Internal Medicine Prometric exam questions with answers

1. Question 1Cardiovascular Medicinemedium

   A 72-year-old man with heart failure with reduced ejection fraction (EF 28%) presents with new atrial fibrillation at 138/min, blood pressure 118/72 mmHg and mild bibasal crackles. Which rate-control drug should be avoided?

   1. AOral bisoprolol at a low starting dose
   2. BIntravenous amiodarone
   3. CIntravenous diltiazem
   4. DIntravenous digoxin
   Show answer and explanation▾

   Answer: C. Intravenous diltiazem

   Non-dihydropyridine calcium channel blockers such as diltiazem and verapamil are negatively inotropic and should be avoided for rate control when LVEF is below 40%, as they can precipitate decompensation. Beta-blockers and digoxin are recommended in HFrEF, with amiodarone an option in haemodynamically fragile patients. Anticoagulation should also be addressed.

2. Question 2Pulmonary and Respiratory Diseaseshard

   A 54-year-old woman has acute pulmonary embolism confirmed on CT pulmonary angiography. Blood pressure is 128/80 mmHg and heart rate 104/min. CT shows right ventricular dilatation and high-sensitivity troponin is raised. What is the most appropriate initial management?

   1. AOral apixaban and early discharge with clinic follow-up
   2. BFull-dose systemic thrombolysis with alteplase
   3. CInsertion of an inferior vena cava filter
   4. DParenteral anticoagulation with close monitoring for haemodynamic deterioration
   Show answer and explanation▾

   Answer: D. Parenteral anticoagulation with close monitoring for haemodynamic deterioration

   Normotensive PE with both RV dysfunction on imaging and a raised troponin is intermediate-high risk; guidelines recommend anticoagulation (usually LMWH) with monitoring, reserving rescue reperfusion for haemodynamic decompensation. Routine thrombolysis in this group reduced decompensation in the PEITHO trial but at the cost of significantly more major and intracranial bleeding, without a mortality benefit. Early discharge is only appropriate for low-risk PE.

3. Question 3Pulmonary and Respiratory Diseaseseasy

   Which pleural fluid result indicates an exudate according to Light's criteria?

   1. APleural fluid LDH one-third of the serum upper limit of normal
   2. BPleural fluid to serum LDH ratio of 0.4
   3. CPleural fluid to serum protein ratio of 0.6
   4. DPleural fluid glucose of 6.0 mmol/L
   Show answer and explanation▾

   Answer: C. Pleural fluid to serum protein ratio of 0.6

   Light's criteria classify an effusion as exudative if any one of the following is met: pleural to serum protein ratio above 0.5, pleural to serum LDH ratio above 0.6, or pleural LDH above two-thirds of the upper limit of normal for serum LDH. A protein ratio of 0.6 therefore meets the criteria. The LDH values given are below threshold, and pleural glucose is not part of Light's criteria.

4. Question 4Gastroenterology and Hepatologyhard

   A 58-year-old man with alcohol-related cirrhosis and ascites has abdominal discomfort and confusion. The ascitic fluid neutrophil count is 620 cells/mm3, serum creatinine is 125 micromol/L (1.4 mg/dL) and bilirubin 70 micromol/L (4.1 mg/dL). Intravenous cefotaxime is started. Which additional treatment reduces his risk of renal failure and death?

   1. AOral norfloxacin added to cefotaxime
   2. BIntravenous albumin on day 1 and day 3
   3. CTherapeutic large-volume paracentesis
   4. DIntravenous terlipressin started immediately
   Show answer and explanation▾

   Answer: B. Intravenous albumin on day 1 and day 3

   An ascitic neutrophil count of 250 cells/mm3 or more diagnoses spontaneous bacterial peritonitis, and adding intravenous albumin (1.5 g/kg at diagnosis and 1 g/kg on day 3) to antibiotics reduces hepatorenal syndrome and mortality, particularly when creatinine or bilirubin is raised as here. Terlipressin is used for established hepatorenal syndrome, not as routine SBP therapy. Norfloxacin is used for prophylaxis, not added to treatment.

5. Question 5Infectious Diseasesmedium

   A 70-year-old woman develops diarrhoea on day 6 of antibiotics for pneumonia, and stool testing confirms Clostridioides difficile infection. White cell count is 11 x10^9/L and creatinine is at her baseline. It is her first episode. Which treatment is preferred?

   1. AIntravenous metronidazole alone for 14 days
   2. BOral fidaxomicin for 10 days
   3. CIntravenous vancomycin for 10 days
   4. DOral rifaximin for 10 days
   Show answer and explanation▾

   Answer: B. Oral fidaxomicin for 10 days

   Current IDSA/SHEA guidance prefers oral fidaxomicin for an initial episode because it lowers recurrence, with oral vancomycin an acceptable alternative. Intravenous vancomycin is not excreted into the colon and is ineffective. Metronidazole is now reserved for non-severe disease when the preferred agents are unavailable, and is not used intravenously alone in this setting.

6. Question 6Infectious Diseasesmedium

   A 62-year-old man has Staphylococcus aureus bacteraemia from an infected peripheral cannula and was started empirically on vancomycin. The isolate is methicillin-sensitive. He has no penicillin allergy. What is the most appropriate change?

   1. ASwitch to intravenous cefazolin or an antistaphylococcal penicillin
   2. BContinue vancomycin for the whole course
   3. CAdd gentamicin to vancomycin for synergy
   4. DSwitch to oral amoxicillin to complete 7 days
   Show answer and explanation▾

   Answer: A. Switch to intravenous cefazolin or an antistaphylococcal penicillin

   For methicillin-sensitive S. aureus, beta-lactams such as cefazolin or flucloxacillin are associated with lower failure and mortality than vancomycin, so therapy should be switched once susceptibilities are known. Management also includes removing the source, repeat blood cultures, echocardiography and usually at least 14 days of intravenous therapy for uncomplicated cases. Amoxicillin is inactive against most S. aureus, and adding gentamicin increases nephrotoxicity without benefit.

7. Question 7Endocrinology, Diabetes and Metabolismeasy

   A 42-year-old man has hypertension requiring three drugs and a serum potassium of 3.1 mmol/L while not taking diuretics. What is the most appropriate initial screening test?

   1. APlasma aldosterone-to-renin ratio
   2. BPlasma free metanephrines
   3. C24-hour urinary free cortisol
   4. DRenal artery Doppler ultrasound
   Show answer and explanation▾

   Answer: A. Plasma aldosterone-to-renin ratio

   Resistant hypertension with spontaneous hypokalaemia strongly suggests primary aldosteronism, and the aldosterone-to-renin ratio is the recommended screening test, ideally with potassium corrected first. Urinary cortisol and metanephrines screen for Cushing syndrome and phaeochromocytoma, which are less likely. Renal artery imaging is not the first test in this presentation.

8. Question 8Endocrinology, Diabetes and Metabolismhard

   A 54-year-old woman with type 2 diabetes taking empagliflozin and metformin is admitted 2 days after a laparoscopic cholecystectomy with vomiting and tachypnoea. Glucose is 11.2 mmol/L (202 mg/dL), pH 7.14, bicarbonate 9 mmol/L and blood ketones 5.8 mmol/L. What is the most appropriate management?

   1. AGive subcutaneous basal insulin and continue empagliflozin
   2. BGive IV sodium bicarbonate and restart empagliflozin once eating
   3. CStop empagliflozin; give IV fluids and fixed-rate insulin with IV dextrose
   4. DStop empagliflozin; give IV fluids only, as the glucose does not require insulin
   Show answer and explanation▾

   Answer: C. Stop empagliflozin; give IV fluids and fixed-rate insulin with IV dextrose

   This is euglycaemic diabetic ketoacidosis precipitated by an SGLT2 inhibitor during surgical stress and reduced intake. Treatment follows DKA principles: stop the drug, give fluids and a fixed-rate insulin infusion to clear ketones, adding dextrose early to prevent hypoglycaemia because glucose is only modestly raised. Withholding insulin because glucose is near normal is the classic error, and bicarbonate is not routinely indicated at this pH.

9. Question 9Nephrology, Fluids and Electrolytesmedium

   A 66-year-old smoker with small cell lung cancer has serum sodium 124 mmol/L, serum osmolality 258 mOsm/kg, urine osmolality 540 mOsm/kg and urine sodium 52 mmol/L. He is clinically euvolaemic and asymptomatic. What is the most appropriate first-line treatment?

   1. AFluid restriction
   2. BOral fludrocortisone
   3. CIntravenous 0.9% sodium chloride
   4. DIntravenous 3% sodium chloride bolus
   Show answer and explanation▾

   Answer: A. Fluid restriction

   Hypotonic hyponatraemia with concentrated urine, high urine sodium and euvolaemia is consistent with SIADH, and fluid restriction is first-line for mild to moderate asymptomatic cases. Isotonic saline can worsen hyponatraemia when urine osmolality is well above that of the infused fluid, because the sodium is excreted and free water retained. Hypertonic saline is reserved for severe symptoms.

10. Question 10Rheumatology and Clinical Immunologymedium

    A 74-year-old man with chronic kidney disease (eGFR 22 mL/min/1.73 m2) who takes apixaban develops acute knee pain and swelling. Aspiration shows negatively birefringent needle-shaped crystals and no organisms. What is the most appropriate treatment for the flare?

    1. AColchicine 500 micrograms three times daily for 2 weeks
    2. BAllopurinol 300 mg daily started immediately
    3. CFull-dose naproxen for 7 days
    4. DA short course of oral prednisolone
    Show answer and explanation▾

    Answer: D. A short course of oral prednisolone

    Corticosteroids, oral or intra-articular, are the safest option for a gout flare in severe CKD with concurrent anticoagulation. NSAIDs risk acute kidney injury and bleeding with apixaban, and full-dose colchicine accumulates in advanced CKD causing toxicity. Allopurinol does not treat a flare, and if started later it should begin at a low dose titrated to target urate.

11. Question 11Emergency and Critical Care Medicineeasy

    A 30-year-old develops widespread urticaria, wheeze and blood pressure 82/50 mmHg minutes after an intravenous antibiotic. The infusion has been stopped. What is the most important immediate treatment?

    1. AIntramuscular adrenaline 0.5 mg (0.5 mL of 1 mg/mL) into the anterolateral thigh
    2. BIntravenous hydrocortisone 200 mg
    3. CNebulised salbutamol 5 mg
    4. DIntravenous chlorphenamine 10 mg
    Show answer and explanation▾

    Answer: A. Intramuscular adrenaline 0.5 mg (0.5 mL of 1 mg/mL) into the anterolateral thigh

    Intramuscular adrenaline is the first-line treatment for anaphylaxis and should be given without delay, repeated after 5 minutes if needed, along with high-flow oxygen and fluid resuscitation. Antihistamines only relieve skin symptoms and corticosteroids are no longer recommended routinely for the acute reaction. Salbutamol may help residual bronchospasm but does not treat shock.

12. Question 12Haematology and Transfusion Medicinehard

    A 67-year-old woman on prophylactic unfractionated heparin after hip surgery has a fall in platelet count from 260 to 95 x10^9/L on day 7, and a new left femoral deep vein thrombosis. What is the most appropriate management?

    1. AStop heparin and transfuse platelets
    2. BStop heparin and start warfarin immediately
    3. CStop heparin and start a non-heparin anticoagulant such as argatroban
    4. DSwitch to treatment-dose low-molecular-weight heparin
    Show answer and explanation▾

    Answer: C. Stop heparin and start a non-heparin anticoagulant such as argatroban

    A greater than 50% fall in platelets 5 to 10 days after heparin exposure with new thrombosis gives a high 4Ts score for heparin-induced thrombocytopenia; all heparin must stop and a non-heparin anticoagulant (argatroban, bivalirudin, fondaparinux or a DOAC in selected cases) be started while confirming the diagnosis. LMWH cross-reacts with HIT antibodies. Warfarin started in the acute phase can cause venous limb gangrene, and platelet transfusion may promote thrombosis.

13. Question 13Oncology and Palliative Caremedium

    A 68-year-old woman with metastatic breast cancer is drowsy and dehydrated. Corrected calcium is 3.6 mmol/L (14.4 mg/dL) and creatinine is mildly raised. What is the most appropriate first step?

    1. AOral cinacalcet
    2. BIntravenous 0.9% sodium chloride rehydration
    3. CIntravenous furosemide to promote calciuria
    4. DIntravenous zoledronic acid as the only initial therapy
    Show answer and explanation▾

    Answer: B. Intravenous 0.9% sodium chloride rehydration

    Severe hypercalcaemia causes volume depletion through nephrogenic diabetes insipidus and vomiting, so the first step is aggressive intravenous isotonic saline, followed by an intravenous bisphosphonate such as zoledronic acid (dose adjusted for renal function) once rehydrating. Giving a bisphosphonate without rehydration risks worsening renal function. Loop diuretics are no longer routine and only used for fluid overload.

14. Question 14Patient Safety, Quality and Evidence-Based Practicemedium

    In a 3-year trial, stroke occurred in 10% of patients receiving placebo and 6% of patients receiving a new drug. How many patients need to be treated for 3 years to prevent one stroke?

    1. A4
    2. B25
    3. C17
    4. D40
    Show answer and explanation▾

    Answer: B. 25

    The absolute risk reduction is 10% minus 6%, which is 4% (0.04), and the number needed to treat is 1/0.04 = 25. The figure of 40 confuses the relative risk reduction (40%) with the NNT. The NNT always refers to a specific time period, here 3 years.

15. Question 15Professionalism, Ethics, Communication and Health Systemseasy

    A 58-year-old woman who speaks limited English needs to give consent for a colonoscopy. Her 14-year-old son offers to translate. What is the most appropriate approach?

    1. AAsk a bilingual ward cleaner to translate
    2. BProceed using simple English and gestures
    3. CUse her son, as he is a family member she trusts
    4. DArrange a trained professional medical interpreter
    Show answer and explanation▾

    Answer: D. Arrange a trained professional medical interpreter

    Valid consent requires that the patient understands the information, and a trained medical interpreter provides accurate, confidential and impartial translation. Children and family members may omit or alter sensitive information and place an inappropriate burden on the child. Untrained staff and simplified English risk misunderstanding, undermining informed consent.

Last reviewed September 2026. Questions are original and written to the published exam blueprint; they are not taken from any real paper.