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CPSP IMM Medicine study materials
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CPSP IMM Medicine practice questions

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Question 1Medicine (Internal Medicine)

A 58-year-old man with type 2 diabetes has an eGFR of 28 mL/min/1.73 m² and a urine albumin-to-creatinine ratio of 350 mg/g. Which medication class slows progression of his diabetic kidney disease independent of glucose lowering?

  1. SGLT2 inhibitors Correct answer.
  2. Thiazolidinediones
  3. Sulfonylureas
  4. Alpha-glucosidase inhibitors

Explanation

SGLT2 inhibitors reduce intraglomerular pressure and slow eGFR decline in diabetic kidney disease with albuminuria, and this benefit is at least partly independent of glycemic control. They are recommended in type 2 diabetes with CKD and elevated albuminuria even when HbA1c is at goal.

Question 2Medicine (Internal Medicine)

A 24-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. TSH is elevated and free T4 is low. Which additional finding best supports a diagnosis of primary hypothyroidism rather than central hypothyroidism?

  1. An elevated TSH with a low free T4 Correct answer.
  2. A low TSH with a high free T4
  3. A normal TSH with a high free T4
  4. A low TSH with a low free T4

Explanation

Primary hypothyroidism is characterized by failure of the thyroid gland, so pituitary TSH rises in response to low thyroid hormone. In central hypothyroidism the pituitary or hypothalamus fails, producing a low or inappropriately normal TSH alongside low free T4.

Question 3Medicine (Internal Medicine)

A 67-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. He has no contraindication to anticoagulation. Which therapy is most appropriate for stroke prevention?

  1. Warfarin only if INR exceeds 3.0
  2. Apixaban 5 mg twice daily Correct answer.
  3. Clopidogrel 75 mg daily
  4. Aspirin 81 mg daily

Explanation

A CHA2DS2-VASc score of 4 confers high stroke risk, and oral anticoagulation is indicated; a direct oral anticoagulant such as apixaban is first-line in nonvalvular atrial fibrillation. Antiplatelet monotherapy is inadequate for stroke prevention in this setting.

Question 4Medicine (Internal Medicine)

A 45-year-old woman has a blood pressure of 158/96 mmHg on three separate visits. She has no diabetes or kidney disease. According to current hypertension guidance, which agent is a reasonable first-line choice?

  1. A direct renin inhibitor
  2. A loop diuretic
  3. An alpha-1 blocker
  4. A thiazide-type diuretic Correct answer.

Explanation

Thiazide-type diuretics, ACE inhibitors, ARBs, and dihydropyridine calcium channel blockers are all acceptable first-line agents for uncomplicated hypertension. Alpha-1 blockers, loop diuretics, and direct renin inhibitors are not preferred initial monotherapy for essential hypertension.

Question 5Medicine (Internal Medicine)

A 30-year-old man has sudden-onset pleuritic chest pain and dyspnea two weeks after knee surgery. He is tachycardic and hypoxic. Which initial diagnostic test is most appropriate in a hemodynamically stable patient?

  1. Ventilation-perfusion scan
  2. CT pulmonary angiography Correct answer.
  3. D-dimer measurement
  4. Lower extremity ultrasound

Explanation

In a stable patient with high clinical probability of pulmonary embolism, CT pulmonary angiography is the preferred confirmatory test because it directly visualizes clot and has high sensitivity and specificity. D-dimer is most useful to exclude PE in low-probability patients.

Question 6Medicine (Internal Medicine)

A 52-year-old woman with a history of gallstones develops severe epigastric pain radiating to the back, with lipase three times the upper limit of normal. Which finding best supports a diagnosis of acute pancreatitis?

  1. An elevated alkaline phosphatase
  2. Lipase elevation greater than three times the upper limit of normal Correct answer.
  3. A prolonged prothrombin time
  4. A positive fecal occult blood test

Explanation

Acute pancreatitis requires at least two of three features: characteristic abdominal pain, lipase or amylase greater than three times the upper limit of normal, and imaging findings. Lipase is more specific than amylase and remains elevated longer.

Question 7Medicine (Internal Medicine)

A 70-year-old woman has a hemoglobin of 9.8 g/dL, a mean corpuscular volume of 72 fL, and a ferritin of 6 ng/mL. Which is the most likely cause of her anemia?

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

Explanation

Microcytic anemia with a very low ferritin strongly indicates iron deficiency, since ferritin is the most specific marker of depleted iron stores. Ferritin is an acute-phase reactant, so a low value is especially reliable.

Question 8Medicine (Internal Medicine)

A 62-year-old man with chronic obstructive pulmonary disease has an acute exacerbation with increased dyspnea and purulent sputum. Which intervention has the strongest evidence for reducing mortality in this setting?

  1. Short-acting bronchodilators
  2. Systemic corticosteroids
  3. Controlled oxygen therapy targeting an appropriate saturation Correct answer.
  4. Oral antibiotics

Explanation

In acute exacerbations of COPD, titrated oxygen therapy to a target saturation of roughly 88 to 92 percent reduces mortality compared with high-flow oxygen, which can worsen hypercapnia. Corticosteroids, antibiotics, and bronchodilators improve symptoms and outcomes but oxygen titration has the clearest mortality benefit.

Question 9Medicine (Internal Medicine)

A 68-year-old man with heart failure and reduced ejection fraction has persistent volume overload despite maximal ACE inhibitor and beta-blocker therapy. Which addition improves survival in this population?

  1. A calcium channel blocker
  2. A mineralocorticoid receptor antagonist Correct answer.
  3. Digoxin
  4. A loop diuretic at higher dose

Explanation

Mineralocorticoid receptor antagonists such as spironolactone reduce mortality and hospitalization in heart failure with reduced ejection fraction. Loop diuretics relieve congestion but have not been shown to improve survival.

Question 10Medicine (Internal Medicine)

A 34-year-old woman presents with polyuria, polydipsia, and a serum sodium of 128 mmol/L. Serum osmolality is low, urine osmolality is high, and urine sodium is elevated while she is euvolemic. Which diagnosis is most likely?

  1. Syndrome of inappropriate antidiuretic hormone Correct answer.
  2. Primary polydipsia
  3. Diabetes insipidus
  4. Osmotic diuresis

Explanation

Euvolemic hypotonic hyponatremia with concentrated urine and elevated urine sodium is characteristic of SIADH. The inappropriate ADH secretion causes water retention and dilutional hyponatremia.

Question 11Medicine (Internal Medicine)

A 55-year-old man with cirrhosis presents with hematemesis. After resuscitation, which medication should be started to reduce the risk of rebleeding from esophageal varices?

  1. A loop diuretic
  2. A selective beta-1 agonist
  3. A proton pump inhibitor
  4. A nonselective beta-blocker Correct answer.

Explanation

Nonselective beta-blockers reduce portal pressure and are used for primary and secondary prophylaxis of variceal bleeding. They lower the risk of rebleeding after an acute variceal hemorrhage.

Question 12Medicine (Internal Medicine)

A 28-year-old woman has a malar rash, photosensitivity, and arthralgia. Which serologic finding is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for SLE and correlate with disease activity and lupus nephritis. Antinuclear antibodies are sensitive but not specific, since they occur in many conditions and in healthy individuals.

Question 13Medicine (Internal Medicine)

A 72-year-old man with hypertension presents with sudden-onset severe headache and a blood pressure of 210/120 mmHg. CT of the head shows an intraparenchymal hemorrhage. Which factor most strongly predicts early hematoma expansion?

  1. Elevated blood pressure at presentation Correct answer.
  2. History of hypertension
  3. Male sex
  4. Age greater than 70 years

Explanation

Elevated systolic blood pressure at presentation is associated with hematoma expansion and worse outcomes in intracerebral hemorrhage. Prompt blood pressure control is therefore a key management target.

Question 14Medicine (Internal Medicine)

A 60-year-old woman with type 2 diabetes has a fasting glucose of 190 mg/dL and an HbA1c of 8.9 percent despite metformin. Which agent is most appropriate when weight loss and cardiovascular risk reduction are priorities?

  1. A GLP-1 receptor agonist Correct answer.
  2. Insulin glargine
  3. A thiazolidinedione
  4. A sulfonylurea

Explanation

GLP-1 receptor agonists promote weight loss and reduce major adverse cardiovascular events in patients with type 2 diabetes and high cardiovascular risk. They are preferred when weight reduction and cardiovascular protection are goals.

Question 15Medicine (Internal Medicine)

A 40-year-old man has a blood pressure of 168/104 mmHg, hypokalemia, and a metabolic alkalosis. Which screening test is most appropriate for suspected primary aldosteronism?

  1. Plasma catecholamines
  2. 24-hour urine metanephrines
  3. Serum cortisol after dexamethasone suppression
  4. Plasma aldosterone concentration and plasma renin activity Correct answer.

Explanation

Primary aldosteronism is screened with the aldosterone-to-renin ratio, using paired plasma aldosterone and renin measurements. An elevated aldosterone with suppressed renin supports the diagnosis.

Question 16Medicine (Internal Medicine)

A 65-year-old man with a history of alcohol use presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be given immediately?

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

Explanation

The triad of confusion, ataxia, and ophthalmoplegia suggests Wernicke encephalopathy, a thiamine deficiency emergency. Thiamine should be given before or with glucose to prevent precipitation or worsening of the syndrome.

Question 17Medicine (Internal Medicine)

A 50-year-old woman has a thyroid nodule. Fine-needle aspiration shows follicular cells, and the cytology is indeterminate. Which finding on ultrasound would most increase concern for malignancy?

  1. Microcalcifications and irregular margins Correct answer.
  2. A nodule that decreases in size over time
  3. A homogeneous hyperechoic nodule
  4. A simple cyst smaller than 2 cm

Explanation

Microcalcifications and irregular margins are sonographic features associated with thyroid malignancy. Indeterminate cytology with suspicious ultrasound features warrants further evaluation, often including diagnostic surgery.

Question 18Medicine (Internal Medicine)

A 58-year-old man with a history of gout presents with acute monoarthritis of the knee. Arthrocentesis yields cloudy fluid with a white blood cell count of 50,000 cells/µL. Which next step is most important?

  1. Order an MRI of the knee
  2. Send synovial fluid for Gram stain and culture Correct answer.
  3. Obtain serum uric acid level
  4. Start allopurinol immediately

Explanation

A synovial white cell count above 50,000 cells/µL raises concern for septic arthritis, and synovial fluid must be sent for Gram stain and culture. Septic arthritis is a medical emergency requiring prompt antibiotics and drainage.

Question 19Medicine (Internal Medicine)

A 70-year-old woman with a history of hypertension and diabetes has a transient episode of right arm weakness lasting 20 minutes that resolves completely. Which factor most strongly determines her early risk of stroke?

  1. The duration of the episode
  2. Her age alone
  3. Her baseline blood pressure
  4. The presence of high-risk features such as carotid stenosis or atrial fibrillation Correct answer.

Explanation

After a transient ischemic attack, early stroke risk is driven by high-risk features such as symptomatic carotid stenosis, atrial fibrillation, and certain brain imaging findings. Risk stratification tools such as the ABCD2 score incorporate some of these elements to guide urgency of evaluation.

Question 20Medicine (Internal Medicine)

A 45-year-old man with no prior illness develops fever, a widespread erythematous rash, and hypotension three days after starting a new medication. Which diagnosis should be considered?

  1. Toxic epidermal necrolysis
  2. Stevens-Johnson syndrome
  3. Drug reaction with eosinophilia and systemic symptoms Correct answer.
  4. Anaphylaxis

Explanation

DRESS syndrome presents with fever, rash, eosinophilia, and internal organ involvement, often weeks after starting a culprit drug. It is distinguished from anaphylaxis, which is immediate, and from SJS/TEN, which feature mucosal erosions and epidermal detachment.

Question 21Medicine (Internal Medicine)

A 62-year-old man with chronic kidney disease has a potassium of 6.8 mmol/L and ECG changes including peaked T waves. Which intervention should be given first to stabilize the myocardium?

  1. Intravenous calcium gluconate Correct answer.
  2. Oral sodium polystyrene sulfonate
  3. Intravenous furosemide
  4. Intravenous insulin with glucose

Explanation

Intravenous calcium stabilizes the myocardial membrane and is the first step in hyperkalemia with ECG changes, acting within minutes. Insulin with glucose, potassium binders, and diuretics lower potassium but do not immediately protect the heart.

Question 22Medicine (Internal Medicine)

A 35-year-old woman presents with recurrent episodes of flushing, diarrhea, and wheezing. A 24-hour urine collection shows elevated 5-hydroxyindoleacetic acid. Which underlying condition is most likely?

  1. Pheochromocytoma
  2. A neuroendocrine tumor of the small intestine Correct answer.
  3. Medullary thyroid carcinoma
  4. A carcinoid tumor of the appendix

Explanation

Carcinoid syndrome results from serotonin-secreting neuroendocrine tumors, most often of the small intestine with liver metastases, and is confirmed by elevated urinary 5-HIAA. Foregut and hindgut tumors less commonly produce the syndrome.

Question 23Medicine (Internal Medicine)

A 55-year-old man with a history of alcohol use disorder presents with confusion and ataxia. He has a prolonged INR, low platelets, and a bilirubin of 4 mg/dL. Which scoring system best estimates his short-term mortality?

  1. Model for End-Stage Liver Disease score Correct answer.
  2. Child-Pugh score
  3. SOFA score
  4. APACHE II score

Explanation

The MELD score incorporates bilirubin, INR, and creatinine and predicts short-term mortality in patients with cirrhosis and acute alcoholic hepatitis. It is used for transplant prioritization and prognosis.

Question 24Medicine (Internal Medicine)

A 68-year-old woman with atrial fibrillation on warfarin presents with an INR of 8.5 and no bleeding. Which management step is most appropriate?

  1. Give fresh frozen plasma immediately
  2. Continue warfarin at the same dose
  3. Start a direct oral anticoagulant without interruption
  4. Withhold warfarin and consider oral vitamin K Correct answer.

Explanation

For a markedly elevated INR without bleeding, warfarin should be withheld and oral vitamin K considered, especially when INR exceeds 10 or bleeding risk is high. Fresh frozen plasma is reserved for serious bleeding or urgent procedures.

Question 25Medicine (Internal Medicine)

A 30-year-old man has a blood pressure of 190/110 mmHg, blurred vision, and a creatinine that has risen from 1.0 to 2.4 mg/dL over one week. Urinalysis shows red cell casts. Which diagnosis is most likely?

  1. Malignant hypertension with thrombotic microangiopathy Correct answer.
  2. Essential hypertension
  3. Renovascular hypertension
  4. Primary hyperaldosteronism

Explanation

Severe hypertension with acute kidney injury and red cell casts suggests malignant hypertension with fibrinoid necrosis and thrombotic microangiopathy. Prompt controlled blood pressure reduction is required to limit end-organ damage.

Question 26Medicine (Internal Medicine)

A 24-year-old medical student is found to have a blood pressure of 148/94 mmHg on two separate clinic visits. He takes no medications and has no symptoms. Which finding on physical examination would most strongly suggest a secondary cause of hypertension in this patient?

  1. A systolic ejection murmur heard at the left upper sternal border
  2. A body mass index of 31 kg/m²
  3. Radiofemoral delay with diminished femoral pulses Correct answer.
  4. Bilateral pitting edema of the ankles

Explanation

Radiofemoral delay and weak femoral pulses point to coarctation of the aorta, a classic secondary cause of hypertension in a young adult. Coarctation should be excluded in any young patient with hypertension before labeling it essential.

Question 27Medicine (Internal Medicine)

A 66-year-old man with a 40 pack-year smoking history reports progressive exertional dyspnea. Spirometry shows a post-bronchodilator FEV1/FVC ratio of 0.58 and an FEV1 of 45 percent of predicted. Which finding on arterial blood gas most directly indicates that he has entered the chronic bronchitis phenotype with chronic hypoxemia?

  1. PaO2 of 62 mmHg with PaCO2 of 48 mmHg Correct answer.
  2. PaO2 of 70 mmHg with PaCO2 of 30 mmHg
  3. PaO2 of 88 mmHg with PaCO2 of 38 mmHg
  4. PaO2 of 95 mmHg with PaCO2 of 35 mmHg

Explanation

Chronic bronchitis with airflow obstruction typically produces hypoxemia with CO2 retention, reflecting a reduced ventilatory response to hypercapnia. A PaO2 under 65 mmHg with an elevated PaCO2 fits this pattern.

Question 28Medicine (Internal Medicine)

A 48-year-old woman with type 2 diabetes and an eGFR of 42 mL/min/1.73 m² has a hemoglobin of 10.1 g/dL. Her ferritin is 180 ng/mL, transferrin saturation is 26 percent, and reticulocyte count is low. Which abnormality most likely explains her anemia?

  1. Relative erythropoietin deficiency from chronic kidney disease Correct answer.
  2. Iron deficiency anemia
  3. Hemolysis from glucose-6-phosphate dehydrogenase deficiency
  4. Vitamin B12 deficiency

Explanation

Anemia of chronic kidney disease results from inadequate erythropoietin production and is normocytic with a low reticulocyte count. Iron stores are adequate here, so iron deficiency is excluded.

Question 29Medicine (Internal Medicine)

A 58-year-old man with decompensated heart failure has a serum sodium of 131 mmol/L, a serum osmolality of 268 mOsm/kg, and a urine osmolality of 520 mOsm/kg. He is clinically hypervolemic with elevated jugular venous pressure and crackles. Which mechanism best explains his hyponatremia?

  1. Excess free water intake exceeding renal diluting capacity
  2. Primary polydipsia with normal ADH suppression
  3. Non-osmotic release of antidiuretic hormone due to reduced effective circulating volume Correct answer.
  4. Osmotic diuresis from hyperglycemia

Explanation

In heart failure, reduced effective arterial volume triggers non-osmotic ADH release, producing concentrated urine and dilutional hyponatremia. The high urine osmolality with low serum osmolality confirms ADH activity.

Question 30Medicine (Internal Medicine)

A 45-year-old man presents with a 3-day history of fever, sore throat, and tender cervical lymphadenopathy. Examination reveals exudative pharyngitis and splenomegaly. Which laboratory finding would most support infectious mononucleosis?

  1. Thrombocytopenia with schistocytes
  2. Eosinophilia of 20 percent
  3. Neutrophilic leukocytosis with band forms
  4. Atypical lymphocytes on peripheral smear Correct answer.

Explanation

Infectious mononucleosis from Epstein-Barr virus produces a lymphocytosis with atypical lymphocytes, reflecting activated T cells. Splenomegaly and exudative pharyngitis fit the same syndrome.

Question 31Medicine (Internal Medicine)

A 70-year-old woman with atrial fibrillation is found to have a heart rate of 48 beats per minute. She takes metoprolol, verapamil, and digoxin. Which medication is most likely responsible for bradycardia with a narrow QRS and no P waves?

  1. Verapamil
  2. Metoprolol
  3. None of these agents slows conduction
  4. Digoxin Correct answer.

Explanation

Digoxin slows AV nodal conduction and can cause bradycardia with atrial fibrillation, particularly with renal impairment or drug interactions. Its toxic effects include atrial fibrillation with a slow ventricular response.

Question 32Medicine (Internal Medicine)

A 33-year-old woman has a 6-month history of fatigue, weight gain, cold intolerance, and constipation. Her TSH is elevated and free T4 is low. Which additional finding is most consistent with primary hypothyroidism?

  1. Elevated calcitonin
  2. Suppressed TSH with elevated free T4
  3. Low TSH with a thyroid nodule
  4. Elevated thyroid peroxidase antibodies Correct answer.

Explanation

Hashimoto thyroiditis is the most common cause of primary hypothyroidism and is characterized by positive thyroid peroxidase antibodies. The elevated TSH with low free T4 confirms a primary thyroid failure.

Question 33Medicine (Internal Medicine)

A 55-year-old man with a history of intravenous drug use presents with fever and a new diastolic murmur at the left sternal border. Blood cultures grow Staphylococcus aureus. Which valve is most likely affected?

  1. Aortic valve
  2. Tricuspid valve Correct answer.
  3. Pulmonary valve
  4. Mitral valve

Explanation

Right-sided endocarditis in intravenous drug users most commonly involves the tricuspid valve and is often caused by Staphylococcus aureus. Tricuspid involvement may produce a murmur that varies with respiration.

Question 34Medicine (Internal Medicine)

A 62-year-old man with type 2 diabetes has a serum creatinine of 1.9 mg/dL and an eGFR of 38 mL/min/1.73 m². His urine albumin-to-creatinine ratio is 450 mg/g. Which medication class most slows progression of his diabetic kidney disease?

  1. Alpha-glucosidase inhibitors
  2. Thiazolidinediones
  3. Loop diuretics
  4. Angiotensin-converting enzyme inhibitors Correct answer.

Explanation

ACE inhibitors reduce intraglomerular pressure and slow progression of albuminuric diabetic kidney disease. They are indicated in patients with diabetes and albuminuria even without hypertension.

Question 35Medicine (Internal Medicine)

A 44-year-old woman presents with episodic palpitations, diaphoresis, and headache. During an episode her blood pressure is 210/110 mmHg. Plasma free metanephrines are markedly elevated. Which imaging study is the most appropriate next step to localize the tumor?

  1. Contrast-enhanced computed tomography of the abdomen and pelvis Correct answer.
  2. Ultrasound of the thyroid gland
  3. Magnetic resonance imaging of the brain
  4. Echocardiography

Explanation

After biochemical confirmation of pheochromocytoma with elevated plasma free metanephrines, abdominal CT localizes the adrenal or extra-adrenal tumor. Imaging should follow biochemical testing rather than precede it.

Question 36Medicine (Internal Medicine)

A 68-year-old man is admitted with confusion and a serum sodium of 116 mmol/L that developed over approximately 48 hours. He has a history of alcohol use disorder and is not seizing. Which initial management is most appropriate?

  1. Rapid correction by 20 mmol/L within 6 hours
  2. Free water restriction alone
  3. Demeclocycline
  4. Hypertonic saline with a goal to raise sodium by 4 to 6 mmol/L over the first few hours Correct answer.

Explanation

Symptomatic severe hyponatremia requires hypertonic saline to raise sodium by 4 to 6 mmol/L acutely to reduce cerebral edema risk. Correction should then be limited to about 8 to 10 mmol/L in 24 hours to avoid osmotic demyelination.

Question 37Medicine (Internal Medicine)

A 57-year-old woman with rheumatoid arthritis treated with prednisone and methotrexate presents with fever and a dry cough. Chest imaging shows bilateral interstitial infiltrates. Bronchoalveolar lavage is positive for Pneumocystis jirovecii. Which treatment is first-line?

  1. Trimethoprim-sulfamethoxazole Correct answer.
  2. Acyclovir
  3. Vancomycin
  4. Azithromycin

Explanation

Trimethoprim-sulfamethoxazole is the first-line treatment for Pneumocystis jirovecii pneumonia, often with adjunctive corticosteroids in moderate to severe disease. Immunosuppression from chronic prednisone is the key risk factor here.

Question 38Medicine (Internal Medicine)

A 50-year-old man with a history of alcohol use disorder presents with confusion and ataxia. He has a prolonged INR, low platelets, and elevated transaminases. Which finding would most strongly support acute alcoholic hepatitis rather than simple steatosis?

  1. An AST-to-ALT ratio of 1.2
  2. A Maddrey discriminant function of 40 Correct answer.
  3. Mild hepatic steatosis on ultrasound
  4. A normal serum bilirubin

Explanation

A Maddrey discriminant function of 32 or higher indicates severe alcoholic hepatitis with high short-term mortality and often warrants corticosteroid therapy. It is calculated from the prothrombin time and bilirubin.

Question 39Medicine (Internal Medicine)

A 29-year-old woman has a blood pressure of 152/96 mmHg and a history of recurrent miscarriages. She reports cold intolerance and dry skin. Which antibody is most likely to be positive?

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

Explanation

Recurrent pregnancy loss with hypertension suggests antiphospholipid syndrome, which is associated with antiphospholipid antibodies. The thyroid symptoms may reflect coexisting autoimmune thyroid disease, but the obstetric history points to antiphospholipid syndrome.

Question 40Medicine (Internal Medicine)

A 74-year-old man with a history of hypertension and atrial fibrillation is admitted with a dense left hemiplegia that began 90 minutes ago. His blood pressure is 186/104 mmHg and his blood glucose is 128 mg/dL. Noncontrast head CT shows no hemorrhage. Which therapy is most appropriate?

  1. Therapeutic anticoagulation with heparin
  2. Intravenous alteplase Correct answer.
  3. Intravenous tenecteplase
  4. Aspirin 325 mg orally

Explanation

Intravenous alteplase is indicated for acute ischemic stroke within 4.5 hours of symptom onset when blood pressure can be controlled below 185/110 mmHg and imaging excludes hemorrhage. Tenecteplase is an alternative in some protocols but alteplase remains the established standard.

Question 41Medicine (Internal Medicine)

A 38-year-old woman has a 2-month history of fatigue, arthralgia, and a malar rash. Urinalysis shows 3+ protein and red blood cell casts. Which serologic test is most specific for her likely diagnosis?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with lupus nephritis. The combination of malar rash, arthralgia, and active urinary sediment supports this diagnosis.

Question 42Medicine (Internal Medicine)

A 65-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. His thiamine level is low. Which treatment should be given before any glucose-containing fluids?

  1. Intravenous glucose
  2. Intravenous naloxone
  3. Intravenous lorazepam
  4. Intravenous thiamine Correct answer.

Explanation

Thiamine should be administered before glucose in patients at risk for Wernicke encephalopathy to prevent precipitation of the syndrome. The clinical triad of confusion, ataxia, and ophthalmoplegia supports this diagnosis.

Question 43Medicine (Internal Medicine)

A 60-year-old woman with type 2 diabetes has a fasting glucose of 195 mg/dL and an HbA1c of 9.1 percent despite metformin and lifestyle changes. She has no history of cardiovascular disease. Which medication class would most effectively lower her HbA1c while promoting weight loss?

  1. Sulfonylureas
  2. Glucagon-like peptide-1 receptor agonists Correct answer.
  3. Insulin
  4. Thiazolidinediones

Explanation

GLP-1 receptor agonists lower HbA1c effectively and promote weight loss, which is beneficial in type 2 diabetes with obesity. They also reduce cardiovascular events in patients with established cardiovascular disease.

Question 44Medicine (Internal Medicine)

A 52-year-old woman with a history of gallstones develops severe epigastric pain radiating to the back. Lipase is three times the upper limit of normal. She has no organ failure and no local complications. Which management is most appropriate?

  1. Immediate endoscopic retrograde cholangiopancreatography
  2. Prophylactic antibiotics
  3. Total parenteral nutrition for 7 days
  4. Early oral feeding as tolerated with intravenous fluids Correct answer.

Explanation

Mild acute pancreatitis without organ failure or local complications is managed with goal-directed intravenous fluids and early oral feeding as tolerated. ERCP is reserved for coexisting cholangitis or persistent biliary obstruction.

Question 45Medicine (Internal Medicine)

A 68-year-old woman with atrial fibrillation on warfarin presents with an INR of 8.5 and no bleeding. Which management is most appropriate?

  1. Give fresh frozen plasma immediately
  2. Hold warfarin alone and observe
  3. Give protamine sulfate
  4. Hold warfarin and give oral vitamin K Correct answer.

Explanation

An INR above 8 without bleeding is managed by withholding warfarin and giving oral vitamin K to lower the INR and reduce bleeding risk. Fresh frozen plasma or prothrombin complex concentrate is reserved for serious bleeding.

Question 46Medicine (Internal Medicine)

A 35-year-old woman presents with recurrent episodes of flushing, diarrhea, and wheezing. A 24-hour urine collection shows elevated 5-hydroxyindoleacetic acid. Which imaging study is most appropriate to locate the primary tumor?

  1. Magnetic resonance imaging of the brain
  2. Positron emission tomography of the thyroid
  3. Ultrasound of the pelvis
  4. Contrast-enhanced computed tomography of the abdomen Correct answer.

Explanation

Carcinoid syndrome from elevated 5-HIAA most often arises from a midgut neuroendocrine tumor, which is best localized with abdominal CT. Imaging should follow biochemical confirmation.

Question 47Medicine (Internal Medicine)

A 72-year-old man with chronic obstructive pulmonary disease has an acute exacerbation with increased dyspnea and purulent sputum. He is not hypoxemic and has no signs of pneumonia. Which treatment is most appropriate?

  1. Immediate noninvasive positive pressure ventilation
  2. Long-term azithromycin without other therapy
  3. Intravenous theophylline
  4. Inhaled bronchodilators with a short course of systemic corticosteroids and antibiotics Correct answer.

Explanation

Acute exacerbations of COPD with increased dyspnea and purulent sputum are treated with short-acting bronchodilators, a short course of systemic corticosteroids, and antibiotics. Noninvasive ventilation is reserved for respiratory failure.

Question 48Medicine (Internal Medicine)

A 58-year-old man with a history of gout presents with acute monoarthritis of the knee. Arthrocentesis yields cloudy fluid with a white blood cell count of 60,000/mm³ and negatively birefringent needle-shaped crystals. Gram stain is negative. Which diagnosis is most likely?

  1. Acute gout flare Correct answer.
  2. Septic arthritis
  3. Reactive arthritis
  4. Pseudogout

Explanation

Negatively birefringent needle-shaped crystals identify monosodium urate, confirming gout even when the synovial white cell count is high. A negative Gram stain further supports a non-infectious crystal arthritis.

Question 49Medicine (Internal Medicine)

A 45-year-old man with no prior illness develops fever, a widespread erythematous rash, and hypotension three days after starting a new medication. He has mucosal erosions and a Nikolsky sign. Which diagnosis is most likely?

  1. Urticarial vasculitis
  2. Staphylococcal scalded skin syndrome
  3. Stevens-Johnson syndrome with toxic epidermal necrolysis Correct answer.
  4. Erythema multiforme minor

Explanation

A drug-triggered eruption with mucosal erosions, hypotension, and a positive Nikolsky sign suggests Stevens-Johnson syndrome or toxic epidermal necrolysis. Prompt withdrawal of the culprit drug and supportive care are essential.

Question 50Medicine (Internal Medicine)

A 30-year-old man has a blood pressure of 190/110 mmHg, blurred vision, and a creatinine that has risen from 1.0 to 2.4 mg/dL over one week. Urinalysis shows proteinuria and red blood cell casts. Which management is most appropriate?

  1. Aggressive diuresis alone
  2. Observation without antihypertensive therapy
  3. Immediate reduction of blood pressure to normal with oral captopril
  4. Controlled blood pressure reduction with intravenous agents and monitoring for cerebral hypoperfusion Correct answer.

Explanation

Malignant hypertension with target-organ damage requires controlled blood pressure reduction, often with intravenous agents, to avoid cerebral and renal hypoperfusion. The rate of reduction should be gradual over hours to days.