INTERNAL MEDICINE PRACTICE EXAM | INTERNAL MEDICINE PRACTICE
QUESTIONS & ANSWERS | COMPREHENSIVE BOARD REVIEW 2026/2027
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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 but not specific). The
presence of either anti-double-stranded DNA (dsDNA) and anti-smith (anti-SM) antibodies is diagnostic
of SLE (very specific but not sensitive).
Treatment is NSAIDs, steroids, immunosuppressants, hydroxychloroquine
Drug-induced: Hydralazine, INH, Procainamide, Phenytoin, Sulfonamides (HIPPS). False-positive test for
syphilis
A 67-year-old man presents to the clinic for evaluation of cough, wheezing, malaise, and shortness of
breath. His social history is positive for daily cigar smoking for 30 years. He reports his symptoms have
been present for four months. He had a similar presentation one year ago and was diagnosed with
bronchitis. Which of the following is most likely on physical examination?
A. Barrel chest
B. Diastolic murmur
C. Pectus carinatum
D. Scaphoid abdomen - ✔✔A. Barrel chest
A 35-year-old Caucasian man presents to the emergency department with slurred speech and right facial
drooping. He had a similar episode a few months ago and did not suffer any residual effects. He also has
a history of deep venous thrombosis in the left leg but has no history of surgeries, hypertension, or
diabetes. Which of the following should be included in the evaluation to determine the cause of this
condition?
QUESTIONS & ANSWERS | COMPREHENSIVE BOARD REVIEW 2026/2027
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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 but not specific). The
presence of either anti-double-stranded DNA (dsDNA) and anti-smith (anti-SM) antibodies is diagnostic
of SLE (very specific but not sensitive).
Treatment is NSAIDs, steroids, immunosuppressants, hydroxychloroquine
Drug-induced: Hydralazine, INH, Procainamide, Phenytoin, Sulfonamides (HIPPS). False-positive test for
syphilis
A 67-year-old man presents to the clinic for evaluation of cough, wheezing, malaise, and shortness of
breath. His social history is positive for daily cigar smoking for 30 years. He reports his symptoms have
been present for four months. He had a similar presentation one year ago and was diagnosed with
bronchitis. Which of the following is most likely on physical examination?
A. Barrel chest
B. Diastolic murmur
C. Pectus carinatum
D. Scaphoid abdomen - ✔✔A. Barrel chest
A 35-year-old Caucasian man presents to the emergency department with slurred speech and right facial
drooping. He had a similar episode a few months ago and did not suffer any residual effects. He also has
a history of deep venous thrombosis in the left leg but has no history of surgeries, hypertension, or
diabetes. Which of the following should be included in the evaluation to determine the cause of this
condition?
