Internal Medicine Prometric exam questions

The Internal Medicine exam in every GCC country

From each regulator's own exam pages; anything a regulator does not publish says so. Assessment mode also depends on your licence title, so confirm your route on your eligibility notice.

12 worked Internal Medicine practice questions

Original exam-style questions from the bank, spread across the blueprint domains. They are not real or recalled exam questions. Try each one, then open the answer for the rationale and reference. None of them appear in the free mock exam, so reading them will not spoil it.

1. Question 1 · Cardiovascular Medicine

   A 42-year-old woman has an untreated LDL cholesterol of 6.6 mmol/L (255 mg/dL), Achilles tendon xanthomata and corneal arcus. Her father had a myocardial infarction at 44. Secondary causes are excluded. On rosuvastatin 40 mg and ezetimibe 10 mg her LDL is 3.5 mmol/L (135 mg/dL) and she has no atherosclerotic disease on imaging. What is the most appropriate next step in her management?

   1. AAccept the current LDL, as she has no established cardiovascular disease
   2. BAdd a PCSK9 inhibitor and offer cascade screening of first-degree relatives
   3. CSubstitute a fibrate for ezetimibe
   4. DRefer for lipoprotein apheresis as the next line of therapy
   Show answer and explanation

   Correct answer: B. Add a PCSK9 inhibitor and offer cascade screening of first-degree relatives

   The phenotype indicates heterozygous familial hypercholesterolaemia, which places her at high cardiovascular risk with an LDL goal below 1.8 mmol/L (70 mg/dL); when maximal statin plus ezetimibe fails to achieve this, a PCSK9 inhibitor is the recommended addition, and cascade screening of first-degree relatives is a core obligation because half will be affected. Accepting an LDL of 3.5 mmol/L leaves lifelong excess risk, fibrates have little LDL-lowering effect, and apheresis is reserved chiefly for homozygous or refractory severe disease.

   Reference: ESC/EAS Guidelines for the Management of Dyslipidaemias, European Heart Journal, 2019; EAS Consensus Statement on Familial Hypercholesterolaemia, 2013

2. Question 2 · Gastroenterology and Hepatology

   A 34-year-old woman with iron deficiency anaemia and intermittent diarrhoea is being investigated for coeliac disease. She has already been on a strict gluten-free diet for four months because a relative suggested it, and her tissue transglutaminase IgA is now normal with a normal total IgA. What is the most appropriate next step?

   1. APerform HLA-DQ2/DQ8 typing and, if negative, exclude coeliac disease
   2. BReassure her that coeliac disease is excluded by the negative serology
   3. CProceed directly to duodenal biopsy while she remains gluten-free
   4. DCheck anti-gliadin IgG antibodies as a more sensitive alternative
   Show answer and explanation

   Correct answer: A. Perform HLA-DQ2/DQ8 typing and, if negative, exclude coeliac disease

   Serology and histology lose sensitivity once gluten has been withdrawn, so a negative result on a gluten-free diet cannot exclude coeliac disease. HLA-DQ2/DQ8 typing has a very high negative predictive value: absence of both haplotypes effectively excludes coeliac disease and avoids an unnecessary gluten challenge, whereas a positive result means a formal gluten challenge with repeat serology and biopsy is required. Biopsy while gluten-free may show healed mucosa and be falsely negative, and anti-gliadin antibodies are obsolete because of poor specificity.

   Reference: ACG Clinical Guideline: Diagnosis and Management of Celiac Disease, 2023; BSG Guidelines on the Diagnosis and Management of Adult Coeliac Disease, 2014

3. Question 3 · Endocrinology, Diabetes and Metabolism

   A 47-year-old man reports increasing ring and shoe size, coarse facial features, macroglossia, carpal tunnel syndrome, new hypertension and impaired glucose tolerance. Acromegaly is suspected. Which testing strategy is most appropriate?

   1. AA single random serum growth hormone level, with acromegaly excluded if it is below 1 microgram/L
   2. BAge- and sex-matched serum IGF-1, with confirmation by failure of growth hormone to suppress during a 75 g oral glucose tolerance test
   3. CPituitary MRI as the initial diagnostic test, with biochemistry only if an adenoma is seen
   4. DOvernight 1 mg dexamethasone suppression test
   Show answer and explanation

   Correct answer: B. Age- and sex-matched serum IGF-1, with confirmation by failure of growth hormone to suppress during a 75 g oral glucose tolerance test

   IGF-1 reflects integrated growth hormone secretion and is the recommended initial biochemical screen, with the diagnosis confirmed by failure of GH to suppress below the assay threshold during an oral glucose tolerance test. Random GH is unreliable because secretion is pulsatile, so a low single value cannot exclude the disease. MRI should follow rather than precede biochemical confirmation because non-functioning pituitary incidentalomas are common, and dexamethasone suppression tests for cortisol excess, not GH excess.

   Reference: Endocrine Society Clinical Practice Guideline, Acromegaly: An Endocrine Society Clinical Practice Guideline (2014); Acromegaly Consensus Group (2020)

4. Question 4 · Rheumatology and Clinical Immunology

   A 44-year-old man with inflammatory myopathy has mechanic's hands, Raynaud phenomenon, non-erosive arthritis and progressive breathlessness. High-resolution CT shows a non-specific interstitial pneumonia pattern. Which myositis-specific antibody is most likely to be positive?

   1. AAnti-Jo-1 (anti-histidyl-tRNA synthetase)
   2. BAnti-Mi-2
   3. CAnti-SRP
   4. DAnti-TIF1-gamma
   Show answer and explanation

   Correct answer: A. Anti-Jo-1 (anti-histidyl-tRNA synthetase)

   The constellation of myositis, interstitial lung disease, mechanic's hands, arthritis, Raynaud phenomenon and fever defines the antisynthetase syndrome, of which anti-Jo-1 is the commonest antibody. Anti-Mi-2 is associated with classic dermatomyositis rash with a good treatment response and little lung disease. Anti-SRP causes a severe necrotising myopathy with very high CK and relative absence of rash, and anti-TIF1-gamma is strongly linked to cancer-associated dermatomyositis.

   Reference: Harrison's Principles of Internal Medicine, 21st edition; ACR/EULAR myositis classification and myositis-specific autoantibody literature (Ann Rheum Dis 2017)

5. Question 5 · Haematology and Transfusion Medicine

   A 55-year-old man with Child-Pugh B cirrhosis requires large-volume paracentesis for tense ascites. He is not bleeding. INR is 2.0, platelets 58 x 10^9/L and fibrinogen 1.6 g/L. What is the most appropriate approach before the procedure?

   1. ATransfuse fresh frozen plasma until the INR falls below 1.5
   2. BProceed with paracentesis without prophylactic plasma or platelet transfusion
   3. CGive intravenous vitamin K and delay the procedure by 48 hours
   4. DTransfuse pooled platelets to achieve a count above 80 x 10^9/L
   Show answer and explanation

   Correct answer: B. Proceed with paracentesis without prophylactic plasma or platelet transfusion

   In cirrhosis the INR reflects reduced procoagulant synthesis but not the parallel fall in protein C, protein S and antithrombin, so haemostasis is rebalanced and the INR does not predict procedural bleeding; paracentesis is a low-risk procedure and prophylactic products are not recommended. Fresh frozen plasma corrects the INR only transiently, carries a volume load that raises portal pressure, and increases transfusion reactions. Vitamin K helps only if there is coexisting deficiency and would not correct synthetic failure, and routine platelet transfusion for a low-risk procedure is unsupported.

   Reference: AASLD Guidance on coagulation disorders in patients with cirrhosis (Hepatology, 2021); EASL Clinical Practice Guidelines on decompensated cirrhosis (2018)

6. Question 6 · Oncology and Palliative Care

   A 33-year-old woman was treated at age 19 with ABVD chemotherapy and mediastinal (mantle-field) radiotherapy for Hodgkin lymphoma and remains in remission. Which long-term surveillance measure is most important to offer her now?

   1. AAnnual abdominal ultrasound for hepatocellular carcinoma
   2. BAnnual breast surveillance with MRI and/or mammography
   3. CAnnual colonoscopy from age 35
   4. DAnnual serum protein electrophoresis for myeloma
   Show answer and explanation

   Correct answer: B. Annual breast surveillance with MRI and/or mammography

   Chest or mantle-field irradiation before the age of about 30 markedly increases the lifetime risk of breast cancer, so annual breast surveillance with MRI (with or without mammography) is recommended starting about 8 years after radiotherapy or from age 25, whichever is later; screening for thyroid dysfunction and premature cardiovascular disease is also required. Hepatocellular carcinoma, colorectal cancer and myeloma are not recognised radiation-field late effects of mantle irradiation and do not warrant this intensity of surveillance.

   Reference: Children's Oncology Group Long-Term Follow-Up Guidelines (v6, 2023); ESMO Clinical Practice Guidelines: Hodgkin Lymphoma - survivorship recommendations (2018)

7. Question 7 · Professionalism, Ethics, Communication and Health Systems

   You have twice reported in writing that a ward's chemotherapy is being prepared without independent double-checking, and a near-miss overdose has already occurred. The department head has taken no action and has told you to 'stop making trouble'. What is the most appropriate next step?

   1. AAccept the decision of the department head, as the responsibility now rests with him
   2. BPublicise the problem on social media to force the hospital to act
   3. CStop treating patients on that ward yourself and take no further action
   4. DEscalate the concern through the next level of the organisation - such as the medical director, patient safety or clinical governance committee - and, if still unaddressed, to the health regulatory authority, documenting each step
   Show answer and explanation

   Correct answer: D. Escalate the concern through the next level of the organisation - such as the medical director, patient safety or clinical governance committee - and, if still unaddressed, to the health regulatory authority, documenting each step

   When a genuine patient safety concern is raised internally and not acted upon, professional duty requires escalation up the governance ladder and ultimately to the regulator, with contemporaneous documentation of each step. Deferring to a superior does not discharge personal responsibility, public disclosure on social media breaches confidentiality and bypasses due process, and personal withdrawal leaves other patients exposed to the same hazard.

   Reference: GMC, Raising and Acting on Concerns About Patient Safety (2012, in force); WHO Patient Safety Curriculum Guide (2011)

8. Question 8 · Pulmonary and Respiratory Diseases

   A 31-year-old woman presents with a 10-day history of fever, painful red nodules on both shins and symmetrical ankle arthralgia. Chest radiograph shows bilateral hilar lymphadenopathy with clear lung fields. She is not breathless, spirometry is normal, and serum calcium and creatinine are normal. What is the most appropriate management?

   1. AMediastinoscopic lymph node biopsy before any treatment
   2. BImmediate high-dose oral corticosteroids
   3. CNon-steroidal anti-inflammatory drugs and observation with follow-up
   4. DEmpirical antituberculous therapy pending culture
   Show answer and explanation

   Correct answer: C. Non-steroidal anti-inflammatory drugs and observation with follow-up

   This constellation of erythema nodosum, bilateral hilar lymphadenopathy, arthralgia and fever is Lofgren syndrome, an acute presentation of sarcoidosis with a spontaneous remission rate above 80% within 2 years, so symptomatic treatment with NSAIDs and observation is appropriate. The clinical picture is sufficiently characteristic that tissue confirmation is not required, avoiding invasive biopsy. Systemic corticosteroids are reserved for significant organ dysfunction such as impaired lung function, hypercalcaemia, cardiac, neurological or ocular disease, and there is no evidence of tuberculosis to justify empirical antituberculous therapy.

   Reference: ATS Clinical Practice Guideline: Diagnosis and Detection of Sarcoidosis, 2020; ERS Guideline on Treatment of Sarcoidosis, 2021

9. Question 9 · Infectious Diseases

   A 41-year-old ART-naive man with newly diagnosed HIV and a CD4 count of 28 cells/microlitre presents with headache and confusion. CSF cryptococcal antigen is positive and India ink shows encapsulated yeasts. He is started on liposomal amphotericin B and flucytosine. What is the most appropriate timing of antiretroviral therapy?

   1. AStart antiretroviral therapy on the same day as antifungal therapy
   2. BStart antiretroviral therapy within 72 hours to reduce mortality
   3. CWithhold antiretroviral therapy permanently until the CD4 count rises spontaneously
   4. DDefer antiretroviral therapy for about 4-6 weeks after starting antifungal therapy
   Show answer and explanation

   Correct answer: D. Defer antiretroviral therapy for about 4-6 weeks after starting antifungal therapy

   In cryptococcal meningitis, early ART markedly increases mortality through immune reconstitution inflammatory syndrome within a closed cranial compartment, so ART is deferred roughly 4-6 weeks (at least 2 weeks after documented clinical and mycological response) while induction antifungal therapy and repeated therapeutic lumbar punctures control intracranial pressure. Same-day or 72-hour initiation is precisely the strategy shown to be harmful in this specific infection, and permanent deferral is never correct.

   Reference: Boulware DR et al. COAT trial. N Engl J Med 2014; WHO Guidelines for Cryptococcal Disease, 2022

10. Question 10 · Nephrology, Fluids and Electrolytes

    A 56-year-old man presents with peripheral oedema. Urine protein is 8 g/24 h, serum albumin is 22 g/L, cholesterol is elevated and creatinine is normal. Serology shows a positive anti-phospholipase A2 receptor antibody; ANA, hepatitis B and C serology and HIV are negative. Which is the most likely underlying glomerular lesion?

    1. AMinimal change disease
    2. BFocal segmental glomerulosclerosis
    3. CAmyloid A amyloidosis
    4. DPrimary membranous nephropathy
    Show answer and explanation

    Correct answer: D. Primary membranous nephropathy

    Anti-PLA2R antibodies are present in roughly 70 to 80% of primary membranous nephropathy and are sufficiently specific that in a patient with preserved renal function and negative secondary serology the diagnosis can be made without biopsy. Minimal change disease and FSGS are not associated with anti-PLA2R and have distinct histology. Amyloidosis would be suggested by a monoclonal protein, cardiac or autonomic involvement and Congo red positivity, and does not produce anti-PLA2R antibodies.

    Reference: KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases, Membranous Nephropathy chapter

11. Question 11 · Emergency and Critical Care Medicine

    An elderly man is found outdoors overnight in winter. Core temperature is 27 degrees C, he is unresponsive with no palpable pulse and the monitor shows ventricular fibrillation. CPR is begun. Which of the following statements is correct?

    1. AIf VF persists after three shocks, further shocks and drugs should be withheld until the core temperature rises above about 30 degrees C, with extracorporeal rewarming preferred where available
    2. BActive rewarming is contraindicated until spontaneous circulation returns
    3. CResuscitation should be abandoned after 20 minutes because survival is impossible at this temperature
    4. DDefibrillation attempts and drug administration should follow standard intervals regardless of temperature
    Show answer and explanation

    Correct answer: A. If VF persists after three shocks, further shocks and drugs should be withheld until the core temperature rises above about 30 degrees C, with extracorporeal rewarming preferred where available

    The hypothermic myocardium is refractory to defibrillation and drug metabolism is markedly slowed, so after three unsuccessful shocks further attempts are deferred until core temperature exceeds roughly 30 degrees C and drug intervals are doubled between 30 and 35 degrees C. Extracorporeal life support rewarming gives the best survival in hypothermic cardiac arrest. Prolonged resuscitation is justified because good neurological recovery has been reported after hours of CPR, hence the maxim that a patient is not dead until warm and dead.

    Reference: European Resuscitation Council Guidelines 2021: Cardiac Arrest in Special Circumstances; AHA ACLS Guidelines (2020)

12. Question 12 · Haematology and Transfusion Medicine

    A 72-year-old woman has an incidental IgG kappa paraprotein of 11 g/L. Haemoglobin, calcium, creatinine and albumin are normal, the serum free light chain ratio is 1.2, whole-body MRI shows no focal lesions and bone marrow biopsy shows 4% clonal plasma cells. What is the most appropriate management?

    1. ADiagnose MGUS and arrange periodic monitoring, initially at six months then annually
    2. BDiagnose smouldering myeloma and start lenalidomide
    3. CDiagnose multiple myeloma and start triplet induction therapy
    4. DProceed directly to autologous stem cell transplantation
    Show answer and explanation

    Correct answer: A. Diagnose MGUS and arrange periodic monitoring, initially at six months then annually

    A paraprotein below 30 g/L, clonal marrow plasma cells below 10%, a normal free light chain ratio and no myeloma-defining event define low-risk MGUS, which is managed by surveillance because the risk of progression is only about 1% per year. Smouldering myeloma requires a paraprotein of 30 g/L or more or 10-60% clonal plasma cells, neither of which is present, so cytotoxic or immunomodulatory therapy would expose her to toxicity without benefit. Transplantation is reserved for symptomatic myeloma in eligible patients.

    Reference: International Myeloma Working Group criteria (Lancet Oncology, 2014); Mayo Clinic risk-stratified MGUS follow-up model (Kyle et al., N Engl J Med 2018)

Internal Medicine reference books and guidelines

Every question in this bank names the textbook or guideline its answer rests on. These are the sources our Internal Medicine questions cite most often - the reading list to revise from alongside the bank.

Where your regulator publishes a reading list, use the editions it names. Exam questions are not taken from any one book.