SPEX Exam Internal Medicine 6

Question 1

A 58-year-old man with a history of alcohol use disorder presents with new-onset ascites. Labs show serum albumin 2.1 g/dL, ascitic fluid albumin 0.8 g/dL, total bilirubin 4.2 mg/dL, and INR 1.9. He is started on spironolactone and furosemide. Two weeks later, his ascites is minimally improved and serum sodium is 128 mEq/L. Which of the following is the most appropriate next step?

Accepted Answer

Perform large-volume paracentesis with albumin infusion

Answer

This patient has diuretic-resistant ascites with dilutional hyponatremia (Na <130 mEq/L), indicating diuretic failure. Large-volume paracentesis (LVP) with albumin infusion (6–8 g per liter of ascites removed) is the appropriate intervention. Fluid restriction alone is insufficient. Tolvaptan (a V2 receptor antagonist) is contraindicated in cirrhotic patients due to increased mortality risk (FDA black box warning). Increasing spironolactone without addressing the hyponatremia risks worsening electrolyte imbalance.

Question 2

A 44-year-old woman with SLE is found to have a serum creatinine of 2.4 mg/dL (baseline 0.9 mg/dL six months ago), hematuria with red cell casts, and 3.5 g/day proteinuria. Renal biopsy shows diffuse proliferative lupus nephritis (ISN/RPS Class IV). She is initiated on high-dose prednisone plus mycophenolate mofetil. Which of the following most accurately describes the role of belimumab in this patient's management?

Accepted Answer

Belimumab can be added as adjunctive therapy to reduce relapse risk during maintenance

Answer

Belimumab (anti-BAFF/BLyS monoclonal antibody) received FDA approval in 2020 as an adjunctive therapy in active lupus nephritis alongside standard of care (mycophenolate or cyclophosphamide plus glucocorticoids). The BLISS-LN trial demonstrated reduced risk of renal flare and improved long-term renal outcomes when added during both induction and maintenance phases. It does not replace standard induction agents and is not contraindicated in Class IV LN.

Question 3

A 67-year-old man with type 2 diabetes, CKD stage 3b (eGFR 38 mL/min/1.73 m²), and heart failure with reduced ejection fraction (EF 32%) presents for medication reconciliation. His HbA1c is 8.1%. He is currently on metformin 500 mg twice daily, insulin glargine, and empagliflozin 10 mg daily. Which statement best reflects the current evidence-based approach to his empagliflozin therapy?

Accepted Answer

Empagliflozin should be continued for its cardiovascular and renal protective effects regardless of glycemic contribution

Answer

SGLT2 inhibitors like empagliflozin have cardiorenal protective effects (reduced HFrEF hospitalization, reduced CKD progression) that are independent of glycemic lowering and persist even at reduced eGFR. Current guidelines (ADA, KDIGO, ACC/AHA) recommend continuing SGLT2 inhibitors for cardioprotection and nephroprotection down to eGFR ≥20 mL/min/1.73 m², even though glycemic efficacy is diminished. The prior contraindication threshold of eGFR <45 applied only to glycemic benefit, not to organ-protective indications.

Question 4

A 52-year-old woman presents with episodic hypertension (BP 210/115 mmHg during attacks), diaphoresis, palpitations, and a 9 kg weight loss over 4 months. 24-hour urine fractionated metanephrines are markedly elevated. CT abdomen reveals a 4.2 cm right adrenal mass. She is scheduled for adrenalectomy in 3 weeks. Which of the following preoperative medication regimens is most appropriate?

Accepted Answer

Begin phenoxybenzamine first; add a beta-blocker only after adequate alpha blockade is achieved

Answer

Preoperative preparation for pheochromocytoma requires alpha-adrenergic blockade FIRST with a non-selective irreversible agent (phenoxybenzamine) for at least 10–14 days before surgery. Beta-blockers are added ONLY after adequate alpha blockade to prevent unopposed alpha stimulation, which could precipitate hypertensive crisis. Labetalol has weak alpha-blocking activity insufficient for pheochromocytoma preparation. Starting a beta-blocker simultaneously or before alpha blockade is potentially dangerous. Calcium channel blockers may be used adjunctively but are not first-line.

Question 5

A 71-year-old man is admitted with community-acquired pneumonia and hypoxemia requiring 4 L/min nasal cannula oxygen. On hospital day 3, he develops acute-onset right leg swelling. Duplex ultrasound confirms proximal DVT. His creatinine is 1.1 mg/dL and platelet count is 88,000/µL (down from 162,000/µL on admission). He received unfractionated heparin (UFH) for 5 days. Which of the following is the most appropriate anticoagulation strategy?

Accepted Answer

Immediately discontinue all heparin products and start argatroban

Answer

This presentation is consistent with heparin-induced thrombocytopenia (HIT): platelet drop >50% from baseline (162K→88K) after 5 days of UFH, with new thrombosis (DVT). The 4Ts score in this scenario would be high (≥6), making HIT highly probable. All heparin products (including LMWH, which cross-reacts with HIT antibodies) must be immediately discontinued. A direct thrombin inhibitor (argatroban, bivalirudin) or fondaparinux should replace heparin. Warfarin alone is contraindicated acutely in HIT due to risk of venous limb gangrene from paradoxical hypercoagulability.

SPEX Exam Practice Test

SPEX Exam Practice Test

SPEX Exam Internal Medicine 6