question 8Internal Medicine (general / specialty content)

A 22-year-old student has a positive tuberculin skin test with 12 mm induration, a normal chest radiograph and no symptoms. Which statement about latent tuberculosis infection is correct?

  1. The patient is currently infectious to close contacts
  2. A negative interferon-gamma release assay excludes infection
  3. Treatment reduces the risk of progression to active disease Correct answer.
  4. Chest radiography is the definitive test for latent infection

Explanation

Latent tuberculosis infection carries a lifetime risk of reactivation, and preventive therapy substantially lowers that risk. Latent infection by definition has no clinical or radiographic disease and is not transmissible.

Question 9Internal Medicine (general / specialty content)

A 62-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. Which anticoagulation strategy is recommended for stroke prevention?

  1. Oral anticoagulation with a direct oral anticoagulant or warfarin Correct answer.
  2. Dual antiplatelet therapy
  3. Aspirin alone
  4. No antithrombotic therapy

Explanation

A CHA2DS2-VASc score of 2 or more in men indicates sufficient stroke risk to warrant oral anticoagulation, and direct oral anticoagulants are preferred over warfarin in most non-valvular cases. Antiplatelet therapy is inferior to anticoagulation for atrial fibrillation stroke prevention.

Question 10Internal Medicine (general / specialty content)

A 55-year-old woman presents with pleuritic chest pain, haemoptysis and dyspnoea six days after total hip replacement. Which investigation is the most appropriate first step to confirm pulmonary embolism?

  1. CT pulmonary angiography Correct answer.
  2. Lower limb venous Doppler ultrasound
  3. D-dimer assay
  4. Ventilation-perfusion scan

Explanation

CT pulmonary angiography is the standard confirmatory imaging test for suspected pulmonary embolism and is particularly appropriate in a patient with high pretest probability. D-dimer is useful mainly to exclude embolism in low-probability patients, and Doppler ultrasound only detects deep vein thrombosis.

Question 11Internal Medicine (general / specialty content)

A 48-year-old man has a serum sodium of 118 mmol/L, confusion and a history of excessive water intake. Which initial management step is most appropriate?

  1. Fluid restriction alone regardless of neurological status
  2. Hypertonic saline with careful monitoring if seizures are present Correct answer.
  3. Rapid correction with normal saline to raise sodium by 12 mmol/L in 24 hours
  4. Intravenous furosemide as monotherapy

Explanation

Severe symptomatic hyponatraemia with neurological features warrants cautious hypertonic saline to raise sodium by a limited amount, typically 4–6 mmol/L, to relieve symptoms while avoiding osmotic demyelination. Asymptomatic or mildly symptomatic cases are managed more conservatively.

Question 12Internal Medicine (general / specialty content)

A 35-year-old woman has a creatinine of 210 µmol/L, haematuria with red cell casts, proteinuria and hypertension. Which diagnosis is most likely?

  1. Acute tubular necrosis
  2. Post-renal obstruction
  3. Prerenal acute kidney injury
  4. Glomerulonephritis Correct answer.

Explanation

Haematuria with red cell casts and proteinuria indicates glomerular bleeding and injury, pointing to a glomerulonephritis. Prerenal injury and acute tubular necrosis produce muddy brown or hyaline casts without dysmorphic red cells, and obstruction is excluded by the absence of hydronephrosis.

Question 13Internal Medicine (general / specialty content)

A 28-year-old woman has fatigue, arthralgia, a malar rash and a positive antinuclear antibody test. Which additional serological finding is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity, particularly lupus nephritis. Antinuclear antibody is sensitive but not specific, and rheumatoid factor and anti-histone antibodies occur in other conditions.

Question 14Internal Medicine (general / specialty content)

A 66-year-old smoker has progressive dyspnoea and a forced expiratory volume in one second to forced vital capacity ratio of 0.58 after bronchodilator. Which intervention has the greatest impact on slowing decline in lung function?

  1. Inhaled short-acting beta-2 agonist as needed
  2. Oral theophylline
  3. Smoking cessation Correct answer.
  4. Regular chest physiotherapy

Explanation

Smoking cessation is the only intervention shown to slow the accelerated decline in forced expiratory volume in one second in chronic obstructive pulmonary disease. Bronchodilators relieve symptoms but do not alter the long-term decline, and theophylline has a narrow role.

Question 15Internal Medicine (general / specialty content)

A 50-year-old man has haematemesis and melaena. After resuscitation, which step is most appropriate in the management of suspected variceal bleeding from cirrhosis?

  1. Give fresh frozen plasma to normalise the INR before endoscopy
  2. Perform immediate transjugular intrahepatic portosystemic shunt
  3. Start a vasoactive agent and prophylactic antibiotics before endoscopy Correct answer.
  4. Give intravenous proton pump inhibitor alone and observe

Explanation

In suspected variceal haemorrhage, vasoactive drugs such as octreotide or terlipressin and prophylactic antibiotics are started early alongside resuscitation, before endoscopic therapy. Routine correction of coagulopathy with fresh frozen plasma is not recommended because it can worsen portal pressure and volume overload.

Question 16Internal Medicine (general / specialty content)

A 40-year-old woman has recurrent nephrolithiasis with a serum calcium of 2.85 mmol/L and an inappropriately elevated parathyroid hormone. Which localisation study is most appropriate before parathyroidectomy?

  1. Neck magnetic resonance angiography
  2. Radioiodine thyroid scan
  3. Sestamibi parathyroid scintigraphy with ultrasound Correct answer.
  4. Serum thyroglobulin measurement

Explanation

In primary hyperparathyroidism, preoperative localisation with sestamibi scintigraphy combined with neck ultrasound guides focused parathyroidectomy. Thyroid scanning and thyroglobulin assess thyroid disease, and magnetic resonance angiography is not a standard localisation technique for parathyroid adenomas.

Question 17Internal Medicine (general / specialty content)

A 72-year-old woman has a fractured neck of femur. Which finding indicates that surgery should be delayed for medical optimisation?

  1. Serum potassium of 6.4 mmol/L with peaked T waves Correct answer.
  2. Haemoglobin of 105 g/L
  3. Age above 70 years
  4. Blood pressure of 148/86 mmHg

Explanation

Severe hyperkalaemia with electrocardiographic changes is a life-threatening metabolic emergency that must be corrected before anaesthesia and surgery. Mild anaemia, moderate hypertension and age alone are not reasons to delay urgent fracture fixation.

Question 18Internal Medicine (general / specialty content)

A 60-year-old man with alcoholic cirrhosis has ascites. Which initial pharmacological approach is most appropriate?

  1. Non-steroidal anti-inflammatory drugs for discomfort
  2. Spironolactone with or without furosemide plus dietary sodium restriction Correct answer.
  3. Large-volume paracentesis as sole long-term therapy
  4. High-dose intravenous furosemide alone

Explanation

First-line management of cirrhotic ascites combines sodium restriction with spironolactone, an aldosterone antagonist that counteracts secondary hyperaldosteronism, often with furosemide added. Non-steroidal anti-inflammatory drugs are avoided because they worsen renal function and sodium retention.

Question 19Internal Medicine (general / specialty content)

A 25-year-old man has sudden severe headache, neck stiffness and photophobia. Which finding on cerebrospinal fluid analysis most strongly suggests bacterial meningitis?

  1. Isolated raised opening pressure with normal cell count
  2. Neutrophil predominance with low glucose and high protein Correct answer.
  3. Lymphocyte predominance with normal glucose
  4. Xanthochromia with equal red cell counts in all tubes

Explanation

Bacterial meningitis typically produces a neutrophilic pleocytosis with low cerebrospinal fluid glucose and elevated protein. Lymphocytic patterns suggest viral or tuberculous meningitis, xanthochromia indicates subarachnoid haemorrhage, and a normal cell count argues against meningeal infection.

Question 20Internal Medicine (general / specialty content)

A 68-year-old man has a serum creatinine of 180 µmol/L and is prescribed a drug eliminated renally. Which pharmacokinetic change should be anticipated?

  1. Increased hepatic first-pass metabolism requiring a higher dose
  2. Increased volume of distribution requiring a larger loading dose
  3. Prolonged elimination half-life requiring dose reduction Correct answer.
  4. Reduced bioavailability requiring a higher oral dose

Explanation

Reduced glomerular filtration slows renal clearance, prolonging the elimination half-life and raising drug exposure, so maintenance doses are reduced or intervals lengthened. Loading doses usually depend on volume of distribution, which is not primarily altered by renal impairment.

Question 21Internal Medicine (general / specialty content)

A 34-year-old woman has a deep vein thrombosis and is started on warfarin. Which principle governs the concurrent use of low molecular weight heparin?

  1. Warfarin alone is sufficient from day one
  2. Heparin is stopped as soon as warfarin is started
  3. Heparin is continued until the INR is therapeutic on two consecutive days Correct answer.
  4. Heparin is continued indefinitely regardless of INR

Explanation

Warfarin initially lowers protein C and can transiently create a prothrombotic state, so parenteral anticoagulation is overlapped until the INR is therapeutic on two consecutive measurements. Stopping heparin early leaves the patient unprotected during this window.

Question 22Internal Medicine (general / specialty content)

A 55-year-old man has type 2 diabetes, a blood pressure of 142/88 mmHg and persistent albuminuria despite good glycaemic control. Which drug class offers the strongest evidence for slowing progression of diabetic kidney disease?

  1. Angiotensin receptor blocker Correct answer.
  2. Alpha-1 blocker
  3. Beta blocker
  4. Thiazide diuretic

Explanation

Blockade of the renin-angiotensin system with an ACE inhibitor or angiotensin receptor blocker reduces intraglomerular pressure and slows progression of albuminuric diabetic kidney disease. The other classes lower blood pressure but lack equivalent renoprotective evidence.

Question 23Internal Medicine (general / specialty content)

A 70-year-old woman has a thyroid-stimulating hormone of 0.02 mIU/L, a free T4 within range and a free T3 elevated. Which diagnosis fits?

  1. T3 toxicosis Correct answer.
  2. Overt hypothyroidism
  3. Subclinical hyperthyroidism
  4. Central hypothyroidism

Explanation

Suppressed TSH with normal free T4 but elevated free T3 defines T3 toxicosis, an early or variant thyrotoxic state in which triiodothyronine is raised before thyroxine. Subclinical hyperthyroidism would have normal free T3 and free T4.

Question 24Internal Medicine (general / specialty content)

A 60-year-old man with heart failure and reduced ejection fraction has persistent volume overload despite maximal ACE inhibitor and beta blocker therapy. Which addition has been shown to reduce both mortality and hospitalisation?

  1. Amiodarone
  2. Digoxin
  3. Nitrate monotherapy
  4. Mineralocorticoid receptor antagonist Correct answer.

Explanation

Mineralocorticoid receptor antagonists such as spironolactone reduce mortality and heart failure hospitalisation in patients with reduced ejection fraction and are recommended after ACE inhibitor and beta blocker optimisation. Digoxin reduces hospitalisation but not mortality, and amiodarone has no role in heart failure outcomes.

Question 25Internal Medicine (general / specialty content)

A 45-year-old man has recurrent calcium oxalate stones. Which metabolic abnormality is most commonly associated with this stone type?

  1. Hypomagnesaemia
  2. Hypercalciuria Correct answer.
  3. Hyperuricaemia
  4. Cystinuria

Explanation

Hypercalciuria is the most frequently identified metabolic abnormality in recurrent calcium oxalate stone formers and is addressed with hydration, dietary sodium restriction and sometimes thiazides. Hyperuricaemia favours uric acid stones, cystinuria causes cystine stones, and hypomagnesaemia is a minor contributor.

Question 26Internal Medicine (general / specialty content)

A 58-year-old man is admitted with confusion and a glucose of 32 mmol/L. He is alert enough to swallow and has no vomiting. According to standard hyperglycaemic emergency protocols, which is the most appropriate first fluid for volume resuscitation in this patient?

  1. 0.9% sodium chloride Correct answer.
  2. 5% dextrose
  3. Ringer's lactate with potassium
  4. 0.45% sodium chloride

Explanation

Isotonic 0.9% saline is the standard initial resuscitation fluid in hyperosmolar hyperglycaemic states and diabetic ketoacidosis, because it restores intravascular volume and reduces serum osmolality without adding glucose. Hypotonic fluids are reserved for later when corrected sodium is high, and dextrose is added only once glucose falls toward the normal range.

Question 27Internal Medicine (general / specialty content)

A 70-year-old woman with a history of hypertension presents with sudden-onset right hemiparesis and aphasia that began 90 minutes ago. Non-contrast CT of the head shows no haemorrhage. Her blood pressure is 178/96 mmHg and she has no other contraindications. Which is the most appropriate next step?

  1. Urgent carotid endarterectomy
  2. Immediate oral aspirin 300 mg
  3. Permissive hypertension with no intervention
  4. Intravenous thrombolysis with alteplase or tenecteplase Correct answer.

Explanation

Acute ischaemic stroke within the thrombolytic window in a patient without haemorrhage on imaging is an indication for intravenous thrombolysis, which improves functional outcome when given promptly. Blood pressure below 185/110 mmHg is acceptable for treatment, and antiplatelet therapy is deferred until haemorrhage is excluded after thrombolysis.

Question 28Internal Medicine (general / specialty content)

A 30-year-old man has episodic palpitations, sweating and headache. Biochemical testing confirms phaeochromocytoma. Before surgical resection, which medication should be started first to prepare him safely?

  1. A loop diuretic
  2. A beta-adrenergic blocker
  3. An alpha-adrenergic blocker Correct answer.
  4. An ACE inhibitor

Explanation

Preoperative preparation for phaeochromocytoma requires alpha-blockade first to control blood pressure and allow volume expansion. Beta-blockade is added only after adequate alpha-blockade, because unopposed alpha stimulation can precipitate a hypertensive crisis.

Question 29Internal Medicine (general / specialty content)

A 65-year-old man with chronic kidney disease has a haemoglobin of 88 g/L. Iron studies show a transferrin saturation of 12% and ferritin of 60 µg/L. Which is the most appropriate next step in managing his anaemia of chronic kidney disease?

  1. Immediate blood transfusion
  2. Erythropoiesis-stimulating agent alone
  3. Intravenous iron supplementation Correct answer.
  4. Oral iron with no further monitoring

Explanation

Absolute iron deficiency in chronic kidney disease, indicated by low transferrin saturation with low ferritin, should be corrected with iron before or alongside erythropoiesis-stimulating agents. Intravenous iron is preferred in advanced kidney disease because oral absorption is poor and intolerance is common.

Question 30Internal Medicine (general / specialty content)

A 24-year-old woman has a body mass index of 17 kg/m², amenorrhoea for eight months, intense fear of weight gain and a distorted body image. Which electrolyte abnormality is most characteristic of her purging behaviour?

  1. Hypocalcaemia with respiratory alkalosis
  2. Hyperkalaemia with metabolic acidosis
  3. Hypernatraemia with metabolic acidosis
  4. Hypokalaemia with metabolic alkalosis Correct answer.

Explanation

Recurrent vomiting in bulimia nervosa or purging-type anorexia causes loss of gastric acid and chloride, producing a hypochloraemic metabolic alkalosis with hypokalaemia. The kidneys conserve sodium and excrete potassium in response to volume depletion, worsening the hypokalaemia.

Question 31Internal Medicine (general / specialty content)

A 72-year-old man has a resting tremor, bradykinesia and rigidity. He is started on levodopa-carbidopa. Which adverse effect is most typically associated with long-term levodopa therapy?

  1. Motor fluctuations and dyskinesias Correct answer.
  2. Neuroleptic malignant syndrome
  3. Acute dystonic reactions
  4. Irreversible tardive dyskinesia

Explanation

Chronic levodopa use in Parkinson disease is associated with motor fluctuations, including wearing-off and on-off phenomena, and levodopa-induced dyskinesias. These reflect the progressive loss of dopaminergic neurons and pulsatile drug delivery rather than an idiosyncratic reaction.

Question 32Internal Medicine (general / specialty content)

A 40-year-old woman has a three-week history of symmetrical proximal muscle weakness, a heliotrope rash and Gottron papules. Which investigation is most useful for detecting an associated malignancy?

  1. Serum creatine kinase alone
  2. Electromyography of proximal muscles
  3. Age-appropriate cancer screening including CT imaging of the chest, abdomen and pelvis Correct answer.
  4. Antinuclear antibody titre

Explanation

Dermatomyositis in adults carries an increased risk of underlying malignancy, so a thorough age-appropriate malignancy screen, often including CT imaging, is recommended at diagnosis. Muscle enzymes, autoantibodies and electromyography support the diagnosis of myositis but do not detect cancer.

Question 33Internal Medicine (general / specialty content)

A 50-year-old man has sudden painless loss of vision in one eye described as a curtain descending over the visual field. Fundoscopy shows a pale retina with a cherry-red spot at the macula. Which structure is most likely occluded?

  1. The central retinal artery Correct answer.
  2. The central retinal vein
  3. The ophthalmic vein
  4. The posterior ciliary artery

Explanation

Central retinal artery occlusion produces sudden painless monocular visual loss with a pale, oedematous retina and a cherry-red spot at the fovea where the choroidal circulation shows through. It is an ophthalmological emergency associated with embolic and atherosclerotic disease.

Question 34Internal Medicine (general / specialty content)

A 62-year-old man with decompensated heart failure has a serum potassium of 6.4 mmol/L and ECG shows peaked T waves. Which is the most appropriate first intervention to protect the myocardium?

  1. Insulin with dextrose infusion
  2. Oral sodium polystyrene sulfonate
  3. Intravenous furosemide
  4. Intravenous calcium gluconate Correct answer.

Explanation

Intravenous calcium stabilises the myocardial membrane and is the first intervention for hyperkalaemia with ECG changes, acting within minutes. Insulin-dextrose and other measures shift potassium intracellularly but take longer to act and do not directly protect the heart.

Question 35Internal Medicine (general / specialty content)

A 28-year-old woman has a two-day history of fever, urinary frequency and flank pain. She is haemodynamically stable and not pregnant. Which is the most appropriate initial antibiotic strategy for acute pyelonephritis in this setting?

  1. Single-dose intramuscular gentamicin with no follow-up
  2. Oral fluoroquinolone after urine culture, with review at 48 hours Correct answer.
  3. Topical antiseptic therapy
  4. Observation without antibiotics

Explanation

Uncomplicated acute pyelonephritis in a stable, non-pregnant patient can be treated with an oral agent with good urinary and tissue penetration, such as a fluoroquinolone, guided by culture results. Treatment should be reviewed at 48 to 72 hours and escalated if there is no improvement.

Question 36Internal Medicine (general / specialty content)

A 55-year-old woman has a serum calcium of 2.9 mmol/L, a phosphate of 0.7 mmol/L and a parathyroid hormone level that is inappropriately normal. She has a history of neck irradiation. Which is the most likely diagnosis?

  1. Hypoparathyroidism
  2. Tertiary hyperparathyroidism
  3. Secondary hyperparathyroidism from chronic kidney disease
  4. Primary hyperparathyroidism Correct answer.

Explanation

Hypercalcaemia with low phosphate and an inappropriately normal or elevated parathyroid hormone indicates primary hyperparathyroidism, and prior neck irradiation is a recognised risk factor. In chronic kidney disease, calcium is typically low or normal with high phosphate and markedly elevated parathyroid hormone.

Question 37Internal Medicine (general / specialty content)

A 45-year-old man has a one-week history of jaundice, dark urine and right upper quadrant discomfort. He recently completed a course of co-amoxiclav. Liver tests show a raised alkaline phosphatase and bilirubin with a modest alanine aminotransferase rise. Which is the most likely pattern of injury?

  1. Hepatocellular drug-induced liver injury
  2. Cholestatic drug-induced liver injury Correct answer.
  3. Ischaemic hepatitis
  4. Acute viral hepatitis

Explanation

Co-amoxiclav is a well-recognised cause of cholestatic or mixed drug-induced liver injury, often with a latency of days to weeks after exposure. Predominant alkaline phosphatase and bilirubin elevation with modest transaminase rise fits a cholestatic pattern.

Question 38Internal Medicine (general / specialty content)

A 35-year-old woman with systemic lupus erythematosus has new proteinuria of 1.8 g per day and an active urinary sediment. Which investigation is most appropriate to establish the diagnosis and guide treatment?

  1. Serum complement levels alone
  2. Renal ultrasound
  3. Repeat urinalysis in three months
  4. Renal biopsy Correct answer.

Explanation

Lupus nephritis is classified by histology, and renal biopsy determines the International Society of Nephrology/Renal Pathology Society class, which guides immunosuppressive therapy. Proteinuria with active sediment warrants prompt biopsy rather than observation.

Question 39Internal Medicine (general / specialty content)

A 68-year-old man has a haemoglobin of 105 g/L, a mean corpuscular volume of 108 fL and a peripheral smear showing oval macrocytes and hypersegmented neutrophils. Which is the most appropriate initial test to identify the cause?

  1. Reticulocyte count
  2. Serum vitamin B12 and folate levels Correct answer.
  3. Serum ferritin
  4. Haemoglobin electrophoresis

Explanation

Macrocytic anaemia with oval macrocytes and hypersegmented neutrophils suggests megaloblastic anaemia due to vitamin B12 or folate deficiency. Measuring both vitamins identifies the deficiency, and distinguishing the two matters because folate replacement alone can worsen neurological damage in B12 deficiency.

Question 40Internal Medicine (general / specialty content)

A 60-year-old woman has a thyroid-stimulating hormone of 0.01 mIU/L with an elevated free T4. She has atrial fibrillation and a heart rate of 118 beats per minute. Which is the most appropriate initial treatment?

  1. Levothyroxine dose reduction
  2. Thyroidectomy as first-line therapy
  3. Radioactive iodine as first-line therapy
  4. A beta-blocker plus an antithyroid drug Correct answer.

Explanation

In overt hyperthyroidism with symptomatic tachycardia or atrial fibrillation, a beta-blocker controls adrenergic symptoms while a thionamide such as carbimazole or methimazole blocks hormone synthesis. Definitive therapy with radioiodine or surgery is considered after the acute thyrotoxic state is controlled.

Question 41Internal Medicine (general / specialty content)

A 55-year-old man has a serum sodium of 128 mmol/L, a serum osmolality of 262 mOsm/kg, a urine osmolality of 480 mOsm/kg and a urine sodium of 60 mmol/L. He is clinically euvolaemic and has no recent diuretic use. Which is the most likely cause?

  1. Primary polydipsia
  2. Diuretic-induced hyponatraemia
  3. Syndrome of inappropriate antidiuretic hormone secretion Correct answer.
  4. Adrenal insufficiency

Explanation

Euvolaemic hypotonic hyponatraemia with concentrated urine and high urine sodium in the absence of diuretics fits the syndrome of inappropriate antidiuretic hormone secretion. The diagnosis requires exclusion of hypothyroidism, adrenal insufficiency and renal disease.

Question 42Internal Medicine (general / specialty content)

A 48-year-old man has a serum creatinine of 210 µmol/L. He is prescribed a drug that is 90% renally cleared and has a narrow therapeutic index. Which pharmacokinetic parameter should be used to guide dose adjustment?

  1. Serum creatinine concentration alone
  2. Serum albumin concentration
  3. Creatinine clearance estimated by the Cockcroft-Gault equation Correct answer.
  4. Body mass index

Explanation

For renally cleared drugs with a narrow therapeutic index, dose adjustment is based on an estimate of glomerular filtration such as Cockcroft-Gault creatinine clearance, which accounts for age, sex and weight. Serum creatinine alone can mislead because it depends on muscle mass and does not reflect clearance directly.

Question 43Internal Medicine (general / specialty content)

A 32-year-old woman has a deep vein thrombosis and is starting warfarin. Which principle governs the initial concurrent use of heparin?

  1. Heparin is continued until the INR has been in the therapeutic range for at least two consecutive days Correct answer.
  2. Warfarin alone is sufficient from day one
  3. Heparin is continued indefinitely regardless of INR
  4. Heparin is stopped as soon as warfarin is started

Explanation

Warfarin initially lowers protein C and protein S before the vitamin K-dependent clotting factors fall, creating a transient prothrombotic state. Heparin overlap for at least five days and until the INR is therapeutic on two consecutive days prevents this early paradoxical thrombosis risk.

Question 44Internal Medicine (general / specialty content)

A 70-year-old man has a history of gout and is admitted with an acute flare affecting the first metatarsophalangeal joint. His renal function is normal and he is not on a statin. Which is the most appropriate treatment for the acute attack?

  1. Withholding all treatment until the flare resolves
  2. Starting a urate-lowering drug and stopping all other therapy
  3. Starting allopurinol at a high dose immediately
  4. Oral colchicine, a non-steroidal anti-inflammatory drug or a short course of corticosteroids Correct answer.

Explanation

Acute gout is treated with an anti-inflammatory agent such as colchicine, a non-steroidal anti-inflammatory drug or corticosteroids, chosen according to comorbidities. Urate-lowering therapy is not started during an acute attack without cover, and existing urate-lowering therapy should not be stopped abruptly.

Question 45Internal Medicine (general / specialty content)

A 45-year-old man has a blood pressure of 170/105 mmHg and laboratory findings of hypokalaemia and metabolic alkalosis. He has no history of diuretic use. Which secondary cause should be screened for first?

  1. Renal artery stenosis
  2. Phaeochromocytoma
  3. Obstructive sleep apnoea
  4. Primary aldosteronism Correct answer.

Explanation

Hypertension with spontaneous or unexplained hypokalaemia and metabolic alkalosis is a classic clue to primary aldosteronism, screened with an aldosterone-to-renin ratio. Hypokalaemia occurs in a minority of cases, so the combination of resistant hypertension and alkalosis should prompt testing.

Question 46Internal Medicine (general / specialty content)

A 58-year-old man has a 40 pack-year smoking history and a 3.2 cm peripheral lung nodule with mediastinal lymph node enlargement on CT. Which investigation is most appropriate to obtain a tissue diagnosis and stage the mediastinum?

  1. Serum carcinoembryonic antigen
  2. Repeat CT in six months
  3. Endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal nodes Correct answer.
  4. Sputum cytology alone

Explanation

Endobronchial ultrasound-guided transbronchial needle aspiration allows minimally invasive sampling of mediastinal lymph nodes for both diagnosis and staging. Accurate mediastinal staging determines whether surgery is appropriate and guides oncological treatment.

Question 47Internal Medicine (general / specialty content)

A 66-year-old woman has a two-week history of progressive ascending symmetrical weakness and areflexia after a diarrhoeal illness. She has mild bulbar weakness and a forced vital capacity of 60% predicted. Which is the most appropriate management?

  1. Antibiotics alone with no immunotherapy
  2. Immediate tracheostomy without immunotherapy
  3. Intravenous immunoglobulin or plasma exchange with monitoring of respiratory function Correct answer.
  4. Oral corticosteroids alone

Explanation

Guillain-Barré syndrome is treated with intravenous immunoglobulin or plasma exchange, which shorten the disease course and reduce disability. Respiratory function must be monitored closely because bulbar weakness and a falling vital capacity predict respiratory failure requiring ventilatory support.

Question 48Internal Medicine (general / specialty content)

A 50-year-old man with cirrhosis has a serum sodium of 126 mmol/L, ascites and peripheral oedema. He is on spironolactone and furosemide. Which is the most appropriate initial management of his hyponatraemia?

  1. Rapid hypertonic saline infusion
  2. Intravenous furosemide bolus
  3. Immediate large-volume paracentesis
  4. Fluid restriction and review of diuretic doses Correct answer.

Explanation

Dilutional hyponatraemia in cirrhosis is managed initially with fluid restriction and adjustment of diuretics, since the underlying problem is impaired free-water clearance. Hypertonic saline is reserved for severe symptomatic hyponatraemia or seizures and risks worsening ascites.

Question 49Internal Medicine (general / specialty content)

A 72-year-old woman has a serum creatinine that rose from 90 to 210 µmol/L over two days. She has been taking an ACE inhibitor and a non-steroidal anti-inflammatory drug and has a urine sodium of 12 mmol/L. Which mechanism best explains her acute kidney injury?

  1. Haemodynamic prerenal injury from loss of prostaglandin-mediated afferent vasodilation and angiotensin-mediated efferent constriction Correct answer.
  2. Acute tubular necrosis from direct nephrotoxicity
  3. Acute interstitial nephritis from an allergic reaction
  4. Acute glomerulonephritis from immune complex deposition

Explanation

The combination of an ACE inhibitor and a non-steroidal anti-inflammatory drug impairs both efferent constriction and afferent vasodilation, causing a haemodynamic prerenal injury with low urine sodium. Stopping the offending drugs and restoring volume is the key management step.

Question 50Internal Medicine (general / specialty content)

A 60-year-old man with alcoholic cirrhosis has ascites. He is haemodynamically stable and has normal renal function. Which is the most appropriate initial pharmacological approach?

  1. No diuretic therapy until paracentesis is required
  2. Spironolactone with or without furosemide, plus dietary sodium restriction Correct answer.
  3. Furosemide alone at high dose
  4. Intravenous albumin alone

Explanation

Ascites in cirrhosis is managed with sodium restriction and a potassium-sparing diuretic such as spironolactone, often combined with furosemide to maintain normokalaemia. Diuretics are titrated to weight loss and renal function, with paracentesis reserved for tense or refractory ascites.