ROSH: Internal Med Exam Prep
ROSH: INTERNAL MED EXAM PREP NEWEST 2026/2027 ACTUAL
EXAM COMPLETE 200 QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) WITH DETAILED RATIONALES
|ALREADY GRADED A+||BRAND NEW VERSION!!
A 53-year-old man presents for a routine complete physical. Screening blood work
is completed that demonstrates a fasting blood glucose of 189 mg/dL and
hemoglobin A1C of 7.8%. The patient is prescribed metformin. Which of the
following is the most common side effect of this medication?
Diarrhea
Hypoglycemia
Lactic acidosis
Vitamin B12 deficiency - Correct Answer-Diarrhea
The adverse effects that are associated with metformin include gastrointestinal
upset, including diarrhea, nausea, a metallic taste in the mouth, and anorexia.
These are the most common side effects associated with this medication, and
patients should be aware of these before beginning this drug. These side effects
are often transient in nature and can be controlled by reducing the dosage of the
medication or discontinuing the drug if the side effects are intolerable.
Hypoglycemia (B) is not a side effect of metformin, which makes it a more
desirable choice than other antidiabetic medications. Hypoglycemia is more
common with insulin and sulfonylurea medications. Lactic acidosis (C) is a serious
but uncommon adverse event that can occur while taking metformin. This drug
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, ROSH: Internal Med Exam Prep
should not be administered to those at risk of developing lactic acidosis, including
those with impaired kidney or liver function, a history of alcohol abuse, or a past
history of lactic acidosis with metformin use. Vitamin B12 deficiency (D) can occur
while taking metformin, however, this side effect is less common and is typically
not severe enough to cause a megaloblastic anemia.
A 65-year-old man with a history of hyperlipidemia who is a current everyday
smoker presents to the emergency department with chest pain that started two
hours ago. The pain began when he was shoveling snow. Physical exam is
unremarkable. His initial ECG is shown above. His initial troponin level is 0.5
ng/mL, and his serum troponin two hours later is 1.2 ng/mL. Which of the
following is the most likely diagnosis?
ANon-ST elevation myocardial infarction
BPrinzmetal angina
CST elevation myocardial infarction
DUnstable angina - Correct Answer-NSTEMI
This patient is presenting with a non-ST elevation myocardial infarction (NSTEMI).
An NSTEMI is the result of atherosclerosis in coronary arteries or coronary artery
vasospasm. Risk factors include hyperlipidemia, cigarette smoking, obesity, and
diabetes mellitus. Patients will present with retrosternal chest pressure that
radiates to the arm or jaw, is worse with exertion, and is not relieved by rest or
nitrates. Other presenting symptoms include nausea, diaphoresis, and dizziness.
Physical examination is typically unremarkable. When a patient has an NSTEMI,
diagnosis is based on elevated troponin values on two occasions taken two hours
apart. The electrocardiogram may show ST depressions or T wave inversions, or it
may be normal. Initial therapy in the emergency department should include
aspirin 325 mg, heparin drip, supplemental oxygen if oxygen saturation is below
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, ROSH: Internal Med Exam Prep
90%, and sublingual nitroglycerin, unless the patient is hypotensive or there is
evidence of right-sided infarction.
Prinzmetal angina (B) is characterized by nonexertional chest pain that typically
occurs early in the morning. It is caused by coronary artery vasospasms. Patients
will have transiently elevated ST segments and are often treated with calcium
channel blockers. ST elevation myocardial infarction (C) presents similarly to an
NSTEMI. Patients will present with crushing, radiating chest pain that is
aggravated by exertion and unrelieved with nitrates, however, ST elevations would
be noted on the ECG. Immediate PCI should be performed for these patients.
Unstable angina (D) also presents similarly to an NSTEMI, however, these patients
do not have ECG changes or elevated troponin levels.
A 35-year-old patient presents to the hospital following a motor vehicle collision.
When you arrive in the exam room, the patient is unresponsive. Which of the
following exam findings most likely indicates early uncal herniation?
Absent oculovestibular reflex
Bilateral pinpoint pupils
Gaze preference away from the lesion
Unilateral dilated and fixed pupil - Correct Answer-Unilateral dilated and fixed
pupil
Supratentorial lesions typically cause coma when the mass translates pressure
inferiorly and causes herniation of the cerebrum through the tentorial notch. The
increase in volume of the subtentorial compartment results in compression of the
brainstem. This process can occur quickly or can be protracted (as is the case in
slow-growing masses). The two most common herniation syndromes are central
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, ROSH: Internal Med Exam Prep
herniation (caused by a mass that directs a vertical vector of force toward the
tentorial notch) and uncal herniation. Uncal herniation results from a unilateral
mass causing a lateral force vector. This force vector pushes the temporal lobe
over the edge of the tentorium and compresses the midbrain. Early transtentorial
herniation will often present with a third cranial nerve palsy because the cranial
nerve runs just inferior to the lateral edge of the tentorium. In the case of uncal
herniation, only the ipsilateral eye will be affected, resulting in unilateral dilated
and fixed pupil, as is the case in the patient in the vignette above.
Question: What coma syndrome is caused by damage to the ventral pons?
Answer: Locked-in syndrome.
A 62-year-old obese woman with diabetes presents to the office complaining of
worsening dyspnea and dizziness. She has a longstanding history of alcohol use
and currently reports decreasing her alcohol consumption to 12 beers per week.
On physical exam, she appears to be in no acute distress. Cardiovascular exam
reveals jugular venous distention and rales bilaterally on auscultation of the lungs.
Which initial diagnostic study is most helpful for eliminating a valvulopathy as the
possible cause of her symptoms?
Cardiac magnetic resonance imaging
Chest radiography
Echocardiography
Electrocardiography - Correct Answer-Echocardiogram
Dilated cardiomyopathy is a broad category of conditions in which the heart
muscle enlarges, causing left ventricular systolic dysfunction defined as an
4|Page
ROSH: INTERNAL MED EXAM PREP NEWEST 2026/2027 ACTUAL
EXAM COMPLETE 200 QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) WITH DETAILED RATIONALES
|ALREADY GRADED A+||BRAND NEW VERSION!!
A 53-year-old man presents for a routine complete physical. Screening blood work
is completed that demonstrates a fasting blood glucose of 189 mg/dL and
hemoglobin A1C of 7.8%. The patient is prescribed metformin. Which of the
following is the most common side effect of this medication?
Diarrhea
Hypoglycemia
Lactic acidosis
Vitamin B12 deficiency - Correct Answer-Diarrhea
The adverse effects that are associated with metformin include gastrointestinal
upset, including diarrhea, nausea, a metallic taste in the mouth, and anorexia.
These are the most common side effects associated with this medication, and
patients should be aware of these before beginning this drug. These side effects
are often transient in nature and can be controlled by reducing the dosage of the
medication or discontinuing the drug if the side effects are intolerable.
Hypoglycemia (B) is not a side effect of metformin, which makes it a more
desirable choice than other antidiabetic medications. Hypoglycemia is more
common with insulin and sulfonylurea medications. Lactic acidosis (C) is a serious
but uncommon adverse event that can occur while taking metformin. This drug
1|Page
, ROSH: Internal Med Exam Prep
should not be administered to those at risk of developing lactic acidosis, including
those with impaired kidney or liver function, a history of alcohol abuse, or a past
history of lactic acidosis with metformin use. Vitamin B12 deficiency (D) can occur
while taking metformin, however, this side effect is less common and is typically
not severe enough to cause a megaloblastic anemia.
A 65-year-old man with a history of hyperlipidemia who is a current everyday
smoker presents to the emergency department with chest pain that started two
hours ago. The pain began when he was shoveling snow. Physical exam is
unremarkable. His initial ECG is shown above. His initial troponin level is 0.5
ng/mL, and his serum troponin two hours later is 1.2 ng/mL. Which of the
following is the most likely diagnosis?
ANon-ST elevation myocardial infarction
BPrinzmetal angina
CST elevation myocardial infarction
DUnstable angina - Correct Answer-NSTEMI
This patient is presenting with a non-ST elevation myocardial infarction (NSTEMI).
An NSTEMI is the result of atherosclerosis in coronary arteries or coronary artery
vasospasm. Risk factors include hyperlipidemia, cigarette smoking, obesity, and
diabetes mellitus. Patients will present with retrosternal chest pressure that
radiates to the arm or jaw, is worse with exertion, and is not relieved by rest or
nitrates. Other presenting symptoms include nausea, diaphoresis, and dizziness.
Physical examination is typically unremarkable. When a patient has an NSTEMI,
diagnosis is based on elevated troponin values on two occasions taken two hours
apart. The electrocardiogram may show ST depressions or T wave inversions, or it
may be normal. Initial therapy in the emergency department should include
aspirin 325 mg, heparin drip, supplemental oxygen if oxygen saturation is below
2|Page
, ROSH: Internal Med Exam Prep
90%, and sublingual nitroglycerin, unless the patient is hypotensive or there is
evidence of right-sided infarction.
Prinzmetal angina (B) is characterized by nonexertional chest pain that typically
occurs early in the morning. It is caused by coronary artery vasospasms. Patients
will have transiently elevated ST segments and are often treated with calcium
channel blockers. ST elevation myocardial infarction (C) presents similarly to an
NSTEMI. Patients will present with crushing, radiating chest pain that is
aggravated by exertion and unrelieved with nitrates, however, ST elevations would
be noted on the ECG. Immediate PCI should be performed for these patients.
Unstable angina (D) also presents similarly to an NSTEMI, however, these patients
do not have ECG changes or elevated troponin levels.
A 35-year-old patient presents to the hospital following a motor vehicle collision.
When you arrive in the exam room, the patient is unresponsive. Which of the
following exam findings most likely indicates early uncal herniation?
Absent oculovestibular reflex
Bilateral pinpoint pupils
Gaze preference away from the lesion
Unilateral dilated and fixed pupil - Correct Answer-Unilateral dilated and fixed
pupil
Supratentorial lesions typically cause coma when the mass translates pressure
inferiorly and causes herniation of the cerebrum through the tentorial notch. The
increase in volume of the subtentorial compartment results in compression of the
brainstem. This process can occur quickly or can be protracted (as is the case in
slow-growing masses). The two most common herniation syndromes are central
3|Page
, ROSH: Internal Med Exam Prep
herniation (caused by a mass that directs a vertical vector of force toward the
tentorial notch) and uncal herniation. Uncal herniation results from a unilateral
mass causing a lateral force vector. This force vector pushes the temporal lobe
over the edge of the tentorium and compresses the midbrain. Early transtentorial
herniation will often present with a third cranial nerve palsy because the cranial
nerve runs just inferior to the lateral edge of the tentorium. In the case of uncal
herniation, only the ipsilateral eye will be affected, resulting in unilateral dilated
and fixed pupil, as is the case in the patient in the vignette above.
Question: What coma syndrome is caused by damage to the ventral pons?
Answer: Locked-in syndrome.
A 62-year-old obese woman with diabetes presents to the office complaining of
worsening dyspnea and dizziness. She has a longstanding history of alcohol use
and currently reports decreasing her alcohol consumption to 12 beers per week.
On physical exam, she appears to be in no acute distress. Cardiovascular exam
reveals jugular venous distention and rales bilaterally on auscultation of the lungs.
Which initial diagnostic study is most helpful for eliminating a valvulopathy as the
possible cause of her symptoms?
Cardiac magnetic resonance imaging
Chest radiography
Echocardiography
Electrocardiography - Correct Answer-Echocardiogram
Dilated cardiomyopathy is a broad category of conditions in which the heart
muscle enlarges, causing left ventricular systolic dysfunction defined as an
4|Page
