COMAT Internal Medicine Exam V1 | COMAT
Internal Medicine Exam V1 | COMAT Internal
Medicine Exam V1
1. A 65-year-old male with a history of heart failure with reduced ejection fraction (HFrEF)
presents for a routine follow-up. He is currently taking lisinopril, carvedilol, and furosemide.
He reports mild dyspnea on exertion. Physical exam reveals a blood pressure of 128/78
mmHg and a heart rate of 72 bpm. Which of the following medications, when added to his
regimen, is most likely to provide a mortality benefit?
A. Amlodipine
B. Digoxin
C. Spironolactone
D. Isosorbide mononitrate
Correct Answer: C
Explanation: In patients with symptomatic HFrEF already on an ACE inhibitor and a beta-
blocker, the addition of a mineralocorticoid receptor antagonist like spironolactone
reduces morbidity and mortality. This therapy is specifically recommended for patients
with an LVEF of 35 percent or less. Clinicians must monitor for hyperkalemia and renal
insufficiency when initiating this medication.
,2. A 42-year-old female presents to the emergency department with sudden-onset sharp
chest pain and shortness of breath. She recently returned from a 12-hour flight. Her heart
rate is 112 bpm, respiratory rate is 24/min, and oxygen saturation is 90% on room air. Her
physical exam shows swelling of the right lower extremity. What is the most appropriate next
step in management?
A. D-dimer assay
B. Chest X-ray
C. CT pulmonary angiography
D. Transthoracic echocardiogram
Correct Answer: C
Explanation: This patient has a high clinical suspicion for pulmonary embolism based on
her symptoms, risk factors (immobilization), and signs of DVT. According to the Wells
criteria, a CT pulmonary angiography (CTPA) is the preferred diagnostic imaging test for
confirming PE in patients with high probability. D-dimer is useful only for excluding PE in
low-probability patients and is not appropriate here.
3. A 55-year-old male with a history of alcohol use disorder presents with hematemesis. He
appears pale and diaphoretic. His blood pressure is 90/60 mmHg and heart rate is 115 bpm.
After establishing two large-bore IV lines and starting fluid resuscitation, what is the most
appropriate next step?
A. Emergency upper endoscopy
,B. Barium swallow study
C. Abdominal ultrasound
D. Nasogastric tube placement
Correct Answer: A
Explanation: Acute upper gastrointestinal bleeding in a patient with potential variceal or
peptic ulcer source requires urgent endoscopic evaluation after stabilization. Endoscopy
allows for both diagnosis and therapeutic intervention, such as band ligation or clipping.
Early intervention is critical to reducing mortality in hemodynamically unstable patients
with GI bleeding.
4. A 72-year-old female is hospitalized for a hip fracture. Her labs show a serum potassium of
6.2 mEq/L. The EKG shows peaked T-waves but no QRS widening. What is the most
immediate treatment to stabilize the cardiac membrane?
A. Insulin and glucose
B. Sodium polystyrene sulfonate
C. Furosemide
D. Calcium gluconate
Correct Answer: D
Explanation: Intravenous calcium (gluconate or chloride) is the fastest way to stabilize the
cardiac myocyte membrane in the setting of hyperkalemia-induced EKG changes. While
, calcium does not lower the potassium level itself, it prevents life-threatening arrhythmias.
Following stabilization, other agents like insulin and glucose are used to shift potassium
intracellularly.
5. A 30-year-old female presents with fatigue, weight gain, and cold intolerance over the last
3 months. Her thyroid-stimulating hormone (TSH) is 15.0 uIU/mL (normal 0.5-4.5) and free T4
is low. What is the most likely underlying diagnosis?
A. Graves disease
B. Pituitary adenoma
C. Subacute thyroiditis
D. Hashimoto thyroiditis
Correct Answer: D
Explanation: Hashimoto thyroiditis is the most common cause of primary hypothyroidism
in iodine-sufficient regions and is characterized by elevated TSH and low T4. It is an
autoimmune condition where antibodies (anti-TPO) lead to chronic lymphocytic
inflammation of the gland. Treatment involves lifelong levothyroxine replacement therapy
titrated to TSH levels.
Internal Medicine Exam V1 | COMAT Internal
Medicine Exam V1
1. A 65-year-old male with a history of heart failure with reduced ejection fraction (HFrEF)
presents for a routine follow-up. He is currently taking lisinopril, carvedilol, and furosemide.
He reports mild dyspnea on exertion. Physical exam reveals a blood pressure of 128/78
mmHg and a heart rate of 72 bpm. Which of the following medications, when added to his
regimen, is most likely to provide a mortality benefit?
A. Amlodipine
B. Digoxin
C. Spironolactone
D. Isosorbide mononitrate
Correct Answer: C
Explanation: In patients with symptomatic HFrEF already on an ACE inhibitor and a beta-
blocker, the addition of a mineralocorticoid receptor antagonist like spironolactone
reduces morbidity and mortality. This therapy is specifically recommended for patients
with an LVEF of 35 percent or less. Clinicians must monitor for hyperkalemia and renal
insufficiency when initiating this medication.
,2. A 42-year-old female presents to the emergency department with sudden-onset sharp
chest pain and shortness of breath. She recently returned from a 12-hour flight. Her heart
rate is 112 bpm, respiratory rate is 24/min, and oxygen saturation is 90% on room air. Her
physical exam shows swelling of the right lower extremity. What is the most appropriate next
step in management?
A. D-dimer assay
B. Chest X-ray
C. CT pulmonary angiography
D. Transthoracic echocardiogram
Correct Answer: C
Explanation: This patient has a high clinical suspicion for pulmonary embolism based on
her symptoms, risk factors (immobilization), and signs of DVT. According to the Wells
criteria, a CT pulmonary angiography (CTPA) is the preferred diagnostic imaging test for
confirming PE in patients with high probability. D-dimer is useful only for excluding PE in
low-probability patients and is not appropriate here.
3. A 55-year-old male with a history of alcohol use disorder presents with hematemesis. He
appears pale and diaphoretic. His blood pressure is 90/60 mmHg and heart rate is 115 bpm.
After establishing two large-bore IV lines and starting fluid resuscitation, what is the most
appropriate next step?
A. Emergency upper endoscopy
,B. Barium swallow study
C. Abdominal ultrasound
D. Nasogastric tube placement
Correct Answer: A
Explanation: Acute upper gastrointestinal bleeding in a patient with potential variceal or
peptic ulcer source requires urgent endoscopic evaluation after stabilization. Endoscopy
allows for both diagnosis and therapeutic intervention, such as band ligation or clipping.
Early intervention is critical to reducing mortality in hemodynamically unstable patients
with GI bleeding.
4. A 72-year-old female is hospitalized for a hip fracture. Her labs show a serum potassium of
6.2 mEq/L. The EKG shows peaked T-waves but no QRS widening. What is the most
immediate treatment to stabilize the cardiac membrane?
A. Insulin and glucose
B. Sodium polystyrene sulfonate
C. Furosemide
D. Calcium gluconate
Correct Answer: D
Explanation: Intravenous calcium (gluconate or chloride) is the fastest way to stabilize the
cardiac myocyte membrane in the setting of hyperkalemia-induced EKG changes. While
, calcium does not lower the potassium level itself, it prevents life-threatening arrhythmias.
Following stabilization, other agents like insulin and glucose are used to shift potassium
intracellularly.
5. A 30-year-old female presents with fatigue, weight gain, and cold intolerance over the last
3 months. Her thyroid-stimulating hormone (TSH) is 15.0 uIU/mL (normal 0.5-4.5) and free T4
is low. What is the most likely underlying diagnosis?
A. Graves disease
B. Pituitary adenoma
C. Subacute thyroiditis
D. Hashimoto thyroiditis
Correct Answer: D
Explanation: Hashimoto thyroiditis is the most common cause of primary hypothyroidism
in iodine-sufficient regions and is characterized by elevated TSH and low T4. It is an
autoimmune condition where antibodies (anti-TPO) lead to chronic lymphocytic
inflammation of the gland. Treatment involves lifelong levothyroxine replacement therapy
titrated to TSH levels.
