INTERNAL MEDICINE PRACTICE 2024 VERSION
FINAL EXAM WITH QUESTIONS AND WELL
DETAILED ANSWERS/ A GRADE
Sourced from Chamberlain university Experts
A 24-year-old woman presents with complaints of excessive thirst over the past several weeks.
She also notes waking up in the middle of the night to urinate. She recently underwent
transsphenoidal resection of a pituitary adenoma. Which of the following is the most likely
diagnosis?
A. Central diabetes insipidus
B. Nephrogenic diabetes insipidus
C. Primary polydipsia
D. Type 2 diabetes mellitus correct answers A. Central diabetes insipidus
Central diabetes insipidus is the most common type of diabetes insipidus, is associated with
deficient secretion of antidiuretic hormone (ADH) by the posterior pituitary.
What is the most common presenting symptom of bladder carcinoma?
A. Nocturia
B. Painless hematuria
C. Unintentional weight loss
D. Urinary frequency correct answers B. Painless hematuria
The primary modality to diagnose bladder cancer is with cystoscopy, which allows for direct
visualization of tissues and biopsy of any abnormalities.
Smoking is the most important risk factor of bladder cancer.
A 25-year-old man presents to the clinic with fever and a sore throat. A throat swab is performed
and the culture comes back positive for group A streptococcus bacteria. What system of his body
is at highest risk for permanent damage if proper treatment for his infection is not administered?
A. Cardiovascular
B. Gastrointestinal
C. Musculoskeletal
D. Pulmonary correct answers A. Cardiovascular
Risk of rheumatic fever and pericarditis.
Remember the Jones criteria for rheumatic fever:
Major: Joints, carditis, nodes, erythema marginatum, sydenham chorea.
Minor: fever, arthralgia, elevated ESR, elevated CRP, and prolonged PR interval.
Need 2 major, or 1 major and 2 minor, or 3 minor
,A 60-year-old man with intermittent claudication returns to the clinic for interpretation of the
results of his ankle-brachial index. Which of the following statements is most accurate?
A. A falsely high index may indicate severely hardened, non-compressible leg vessels
B. A low ankle-brachial index indicates peripheral venous insufficiency
C. An ankle-brachial index of 1.2 indicates severe disease
D. It is the ratio of ankle to arm diastolic blood pressure correct answers A. A falsely high index
may indicate severely hardened, non-compressible leg vessels.
The ankle-brachial index is calculated by measuring the systolic blood pressure in the arm and at
the ankle. A ratio of ankle systolic blood pressure to brachial systolic blood pressure under 0.90
is indicative of peripheral arterial disease. A falsely high ankle-brachial index can occur when a
patient has severely hardened peripheral arteries which are non-compressible.
A 22-year-old man presents to the office for his one week follow up after his third concussion in
four years. The patient plays rugby on his college intramural team. His most recent concussion
was complicated by a period of loss of consciousness at the time of injury. He admits to having
headaches and intermittent dizziness for the past couple of days. His headache appears to be
tension-type in nature. He is eager to return to rugby and is requesting clearance to play. Which
of the following is the most appropriate education to give your patient?
A. Can return as headaches after a concussion are expected
B. Can return as subsequent concussions increase resilience to future ones
C. Cannot return as patient is currently symptomatic
D. Cannot return as patient meets criteria for chronic traumatic encephalopathy correct answers
C. Cannot return as patient is currently symptomatic
A 64-year-old man presents to the clinic reporting a progressive tremor affecting his hands. He
states the symptom onset was approximately seven years ago. He states his tremor is now
affecting his writing but appears to improve in the evenings after a glass of wine. He has no
significant medical history. He does report that his mother had a similar problem but never
sought medical attention. On exam, he has no tremor at rest but develops an increasing amplitude
tremor in both upper extremities when reaching for items. No bradykinesia or rigidity is present.
The rest of his examination is unremarkable. Which of the following is the most likely
diagnosis?
A. Essential tremor
B. Huntington disease
C. Parkinson disease
D. Wilson disease correct answers A. Essential tremor
Diagnosis is made clinically on the basis of family history, as an autosomal dominant
transmission occurs in many cases, and clinical presentation.
Initial treatment may be episodic, with primidone or propranolol, however, long-term treatment
is usually with propranolol or topiramate
Complaining of hand tremor that is exacerbated by action and improved after alcohol
consumption
,Which of the following best describes the etiology of the jaundice seen in patients with thyroid
storm?
A. Direct constricting effects of thyroid hormone on the biliary duct
B. Hepatic tissue hypoxia due to increased peripheral consumption of oxygen
C. Hypotension leading to decreased gut motility
D. Impaired reabsorption of thyroid hormone in the enterohepatic circulation correct answers B.
Hepatic tissue hypoxia due to increased peripheral consumption of oxygen.
Signs and symptoms of thyroid storm include hyperpyrexia, nausea, vomiting, diarrhea, mental
status changes, jaundice, high-output congestive heart failure, cardiac tachyarrhythmias,
hypertension, and diaphoresis.
PE will show goiter, lid lag, hand tremor, and warm, moist skin
Labs will show low TSH and high free T4 or T3
Most commonly caused by an acute event
Treatment is: 1) beta blocker (propranolol) 2) thionamide (propylthiouracil or methimazole) 3)
iodine solution 4) glucocorticoids
Which of the following is associated with aortic stenosis?
A. de Musset sign
B. Holodiastolic decrescendo murmur
C. Syncope
D. Wide pulse pressure correct answers C. Syncope
Patient will be older
With a history of diabetes, hypertension
Complaining of dyspnea, chest pain, syncope
PE will show crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically
split S2, S4 gallop
Most commonly caused by degenerative calcification
Treatment is aortic valve replacement
Comments: murmur decreases with Valsalva
A 32-year-old woman with Marfan syndrome is brought to the emergency department by her
husband after she experienced a syncopal episode. She complains of acute onset of sharp
substernal chest pain with radiation to her back. On arrival, her vital signs are T 37.3C, HR 130,
BP 90/40, RR 27. The blood pressure is similar in bilateral arms. Physical examination reveals
no jugular venous distention and heart sounds are auscultated clearly without murmurs, rubs, or
gallops. Which of the following is the most appropriate next step in the management of this
patients condition?
A. Labetalol
B. Nitroprusside
C. Norepinephrine
D. Normal saline correct answers D. Normal saline
The cause of the hypotension should be determined and first-line treatment of hypotension in the
setting of aortic dissection with aortic rupture or tamponade is fluid resuscitation
, CT angiogram is the gold standard for diagnosis of dissection.
A 35-year-old man presents to the office with acute onset right flank pain radiating to the groin
with intermittent nausea and vomiting. A urinalysis and computed tomography of the abdomen
and pelvis without contrast were ordered. An urgent referral for outpatient urologist evaluation
would be most appropriate for which of the following findings?
A. A 3 mm stone in the distal ureter
B. A 9 mm mid-ureteral stone
C. Hydronephrosis with urinary tract infection
D. Ureteral obstruction from a stone in a transplanted kidney correct answers B. A 9 mm mid-
ureteral stone
Stones that are < 4 mm in diameter are likely to pass on their own with minimal medical
management. Stones that are > 8 mm in diameter, however, are unlikely to pass spontaneously
and may require stent placement, percutaneous nephrostomy, extracorporeal shockwave
lithotripsy, ureteroscopy, and nephrostolithotomy. Therefore, an urgent referral for outpatient
urologist evaluation is recommended for a patient with a 9 mm mid-ureteral stone who is likely
to need further management
Treatment is:
< 5 mm: likely to pass spontaneously
> 8 mm: unlikely to pass, lithotripsy
A 35-year-old woman presents to the clinic complaining of worsening symptoms related to her
recently diagnosed scleroderma (systemic sclerosis). Which of the following symptoms is most
consistent with the diagnosis of scleroderma?
A. Dry mouth and dry eye complaints
B. Skin tightening around the fingers with pitting at the fingertips
C. Tenderness at the temporal areas
D. Weakness of proximal muscles without pain correct answers B. Skin tightening around the
fingers with pitting at the fingertips
Classically, limited cutaneous scleroderma causes CREST syndrome; Calcinosis of the skin,
Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. Laboratory
studies may reveal elevated antinuclear antibody (present in all patients but has low specificity),
anti-topoisomerase I (anti-Scl-70) antibody (specific for diffuse disease), anti-centromere
antibody (specific for limited disease).
Which of the following conditions is most commonly associated with malar or "butterfly" rash?
A. Parvovirus B19 infection
B. Pregnancy
C. Rosacea
D. Systemic lupus erythematosus correct answers D. Systemic lupus erythematosus
Systemic lupus erythematosus is most commonly seen in African-American patients of
childbearing age. Antinuclear antibodies (ANA) is the best initial screening test (most sensitive
FINAL EXAM WITH QUESTIONS AND WELL
DETAILED ANSWERS/ A GRADE
Sourced from Chamberlain university Experts
A 24-year-old woman presents with complaints of excessive thirst over the past several weeks.
She also notes waking up in the middle of the night to urinate. She recently underwent
transsphenoidal resection of a pituitary adenoma. Which of the following is the most likely
diagnosis?
A. Central diabetes insipidus
B. Nephrogenic diabetes insipidus
C. Primary polydipsia
D. Type 2 diabetes mellitus correct answers A. Central diabetes insipidus
Central diabetes insipidus is the most common type of diabetes insipidus, is associated with
deficient secretion of antidiuretic hormone (ADH) by the posterior pituitary.
What is the most common presenting symptom of bladder carcinoma?
A. Nocturia
B. Painless hematuria
C. Unintentional weight loss
D. Urinary frequency correct answers B. Painless hematuria
The primary modality to diagnose bladder cancer is with cystoscopy, which allows for direct
visualization of tissues and biopsy of any abnormalities.
Smoking is the most important risk factor of bladder cancer.
A 25-year-old man presents to the clinic with fever and a sore throat. A throat swab is performed
and the culture comes back positive for group A streptococcus bacteria. What system of his body
is at highest risk for permanent damage if proper treatment for his infection is not administered?
A. Cardiovascular
B. Gastrointestinal
C. Musculoskeletal
D. Pulmonary correct answers A. Cardiovascular
Risk of rheumatic fever and pericarditis.
Remember the Jones criteria for rheumatic fever:
Major: Joints, carditis, nodes, erythema marginatum, sydenham chorea.
Minor: fever, arthralgia, elevated ESR, elevated CRP, and prolonged PR interval.
Need 2 major, or 1 major and 2 minor, or 3 minor
,A 60-year-old man with intermittent claudication returns to the clinic for interpretation of the
results of his ankle-brachial index. Which of the following statements is most accurate?
A. A falsely high index may indicate severely hardened, non-compressible leg vessels
B. A low ankle-brachial index indicates peripheral venous insufficiency
C. An ankle-brachial index of 1.2 indicates severe disease
D. It is the ratio of ankle to arm diastolic blood pressure correct answers A. A falsely high index
may indicate severely hardened, non-compressible leg vessels.
The ankle-brachial index is calculated by measuring the systolic blood pressure in the arm and at
the ankle. A ratio of ankle systolic blood pressure to brachial systolic blood pressure under 0.90
is indicative of peripheral arterial disease. A falsely high ankle-brachial index can occur when a
patient has severely hardened peripheral arteries which are non-compressible.
A 22-year-old man presents to the office for his one week follow up after his third concussion in
four years. The patient plays rugby on his college intramural team. His most recent concussion
was complicated by a period of loss of consciousness at the time of injury. He admits to having
headaches and intermittent dizziness for the past couple of days. His headache appears to be
tension-type in nature. He is eager to return to rugby and is requesting clearance to play. Which
of the following is the most appropriate education to give your patient?
A. Can return as headaches after a concussion are expected
B. Can return as subsequent concussions increase resilience to future ones
C. Cannot return as patient is currently symptomatic
D. Cannot return as patient meets criteria for chronic traumatic encephalopathy correct answers
C. Cannot return as patient is currently symptomatic
A 64-year-old man presents to the clinic reporting a progressive tremor affecting his hands. He
states the symptom onset was approximately seven years ago. He states his tremor is now
affecting his writing but appears to improve in the evenings after a glass of wine. He has no
significant medical history. He does report that his mother had a similar problem but never
sought medical attention. On exam, he has no tremor at rest but develops an increasing amplitude
tremor in both upper extremities when reaching for items. No bradykinesia or rigidity is present.
The rest of his examination is unremarkable. Which of the following is the most likely
diagnosis?
A. Essential tremor
B. Huntington disease
C. Parkinson disease
D. Wilson disease correct answers A. Essential tremor
Diagnosis is made clinically on the basis of family history, as an autosomal dominant
transmission occurs in many cases, and clinical presentation.
Initial treatment may be episodic, with primidone or propranolol, however, long-term treatment
is usually with propranolol or topiramate
Complaining of hand tremor that is exacerbated by action and improved after alcohol
consumption
,Which of the following best describes the etiology of the jaundice seen in patients with thyroid
storm?
A. Direct constricting effects of thyroid hormone on the biliary duct
B. Hepatic tissue hypoxia due to increased peripheral consumption of oxygen
C. Hypotension leading to decreased gut motility
D. Impaired reabsorption of thyroid hormone in the enterohepatic circulation correct answers B.
Hepatic tissue hypoxia due to increased peripheral consumption of oxygen.
Signs and symptoms of thyroid storm include hyperpyrexia, nausea, vomiting, diarrhea, mental
status changes, jaundice, high-output congestive heart failure, cardiac tachyarrhythmias,
hypertension, and diaphoresis.
PE will show goiter, lid lag, hand tremor, and warm, moist skin
Labs will show low TSH and high free T4 or T3
Most commonly caused by an acute event
Treatment is: 1) beta blocker (propranolol) 2) thionamide (propylthiouracil or methimazole) 3)
iodine solution 4) glucocorticoids
Which of the following is associated with aortic stenosis?
A. de Musset sign
B. Holodiastolic decrescendo murmur
C. Syncope
D. Wide pulse pressure correct answers C. Syncope
Patient will be older
With a history of diabetes, hypertension
Complaining of dyspnea, chest pain, syncope
PE will show crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically
split S2, S4 gallop
Most commonly caused by degenerative calcification
Treatment is aortic valve replacement
Comments: murmur decreases with Valsalva
A 32-year-old woman with Marfan syndrome is brought to the emergency department by her
husband after she experienced a syncopal episode. She complains of acute onset of sharp
substernal chest pain with radiation to her back. On arrival, her vital signs are T 37.3C, HR 130,
BP 90/40, RR 27. The blood pressure is similar in bilateral arms. Physical examination reveals
no jugular venous distention and heart sounds are auscultated clearly without murmurs, rubs, or
gallops. Which of the following is the most appropriate next step in the management of this
patients condition?
A. Labetalol
B. Nitroprusside
C. Norepinephrine
D. Normal saline correct answers D. Normal saline
The cause of the hypotension should be determined and first-line treatment of hypotension in the
setting of aortic dissection with aortic rupture or tamponade is fluid resuscitation
, CT angiogram is the gold standard for diagnosis of dissection.
A 35-year-old man presents to the office with acute onset right flank pain radiating to the groin
with intermittent nausea and vomiting. A urinalysis and computed tomography of the abdomen
and pelvis without contrast were ordered. An urgent referral for outpatient urologist evaluation
would be most appropriate for which of the following findings?
A. A 3 mm stone in the distal ureter
B. A 9 mm mid-ureteral stone
C. Hydronephrosis with urinary tract infection
D. Ureteral obstruction from a stone in a transplanted kidney correct answers B. A 9 mm mid-
ureteral stone
Stones that are < 4 mm in diameter are likely to pass on their own with minimal medical
management. Stones that are > 8 mm in diameter, however, are unlikely to pass spontaneously
and may require stent placement, percutaneous nephrostomy, extracorporeal shockwave
lithotripsy, ureteroscopy, and nephrostolithotomy. Therefore, an urgent referral for outpatient
urologist evaluation is recommended for a patient with a 9 mm mid-ureteral stone who is likely
to need further management
Treatment is:
< 5 mm: likely to pass spontaneously
> 8 mm: unlikely to pass, lithotripsy
A 35-year-old woman presents to the clinic complaining of worsening symptoms related to her
recently diagnosed scleroderma (systemic sclerosis). Which of the following symptoms is most
consistent with the diagnosis of scleroderma?
A. Dry mouth and dry eye complaints
B. Skin tightening around the fingers with pitting at the fingertips
C. Tenderness at the temporal areas
D. Weakness of proximal muscles without pain correct answers B. Skin tightening around the
fingers with pitting at the fingertips
Classically, limited cutaneous scleroderma causes CREST syndrome; Calcinosis of the skin,
Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. Laboratory
studies may reveal elevated antinuclear antibody (present in all patients but has low specificity),
anti-topoisomerase I (anti-Scl-70) antibody (specific for diffuse disease), anti-centromere
antibody (specific for limited disease).
Which of the following conditions is most commonly associated with malar or "butterfly" rash?
A. Parvovirus B19 infection
B. Pregnancy
C. Rosacea
D. Systemic lupus erythematosus correct answers D. Systemic lupus erythematosus
Systemic lupus erythematosus is most commonly seen in African-American patients of
childbearing age. Antinuclear antibodies (ANA) is the best initial screening test (most sensitive
