Internal Medicine CME Sample Questions

Internal Medicine CME Sample Question 2

A 54-year-old man with a history of hypertension and obesity (BMI 32 kg/m²) is admitted to the ICU with severe community-acquired pneumonia complicated by septic shock. He was intubated 6 hours ago for progressive hypoxemic respiratory failure despite high-flow nasal cannula oxygen therapy. His predicted body weight is 70 kg based on height and gender. Current ventilator settings include volume control mode with tidal volume 700 mL (10 mL/kg predicted body weight), respiratory rate 20 breaths/min, FiO₂ 0.6, and PEEP 10 cmH₂O. Vital signs show blood pressure 95/60 mmHg on norepinephrine, heart rate 105 bpm, and oxygen saturation 91%. Arterial blood gas reveals pH 7.32, PaCO₂ 48 mmHg, and PaO₂/FiO₂ ratio of 140. Plateau pressure is 32 cmH₂O with normal airway resistance. Chest radiograph demonstrates bilateral alveolar infiltrates consistent with ARDS. Which of the following represents the most appropriate adjustment to mechanical ventilation?

• AIncrease tidal volume to 12 mL/kg predicted body weight to improve oxygenation
• BDecrease tidal volume to 6 mL/kg predicted body weight and increase respiratory rate
• CDecrease PEEP to 5 cmH₂O to reduce plateau pressure
• DMaintain current ventilator settings and monitor closely

Internal Medicine CME Sample Question 3

A 52-year-old woman presents to the rheumatology clinic with a 6-month history of progressive exertional dyspnea and proximal muscle weakness affecting her shoulders and hips. She reports difficulty climbing stairs and rising from chairs, along with morning stiffness in her hands, wrists, and knees lasting 2-3 hours. She has developed thickened, hyperkeratotic skin lesions over the lateral aspects and tips of her fingers that crack and bleed with manual labor. She denies photosensitive rashes, oral ulcers, or Raynaud phenomenon. Physical examination reveals symmetric weakness in shoulder abduction (4/5) and hip flexion (4/5), with normal distal strength. Pulmonary examination shows bibasilar fine crackles. Dermatologic examination reveals hyperkeratotic, fissured lesions on the radial aspects of her index fingers and thumbs, described as “mechanic’s hands.” Laboratory studies show creatine kinase 2,800 U/L (normal 30-200), ESR 68 mm/hr, and positive anti-Jo-1 antibodies. High-resolution CT of the chest demonstrates bilateral lower lobe ground-glass opacities and subpleural reticulation consistent with nonspecific interstitial pneumonia pattern. Pulmonary function tests show reduced DLCO at 65% predicted. Which of the following is the most likely diagnosis?

• ASystemic lupus erythematosus
• BPolymyositis
• CAntisynthetase syndrome
• DSystemic sclerosis
• EMixed connective tissue disease

Internal Medicine CME Sample Question 4

A 62-year-old woman with metastatic melanoma was started on pembrolizumab (anti-PD-1 therapy) 4 months ago and has shown excellent response with tumor regression. She presents to oncology clinic with a 6-week history of progressive fatigue, 8-pound weight gain despite decreased appetite, worsening constipation requiring daily laxatives, cold intolerance, and dry skin with hair thinning. She reports feeling “sluggish” and having difficulty concentrating at work. Her melanoma remains stable on recent imaging. She has no personal or family history of thyroid disease and was euthyroid prior to starting immunotherapy. Physical examination reveals bradycardia (heart rate 58 bpm), delayed deep tendon reflexes, periorbital puffiness, and coarse, dry skin. There is no palpable thyroid enlargement or nodules. Laboratory studies reveal TSH 28 mIU/L (reference range 0.4–4.0), free T4 0.5 ng/dL (reference range 0.8–1.8), and thyroid peroxidase antibodies 450 IU/mL (normal <35). Complete blood count and comprehensive metabolic panel are otherwise normal. Which of the following is the most appropriate next step in management?

• ADiscontinue pembrolizumab and start high-dose corticosteroids
• BStart levothyroxine replacement therapy and continue pembrolizumab
• CStart methimazole and beta-blocker therapy
• DObserve and repeat thyroid function tests in 4 weeks
• ERefer for urgent thyroidectomy

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