MD Internal Medicine 3 — Questions and Answers
Question 1: A 50-year-old man with alcoholic liver disease presents with confusion and asterixis. Labs show elevated ammonia. Which dietary modification is most appropriate?
- Eliminate all protein intake
- Restrict sodium to <2 g/day
- Moderate protein intake with preference for branched-chain amino acids (Correct answer)
- High-fat, low-carbohydrate diet
Correct answer: Moderate protein intake with preference for branched-chain amino acids
Hepatic encephalopathy patients should receive adequate protein (preferably plant-based or branched-chain amino acids) rather than protein restriction, which worsens sarcopenia and outcomes.
Question 2: A 40-year-old woman presents with fatigue, arthralgia, and a butterfly-shaped facial rash. ANA is positive at 1:320 with anti-dsDNA antibodies detected. Which of the following best monitors disease activity?
- Anti-Smith antibody
- Anti-dsDNA antibody titers and complement levels (Correct answer)
- Anti-Ro/SSA antibody
- ANA titer alone
Correct answer: Anti-dsDNA antibody titers and complement levels
Anti-dsDNA titers correlate with SLE disease activity, particularly lupus nephritis, and falling complement levels (C3, C4) reflect active immune complex deposition.
Question 3: A patient presents with severe hyponatremia (Na 118 mEq/L) and is asymptomatic. Urine osmolality is 600 mOsm/kg and urine Na is 55 mEq/L. Serum osmolality is low. What is the most likely cause?
- Primary polydipsia
- SIADH (Correct answer)
- Adrenal insufficiency
- Hypothyroidism
Correct answer: SIADH
SIADH presents with euvolemic hyponatremia, inappropriately concentrated urine (>100 mOsm/kg), and high urine sodium (>40 mEq/L), reflecting inappropriate ADH secretion.
Question 4: A 60-year-old man with CKD stage 3 is found to have hyperkalemia (K 6.2 mEq/L) on routine labs. He is on lisinopril and spironolactone. ECG shows peaked T-waves. What is the first step in management?
- Administer sodium polystyrene sulfonate
- Give IV calcium gluconate (Correct answer)
- Start hemodialysis
- Administer IV insulin and dextrose
Correct answer: Give IV calcium gluconate
IV calcium gluconate is given first to stabilize the cardiac membrane and prevent arrhythmias when ECG changes are present; it does not lower potassium but protects the heart.
Question 5: A 35-year-old woman with no prior cardiac history develops palpitations, diaphoresis, and hypertension to 210/120 mmHg lasting 20 minutes. 24-hour urine metanephrines are markedly elevated. What is the treatment of choice?
- Beta-blocker alone
- Alpha-blocker followed by beta-blocker, then surgical resection (Correct answer)
- ACE inhibitor and calcium channel blocker
- Emergent adrenalectomy without preoperative blockade
Correct answer: Alpha-blocker followed by beta-blocker, then surgical resection
Pheochromocytoma requires alpha-blockade (phenoxybenzamine) before beta-blockade to prevent unopposed alpha-mediated hypertensive crisis, followed by surgical resection.
Question 6: A 55-year-old man with a 30 pack-year smoking history is found to have a 1.2 cm solid pulmonary nodule on CT. What is the recommended next step per current guidelines?
- Immediate surgical resection
- PET scan now
- CT follow-up at 3 months (Correct answer)
- No further workup needed
Correct answer: CT follow-up at 3 months
Per Fleischner Society guidelines, a solid nodule >6 mm in a high-risk patient warrants CT follow-up at 3–6 months to assess growth rate before further intervention.
Question 7: A 70-year-old woman is started on bisphosphonate therapy for osteoporosis. After 5 years of treatment, which rare but serious complication should be considered if she develops thigh pain?
- Osteosarcoma
- Avascular necrosis of the femoral head
- Atypical femoral fracture (Correct answer)
- Stress reaction from exercise
Correct answer: Atypical femoral fracture
Long-term bisphosphonate use is associated with atypical femoral fractures, often preceded by prodromal thigh or groin pain; this is a recognized class-effect complication.
MD Internal Medicine 3
A 50-year-old man with alcoholic liver disease presents with confusion and asterixis.
Labs show elevated ammonia.
Which dietary modification is most appropriate?