Internal Medicine Practice Exam-Graded
A
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 answer-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 answer-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 70-year-old male is beginning treatment for peripheral vascular disease. He has a 50
pack year smoking history and is currently smoking one pack per day. His ankle-
brachial index is 0.76, and his dorsalis pedis pulses are diminished bilaterally. His main
complaint is a reduction in his ability to continue morning walks with his brother due to
pain in his calves that resolves with rest. Which of the following is the most appropriate
therapy?
A. Aspirin, cilostazol, rosuvastatin, smoking cessation, and structured exercise
B. Aspirin, rosuvastatin, smoking cessation, and surgical referral
C. Clopidogrel, endovascular reperfusion, rosuvastatin, and smoking cessation
D. Clopidogrel, structured exercise, and smoking cessation - correct answer-A. Aspirin,
cilostazol, rosuvastatin, smoking cessation, and structured exercise
A 54-year-old man presents to the clinic with a complaint of a productive cough and
progressive dyspnea on exertion. His cough was initially dry, 12 years ago, but
,progressed to productive one year ago. He denies any smoking history, and has
otherwise been healthy. He is a mason by trade and enjoys stone sculpting with his wife
as a hobby. Which of the following is most likely to confirm the suspected diagnosis?
A. Chest X-ray
B. Complete blood count with differential
C. Pulmonary function test
D. Tuberculin skin test - correct answer-A. Chest X-ray
A chest X-ray is most likely to confirm the suspected diagnosis of pneumoconiosis,
specifically silicosis. Pneumoconioses are a group of restrictive chronic lung diseases
caused by inhalation of particulate matter and are usually related to occupational
exposure
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 answer-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 answer-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
answer-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 answer-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
answer-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 answer-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 answer-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 answer-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,
A
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 answer-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 answer-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 70-year-old male is beginning treatment for peripheral vascular disease. He has a 50
pack year smoking history and is currently smoking one pack per day. His ankle-
brachial index is 0.76, and his dorsalis pedis pulses are diminished bilaterally. His main
complaint is a reduction in his ability to continue morning walks with his brother due to
pain in his calves that resolves with rest. Which of the following is the most appropriate
therapy?
A. Aspirin, cilostazol, rosuvastatin, smoking cessation, and structured exercise
B. Aspirin, rosuvastatin, smoking cessation, and surgical referral
C. Clopidogrel, endovascular reperfusion, rosuvastatin, and smoking cessation
D. Clopidogrel, structured exercise, and smoking cessation - correct answer-A. Aspirin,
cilostazol, rosuvastatin, smoking cessation, and structured exercise
A 54-year-old man presents to the clinic with a complaint of a productive cough and
progressive dyspnea on exertion. His cough was initially dry, 12 years ago, but
,progressed to productive one year ago. He denies any smoking history, and has
otherwise been healthy. He is a mason by trade and enjoys stone sculpting with his wife
as a hobby. Which of the following is most likely to confirm the suspected diagnosis?
A. Chest X-ray
B. Complete blood count with differential
C. Pulmonary function test
D. Tuberculin skin test - correct answer-A. Chest X-ray
A chest X-ray is most likely to confirm the suspected diagnosis of pneumoconiosis,
specifically silicosis. Pneumoconioses are a group of restrictive chronic lung diseases
caused by inhalation of particulate matter and are usually related to occupational
exposure
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 answer-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 answer-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
answer-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 answer-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
answer-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 answer-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 answer-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 answer-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,
