ITE General Internal Medicine 3 — Questions and Answers
Question 1: A 68-year-old man with atrial fibrillation and a CHA₂DS₂-VASc score of 4 is started on anticoagulation. Which anticoagulant requires routine INR monitoring?
- Warfarin (Correct answer)
- Apixaban
- Rivaroxaban
- Dabigatran
Correct answer: Warfarin
Warfarin requires routine INR monitoring (target 2-3) due to its narrow therapeutic index and variable metabolism.
Question 2: A 55-year-old woman presents with sudden onset severe headache described as 'the worst headache of my life.' CT head is negative. What is the next best step?
- Lumbar puncture (Correct answer)
- MRI brain with gadolinium
- Repeat CT in 6 hours
- Discharge with analgesics
Correct answer: Lumbar puncture
Lumbar puncture is required after a negative CT to detect xanthochromia, which indicates subarachnoid hemorrhage not visible on CT.
Question 3: A 40-year-old woman with SLE develops worsening hypertension and proteinuria of 3.5 g/day. Serum creatinine rises from 0.9 to 1.8 mg/dL over 3 months. The next best step is:
- Kidney biopsy (Correct answer)
- Increase hydroxychloroquine dose
- Start cyclophosphamide empirically
- Repeat urinalysis in 6 months
Correct answer: Kidney biopsy
Kidney biopsy is needed to classify lupus nephritis histologically, which guides immunosuppressive therapy selection.
Question 4: A 62-year-old man presents with episodic headaches, palpitations, and diaphoresis. Blood pressure is 185/110 mmHg during an episode. 24-hour urine metanephrines are elevated. What is the most appropriate initial treatment before surgery?
- Alpha-blocker (phenoxybenzamine) followed by beta-blocker (Correct answer)
- Beta-blocker alone
- Calcium channel blocker alone
- ACE inhibitor alone
Correct answer: Alpha-blocker (phenoxybenzamine) followed by beta-blocker
Alpha-blockade must be established before beta-blockade in pheochromocytoma to prevent paradoxical hypertension from unopposed alpha stimulation.
Question 5: A 48-year-old woman presents with progressive proximal muscle weakness and difficulty rising from a chair. CK is 3500 U/L. ANA is positive. What is the most likely diagnosis?
- Polymyositis (Correct answer)
- Fibromyalgia
- Multiple sclerosis
- Myasthenia gravis
Correct answer: Polymyositis
Polymyositis presents with symmetric proximal muscle weakness, elevated CK, and positive ANA; EMG and muscle biopsy confirm the diagnosis.
Question 6: A 30-year-old man presents with recurrent episodes of painless rectal bleeding and crampy abdominal pain. Colonoscopy shows continuous mucosal inflammation from the rectum to the splenic flexure. The most likely diagnosis is:
- Ulcerative colitis (Correct answer)
- Crohn's disease
- Ischemic colitis
- Infectious colitis
Correct answer: Ulcerative colitis
Ulcerative colitis characteristically begins in the rectum and extends proximally in a continuous pattern, unlike the skip lesions of Crohn's disease.
Question 7: A 70-year-old man on warfarin for atrial fibrillation presents with an INR of 8.5 and active bleeding from a GI source. The most appropriate immediate treatment is:
- 4-factor prothrombin complex concentrate (PCC) plus vitamin K IV (Correct answer)
- Fresh frozen plasma alone
- Vitamin K IV alone
- Withhold warfarin and observe
Correct answer: 4-factor prothrombin complex concentrate (PCC) plus vitamin K IV
4-factor PCC provides rapid reversal of warfarin anticoagulation and is preferred over FFP for life-threatening bleeding due to faster administration and smaller volume.
ITE General Internal Medicine 3
A 68-year-old man with atrial fibrillation and a CHA₂DS₂-VASc score of 4 is started on anticoagulation.
Which anticoagulant requires routine INR monitoring?