ITE General Internal Medicine 4 — Questions and Answers
Question 1: A 55-year-old man with newly diagnosed type 2 diabetes has an A1C of 8.2%, eGFR of 55 mL/min, and established cardiovascular disease. Which medication has the greatest cardiovascular mortality benefit?
- Empagliflozin (SGLT-2 inhibitor) (Correct answer)
- Glipizide (sulfonylurea)
- Sitagliptin (DPP-4 inhibitor)
- Pioglitazone (thiazolidinedione)
Correct answer: Empagliflozin (SGLT-2 inhibitor)
SGLT-2 inhibitors like empagliflozin have demonstrated cardiovascular mortality reduction in patients with established CVD in landmark trials (EMPA-REG).
Question 2: A 45-year-old woman with known HIV on antiretroviral therapy presents with confusion, fever, and neck stiffness. CD4 count is 80 cells/μL. CSF shows lymphocytic pleocytosis and positive India ink stain. The treatment of choice is:
- Liposomal amphotericin B plus flucytosine (Correct answer)
- Fluconazole alone
- Voriconazole
- Caspofungin
Correct answer: Liposomal amphotericin B plus flucytosine
Cryptococcal meningitis induction therapy requires liposomal amphotericin B plus flucytosine for 2 weeks, followed by fluconazole consolidation.
Question 3: A 32-year-old woman with antiphospholipid syndrome (APS) and history of DVT is pregnant. How should her anticoagulation be managed during pregnancy?
- Low molecular weight heparin (LMWH) throughout pregnancy (Correct answer)
- Warfarin throughout pregnancy
- Aspirin alone
- No anticoagulation needed during pregnancy
Correct answer: Low molecular weight heparin (LMWH) throughout pregnancy
LMWH is the anticoagulant of choice in pregnancy as warfarin crosses the placenta and is teratogenic, particularly in the first trimester.
Question 4: A 65-year-old man with chronic hepatitis C cirrhosis presents with confusion, asterixis, and ammonia level of 120 μmol/L. Which treatment reduces ammonia production in the gut?
- Lactulose (Correct answer)
- Rifaximin alone as initial therapy
- Neomycin as first-line
- Sodium benzoate
Correct answer: Lactulose
Lactulose is first-line for hepatic encephalopathy; it acidifies colonic contents, trapping ammonia as ammonium and promoting its excretion.
Question 5: A 58-year-old woman with rheumatoid arthritis on methotrexate and prednisone presents with fever, productive cough, and bilateral infiltrates. LDH is elevated. BAL shows Pneumocystis jirovecii. The drug of choice is:
- Trimethoprim-sulfamethoxazole (TMP-SMX) (Correct answer)
- Dapsone
- Atovaquone
- Clindamycin plus primaquine
Correct answer: Trimethoprim-sulfamethoxazole (TMP-SMX)
TMP-SMX is the treatment of choice for PCP pneumonia; adjunctive steroids are added when PaO₂ <70 mmHg or A-a gradient >35 mmHg.
Question 6: A 74-year-old man presents with fatigue and is found to have hemoglobin 9.2 g/dL, MCV 110 fL, hypersegmented neutrophils, and normal iron studies. Serum B12 is low. What is the most common cause of B12 deficiency in the elderly?
- Pernicious anemia (autoimmune gastritis) (Correct answer)
- Dietary deficiency
- Celiac disease
- Crohn's disease involving the terminal ileum
Correct answer: Pernicious anemia (autoimmune gastritis)
Pernicious anemia due to autoimmune destruction of gastric parietal cells is the most common cause of B12 deficiency in the elderly.
Question 7: A 50-year-old woman presents with severe epigastric pain radiating to the back, nausea, and vomiting after a fatty meal. Amylase is 1800 U/L and lipase is 4200 U/L. The most important initial treatment is:
- Aggressive IV fluid resuscitation (Correct answer)
- Early ERCP within 24 hours
- Immediate surgical consultation for debridement
- Broad-spectrum antibiotics
Correct answer: Aggressive IV fluid resuscitation
Aggressive IV fluid resuscitation (250-500 mL/hr of crystalloid) is the cornerstone of acute pancreatitis management to prevent organ failure.
ITE General Internal Medicine 4
A 55-year-old man with newly diagnosed type 2 diabetes has an A1C of 8.2%, eGFR of 55 mL/min, and established cardiovascular disease.
Which medication has the greatest cardiovascular mortality benefit?