Prometric Exam Questions for Internal Medicine Specialists 2026: 15 Practice MCQs with Answers and Rationale for the INT5921 Paper

The internal medicine specialist paper (INT5921; consultants sit INT5732) is written at the level of a registrar managing an acute medical take: diagnosis from a clinical vignette, the next best investigation, first-line treatment by current guideline, and the complication to anticipate. It is usually 100 to 150 single-best-answer questions in 2.5 to 3 hours, with a pass mark of about 60% for specialists and 70% for consultants.

The fifteen questions below follow that blueprint. Allow about 70 seconds each and read every rationale; specialists lose marks on the systems they refer out, so the set deliberately spans all of them.

For titles, exemptions and the route, read the internal medicine specialist guide. For timed papers use the Internal Medicine specialist bank or the consultant bank.

Cardiology

Question 1

A 62-year-old man presents with 40 minutes of crushing chest pain. ECG shows ST elevation in V1 to V4. The nearest catheterisation laboratory can achieve device time within 90 minutes. The best reperfusion strategy is:

1. Thrombolysis with alteplase
2. Primary percutaneous coronary intervention
3. Intravenous heparin alone and observation
4. Elective angiography next week

Answer: B. Primary PCI is preferred for STEMI when it can be delivered within about 120 minutes of first medical contact. Thrombolysis is reserved for when timely PCI is not available. Dual antiplatelet therapy and anticoagulation are given on the way.

Question 2

A 70-year-old woman with atrial fibrillation has hypertension, diabetes and a previous TIA. Her CHA₂DS₂-VASc score and the recommended therapy are:

1. Score 2; aspirin
2. Score 6; oral anticoagulation, preferably a DOAC
3. Score 1; no therapy
4. Score 6; aspirin plus clopidogrel

Answer: B. Age 65 to 74 (1), female (1), hypertension (1), diabetes (1), prior TIA (2) gives 6. Anticoagulation is indicated; a DOAC is preferred over warfarin in non-valvular AF. Antiplatelet therapy is not an alternative for stroke prevention in AF.

Respiratory

Question 3

A patient with COPD has a pH of 7.28, PaCO₂ of 9 kPa and PaO₂ of 7 kPa on controlled oxygen despite an hour of nebulisers and steroids. The next step is:

1. Increase oxygen to 15 L/min via non-rebreather mask
2. Non-invasive ventilation (BiPAP)
3. Intravenous aminophylline alone
4. Discharge with antibiotics

Answer: B. Acute hypercapnic respiratory failure with acidosis persisting after initial treatment is the indication for NIV, with a target saturation of 88 to 92%. High-flow oxygen worsens hypercapnia in this group.

Question 4

Which finding is a criterion for a high-risk (complicated) parapneumonic effusion that needs chest tube drainage?

1. Pleural fluid pH below 7.2
2. Pleural fluid protein 25 g/L
3. Clear, straw-coloured fluid
4. Fluid glucose above 3.5 mmol/L

Answer: A. A pH under 7.2, frank pus, positive Gram stain or culture, or loculation indicate an infected space that antibiotics alone will not clear. Glucose is usually low in empyema.

Gastroenterology and hepatology

Question 5

A 50-year-old man with alcohol-related cirrhosis presents with haematemesis. After resuscitation, which drug should be started before endoscopy?

1. Terlipressin (or octreotide) and prophylactic antibiotics
2. High-dose oral iron
3. Propranolol only
4. Warfarin

Answer: A. Vasoactive therapy reduces portal pressure and bleeding, and antibiotic prophylaxis reduces infection and mortality in cirrhotic bleeding. Endoscopic band ligation follows within 12 hours. Beta blockers are for secondary prophylaxis, not the acute bleed.

Question 6

Which serological pattern indicates chronic hepatitis B infection?

1. HBsAg negative, anti-HBs positive, anti-HBc negative
2. HBsAg positive for more than 6 months, anti-HBc IgG positive
3. HBsAg negative, anti-HBc positive, anti-HBs positive
4. Anti-HBs positive only

Answer: B. Persistent surface antigen beyond six months defines chronic infection. Pattern A is vaccination, pattern C is resolved past infection. Gulf licensing often requires hepatitis B serology, so this comes up in both exam and practice.

Nephrology and electrolytes

Question 7

A patient has a serum potassium of 6.8 mmol/L with peaked T waves. The first drug to give is:

1. Intravenous calcium gluconate 10%
2. Oral calcium resonium
3. Furosemide
4. Sodium bicarbonate alone

Answer: A. Calcium stabilises the myocardium within minutes and is given first when ECG changes are present. Insulin with dextrose and nebulised salbutamol then shift potassium into cells, and removal follows with diuretics, binders or dialysis.

Question 8

An elderly woman on a thiazide has a sodium of 118 mmol/L, is drowsy and has had a seizure. The appropriate treatment is:

1. Rapid correction to normal with 3% saline over one hour
2. A bolus of hypertonic 3% saline to raise sodium by 4 to 6 mmol/L, then slow correction not exceeding about 8 mmol/L in 24 hours
3. Fluid restriction alone
4. Oral salt tablets

Answer: B. Severe symptomatic hyponatraemia needs a small, rapid rise to stop seizures, then controlled correction to avoid osmotic demyelination. Over-rapid correction is the exam's favourite trap.

Endocrinology

Question 9

A 24-year-old with type 1 diabetes has a glucose of 28 mmol/L, pH 7.1, bicarbonate 10 mmol/L and ketones 5 mmol/L. After starting fluids, insulin is given as:

1. A fixed-rate intravenous infusion of about 0.1 units/kg/hour, continuing long-acting insulin
2. Subcutaneous sliding scale only
3. No insulin until potassium is known to be high
4. A single bolus of 50 units

Answer: A. DKA is treated with fluids, fixed-rate IV insulin, potassium replacement once the level is known to be below about 5.5 mmol/L, and glucose added when blood glucose falls below 14 mmol/L. Insulin is held only if potassium is dangerously low.

Question 10

Which finding supports a diagnosis of primary hyperaldosteronism in a hypertensive patient?

1. High renin, low aldosterone
2. Low renin, high aldosterone, often with hypokalaemia
3. High cortisol with loss of diurnal rhythm
4. Raised urinary metanephrines

Answer: B. A suppressed renin with raised aldosterone (high aldosterone-to-renin ratio) is the screening pattern. Raised metanephrines suggest phaeochromocytoma; loss of cortisol rhythm suggests Cushing's.

Infectious disease

Question 11

A patient with suspected bacterial meningitis is in the emergency department. Lumbar puncture will be delayed for CT. The correct action is:

1. Wait for the CT and LP before any treatment
2. Take blood cultures and give intravenous ceftriaxone plus dexamethasone immediately, adding ampicillin if Listeria is a risk
3. Give oral antibiotics
4. Give antivirals only

Answer: B. Antibiotics must not be delayed for imaging. Dexamethasone given with or before the first dose reduces neurological complications in pneumococcal meningitis. Ampicillin covers Listeria in those over 50, pregnant or immunocompromised.

Question 12

Standard first-line treatment for drug-sensitive pulmonary tuberculosis consists of:

1. Two months of isoniazid, rifampicin, pyrazinamide and ethambutol, then four months of isoniazid and rifampicin
2. Six months of rifampicin alone
3. Twelve months of isoniazid alone
4. Two weeks of a fluoroquinolone

Answer: A. The 2HRZE/4HR regimen remains standard, with pyridoxine to prevent isoniazid neuropathy and baseline liver and visual checks. Gulf countries screen all expatriate workers for TB, so this is a frequent exam item.

Haematology and rheumatology

Question 13

A patient on unfractionated heparin develops a 50% fall in platelet count on day 6 with a new thrombosis. The management is:

1. Continue heparin and transfuse platelets
2. Stop all heparin, including flushes, and start a non-heparin anticoagulant such as argatroban or fondaparinux
3. Switch to low-molecular-weight heparin
4. Start warfarin immediately

Answer: B. This is heparin-induced thrombocytopenia with thrombosis. All heparin is stopped, a non-heparin anticoagulant is started, and warfarin is introduced only after platelets recover. LMWH cross-reacts and is contraindicated.

Question 14

A 45-year-old man has an acutely swollen, hot first metatarsophalangeal joint. He has chronic kidney disease stage 4. The most appropriate acute treatment is:

1. High-dose NSAID
2. Colchicine at full dose
3. Oral or intra-articular corticosteroid
4. Start allopurinol today and nothing else

Answer: C. NSAIDs are contraindicated in advanced CKD and colchicine needs dose reduction and caution. Corticosteroids are effective and safe for the acute attack. Urate-lowering therapy is started after the flare settles, not during it.

Acute medicine

Question 15

A 68-year-old woman has a temperature of 39 °C, heart rate 120, respiratory rate 28, blood pressure 85/50 mmHg and lactate 4.5 mmol/L with a presumed urinary source. Within the first hour, the essential actions are:

1. Blood cultures, broad-spectrum intravenous antibiotics, 30 mL/kg crystalloid, lactate measurement and urine output monitoring
2. Oral antibiotics and review tomorrow
3. Vasopressors before any fluid
4. Await culture results before antibiotics

Answer: A. This is septic shock. The hour-one bundle is cultures, antibiotics, fluids, lactate and monitoring, with vasopressors if the mean arterial pressure stays below 65 mmHg after fluid.

How to use these questions

• Work every system, including the ones you refer. The paper does not know your subspecialty.
• Check current guidelines for AF anticoagulation, DKA, sepsis, hyponatraemia and TB; the exam follows them, not what you learned a decade ago.
• Aim ten points above the pass mark on mocks, especially for the consultant paper at 70%.
• Practise under time in the Internal Medicine bank; the method is in how to use a question bank.

Other specialty banks and sizes are listed in specialty question banks for doctors. Licensing routes: DHA, SCFHS. When you hold eligibility, join the doctor talent pool.

Frequently asked questions

How many questions are in the internal medicine specialist Prometric exam?

Usually 100 to 150 in 2.5 to 3 hours. Your eligibility notice states the exact format.

What is the pass mark?

About 60% for the specialist paper and 70% for the consultant paper, scaled at some authorities.

Is the specialist exam harder than the GP exam?

It is deeper rather than broader: registrar-level management across all medical systems, with more guideline-specific detail.

Can an MRCP or FCPS holder skip the exam?

Often, depending on the authority's recognition list and the title applied for. Check the exemptions guide.

Are these real exam questions?

No. They are original practice questions written to the published blueprint. Real exam content is confidential.