Practice Questions | Verified Answers &
Rationales
Welcome to this focused internal medicine practice exam for COMLEX Level 2-CE. This resource contains 210
high-yield questions covering cardiology, pulmonology, gastroenterology, renal, endocrinology, and
infectious disease. Each question mirrors COMLEX-style clinical vignettes. Every answer includes a clear
rationale of no more than three lines. Use this exam to strengthen your internal medicine knowledge and
test-taking skills.
Key Topics Covered
Cardiology – Heart failure, arrhythmias, ischemic heart disease, valvular disease, hypertension
Pulmonology – COPD, asthma, pneumonia, pulmonary embolism, interstitial lung disease
Gastroenterology – GERD, peptic ulcer disease, inflammatory bowel disease, hepatitis, pancreatitis
Renal – Acute kidney injury, chronic kidney disease, glomerulonephritis, nephrolithiasis
Endocrine – Diabetes, thyroid disorders, adrenal insufficiency, osteoporosis
Infectious Disease – Pneumonia, UTI, endocarditis, meningitis, sepsis, HIV
Questions 1–210
1. A 68-year-old male with a history of hypertension presents with progressive dyspnea on exertion,
orthopnea, and paroxysmal nocturnal dyspnea. On exam, he has crackles in bilateral lung bases and
an S3 gallop. Which medication is first-line to reduce mortality in heart failure with reduced ejection
fraction?
A) Furosemide
B) Metoprolol succinate
C) Digoxin
D) Hydralazine
Answer B: Metoprolol succinate
Rationale: Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) reduce mortality in HFrEF. Diuretics
control symptoms but do not improve survival. ACE inhibitors also reduce mortality.
,2. A 45-year-old male presents with a 3-day history of fever, productive cough with green sputum,
and pleuritic chest pain. Chest X-ray shows a right lower lobe infiltrate. He has no comorbidities.
Which antibiotic is most appropriate for outpatient treatment?
A) Amoxicillin
B) Doxycycline
C) Levofloxacin
D) Azithromycin
Answer D: Azithromycin
Rationale: For outpatient community-acquired pneumonia in healthy patients, a macrolide (azithromycin)
or doxycycline is first-line. Fluoroquinolones reserved for comorbidities or treatment failure. Amoxicillin not
preferred due to atypical coverage.
3. A 62-year-old female with type 2 diabetes presents with a several-week history of nausea, early
satiety, and bloating. Gastric emptying study shows delayed emptying. Which medication is first-line
for gastroparesis?
A) Metoclopramide
B) Erythromycin
C) Domperidone
D) Ondansetron
Answer A: Metoclopramide
Rationale: Metoclopramide (prokinetic and antiemetic) is first-line but carries risk of tardive dyskinesia.
Erythromycin is second-line due to tachyphylaxis. Domperidone not FDA approved.
4. A 55-year-old male with a history of hypertension presents with acute onset of severe, tearing
chest pain radiating to the back. Blood pressure is 200/110 mmHg in the right arm and 110/70
mmHg in the left arm. Which initial imaging study is most appropriate?
A) Chest X-ray
B) CT angiography of the chest
C) Transthoracic echocardiogram
D) Transesophageal echocardiogram
Answer B: CT angiography of the chest
Rationale: CT angiography is the fastest and most accurate test for aortic dissection. Unequal arm pressures
suggest Stanford type A (ascending) dissection. Immediate surgical consultation.
,5. A 34-year-old male presents with episodic watery diarrhea, abdominal cramping, and flushing. He
has a history of asthma. Twenty-four hour urine 5-HIAA is elevated. Which tumor is most likely?
A) Carcinoid tumor
B) Gastrinoma
C) VIPoma
D) Pheochromocytoma
Answer A: Carcinoid tumor
Rationale: Carcinoid syndrome (flushing, diarrhea, wheezing) from serotonin secretion; 5-HIAA is
diagnostic. Octreotide controls symptoms. Locate with CT or octreotide scan.
6. A 72-year-old female with chronic kidney disease stage 4 presents with fatigue, bone pain, and a
serum calcium of 8.5 mg/dL, phosphorus 6.2 mg/dL, and PTH 450 pg/mL. Which medication is first-
line to lower PTH?
A) Calcitriol
B) Calcium acetate
C) Sevelamer
D) Cinacalcet
Answer A: Calcitriol
Rationale: Active vitamin D (calcitriol) suppresses PTH in secondary hyperparathyroidism of CKD.
Phosphate binders (sevelamer, calcium acetate) control phosphorus. Cinacalcet is used if calcitriol fails.
7. A 45-year-old male presents with a several-week history of dysuria, increased frequency, and
suprapubic pain. He has a history of benign prostatic hyperplasia. Urinalysis shows leukocytes and
nitrites. Which antibiotic is appropriate for complicated cystitis?
A) Nitrofurantoin
B) Ciprofloxacin for 7 days
C) Trimethoprim-sulfamethoxazole for 3 days
D) Cephalexin
Answer B: Ciprofloxacin for 7 days
Rationale: Complicated UTI (male, catheter, anatomic abnormality) requires longer course (7-14 days) and
often fluoroquinolones. Nitrofurantoin is for uncomplicated cystitis in women. TMP-SMX also but
fluoroquinolones common.
, 8. A 68-year-old male with a history of heart failure with reduced ejection fraction presents with
worsening dyspnea and edema. His medications include lisinopril, carvedilol, and furosemide. Which
additional medication has been shown to reduce mortality in HFrEF?
A) Spironolactone
B) Digoxin
C) Hydralazine
D) Diltiazem
Answer A: Spironolactone
Rationale: Mineralocorticoid receptor antagonists (spironolactone, eplerenone) reduce mortality in HFrEF.
Digoxin reduces hospitalizations but not mortality. Hydralazine/nitrate beneficial in African Americans.
9. A 55-year-old female presents with a 2-day history of fever, chills, and right flank pain. She has no
dysuria. Urinalysis shows leukocyte esterase and nitrites. Which diagnosis is most likely?
A) Pyelonephritis
B) Cystitis
C) Nephrolithiasis
D) Appendicitis
Answer A: Pyelonephritis
Rationale: Fever, flank pain, and pyuria indicate acute pyelonephritis; requires 7-14 days of antibiotics
(fluoroquinolone or cephalosporin). Outpatient treatment if mild; hospitalize if severe. Urine culture guides
therapy.
10. A 62-year-old male with COPD (FEV1 45% predicted) presents with increasing dyspnea, cough,
and purulent sputum. He is afebrile. Which antibiotic is appropriate for acute exacerbation without
risk factors for Pseudomonas?
A) Doxycycline
B) Levofloxacin
C) Amoxicillin-clavulanate
D) Azithromycin
Answer A: Doxycycline
Rationale: For mild-moderate exacerbations, doxycycline, macrolides, or amoxicillin-clavulanate are
options. Fluoroquinolones reserved for severe exacerbations or frequent exacerbations. Duration 5-7 days.
Rationales
Welcome to this focused internal medicine practice exam for COMLEX Level 2-CE. This resource contains 210
high-yield questions covering cardiology, pulmonology, gastroenterology, renal, endocrinology, and
infectious disease. Each question mirrors COMLEX-style clinical vignettes. Every answer includes a clear
rationale of no more than three lines. Use this exam to strengthen your internal medicine knowledge and
test-taking skills.
Key Topics Covered
Cardiology – Heart failure, arrhythmias, ischemic heart disease, valvular disease, hypertension
Pulmonology – COPD, asthma, pneumonia, pulmonary embolism, interstitial lung disease
Gastroenterology – GERD, peptic ulcer disease, inflammatory bowel disease, hepatitis, pancreatitis
Renal – Acute kidney injury, chronic kidney disease, glomerulonephritis, nephrolithiasis
Endocrine – Diabetes, thyroid disorders, adrenal insufficiency, osteoporosis
Infectious Disease – Pneumonia, UTI, endocarditis, meningitis, sepsis, HIV
Questions 1–210
1. A 68-year-old male with a history of hypertension presents with progressive dyspnea on exertion,
orthopnea, and paroxysmal nocturnal dyspnea. On exam, he has crackles in bilateral lung bases and
an S3 gallop. Which medication is first-line to reduce mortality in heart failure with reduced ejection
fraction?
A) Furosemide
B) Metoprolol succinate
C) Digoxin
D) Hydralazine
Answer B: Metoprolol succinate
Rationale: Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) reduce mortality in HFrEF. Diuretics
control symptoms but do not improve survival. ACE inhibitors also reduce mortality.
,2. A 45-year-old male presents with a 3-day history of fever, productive cough with green sputum,
and pleuritic chest pain. Chest X-ray shows a right lower lobe infiltrate. He has no comorbidities.
Which antibiotic is most appropriate for outpatient treatment?
A) Amoxicillin
B) Doxycycline
C) Levofloxacin
D) Azithromycin
Answer D: Azithromycin
Rationale: For outpatient community-acquired pneumonia in healthy patients, a macrolide (azithromycin)
or doxycycline is first-line. Fluoroquinolones reserved for comorbidities or treatment failure. Amoxicillin not
preferred due to atypical coverage.
3. A 62-year-old female with type 2 diabetes presents with a several-week history of nausea, early
satiety, and bloating. Gastric emptying study shows delayed emptying. Which medication is first-line
for gastroparesis?
A) Metoclopramide
B) Erythromycin
C) Domperidone
D) Ondansetron
Answer A: Metoclopramide
Rationale: Metoclopramide (prokinetic and antiemetic) is first-line but carries risk of tardive dyskinesia.
Erythromycin is second-line due to tachyphylaxis. Domperidone not FDA approved.
4. A 55-year-old male with a history of hypertension presents with acute onset of severe, tearing
chest pain radiating to the back. Blood pressure is 200/110 mmHg in the right arm and 110/70
mmHg in the left arm. Which initial imaging study is most appropriate?
A) Chest X-ray
B) CT angiography of the chest
C) Transthoracic echocardiogram
D) Transesophageal echocardiogram
Answer B: CT angiography of the chest
Rationale: CT angiography is the fastest and most accurate test for aortic dissection. Unequal arm pressures
suggest Stanford type A (ascending) dissection. Immediate surgical consultation.
,5. A 34-year-old male presents with episodic watery diarrhea, abdominal cramping, and flushing. He
has a history of asthma. Twenty-four hour urine 5-HIAA is elevated. Which tumor is most likely?
A) Carcinoid tumor
B) Gastrinoma
C) VIPoma
D) Pheochromocytoma
Answer A: Carcinoid tumor
Rationale: Carcinoid syndrome (flushing, diarrhea, wheezing) from serotonin secretion; 5-HIAA is
diagnostic. Octreotide controls symptoms. Locate with CT or octreotide scan.
6. A 72-year-old female with chronic kidney disease stage 4 presents with fatigue, bone pain, and a
serum calcium of 8.5 mg/dL, phosphorus 6.2 mg/dL, and PTH 450 pg/mL. Which medication is first-
line to lower PTH?
A) Calcitriol
B) Calcium acetate
C) Sevelamer
D) Cinacalcet
Answer A: Calcitriol
Rationale: Active vitamin D (calcitriol) suppresses PTH in secondary hyperparathyroidism of CKD.
Phosphate binders (sevelamer, calcium acetate) control phosphorus. Cinacalcet is used if calcitriol fails.
7. A 45-year-old male presents with a several-week history of dysuria, increased frequency, and
suprapubic pain. He has a history of benign prostatic hyperplasia. Urinalysis shows leukocytes and
nitrites. Which antibiotic is appropriate for complicated cystitis?
A) Nitrofurantoin
B) Ciprofloxacin for 7 days
C) Trimethoprim-sulfamethoxazole for 3 days
D) Cephalexin
Answer B: Ciprofloxacin for 7 days
Rationale: Complicated UTI (male, catheter, anatomic abnormality) requires longer course (7-14 days) and
often fluoroquinolones. Nitrofurantoin is for uncomplicated cystitis in women. TMP-SMX also but
fluoroquinolones common.
, 8. A 68-year-old male with a history of heart failure with reduced ejection fraction presents with
worsening dyspnea and edema. His medications include lisinopril, carvedilol, and furosemide. Which
additional medication has been shown to reduce mortality in HFrEF?
A) Spironolactone
B) Digoxin
C) Hydralazine
D) Diltiazem
Answer A: Spironolactone
Rationale: Mineralocorticoid receptor antagonists (spironolactone, eplerenone) reduce mortality in HFrEF.
Digoxin reduces hospitalizations but not mortality. Hydralazine/nitrate beneficial in African Americans.
9. A 55-year-old female presents with a 2-day history of fever, chills, and right flank pain. She has no
dysuria. Urinalysis shows leukocyte esterase and nitrites. Which diagnosis is most likely?
A) Pyelonephritis
B) Cystitis
C) Nephrolithiasis
D) Appendicitis
Answer A: Pyelonephritis
Rationale: Fever, flank pain, and pyuria indicate acute pyelonephritis; requires 7-14 days of antibiotics
(fluoroquinolone or cephalosporin). Outpatient treatment if mild; hospitalize if severe. Urine culture guides
therapy.
10. A 62-year-old male with COPD (FEV1 45% predicted) presents with increasing dyspnea, cough,
and purulent sputum. He is afebrile. Which antibiotic is appropriate for acute exacerbation without
risk factors for Pseudomonas?
A) Doxycycline
B) Levofloxacin
C) Amoxicillin-clavulanate
D) Azithromycin
Answer A: Doxycycline
Rationale: For mild-moderate exacerbations, doxycycline, macrolides, or amoxicillin-clavulanate are
options. Fluoroquinolones reserved for severe exacerbations or frequent exacerbations. Duration 5-7 days.
