Page 1 of 30
INTERNAL MEDICINE COMAT REVIEW
EXAM COMPLETE
QUESTIONS AND CORRECT ANSWERS
WITH DETAILED EXPLANATIONS
CURRENT TESTING
D
Subsection 1: Cardiology (Questions 1–15)
O
1. A 65-year-old male with hypertension and diabetes presents with substernal chest
pressure when walking two blocks, relieved with rest. ECG shows no ST changes. What is
N
the most appropriate initial diagnostic test?
O
A. Coronary angiography
T
B. Exercise stress test (if patient can exercise and ECG interpretable) C. CT angiography
D. Resting echocardiogram
C
Answer: B. Exercise stress test (if patient can exercise and
O
ECG interpretable)
PY
Explanation: Stable angina symptoms warrant stress testing to assess for inducible ischemia.
Exercise ECG is first-line if patient is able to exercise and baseline ECG is normal.
2. A 72-year-old with dyspnea on exertion and orthopnea has an ejection fraction of 35% on
echocardiogram. Which medication class has been shown to reduce mortality in heart
failure with reduced ejection fraction (HFrEF)?
A. Calcium channel blockers
B. Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) C. Thiazide diuretics
D. Direct vasodilators (hydralazine/isosorbide dinitrate) – used in certain populations
Answer: B. Beta-blockers (carvedilol, metoprolol succinate, bisoprolol)
Explanation: Beta-blockers improve survival in HFrEF. Also disease-modifying:
ACEi/ARB/ARNI, MRAs, SGLT2 inhibitors. Loop diuretics are for symptom relief only.
3. A 55-year-old presents with acute onset of tearing chest pain radiating to the back, pulse
110, BP 160/90 in right arm, 100/70 in left arm. What is the most likely diagnosis?
, Page 2 of 30
A. Myocardial infarction
B. Pulmonary embolism
C. Acute aortic dissection
D. Pericarditis
Answer: C. Acute aortic dissection
Explanation: Tearing chest pain with pulse or BP differential between arms is classic for
aortic dissection. Immediate CT angiography and surgical or medical management (beta-
blockers, emergent surgery for type A).
4. A patient with atrial fibrillation has a CHA₂DS₂-VASc score of 4 and a HAS-BLED score
of 2. What is the recommended therapy?
A. Aspirin alone
B. Oral anticoagulation (warfarin or DOAC)
D
C. No anticoagulation
O
D. Left atrial appendage occlusion only
N
Answer: B. Oral anticoagulation (warfarin or DOAC) Explanation: CHA₂DS₂-VASc ≥2 in
men or ≥3 in women indicates anticoagulation. HAS-BLED score assesses bleeding risk but
O
does not override the benefit of anticoagulation for stroke prevention.
T
5. A 45-year-old with hypertension has an ECG showing left ventricular hypertrophy.
C
Which finding on physical exam is most consistent with this diagnosis?
O
A. Widely split S2
PY
B. Sustained and enlarged point of maximal impulse (PMI) C. Opening snap
D. Pericardial friction rub
Answer: B. Sustained and enlarged point of maximal impulse (PMI)
Explanation: LVH results in a sustained, apical impulse that is displaced laterally. ECG
voltage criteria (e.g., Sokolow-Lyon) confirm LVH.
6. A 68-year-old with chronic heart failure develops new onset of confusion, nausea, and
serum sodium of 118 mEq/L. He is on lisinopril, furosemide, and carvedilol. Which
medication is most likely contributing?
A. Lisinopril (ACE inhibitor can cause SIADH? Actually more often thiazides; but ACEi can
cause hyponatremia, less common)
B. Furosemide (loop diuretic, less common cause of
hyponatremia than thiazides)
C. Carvedilol
, Page 3 of 30
D. The combination of all three
Answer: A. Lisinopril (ACE inhibitor can cause SIADH? Actually more often thiazides; but
ACEi can cause hyponatremia, less common)
Explanation: ACE inhibitors can cause SIADH leading to hyponatremia. Thiazides are more
notorious. Evaluate volume status and hold offending agent.
7. A murmur is best heard at the right upper sternal border, radiates to the carotids, and is
systolic. Which murmur is this?
A. Mitral regurgitation (apex, axilla)
B. Aortic stenosis (crescendo-decrescendo, ejection systolic)
C. Pulmonic stenosis (left upper sternal border)
D. Tricuspid regurgitation (left lower sternal border)
Answer: B. Aortic stenosis (crescendo-decrescendo, ejection systolic)
D
Explanation: Aortic stenosis murmur is systolic, harsh, at 2nd ICS right sternal border,
O
radiating to carotids. Associated with pulsus parvus et tardus.
8. A patient with acute pericarditis is expected to have which ECG finding?
N
A. ST elevation in all leads except aVR and V1 (concave up)
O
B. ST depression in precordial leads
T
C. Q waves
C
D. Prolonged QT interval
O
Answer: A. ST elevation in all leads except aVR and V1
PY
(concave up)
Explanation: Diffuse concave ST elevation is classic. PR depression may also be seen. Later
stages show T wave inversions.
9. Which finding is most specific for hypertrophic cardiomyopathy?
A. Ejection click
B. Systolic murmur that increases with Valsalva (decreased preload)
C. Diastolic rumble
D. Fixed splitting of S2
Answer: B. Systolic murmur that increases with Valsalva
(decreased preload)
Explanation: Hypertrophic cardiomyopathy murmur (LVOT obstruction) increases with
decreased preload (standing, Valsalva) and decreases with increased preload (squatting, hand
grip).
INTERNAL MEDICINE COMAT REVIEW
EXAM COMPLETE
QUESTIONS AND CORRECT ANSWERS
WITH DETAILED EXPLANATIONS
CURRENT TESTING
D
Subsection 1: Cardiology (Questions 1–15)
O
1. A 65-year-old male with hypertension and diabetes presents with substernal chest
pressure when walking two blocks, relieved with rest. ECG shows no ST changes. What is
N
the most appropriate initial diagnostic test?
O
A. Coronary angiography
T
B. Exercise stress test (if patient can exercise and ECG interpretable) C. CT angiography
D. Resting echocardiogram
C
Answer: B. Exercise stress test (if patient can exercise and
O
ECG interpretable)
PY
Explanation: Stable angina symptoms warrant stress testing to assess for inducible ischemia.
Exercise ECG is first-line if patient is able to exercise and baseline ECG is normal.
2. A 72-year-old with dyspnea on exertion and orthopnea has an ejection fraction of 35% on
echocardiogram. Which medication class has been shown to reduce mortality in heart
failure with reduced ejection fraction (HFrEF)?
A. Calcium channel blockers
B. Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) C. Thiazide diuretics
D. Direct vasodilators (hydralazine/isosorbide dinitrate) – used in certain populations
Answer: B. Beta-blockers (carvedilol, metoprolol succinate, bisoprolol)
Explanation: Beta-blockers improve survival in HFrEF. Also disease-modifying:
ACEi/ARB/ARNI, MRAs, SGLT2 inhibitors. Loop diuretics are for symptom relief only.
3. A 55-year-old presents with acute onset of tearing chest pain radiating to the back, pulse
110, BP 160/90 in right arm, 100/70 in left arm. What is the most likely diagnosis?
, Page 2 of 30
A. Myocardial infarction
B. Pulmonary embolism
C. Acute aortic dissection
D. Pericarditis
Answer: C. Acute aortic dissection
Explanation: Tearing chest pain with pulse or BP differential between arms is classic for
aortic dissection. Immediate CT angiography and surgical or medical management (beta-
blockers, emergent surgery for type A).
4. A patient with atrial fibrillation has a CHA₂DS₂-VASc score of 4 and a HAS-BLED score
of 2. What is the recommended therapy?
A. Aspirin alone
B. Oral anticoagulation (warfarin or DOAC)
D
C. No anticoagulation
O
D. Left atrial appendage occlusion only
N
Answer: B. Oral anticoagulation (warfarin or DOAC) Explanation: CHA₂DS₂-VASc ≥2 in
men or ≥3 in women indicates anticoagulation. HAS-BLED score assesses bleeding risk but
O
does not override the benefit of anticoagulation for stroke prevention.
T
5. A 45-year-old with hypertension has an ECG showing left ventricular hypertrophy.
C
Which finding on physical exam is most consistent with this diagnosis?
O
A. Widely split S2
PY
B. Sustained and enlarged point of maximal impulse (PMI) C. Opening snap
D. Pericardial friction rub
Answer: B. Sustained and enlarged point of maximal impulse (PMI)
Explanation: LVH results in a sustained, apical impulse that is displaced laterally. ECG
voltage criteria (e.g., Sokolow-Lyon) confirm LVH.
6. A 68-year-old with chronic heart failure develops new onset of confusion, nausea, and
serum sodium of 118 mEq/L. He is on lisinopril, furosemide, and carvedilol. Which
medication is most likely contributing?
A. Lisinopril (ACE inhibitor can cause SIADH? Actually more often thiazides; but ACEi can
cause hyponatremia, less common)
B. Furosemide (loop diuretic, less common cause of
hyponatremia than thiazides)
C. Carvedilol
, Page 3 of 30
D. The combination of all three
Answer: A. Lisinopril (ACE inhibitor can cause SIADH? Actually more often thiazides; but
ACEi can cause hyponatremia, less common)
Explanation: ACE inhibitors can cause SIADH leading to hyponatremia. Thiazides are more
notorious. Evaluate volume status and hold offending agent.
7. A murmur is best heard at the right upper sternal border, radiates to the carotids, and is
systolic. Which murmur is this?
A. Mitral regurgitation (apex, axilla)
B. Aortic stenosis (crescendo-decrescendo, ejection systolic)
C. Pulmonic stenosis (left upper sternal border)
D. Tricuspid regurgitation (left lower sternal border)
Answer: B. Aortic stenosis (crescendo-decrescendo, ejection systolic)
D
Explanation: Aortic stenosis murmur is systolic, harsh, at 2nd ICS right sternal border,
O
radiating to carotids. Associated with pulsus parvus et tardus.
8. A patient with acute pericarditis is expected to have which ECG finding?
N
A. ST elevation in all leads except aVR and V1 (concave up)
O
B. ST depression in precordial leads
T
C. Q waves
C
D. Prolonged QT interval
O
Answer: A. ST elevation in all leads except aVR and V1
PY
(concave up)
Explanation: Diffuse concave ST elevation is classic. PR depression may also be seen. Later
stages show T wave inversions.
9. Which finding is most specific for hypertrophic cardiomyopathy?
A. Ejection click
B. Systolic murmur that increases with Valsalva (decreased preload)
C. Diastolic rumble
D. Fixed splitting of S2
Answer: B. Systolic murmur that increases with Valsalva
(decreased preload)
Explanation: Hypertrophic cardiomyopathy murmur (LVOT obstruction) increases with
decreased preload (standing, Valsalva) and decreases with increased preload (squatting, hand
grip).
