MD Internal Medicine 2 — Questions and Answers
Question 1: A 58-year-old man with type 2 diabetes presents with a serum creatinine of 2.4 mg/dL and a urine albumin-to-creatinine ratio of 350 mg/g. Which medication class provides the most renoprotective benefit in this setting?
- Calcium channel blockers
- SGLT2 inhibitors (Correct answer)
- Sulfonylureas
- Alpha-blockers
Correct answer: SGLT2 inhibitors
SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin) have demonstrated significant renoprotective effects in diabetic kidney disease, reducing progression of CKD and cardiovascular events.
Question 2: A 45-year-old woman presents with episodic flushing, diarrhea, and wheezing. Urine 5-HIAA levels are markedly elevated. What is the most likely diagnosis?
- Pheochromocytoma
- Carcinoid syndrome (Correct answer)
- Systemic mastocytosis
- VIPoma
Correct answer: Carcinoid syndrome
Carcinoid syndrome results from serotonin-secreting neuroendocrine tumors, causing flushing, diarrhea, and wheezing; elevated urinary 5-HIAA confirms serotonin overproduction.
Question 3: A patient with rheumatoid arthritis on methotrexate develops macrocytic anemia and oral ulcers. What is the most appropriate intervention?
- Discontinue methotrexate permanently
- Add folic acid supplementation (Correct answer)
- Switch to hydroxychloroquine
- Initiate vitamin B12 injections
Correct answer: Add folic acid supplementation
Methotrexate acts as a folate antagonist; folic acid supplementation reduces mucosal and hematologic side effects without significantly diminishing the drug's anti-inflammatory efficacy.
Question 4: A 72-year-old woman is found to have a serum calcium of 11.8 mg/dL. Intact PTH is 95 pg/mL (normal 15–65). She is asymptomatic. What is the most likely diagnosis?
- Malignancy-associated hypercalcemia
- Primary hyperparathyroidism (Correct answer)
- Vitamin D toxicity
- Familial hypocalciuric hypercalcemia
Correct answer: Primary hyperparathyroidism
Elevated PTH in the setting of hypercalcemia is diagnostic of primary hyperparathyroidism, most commonly caused by a solitary parathyroid adenoma.
Question 5: Which finding on spirometry is most consistent with obstructive lung disease?
- FEV1/FVC > 0.70 with reduced TLC
- FEV1/FVC < 0.70 with normal or increased TLC (Correct answer)
- Reduced FVC with normal FEV1/FVC ratio
- Increased DLCO with normal FEV1/FVC
Correct answer: FEV1/FVC < 0.70 with normal or increased TLC
Obstructive physiology is defined by a reduced FEV1/FVC ratio (<0.70 post-bronchodilator); air trapping leads to normal or elevated TLC.
Question 6: A 30-year-old woman presents with fatigue, cold intolerance, constipation, and a TSH of 18 mIU/L with a low free T4. Thyroid peroxidase antibodies are positive. What is the most likely diagnosis?
- Subacute thyroiditis
- Graves' disease
- Hashimoto's thyroiditis (Correct answer)
- Secondary hypothyroidism
Correct answer: Hashimoto's thyroiditis
Hashimoto's thyroiditis is an autoimmune condition characterized by positive TPO antibodies, elevated TSH, low free T4, and clinical hypothyroidism.
Question 7: A 65-year-old man with a history of hypertension and smoking presents with sudden-onset severe tearing chest pain radiating to the back. Blood pressure is 180/100 mmHg in the right arm and 140/85 mmHg in the left arm. What is the most urgent next step?
- Administer IV heparin
- Obtain CT angiography of the chest (Correct answer)
- Perform emergent PCI
- Give thrombolytics
Correct answer: Obtain CT angiography of the chest
The clinical picture — tearing pain, hypertension, and blood pressure differential between arms — strongly suggests aortic dissection; CT angiography is the diagnostic test of choice.
MD Internal Medicine 2
A 58-year-old man with type 2 diabetes presents with a serum creatinine of 2.4 mg/dL and a urine albumin-to-creatinine ratio of 350 mg/g.
Which medication class provides the most renoprotective benefit in this setting?