Sample Questions for the Emirati Board of Internal Medicine

1. Cardiology

Q1: A 65-year-old man presents to the emergency department with severe, crushing chest pain radiating to his left shoulder and jaw, along with profuse sweating and nausea. ECG reveals ST-segment elevation in leads V1 to V4, and his blood pressure is 100/60 mmHg. Which intervention should be initiated immediately after the patient is confirmed to be a candidate for reperfusion therapy?
a) IV beta-blockers
b) Fibrinolytic therapy
c) IV nitroglycerin
d) Percutaneous coronary intervention (PCI)
e) IV heparin
Answer: d) Percutaneous coronary intervention (PCI)
Explanation: ST-segment elevation in leads V1 to V4 suggests an anterior wall myocardial infarction, typically caused by occlusion of the left anterior descending (LAD) artery, which supplies the anterior wall of the heart. Anterior wall infarctions are serious due to the risk of large infarct size, potential cardiogenic shock, and significant mortality if left untreated.
For ST-segment elevation myocardial infarction (STEMI), primary PCI is the preferred method of reperfusion therapy over fibrinolytic therapy, especially when performed within 90 minutes of first medical contact. PCI is more effective at restoring blood flow, has a lower risk of intracranial hemorrhage compared to fibrinolytics, and is associated with improved survival rates. While IV heparin, nitroglycerin, and beta-blockers may have roles in adjunct therapy, immediate PCI takes priority in eligible patients.

2. Pulmonology

Q2: A 50-year-old female smoker presents with progressive shortness of breath, cough with minimal sputum production, and an oxygen saturation of 89% on room air. Spirometry shows FEV1/FVC < 0.7 and a decreased FEV1 with no improvement after bronchodilator administration. Chest X-ray reveals hyperinflation and flattened diaphragms. Despite her low oxygen levels, you decide to avoid oxygen therapy initially. What is the most likely reason for this decision?
a) Risk of CO2 retention due to hypoxic drive suppression
b) High risk of oxygen toxicity
c) Limited efficacy of oxygen therapy in chronic obstructive pulmonary disease (COPD)
d) Oxygen therapy can exacerbate bronchospasm
e) Potential risk of worsening the patient’s hypertension
Answer: a) Risk of CO2 retention due to hypoxic drive suppression
Explanation: In advanced COPD, chronic hypoxemia and hypercapnia are common. Many COPD patients rely on a hypoxic drive for respiratory stimulation due to chronic CO2 retention. Supplemental oxygen can suppress this drive, resulting in further CO2 retention and potentially life-threatening hypercapnia. For these patients, oxygen is carefully titrated to maintain an SpO2 of around 88-92% to avoid depressing their hypoxic drive. Abrupt increases in oxygen levels, particularly above 92%, may reduce the respiratory rate, worsening hypercapnia and potentially leading to respiratory failure. This is why low-flow oxygen therapy is cautiously used and titrated.


3. Gastroenterology

Q3: A 58-year-old man with a history of chronic alcohol use and cirrhosis presents with abdominal distention, confusion, and an elevated serum ammonia level. His abdominal ultrasound shows no portal vein thrombosis. Which of the following medications should be started to manage his condition?
a) Spironolactone and furosemide
b) Lactulose and rifaximin
c) Octreotide and propranolol
d) IV albumin and terlipressin
e) Ceftriaxone and vitamin K
Answer: b) Lactulose and rifaximin
Explanation: The patient’s confusion, elevated ammonia level, and history of cirrhosis suggest hepatic encephalopathy, a neuropsychiatric complication of liver disease caused by the accumulation of toxins such as ammonia, which the liver cannot adequately detoxify. Lactulose is a first-line treatment that acidifies the colon, converting ammonia (NH3) to ammonium (NH4+), which is less readily absorbed and thus excreted in the stool. Lactulose also acts as a laxative, promoting stool passage and further reducing ammonia levels.
Rifaximin is a non-absorbable antibiotic that reduces ammonia-producing bacteria in the gut, thereby lowering ammonia production. Together, lactulose and rifaximin reduce serum ammonia levels, treating and preventing hepatic encephalopathy. Other options, like spironolactone and furosemide, manage ascites but do not address ammonia; octreotide and propranolol are used in variceal bleeding prophylaxis, and albumin and terlipressin are for hepatorenal syndrome.

4. Endocrinology

Q4: A 45-year-old woman with a recent diagnosis of primary hypothyroidism presents with fatigue and weakness. Laboratory tests show TSH of 8.2 mIU/L (normal range: 0.4-4.5 mIU/L) and low free T4. Her physician prescribed levothyroxine two months ago, but her symptoms persist, and she shows no improvement in TSH levels. Which of the following is the most likely cause of her persistent symptoms?
a) She is not taking the medication consistently
b) She is taking levothyroxine with calcium supplements
c) She requires a higher dose of levothyroxine
d) She has developed secondary hypothyroidism
e) She has concurrent adrenal insufficiency
Answer: b) She is taking levothyroxine with calcium supplements
Explanation: Calcium interferes with the absorption of levothyroxine when taken together, leading to inadequate medication levels and suboptimal therapeutic effect. Levothyroxine should be taken on an empty stomach, ideally 30-60 minutes before other medications or meals, to ensure proper absorption. If taken with calcium or iron supplements, these should be spaced out by at least 4 hours. Although other options are possible, calcium supplement interference is the most common cause of persistent symptoms and unchanged TSH levels in patients on levothyroxine.

5. Nephrology
Q5: A 68-year-old man with diabetes and hypertension presents with generalized weakness, nausea, and EKG changes showing peaked T waves. Laboratory results show a serum potassium of 6.8 mEq/L and serum creatinine of 2.5 mg/dL. After administering IV calcium gluconate, what should be the next step in management?
a) Intravenous furosemide
b) IV insulin with glucose
c) Sodium polystyrene sulfonate (Kayexalate)
d) Dialysis
e) Sodium bicarbonate
Answer: b) IV insulin with glucose
Explanation: Hyperkalemia, especially with EKG changes such as peaked T waves, requires urgent management to prevent arrhythmias. IV calcium gluconate stabilizes the cardiac cell membrane but does not lower potassium levels. The next step is to shift potassium intracellularly using IV insulin, accompanied by glucose to prevent hypoglycemia. This provides a rapid, temporary reduction in serum potassium. Additional treatments like furosemide (to promote renal potassium excretion) and sodium polystyrene sulfonate (to exchange potassium in the gut) may be used but are slower and not suitable for immediate action.

6. Infectious Diseases
Q6: A 35-year-old man returns from a trip to an endemic area and presents with high fever, chills, and hemolytic anemia. His peripheral blood smear shows ring forms within red blood cells. Which is the best initial treatment for this patient?
a) Doxycycline
b) Ciprofloxacin
c) Artesunate
d) Metronidazole
e) Isoniazid
Answer: c) Artesunate
Explanation: The presence of ring forms within red blood cells suggests Plasmodium falciparum malaria, which is potentially life-threatening. Artesunate is the preferred treatment for severe malaria due to its rapid action, particularly effective against P. falciparum. Doxycycline may be used as adjunctive therapy but is not adequate as monotherapy in severe cases. Other antibiotics, such as ciprofloxacin and metronidazole, are not effective for malaria, and isoniazid is specific for tuberculosis.

7. Rheumatology

Q7: A 50-year-old woman complains of joint pain, morning stiffness lasting more than an hour, and symmetrical swelling in the hands and wrists. Laboratory results show positive rheumatoid factor (RF) and elevated anti-cyclic citrullinated peptide (anti-CCP) antibodies. Which of the following medications is most appropriate for early intervention to prevent joint damage?
a) Prednisone
b) Methotrexate
c) Acetaminophen
d) Hydroxychloroquine
e) Naproxen
Answer: b) Methotrexate
Explanation: Methotrexate is the first-line disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis, which is indicated to prevent joint damage and disease progression. Methotrexate helps reduce inflammation, control symptoms, and slow the progression of joint and tissue destruction. NSAIDs like naproxen can manage symptoms but do not prevent disease progression. Prednisone may offer quick symptom relief but has long-term side effects and is not a substitute for a DMARD.

8. Hematology

Q8: A 27-year-old woman with fatigue, pallor, and jaundice has a family history of similar symptoms. Lab results show hemoglobin of 9 g/dL, MCV of 75 fL, and elevated reticulocyte count. A peripheral blood smear reveals spherocytes. Which is the best diagnostic test for confirming her condition?
a) Hemoglobin electrophoresis
b) Coombs test
c) Osmotic fragility test
d) Bone marrow biopsy
e) Serum iron studies
Answer: c) Osmotic fragility test
Explanation: The clinical presentation and lab findings (spherocytes, elevated reticulocyte count, and family history) suggest hereditary spherocytosis, a hemolytic anemia caused by a membrane protein defect. The osmotic fragility test assesses red cell stability in hypotonic solutions, which is diagnostic for hereditary spherocytosis as these cells are more susceptible to lysis due to their spherical shape.