FREE Internal Medicine Board Review Questions and Answers
A 25-year-old man with a severe asthma attack is admitted to the emergency room. He also feels queasy and reports having diarrhea and vomiting. With many hospitalizations and one intubation five years ago, the patient has a long history of severe asthma. He started having breathing problems two days ago, which have worsened. He attempted home nebulizers for ipratropium, cromolyn treatment, and albuterol, but nothing helped his symptoms. Peak flow rates in the hospital are over 50% lower than the baseline. Which medication from the list below must be added to the patient's treatment plan to help him with his present symptoms?
Explanation:
It would be best to supplement the effects of bronchodilators by lowering inflammation around the airways using an intravenous steroid drug, such as hydrocortisone. When the side effects of systemic steroids are to be avoided, beclomethasone (Choice A), a surface-acting steroid administered in aerosol form, is employed. These medications, however, are likewise of limited value in the short-term management of bronchospasm. Mast cell stabilizer disodium cromoglycate (option B) is solely employed to stop asthmatic bronchospasm. This agent does nothing to stop an episode after the bronchospasm has started. A methylxanthine phosphodiesterase inhibitor called theophylline (choice D) is occasionally helpful for long-term asthma management, although it is less effective for the acute management of bronchospasm. Theophylline is less effective than inhaled steroids, even in treating persistent asthma. In this situation (option E), an intravenous steroid is chosen over an oral steroid like prednisone since the patient has a history of recent nausea and vomiting, which may hinder the absorption of oral medicines. In an emergency, oral medication typically has the same effect as intravenous medication. The absorption of oral medication is a problem in this situation.
An obese 32-year-old woman arrives with ongoing right knee pain. She rejects any claims of injury, bruising, fever, rash, or general ill health. She has never experienced anything like this. She doesn't have any unique medical history. She owns a women's clothing store, which keeps her busy but stressed. The knees are symmetrical and show no erythema, effusion, edema, or warmth. When felt, the distal femur is painful. On the right, there is less room for mobility. On the diseased femur, on an x-ray, there is a lucent, lytic lesion. Which diagnosis is more likely?
Explanation:
Giant cell tumors (GCT; option D) are intricate but mostly benign bone malignancies. Years after the original diagnosis, they frequently become locally destructive and spread to the lymph nodes or lungs. In 10% of cases, local recurrence following therapy is a difficulty. Although GCTs comprise less than 10% of all primary tumors, they tend to affect women and younger individuals (ages 25–40) more frequently than other groups. One of the common complaints is gradually getting more muscular pain at the tumor location. A pathological fracture results in a diagnosis in 15% of instances. Upon examination, a palpable enlargement with warmth, pain, or restricted range of motion may be seen. The appearance of a well-defined, lucent "soap bubble" on a radiograph is distinctive. Surgery, specifically intralesional excision by "extended" curettage, is the basis of treatment. Recurrence locally is frequent. In June 2013, the FDA authorized denosumab for resectable giant cell tumors. Radiotherapy, chemotherapy, and surgery are all options for treating pulmonary metastases.
Osteoarthritis, option A, is a degenerative joint condition. Obesity, past joint damage, gender, and advanced age are risk factors. Pain is the predominant symptom. Everyday X-ray observations include joint space narrowing, osteophytes, subchondral cyst formation, and subchondral bone sclerosis. Osteogenic sarcoma, a bone cancer that typically affects people under 20, is Choice B. The main issue is pain, which is frequently worse at night. The proximal end of the afflicted tibia, humerus, or distal femur may enlarge. The lytic tumor with irregular margins, soft tissue expansion, and "Codman's Triangle," which denotes reactive periosteal production of new bone, is the hallmark x-ray findings. Ewing's sarcoma, option C, is a soft tissue or bone cancer. It typically affects children or adults under 20 years old and can happen anywhere in the body. Long bones and the pelvis are frequently impacted. Pain is often the initial complaint, and other symptoms, including fever, anemia, and an elevated white blood cell count, point to an inflammatory process. Radiographs indicate lytic lesions and a periosteal reaction, sometimes called an "onion skin" reaction. Choice E (chondrosarcoma) is a type of cancer that often develops from cartilage and affects the pelvis, shoulders, ribs, or ends of long bones. One of the most frequent initial complaints is pain, especially at night. On radiographs, calcified cartilage and areas of demineralization may be visible. Synthesis: Young adult women had a higher incidence of giant cell tumors (25–40-year-olds). Pain is the initial complaint, either present or absent from a pathological fracture. An apparent "soap bubble" lesion on radiographs is a characteristic feature. The majority of treatment is surgery. In June 2013, the FDA authorized denosumab for resectable giant cell tumors. Radiotherapy, chemotherapy, and surgery are all options for treating pulmonary metastases.
A 63-year-old woman with a significant past medical history of breast cancer arrives at the hospital with a three-day history of sore throat, exhaustion, and a petechial rash throughout the anterior abdominal wall and lower extremities. A white blood cell count of 115.5 cells/ul (average: 3.5-10.5 cells/ul), of which 77% blasts, a hemoglobin level of 6.1 g/dl (average: 12–16 g/dl), and a platelet count of 22,000/ul (average: 150–400 thousand/ul) are all revealed by laboratory tests. She receives induction therapy while being treated at the hospital. Which of these statements is accurate:
Explanation:
The number of cancer survivors has increased due to advancements in cancer therapy. Many survivors deal with lifelong issues like melancholy, worry about recurrence or relapse, infertility, toxic side effects from treatment such as neuropathy, and secondary cancers. Anthracycline was used to treat this patient, and it has been shown to increase the risk of myelodysplastic syndrome and acute leukemia. One series showed that 1% of all treated patients were at risk (Campone et al., Annals of Oncology, 2005). Chemotherapy is frequently ineffective for those who acquire therapy-related MDS or AML, and their survival is usually only moderately long. Secondary leukemias and cardiomyopathy are linked to anthracyclines.
A 50-year-old patient with a history of hypertension, hyperlipidemia, and alcoholism arrives at the emergency room with a strong cough, a fever, chills, and generalized weakness. Her family adds that she has been acting confused, and she claims that she has had those symptoms for over a week. She recently resumed drinking and is currently taking Lipitor and Atenolol. Vitals: temperature is 102.5 degrees Fahrenheit, heart rate is 105 beats per minute, blood pressure is 110/75, and respiratory rate is 22. During a physical examination, the right lower lobe (RLL) exhibits diminished breath sounds correlated with an RLL infiltrate on a chest x-ray. What is your prevailing medical opinion?
Explanation:
Sepsis is an infection-related systemic inflammatory response syndrome (SIRS). Based on her history of alcohol use and a chest x-ray finding, this patient has sepsis, most likely caused by aspiration pneumonia. According to recommendations for sepsis patients, the following procedures should be carried out within three hours of triage: lactate levels should be monitored, blood cultures should be taken, broad-spectrum antibiotics should be given, and aggressive IV fluids should be given if hypotension is present. Within six hours of triage, vasopressors should be provided if hypotension is still present. If arterial hypotension persists despite fluids, central venous pressure and oxygen saturation should be evaluated. This condition is known as septic shock and is characterized by severe sepsis, hypotension, and resistance to IV fluid resuscitation. b. Multiple Organ Dysfunction Syndrome is characterized by impaired organ function caused by an acute insult and necessitating medical intervention to maintain homeostasis. c. SIRS, an inflammatory reaction to insult, is diagnosed when a patient meets two or more of the requirements listed below: ‥ A temperature between 96.8°F (36°C) and 100.9°F (38°C) ‥ A heartbeat > 90 bpm ‥ A breathing rate > 90 ‥ More than or equal to 4,000 or more than 10% bands in the white blood cell count d. The term "severe sepsis" refers to sepsis that includes organ failure, hypotension, or hypoperfusion. Summary: A known infection causes sepsis, a systemic inflammatory response system. Based on carefully performed studies that advised actions between 3 and 6 hours after triage and are linked to decreased mortality, specific scheduled guidelines have been released.
A 50-year-old patient with a history of hypertension, hyperlipidemia, and alcoholism arrives at the emergency room with a strong cough, a fever, chills, and generalized weakness. Her family adds that she has been acting confused, and she claims that she has had those symptoms for over a week. She recently resumed drinking and is currently taking Lipitor and Atenolol. Vitals: temperature is 102.5 degrees Fahrenheit, heart rate is 105 beats per minute, blood pressure is 110/75, and respiratory rate is 22. During a physical examination, the right lower lobe (RLL) exhibits diminished breath sounds correlated with an RLL infiltrate on a chest x-ray. What is your prevailing medical opinion?
Explanation:
A patient with chronic obstructive pulmonary disease (COPD) with recent changes in the change of voice suggests lung carcinoma (the hoarseness is due to metastatic disease involving the recurrent laryngeal nerve. This indicates extra pulmonic spread and incurability by surgical means. The other symptoms described can all be seen with an exacerbation of his COPD and do not necessarily imply any factors that would result in an incurable lung lesion. The only chance for a cure for lung carcinoma is surgical resection. (Chemotherapy and radiation therapy in patients with oat cell carcinoma of the lung can cause remission, but these therapies are not curative.) Patients who have malignant pleural effusions, evidence of contralateral lymphadenopathy or lung involvement, or any extra pulmonic spread are not considered surgically curable.
An ER visit for a 46-year-old male with non-alcoholic cirrhosis and a history of splenectomy following a car accident five years prior reveals a 102 F fever, nausea, weakness, stomach discomfort, and myalgia. The patient and his dog had trekked on Cape Cod two weeks earlier. Temperatures upon arrival were 103°F, 108°F, RR 12, Sa02 98% in RA, and BP 90/70. During the examination, the patient appears sickly and is feeble, febrile, and tachycardic. WBC 14.6; Platelets 218000; Hb 10; Na 136; K 4.0; BUN 22; Cr 1.3; are the results of the lab tests. Additional labs are pending. The image below shows a blood smear. Intravenous fluids and supportive treatment are initiated for the patient after admission to the MICU. What specific therapy is being used?
Explanation:
Doxycycline, Quinine, and Clindamycin. Babesia parasites are visible in a blood smear. The most typical form observed under a microscope is a ring-shaped structure with pale blue cytoplasm and one to two red chromatic spots. These ring forms can be mistaken for Plasmodium falciparum trophozoites due to their similar appearance. Ticks transmit babesiosis and can be fatal, especially in those with their spleen removed. Babesiosis, human granulocytic anaplasmosis, and Lyme disease are all diseases spread by deer ticks. Therefore, they can all be seen together (Ixodes scapularis). In patients with healthy immune systems, sickness may be asymptomatic or mild. Atovaquone and azithromycin are the recommended treatments for babesiosis, while Clindamycin and Quinine are preferable when a patient is unwell. As indicated above, co-infection is common. Thus, doxycycline should be added while awaiting results from other laboratories. This patient has tachycardia, hypotension, a fever of 103, and is severely dehydrated. Additionally, his splenectomy puts him at significant risk for decompensation. The Johns Hopkins Antibiotic Guide is cited as one source. 2. Up-to-date: clinical signs, babesiosis diagnosis, therapy, and prevention.
A 34-year-old mother of three brings concerns of restlessness, agitation, palpitations, sweating, and a dramatic 8-pound weight loss to her primary care physician (without any dietary or exercise intervention). She also complains of fine trembling and heat sensitivity. She categorically denied using any form of tobacco, alcohol, or caffeine. Her vital signs are as follows: 37 °C (98.6 °F), 120 beats per minute for her heartbeat, 140/80 mmHg for her blood pressure, and 20 beats per minute for her breathing. During a physical examination, the doctor noted pre-tibial myxedema, lid lag, a distinctive gaze, and fine tremors. The thyroid gland is lobular and diffusely enlarged when palpated. On auscultation, a bruit is audible over the surface of the gland. According to lab tests, TSH levels are deficient, and radioactive iodine uptake is boosted. Graves disease is identified, and potential therapies are addressed. What long-term risks are there if a patient chooses radioactive iodine therapy?
Explanation:
About 70% of patients who receive radioactive iodine therapy develop hypothyroidism within ten years of treatment. Cholestasis (Choice A) and granulocytopenia are side effects of anti-thyroid medicines such as propylthiouracil, one type of treatment (Choice B). Surgery for the thyroid, such as a subtotal thyroidectomy, increases the chance of harm to the recurrent laryngeal nerve. Hemorrhage, hypoparathyroidism, and hypothyroidism are further problems. Choice E is incorrect because there is no proof that radioactive iodine therapy can raise cancer risk. References: Chapman, E. M., and Dunn, J. T. (1964). Following radioactive-iodine treatment for thyrotoxicosis, the incidence of hypothyroidism is increasing. 1037–1042 in New England Journal of Medicine, 271(20).