SPEX 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 450 mg/g. Which medication class is MOST important to initiate to slow progression of his diabetic kidney disease?
- Calcium channel blocker
- SGLT2 inhibitor (Correct answer)
- Thiazide diuretic
- Beta-blocker
Correct answer: SGLT2 inhibitor
SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin) have demonstrated significant nephroprotective effects in diabetic kidney disease, reducing progression to ESRD.
Question 2: A 45-year-old woman presents with fatigue, cold intolerance, and constipation. Labs show TSH 28 mIU/L and free T4 0.4 ng/dL. What is the most appropriate initial treatment?
- Levothyroxine 25–50 mcg daily (Correct answer)
- Propylthiouracil 100 mg TID
- Radioactive iodine ablation
- Methimazole 10 mg daily
Correct answer: Levothyroxine 25–50 mcg daily
Primary hypothyroidism is treated with levothyroxine; low doses are used initially, especially in the elderly or those with cardiac disease.
Question 3: A 70-year-old man develops sudden-onset severe headache, neck stiffness, and photophobia. CT head is negative. What is the next best step?
- Start empiric antibiotics and defer lumbar puncture
- Perform lumbar puncture immediately (Correct answer)
- Obtain MRI brain with contrast
- Administer sumatriptan and observe
Correct answer: Perform lumbar puncture immediately
A negative CT followed by lumbar puncture is required to rule out subarachnoid hemorrhage and meningitis when clinical suspicion is high.
Question 4: Which finding is MOST specific for systemic lupus erythematosus (SLE)?
- Positive ANA (1:160)
- Anti-double-stranded DNA (anti-dsDNA) antibody (Correct answer)
- Elevated ESR
- Positive rheumatoid factor
Correct answer: Anti-double-stranded DNA (anti-dsDNA) antibody
Anti-dsDNA antibodies are highly specific for SLE and correlate with disease activity, particularly nephritis.
Question 5: A patient with COPD has an FEV1/FVC ratio of 0.58 and FEV1 of 42% predicted. Which GOLD stage does this represent?
- GOLD 1 (Mild)
- GOLD 2 (Moderate)
- GOLD 3 (Severe) (Correct answer)
- GOLD 4 (Very Severe)
Correct answer: GOLD 3 (Severe)
GOLD Stage 3 (Severe) is defined by FEV1 30–49% predicted with obstructive pattern (FEV1/FVC <0.70).
Question 6: A 62-year-old woman with a history of osteoporosis is started on alendronate. She returns 1 month later with severe retrosternal chest pain worse with swallowing. What is the most likely complication?
- Esophageal erosions or ulceration (Correct answer)
- Osteonecrosis of the jaw
- Atrial fibrillation
- Renal tubular acidosis
Correct answer: Esophageal erosions or ulceration
Bisphosphonates like alendronate can cause esophageal ulceration; patients must remain upright for 30 minutes after taking the medication.
Question 7: A 55-year-old man with hypertension and gout presents with a serum uric acid of 9.8 mg/dL and his third gout flare this year. Which antihypertensive agent would be MOST beneficial to add given his history?
- Hydrochlorothiazide
- Losartan (Correct answer)
- Metoprolol
- Amlodipine
Correct answer: Losartan
Losartan (an ARB) has uricosuric properties that lower serum uric acid, making it a preferred antihypertensive in patients with gout.
SPEX 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 450 mg/g.
Which medication class is MOST important to initiate to slow progression of his diabetic kidney disease?