Bachelor of Science in Nursing: Advanced Clinical
Management (ACM 400) Comprehensive Clinical Medicine
& Integrated Healthcare Systems Examination
Phase 1: Internal Medicine (Cardiovascular, Respiratory, and
Endocrinology)
Section 1: Cardiovascular Medicine
Q1. A 58-year-old male with a history of hypertension and smoking presents with sudden-onset
tearing chest pain radiating to the back. His BP is 180/100 mmHg in the right arm and 140/85 mmHg in
the left. What is the most likely diagnosis and the gold-standard diagnostic test?
Answer: The diagnosis is Aortic Dissection. The gold-standard diagnostic test is a CT
Angiography (CTA) of the chest and abdomen. Transesophageal Echocardiography (TEE) is an
alternative if the patient is hemodynamically unstable.
Clinical Pearl: The blood pressure discrepancy between arms is a classic diagnostic "red flag."
Q2. Differentiate between the three types of Acute Coronary Syndrome (ACS) based on Biomarkers
and ECG findings.
Type ECG Findings Cardiac Biomarkers (Troponin)
Unstable Angina Normal or ST depression/T-wave inversion Negative
NSTEMI ST depression or T-wave inversion Positive
STEMI ST-elevation in 2+ contiguous leads Positive
Q3. A patient with Heart Failure is prescribed Spironolactone. What electrolyte imbalance must the
clinician monitor, and what is the drug's mechanism of action?
Answer: Monitor for Hyperkalemia (high potassium). Spironolactone is a Potassium-sparing
diuretic that acts as an aldosterone antagonist in the distal convoluted tubule.
, Section 2: Respiratory Medicine
Q4. Describe the "CURB-65" score used to assess the severity of Community-Acquired Pneumonia
(CAP).
Answer: The CURB-65 score determines whether a patient requires outpatient care, ward
admission, or ICU care:
1. Confusion (New onset).
2. Urea >7 mmol/L.
3. Respiratory Rate $\ge$ 30 breaths/min.
4. Blood Pressure (Systolic <90 or Diastolic $\le$ 60 mmHg).
5. 65 - Age $\ge$ 65 years.
Scoring: 0–1 (Outpatient), 2 (Inpatient), 3+ (Consider ICU).
Q5. A 30-year-old female on oral contraceptives presents with sudden dyspnea, pleuritic chest pain,
and a heart rate of 120 bpm. Her D-dimer is elevated. What is the next best step in management?
Answer: Perform a CT Pulmonary Angiogram (CTPA) to confirm a Pulmonary Embolism (PE). If
CTPA is contraindicated (e.g., renal failure), a Ventilation-Perfusion (V/Q) scan is performed.
Q6. What are the hallmark findings of Chronic Obstructive Pulmonary Disease (COPD) on a Chest X-
ray?
Answer: Hyperinflation of the lungs, flattened diaphragm, increased retrosternal airspace, and a
"narrow" or "tubular" heart.
Section 3: Endocrinology
Q7. A type 1 diabetic patient is brought to the ER unconscious. Their breath smells fruity, and lab
results show Blood Glucose of 25 mmol/L and the presence of ketones in the urine. Outline the three
pillars of management for this condition (DKA).
Answer: The condition is Diabetic Ketoacidosis (DKA). Management pillars are:
Management (ACM 400) Comprehensive Clinical Medicine
& Integrated Healthcare Systems Examination
Phase 1: Internal Medicine (Cardiovascular, Respiratory, and
Endocrinology)
Section 1: Cardiovascular Medicine
Q1. A 58-year-old male with a history of hypertension and smoking presents with sudden-onset
tearing chest pain radiating to the back. His BP is 180/100 mmHg in the right arm and 140/85 mmHg in
the left. What is the most likely diagnosis and the gold-standard diagnostic test?
Answer: The diagnosis is Aortic Dissection. The gold-standard diagnostic test is a CT
Angiography (CTA) of the chest and abdomen. Transesophageal Echocardiography (TEE) is an
alternative if the patient is hemodynamically unstable.
Clinical Pearl: The blood pressure discrepancy between arms is a classic diagnostic "red flag."
Q2. Differentiate between the three types of Acute Coronary Syndrome (ACS) based on Biomarkers
and ECG findings.
Type ECG Findings Cardiac Biomarkers (Troponin)
Unstable Angina Normal or ST depression/T-wave inversion Negative
NSTEMI ST depression or T-wave inversion Positive
STEMI ST-elevation in 2+ contiguous leads Positive
Q3. A patient with Heart Failure is prescribed Spironolactone. What electrolyte imbalance must the
clinician monitor, and what is the drug's mechanism of action?
Answer: Monitor for Hyperkalemia (high potassium). Spironolactone is a Potassium-sparing
diuretic that acts as an aldosterone antagonist in the distal convoluted tubule.
, Section 2: Respiratory Medicine
Q4. Describe the "CURB-65" score used to assess the severity of Community-Acquired Pneumonia
(CAP).
Answer: The CURB-65 score determines whether a patient requires outpatient care, ward
admission, or ICU care:
1. Confusion (New onset).
2. Urea >7 mmol/L.
3. Respiratory Rate $\ge$ 30 breaths/min.
4. Blood Pressure (Systolic <90 or Diastolic $\le$ 60 mmHg).
5. 65 - Age $\ge$ 65 years.
Scoring: 0–1 (Outpatient), 2 (Inpatient), 3+ (Consider ICU).
Q5. A 30-year-old female on oral contraceptives presents with sudden dyspnea, pleuritic chest pain,
and a heart rate of 120 bpm. Her D-dimer is elevated. What is the next best step in management?
Answer: Perform a CT Pulmonary Angiogram (CTPA) to confirm a Pulmonary Embolism (PE). If
CTPA is contraindicated (e.g., renal failure), a Ventilation-Perfusion (V/Q) scan is performed.
Q6. What are the hallmark findings of Chronic Obstructive Pulmonary Disease (COPD) on a Chest X-
ray?
Answer: Hyperinflation of the lungs, flattened diaphragm, increased retrosternal airspace, and a
"narrow" or "tubular" heart.
Section 3: Endocrinology
Q7. A type 1 diabetic patient is brought to the ER unconscious. Their breath smells fruity, and lab
results show Blood Glucose of 25 mmol/L and the presence of ketones in the urine. Outline the three
pillars of management for this condition (DKA).
Answer: The condition is Diabetic Ketoacidosis (DKA). Management pillars are:
