Free Internal Medicine Board Review MCQ Questions and Answers — Questions and Answers
Question 1: A 68-year-old man who is a patient in the emergency room woke up with palpitations, chest pain, dyspnea, and vertigo. He claims his heart is "beating," but he has no history of heart disease or high blood pressure. His pulse is quick and erratic, his blood pressure is 85/60 mmHg, and crackles can be heard at the bases of his lungs. His standard laboratory tests, including a troponin level, are expected. His EKG reveals atrial fibrillation with a 130-beat-per-minute ventricular response. Which course of action is ideal?
- Delayed cardioversion after anticoagulation
- Immediate cardioversion
- Intravenous beta-blocker
- Intravenous digoxin (Correct answer)
Correct answer: Intravenous digoxin
The patient presents with atrial fibrillation, rapid ventricular response, and signs of hemodynamic instability including hypotension and crackles, indicating heart failure. Digoxin is a cardiac glycoside that slows the ventricular rate in atrial fibrillation by increasing vagal tone and slowing AV nodal conduction, while also improving cardiac contractility, making it a suitable choice for rate control in hemodynamically unstable patients with concomitant heart failure.
Question 2: An intermittent, mid-sternal chest ache that typically lasts 5 to 10 minutes affects a 57-year-old male. Both when we are working and when we are not. His throat also feels sore, which occasionally gets better with antacids. He stopped smoking around the age of 50. He denies having other serious medical issues. His type 2 diabetes and hypertension run in the family. His height is 70 inches, weight is 210 pounds, blood pressure is 135/85 mmHg, and pulse is regular at 76. Auscultation reveals his chest is clean and free of cardiac rubs or murmurs. The overall evaluation is unfavorable. He has a normal electrocardiogram. What logical step would result in the best chance of a diagnosis?
- Troponin Level
- Technetium Tc99m Sestamibi stress test (Correct answer)
- EGD Endoscopy
- Coronary Angiography
Correct answer: Technetium Tc99m Sestamibi stress test
The patient's intermittent chest pain, combined with multiple risk factors for coronary artery disease (type 2 diabetes, hypertension, obesity, family history) and a normal resting EKG, warrants further investigation for inducible ischemia. A Technetium Tc99m Sestamibi stress test is an excellent non-invasive diagnostic step to evaluate for perfusion abnormalities that might not be evident at rest, providing the best chance of diagnosing coronary artery disease.
Question 3: A 52-year-old guy with Type 2 diabetes attends the clinic for his yearly checkup. The only drug he takes is metformin. His serum creatinine level was 1.8 mg/dL, and his most recent hemoglobin A1C result was 6.5%. Despite having a high blood pressure of 170–175 mm/Hg, the remainder of his evaluation is negative. Although his chest x-ray is normal, left ventricular hypertrophy is suggested by his EKG. Which medication would be best for treating his hypertension?
- Thiazide diuretic
- Beta-blocker
- Calcium channel blocker (CCB)
- Angiotensin receptor blocker (ARB) (Correct answer)
Correct answer: Angiotensin receptor blocker (ARB)
Angiotensin receptor blockers (ARBs) are the preferred medication for treating hypertension in patients with type 2 diabetes and evidence of renal impairment (creatinine 1.8 mg/dL), as they are renoprotective. They also effectively reduce blood pressure and can help regress left ventricular hypertrophy, making them an ideal choice for this patient's complex profile.
Question 4: You are meeting a 20-year-old male who has complained for the previous two months about "puffy eyes" and "swollen ankles." Additionally, he says that his pee "sort of looks frothy and foamy." His vital signs during the examination are within normal ranges, and the funduscopy is uneventful save for minor bilateral edema 2+ in the bilateral feet to the ankle. He has never experienced any health issues or operations. His tests show an average serum creatinine level; a considerable 4-plus protein level without blood or bacteria is found in the urine. He has had a kidney biopsy, which on light microscopy appears normal but, on electron microscopy, reveals diffuse podocyte effacement. Negative immunofluorescence results. Which medical intervention is ideal for this patient?
- Cyclophosphamide
- Tacrolimus
- Rituximab
- Corticosteroids (Correct answer)
Correct answer: Corticosteroids
The patient's symptoms (puffy eyes, swollen ankles, frothy urine) and lab findings (significant proteinuria, normal serum creatinine, diffuse podocyte effacement on electron microscopy) are classic for Minimal Change Disease, a common cause of nephrotic syndrome. Corticosteroids are the first-line treatment for inducing remission in Minimal Change Disease due to their potent immunosuppressive and anti-inflammatory effects.
Question 5: A 25-year-old lady who has been experiencing lethargy and polyuria for the past nine months comes into your office for an examination. She also had anorexia and a mysterious 12-pound weight drop. She has also experienced nocturnal sweats for a few months. She exhibited minor hypercalcemia upon evaluation of her lab results from her yearly visit roughly nine months prior, while all other tests, including glucose, were normal. She has been playing tennis outside more frequently and anticipated feeling better as a result of the increased exercise. She doesn't have a history of fractures or nephrolithiasis. No history of hypercalcemia in the family. She doesn't use any prescription drugs. <br> Physical exam: <br> Weight 125 pounds, height 5’2”, blood pressure 102/74 mmHg, heart rate 94 bpm <br> She has dry mucous membranes and delayed deep tendon reflexes. Otherwise unremarkable. <br> You send her to the lab to evaluate her symptoms and history of mild hypercalcemia. Her lab results are remarkable for Calcium = 13.1 mg/dL (8.9-10.1 mg/dL) <br> Phosphorus = 5.0 mg/dL (2.5-4.5 mg/dL) <br> Creatinine = 1.4 mg/dL (0.6-1.1 mg/dL) <br> Serum urea nitrogen = 22 mg/dL (6-21 mg/dL) <br> Intact PTH = 4 pg/mL (10-65 pg/mL) <br> 25-Hydroxyvitamin D = 24 ng/mL (25-80 ng/mL) <br> 1,25-Hydroxyvitamin D = 90 pg/mL (16-65 pg/mL) <br> Alkaline phosphatase = 99 U/L (37-98 U/L) <br) Which medication would best address the cause of this patient’s hypercalcemia?
- Prednisone (Correct answer)
- Calcitonin
- Zolendronic acid
- Cinacalcet
Correct answer: Prednisone
The patient's presentation of significant hypercalcemia, suppressed PTH, and elevated 1,25-Hydroxyvitamin D, along with symptoms like weight loss and polyuria, strongly suggests a granulomatous disease (e.g., sarcoidosis) or lymphoma. These conditions can cause unregulated production of 1,25-Hydroxyvitamin D, leading to hypercalcemia. Prednisone, a corticosteroid, is the appropriate treatment as it inhibits the activity of 1-alpha-hydroxylase in granulomas, thereby reducing 1,25-Hydroxyvitamin D production and subsequently lowering calcium levels.
Question 6: A middle-aged man who was experiencing chest problems went to the emergency room. Results from the lab and the EKG showed a non-ST elevation of myocardial infarction (NSTEMI). His left anterior descending artery had a significant branch that was 95% blocked, according to an angiography (LAD). Less than 40% of his other streets seemed to be stopped. The highly clogged vessel underwent balloon angioplasty, and a drug-eluting stent was implanted. The patient claims that following the treatment, he is pain-free. Now that his resting EKG is normal, ischemia cannot be detected by an isotope stress test. With the exception of which drug the patient should be released on all the following medications?
- Warfarin (Correct answer)
- ACE inhibitor
- Clopidogrel
- Statin
Correct answer: Warfarin
Following an NSTEMI and percutaneous coronary intervention (PCI) with a drug-eluting stent, patients are typically discharged on dual antiplatelet therapy (e.g., aspirin and clopidogrel), a statin, and an ACE inhibitor for secondary prevention. Warfarin is an anticoagulant primarily used for conditions like atrial fibrillation or prosthetic heart valves, and it is not routinely indicated for post-NSTEMI patients with a stent unless there is an additional specific indication for anticoagulation, which is not mentioned here.
Question 7: Which of the following statements about a ventilator with volume control is false?
- lung injury may occur at high pressures
- Minute ventilation volume can be preset
- Pressure is controlled (Correct answer)
- Tidal volume is preset and fixed
Correct answer: Pressure is controlled
In volume-controlled ventilation, the tidal volume (the amount of air delivered with each breath) is preset and fixed, ensuring a consistent minute ventilation. The pressure required to deliver this preset volume will vary depending on the patient's lung compliance and airway resistance, meaning that pressure is a variable outcome and is *not* directly controlled in this mode.
Free Internal Medicine Board Review MCQ Questions and Answers
A 68-year-old man who is a patient in the emergency room woke up with palpitations, chest pain, dyspnea, and vertigo.
He claims his heart is "beating," but he has no history of heart disease or high blood pressure.
His pulse is quick and erratic, his blood pressure is 85/60 mmHg, and crackles can be heard at the bases of his lungs.
His standard laboratory tests, including a troponin level, are expected.
His EKG reveals atrial fibrillation with a 130-beat-per-minute ventricular response.
Which course of action is ideal?