MED700 Internal Medicine Clerkship Practice Questions and Answers
Updated 2026 | Complete Clinical Medicine Rotation Study Guide with
Verified Questions, Detailed Rationales, Differential Diagnosis, Diagnostic
Workup, Treatment Planning, Evidence-Based Medicine, Cardiovascular,
Respiratory, Renal, Endocrine & Gastrointestinal Disorders & Clerkship
Exam Prep
Question 1: A 68-year-old man with hypertension and type 2 diabetes presents with
progressive dyspnea on exertion, orthopnea, and bilateral lower extremity edema.
Echocardiography reveals an ejection fraction of 35% with left ventricular dilation.
Which of the following medications has been shown to reduce mortality in patients
with this condition?
A. Furosemide
B. Digoxin
C. Sacubitril/valsartan
D. Amlodipine
CORRECT ANSWER: C. Sacubitril/valsartan
Rationale: Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), has
demonstrated superior mortality reduction compared to ACE inhibitors in patients with
heart failure with reduced ejection fraction (HFrEF). Current guidelines recommend
ARNI as first-line therapy for eligible patients with HFrEF to reduce hospitalizations and
cardiovascular death. Furosemide provides symptomatic relief but does not improve
mortality. Digoxin reduces hospitalizations but has no mortality benefit. Amlodipine is
safe in heart failure but does not confer mortality reduction.
Question 2: A 55-year-old woman presents with acute onset of severe, tearing
chest pain radiating to her back. Blood pressure is 180/100 mm Hg in the right arm
and 150/85 mm Hg in the left arm. ECG shows no ST-segment changes. Which
diagnostic study is most appropriate as the initial test to confirm the suspected
diagnosis?
A. Transthoracic echocardiography
B. CT angiography of the chest
C. Coronary angiography
D. Transesophageal echocardiography
CORRECT ANSWER: B. CT angiography of the chest
Rationale: The clinical presentation is classic for acute aortic dissection. CT
angiography of the chest is the preferred initial imaging modality due to its high
sensitivity and specificity, rapid acquisition, and widespread availability. It allows
visualization of the entire aorta and identification of the intimal flap, entry tear, and
branch vessel involvement. Transthoracic echocardiography has limited sensitivity for
dissection. Transesophageal echocardiography is highly accurate but more invasive and
,less readily available. Coronary angiography is indicated for suspected acute coronary
syndrome, not aortic dissection.
Question 3: A 72-year-old man with known coronary artery disease presents with 30
minutes of substernal chest pressure at rest. ECG shows 2 mm ST-segment
elevation in leads II, III, and aVF. Which of the following is the most appropriate
immediate management step?
A. Administer sublingual nitroglycerin and observe
B. Activate the cardiac catheterization laboratory for primary percutaneous
coronary intervention
C. Initiate thrombolytic therapy with alteplase
D. Obtain serial cardiac biomarkers before intervention
CORRECT ANSWER: B. Activate the cardiac catheterization laboratory for primary
percutaneous coronary intervention
Rationale: This patient has an ST-elevation myocardial infarction (STEMI) involving the
inferior wall. Primary percutaneous coronary intervention (PCI) is the preferred
reperfusion strategy when available within 90-120 minutes of first medical contact, as it
provides superior outcomes compared to thrombolysis. Thrombolytic therapy is an
alternative only if PCI cannot be performed promptly. Serial biomarkers should not
delay reperfusion therapy. Nitroglycerin may relieve symptoms but does not address the
underlying coronary occlusion.
Question 4: A 45-year-old woman presents with palpitations and lightheadedness.
ECG reveals a narrow-complex tachycardia at 180 beats per minute with no visible
P waves. Vagal maneuvers are unsuccessful. Which medication is the most
appropriate initial pharmacologic treatment?
A. Amiodarone
B. Adenosine
C. Metoprolol
D. Digoxin
CORRECT ANSWER: B. Adenosine
Rationale: The clinical and ECG findings are consistent with atrioventricular nodal
reentrant tachycardia (AVNRT), the most common type of supraventricular tachycardia.
Adenosine is the first-line pharmacologic agent for acute termination of stable narrow-
complex SVT due to its rapid onset, short half-life, and high efficacy in blocking AV nodal
conduction. Beta-blockers or calcium channel blockers are alternatives. Amiodarone is
reserved for unstable patients or those with structural heart disease. Digoxin has a
slower onset and is not preferred for acute termination.
Question 5: A 60-year-old man with a history of myocardial infarction presents for
routine follow-up. He is asymptomatic. Echocardiogram shows an ejection fraction
,of 30%. Which of the following medications should be initiated to reduce the risk of
sudden cardiac death?
A. Amiodarone
B. Metoprolol succinate
C. Diltiazem
D. Flecainide
CORRECT ANSWER: B. Metoprolol succinate
Rationale: Beta-blockers, particularly metoprolol succinate, carvedilol, or bisoprolol,
are cornerstone therapy in patients with reduced ejection fraction following myocardial
infarction. They reduce mortality, including sudden cardiac death, by mitigating
sympathetic overactivity and ventricular arrhythmias. Amiodarone may suppress
arrhythmias but has not shown mortality benefit and carries significant adverse effects.
Flecainide is contraindicated in structural heart disease due to proarrhythmic risk.
Diltiazem is not indicated for mortality reduction in heart failure.
Question 6: A 70-year-old woman presents with new-onset atrial fibrillation with
rapid ventricular response. She has no structural heart disease. Her CHA₂DS₂-VASc
score is 3. Which of the following is the most appropriate anticoagulation strategy?
A. Aspirin 81 mg daily
B. Apixaban 5 mg twice daily
C. Warfarin with target INR 2.5-3.5
D. No anticoagulation; rate control only
CORRECT ANSWER: B. Apixaban 5 mg twice daily
Rationale: For patients with nonvalvular atrial fibrillation and a CHA₂DS₂-VASc score ≥2
in men or ≥3 in women, oral anticoagulation is indicated to reduce stroke risk. Direct
oral anticoagulants (DOACs) like apixaban are preferred over warfarin due to
comparable efficacy, lower intracranial bleeding risk, and no need for routine
monitoring. Aspirin is insufficient for stroke prevention in this risk category. Warfarin
remains an option but requires INR monitoring and has more drug-food interactions.
Question 7: A 58-year-old man presents with exertional dyspnea and fatigue.
Physical examination reveals a harsh systolic murmur at the right upper sternal
border radiating to the carotids. Echocardiography confirms severe aortic stenosis
with a mean gradient of 45 mm Hg and valve area of 0.8 cm². He is asymptomatic at
rest. What is the most appropriate management?
A. Immediate surgical aortic valve replacement
B. Close clinical and echocardiographic monitoring
C. Initiate afterload reduction with hydralazine
D. Start beta-blocker therapy to reduce myocardial oxygen demand
CORRECT ANSWER: B. Close clinical and echocardiographic monitoring
, Rationale: Asymptomatic patients with severe aortic stenosis should undergo close
monitoring with serial clinical evaluations and echocardiography every 6-12 months.
Intervention (surgical or transcatheter valve replacement) is indicated upon
development of symptoms, left ventricular dysfunction, or abnormal exercise testing.
Afterload reduction is generally avoided in severe aortic stenosis due to risk of
hypotension. Beta-blockers may be used cautiously for rate control but do not alter
disease progression.
Question 8: A 65-year-old woman with hypertension presents for blood pressure
management. Her average home blood pressure readings are 148/92 mm Hg. She
has no other comorbidities. According to current guidelines, what is the target
blood pressure for this patient?
A. <150/90 mm Hg
B. <130/80 mm Hg
C. <140/90 mm Hg
D. <120/80 mm Hg
CORRECT ANSWER: B. <130/80 mm Hg
Rationale: The 2025 AHA/ACC hypertension guidelines recommend a universal blood
pressure goal of <130/80 mm Hg for most adults, including those with hypertension
without compelling indications
journalfeed.org
. This target is based on evidence demonstrating reduced cardiovascular events with
intensive blood pressure control. The <120/80 mm Hg goal is reserved for select high-
risk patients in specific trials. The <140/90 mm Hg threshold represents older guideline
recommendations.
Question 9: A 50-year-old man presents with acute onset of dyspnea, pleuritic
chest pain, and tachycardia. D-dimer is elevated. CT pulmonary angiography
confirms a segmental pulmonary embolism. He is hemodynamically stable with no
contraindications to anticoagulation. Which of the following is the most
appropriate initial treatment?
A. Unfractionated heparin infusion
B. Rivaroxaban 15 mg twice daily for 21 days, then 20 mg daily
C. Warfarin with bridging heparin
D. Inferior vena cava filter placement
CORRECT ANSWER: B. Rivaroxaban 15 mg twice daily for 21 days, then 20 mg daily
Rationale: For hemodynamically stable patients with acute pulmonary embolism, direct
oral anticoagulants (DOACs) like rivaroxaban are preferred first-line therapy due to rapid
onset, fixed dosing, and no need for routine monitoring. Rivaroxaban has a specific
loading regimen for acute VTE treatment. Unfractionated heparin is reserved for
patients with severe renal impairment or high bleeding risk requiring rapid reversibility.
Updated 2026 | Complete Clinical Medicine Rotation Study Guide with
Verified Questions, Detailed Rationales, Differential Diagnosis, Diagnostic
Workup, Treatment Planning, Evidence-Based Medicine, Cardiovascular,
Respiratory, Renal, Endocrine & Gastrointestinal Disorders & Clerkship
Exam Prep
Question 1: A 68-year-old man with hypertension and type 2 diabetes presents with
progressive dyspnea on exertion, orthopnea, and bilateral lower extremity edema.
Echocardiography reveals an ejection fraction of 35% with left ventricular dilation.
Which of the following medications has been shown to reduce mortality in patients
with this condition?
A. Furosemide
B. Digoxin
C. Sacubitril/valsartan
D. Amlodipine
CORRECT ANSWER: C. Sacubitril/valsartan
Rationale: Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), has
demonstrated superior mortality reduction compared to ACE inhibitors in patients with
heart failure with reduced ejection fraction (HFrEF). Current guidelines recommend
ARNI as first-line therapy for eligible patients with HFrEF to reduce hospitalizations and
cardiovascular death. Furosemide provides symptomatic relief but does not improve
mortality. Digoxin reduces hospitalizations but has no mortality benefit. Amlodipine is
safe in heart failure but does not confer mortality reduction.
Question 2: A 55-year-old woman presents with acute onset of severe, tearing
chest pain radiating to her back. Blood pressure is 180/100 mm Hg in the right arm
and 150/85 mm Hg in the left arm. ECG shows no ST-segment changes. Which
diagnostic study is most appropriate as the initial test to confirm the suspected
diagnosis?
A. Transthoracic echocardiography
B. CT angiography of the chest
C. Coronary angiography
D. Transesophageal echocardiography
CORRECT ANSWER: B. CT angiography of the chest
Rationale: The clinical presentation is classic for acute aortic dissection. CT
angiography of the chest is the preferred initial imaging modality due to its high
sensitivity and specificity, rapid acquisition, and widespread availability. It allows
visualization of the entire aorta and identification of the intimal flap, entry tear, and
branch vessel involvement. Transthoracic echocardiography has limited sensitivity for
dissection. Transesophageal echocardiography is highly accurate but more invasive and
,less readily available. Coronary angiography is indicated for suspected acute coronary
syndrome, not aortic dissection.
Question 3: A 72-year-old man with known coronary artery disease presents with 30
minutes of substernal chest pressure at rest. ECG shows 2 mm ST-segment
elevation in leads II, III, and aVF. Which of the following is the most appropriate
immediate management step?
A. Administer sublingual nitroglycerin and observe
B. Activate the cardiac catheterization laboratory for primary percutaneous
coronary intervention
C. Initiate thrombolytic therapy with alteplase
D. Obtain serial cardiac biomarkers before intervention
CORRECT ANSWER: B. Activate the cardiac catheterization laboratory for primary
percutaneous coronary intervention
Rationale: This patient has an ST-elevation myocardial infarction (STEMI) involving the
inferior wall. Primary percutaneous coronary intervention (PCI) is the preferred
reperfusion strategy when available within 90-120 minutes of first medical contact, as it
provides superior outcomes compared to thrombolysis. Thrombolytic therapy is an
alternative only if PCI cannot be performed promptly. Serial biomarkers should not
delay reperfusion therapy. Nitroglycerin may relieve symptoms but does not address the
underlying coronary occlusion.
Question 4: A 45-year-old woman presents with palpitations and lightheadedness.
ECG reveals a narrow-complex tachycardia at 180 beats per minute with no visible
P waves. Vagal maneuvers are unsuccessful. Which medication is the most
appropriate initial pharmacologic treatment?
A. Amiodarone
B. Adenosine
C. Metoprolol
D. Digoxin
CORRECT ANSWER: B. Adenosine
Rationale: The clinical and ECG findings are consistent with atrioventricular nodal
reentrant tachycardia (AVNRT), the most common type of supraventricular tachycardia.
Adenosine is the first-line pharmacologic agent for acute termination of stable narrow-
complex SVT due to its rapid onset, short half-life, and high efficacy in blocking AV nodal
conduction. Beta-blockers or calcium channel blockers are alternatives. Amiodarone is
reserved for unstable patients or those with structural heart disease. Digoxin has a
slower onset and is not preferred for acute termination.
Question 5: A 60-year-old man with a history of myocardial infarction presents for
routine follow-up. He is asymptomatic. Echocardiogram shows an ejection fraction
,of 30%. Which of the following medications should be initiated to reduce the risk of
sudden cardiac death?
A. Amiodarone
B. Metoprolol succinate
C. Diltiazem
D. Flecainide
CORRECT ANSWER: B. Metoprolol succinate
Rationale: Beta-blockers, particularly metoprolol succinate, carvedilol, or bisoprolol,
are cornerstone therapy in patients with reduced ejection fraction following myocardial
infarction. They reduce mortality, including sudden cardiac death, by mitigating
sympathetic overactivity and ventricular arrhythmias. Amiodarone may suppress
arrhythmias but has not shown mortality benefit and carries significant adverse effects.
Flecainide is contraindicated in structural heart disease due to proarrhythmic risk.
Diltiazem is not indicated for mortality reduction in heart failure.
Question 6: A 70-year-old woman presents with new-onset atrial fibrillation with
rapid ventricular response. She has no structural heart disease. Her CHA₂DS₂-VASc
score is 3. Which of the following is the most appropriate anticoagulation strategy?
A. Aspirin 81 mg daily
B. Apixaban 5 mg twice daily
C. Warfarin with target INR 2.5-3.5
D. No anticoagulation; rate control only
CORRECT ANSWER: B. Apixaban 5 mg twice daily
Rationale: For patients with nonvalvular atrial fibrillation and a CHA₂DS₂-VASc score ≥2
in men or ≥3 in women, oral anticoagulation is indicated to reduce stroke risk. Direct
oral anticoagulants (DOACs) like apixaban are preferred over warfarin due to
comparable efficacy, lower intracranial bleeding risk, and no need for routine
monitoring. Aspirin is insufficient for stroke prevention in this risk category. Warfarin
remains an option but requires INR monitoring and has more drug-food interactions.
Question 7: A 58-year-old man presents with exertional dyspnea and fatigue.
Physical examination reveals a harsh systolic murmur at the right upper sternal
border radiating to the carotids. Echocardiography confirms severe aortic stenosis
with a mean gradient of 45 mm Hg and valve area of 0.8 cm². He is asymptomatic at
rest. What is the most appropriate management?
A. Immediate surgical aortic valve replacement
B. Close clinical and echocardiographic monitoring
C. Initiate afterload reduction with hydralazine
D. Start beta-blocker therapy to reduce myocardial oxygen demand
CORRECT ANSWER: B. Close clinical and echocardiographic monitoring
, Rationale: Asymptomatic patients with severe aortic stenosis should undergo close
monitoring with serial clinical evaluations and echocardiography every 6-12 months.
Intervention (surgical or transcatheter valve replacement) is indicated upon
development of symptoms, left ventricular dysfunction, or abnormal exercise testing.
Afterload reduction is generally avoided in severe aortic stenosis due to risk of
hypotension. Beta-blockers may be used cautiously for rate control but do not alter
disease progression.
Question 8: A 65-year-old woman with hypertension presents for blood pressure
management. Her average home blood pressure readings are 148/92 mm Hg. She
has no other comorbidities. According to current guidelines, what is the target
blood pressure for this patient?
A. <150/90 mm Hg
B. <130/80 mm Hg
C. <140/90 mm Hg
D. <120/80 mm Hg
CORRECT ANSWER: B. <130/80 mm Hg
Rationale: The 2025 AHA/ACC hypertension guidelines recommend a universal blood
pressure goal of <130/80 mm Hg for most adults, including those with hypertension
without compelling indications
journalfeed.org
. This target is based on evidence demonstrating reduced cardiovascular events with
intensive blood pressure control. The <120/80 mm Hg goal is reserved for select high-
risk patients in specific trials. The <140/90 mm Hg threshold represents older guideline
recommendations.
Question 9: A 50-year-old man presents with acute onset of dyspnea, pleuritic
chest pain, and tachycardia. D-dimer is elevated. CT pulmonary angiography
confirms a segmental pulmonary embolism. He is hemodynamically stable with no
contraindications to anticoagulation. Which of the following is the most
appropriate initial treatment?
A. Unfractionated heparin infusion
B. Rivaroxaban 15 mg twice daily for 21 days, then 20 mg daily
C. Warfarin with bridging heparin
D. Inferior vena cava filter placement
CORRECT ANSWER: B. Rivaroxaban 15 mg twice daily for 21 days, then 20 mg daily
Rationale: For hemodynamically stable patients with acute pulmonary embolism, direct
oral anticoagulants (DOACs) like rivaroxaban are preferred first-line therapy due to rapid
onset, fixed dosing, and no need for routine monitoring. Rivaroxaban has a specific
loading regimen for acute VTE treatment. Unfractionated heparin is reserved for
patients with severe renal impairment or high bleeding risk requiring rapid reversibility.
