FREE Internal Medicine Board Review MCQ Questions and Answers
A 68-year-old man who is a patient in the emergency room woke up with palpitations, chest pain, dyspnea, and vertigo. He claims his heart is "beating," but he has no history of heart disease or high blood pressure. His pulse is quick and erratic, his blood pressure is 85/60 mmHg, and crackles can be heard at the bases of his lungs. His standard laboratory tests, including a troponin level, are expected. His EKG reveals atrial fibrillation with a 130-beat-per-minute ventricular response. Which course of action is ideal?
Explanation:
The man's cardiac rhythm is atrial fibrillation (AF) with a rapid ventricular response. AF is the most common arrhythmia, originating in the atria or pulmonary veins. Typical EKG findings are an irregularly irregular rhythm with no visible P-waves. The rhythm may be asymptomatic but is associated with a rapid ventricular rate and signs of cardiovascular instability. Synchronized electrical cardioversion is optimal for acute arrhythmia (onset less than 48 hours) with severe cardiovascular symptoms. Patients with chronic AF require several weeks of anticoagulants (usually warfarin), followed by elective cardioversion. Prescribe either beta-blockers or digoxin for rate control, or rhythm control with sotalol or amiodarone. There is no clear-cut best practice. Anticoagulation is always indicated to reduce stroke risk from thromboembolic originating in the atrial appendage.
A middle-aged man who was experiencing chest problems went to the emergency room. Results from the lab and the EKG showed a non-ST elevation of myocardial infarction (NSTEMI). His left anterior descending artery had a significant branch that was 95% blocked, according to an angiography (LAD). Less than 40% of his other streets seemed to be stopped. The highly clogged vessel underwent balloon angioplasty, and a drug-eluting stent was implanted. The patient claims that following the treatment, he is pain-free. Now that his resting EKG is normal, ischemia cannot be detected by an isotope stress test. With the exception of which drug the patient should be released on all the following medications?
Explanation:
Warfarin is not usually indicated for coronary artery disease patients unless their CAD is complicated by atrial fibrillation or venous thromboembolism. Clopidogrel, a platelet inhibitor, is generally prescribed to diminish the chance of stent thrombosis. However, 15% to 48% of patients are resistant, so higher doses of clopidogrel or another anti-platelet drug (e.g., prasugrel) may be employed. If the patient's bleeding risk is low, add Aspirin for dual anti-platelet therapy. A statin is definitely indicated even if the patient's LDL cholesterol is in the normal range. Many cardiologists believe LDL cholesterol should be reduced to less than 70 mg/dL in CAD patients. Angiotensin-converting enzyme (ACE) inhibitors have a protective effect on the brains, hearts, and kidneys of CAD patients, in addition to their antihypertensive action.
Which of the following statements about a ventilator with volume control is false?
Explanation:
Mechanical respirators are classified as conventional volume-controlled ventilators (VCV) or more modern pressure-controlled ventilators (PCV). The respiratory therapist sets the VCV tidal volume so the patient receives fixed minute ventilation, wherein the pressure is set, and may or may not provide adequate minute ventilation, depending on the patient's airway resistance and lung compliance. Pressure can fluctuate in a VCV. If pressure is too high to deliver an adequate tidal volume then ventilator-induced lung injury, )VILI), results. The respiratory therapist manipulates mean airway pressure in a PCV by increasing the respiratory time, thus diminishing the mean airway pressure and reducing the likelihood of high peak values. Controlled mandatory ventilation (CMV) is the mode usually reserved for unconscious or heavily sedated patients. Assist-control (AC is the mode on which a fixed respiratory rate and tidal volume are delivered if the patient's respiratory effort is inadequate. Synchronized intermittent mandatory ventilation (SIMV) is the mode in which the respiratory therapist delivers a set tidal volume at a set rate, but does not supplement the patient's spontaneous breathing.
A 52-year-old guy with Type 2 diabetes attends the clinic for his yearly checkup. The only drug he takes is metformin. His serum creatinine level was 1.8 mg/dL, and his most recent hemoglobin A1C result was 6.5%. Despite having a high blood pressure of 170–175 mm/Hg, the remainder of his evaluation is negative. Although his chest x-ray is normal, left ventricular hypertrophy is suggested by his EKG. Which medication would be best for treating his hypertension?
Explanation:
Angiotensin receptor blocker (ARB). hypertension is common among diabetics and contributes to such complications as myocardial infarction, heart failure, stroke, diabetic nephropathy, and microvascular disease. the American Diabetes Association (ADA) recommends reducing the diabetic's blood pressure below 130/80 mm/Hg 9 (rather than below 140/90 mm/Hg for the general population with isolated hypertension). Rarely is a single drug sufficient to achieve the ADA's target goal. The patient's elevated creatinine and LVH indicate end-organ damage, so immediate antihypertensive therapy is required. The ADA and JNC8 guidelines recommend initiating pharmacologic therapy in patients under 606 with diabetes using either an ACE Inhibitor or ARB therapy (but never together) because of their renal protective action and low incidence of side effects. Add additional drugs with different mechanisms of action to reach the target goal, instead of increasing the dose of a single agent. If the diabetic has ischemic heart disease, add a dihydropyridine CCB or beta-blocker. Thiazide diuretics are recommended as a first-line treatment option in individuals without diabetes.
A 25-year-old lady who has been experiencing lethargy and polyuria for the past nine months comes into your office for an examination. She also had anorexia and a mysterious 12-pound weight drop. She has also experienced nocturnal sweats for a few months. She exhibited minor hypercalcemia upon evaluation of her lab results from her yearly visit roughly nine months prior, while all other tests, including glucose, were normal. She has been playing tennis outside more frequently and anticipated feeling better as a result of the increased exercise. She doesn't have a history of fractures or nephrolithiasis. No history of hypercalcemia in the family. She doesn't use any prescription drugs.
Physical exam:
Weight 125 pounds, height 5’2”, blood pressure 102/74 mmHg, heart rate 94 bpm
She has dry mucous membranes and delayed deep tendon reflexes. Otherwise unremarkable.
You send her to the lab to evaluate her symptoms and history of mild hypercalcemia. Her lab results are remarkable for Calcium = 13.1 mg/dL (8.9-10.1 mg/dL)
Phosphorus = 5.0 mg/dL (2.5-4.5 mg/dL)
Creatinine = 1.4 mg/dL (0.6-1.1 mg/dL)
Serum urea nitrogen = 22 mg/dL (6-21 mg/dL)
Intact PTH = 4 pg/mL (10-65 pg/mL)
25-Hydroxyvitamin D = 24 ng/mL (25-80 ng/mL)
1,25-Hydroxyvitamin D = 90 pg/mL (16-65 pg/mL)
Alkaline phosphatase = 99 U/L (37-98 U/L) <br)
Which medication would best address the cause of this patient’s hypercalcemia?
Explanation:
This patient has sarcoidosis which is associated with hypercalcemia. Hypercalcemia occurs in 11% of patients with sarcoidosis, hypercalciuria in 40%, and renal calculi in 11%. Intrarenal calcium deposition can result in renal failure. Sarcoidal macrophages have 25-hydroxyvitamin D–1alpha- hydroxylase, which converts 25-hydroxyvitamin D to the more active vitamin D metabolite, 1,25 dihydroxy vitamin D. Renal formation of 1,25-dihydroxy vitamin D is tightly regulated, but the extrarenal formation is not. This patient’s hypercalcemia was made worse with increased sun exposure and may have increased her risk for dehydration. The best initial treatment is prednisone since glucocorticoids decrease the conversion of 25-hydroxyvitamin D to 1,25-dihydroxy vitamin D via 1alpha-hydroxylation. None of the other options work on decreasing 1,25-dihydroxy vitamin D production so they would only be modestly effective (zoledronic acid, calcitriol) or not effective at all (cinacalcet).
An intermittent, mid-sternal chest ache that typically lasts 5 to 10 minutes affects a 57-year-old male. Both when we are working and when we are not. His throat also feels sore, which occasionally gets better with antacids. He stopped smoking around the age of 50. He denies having other serious medical issues. His type 2 diabetes and hypertension run in the family. His height is 70 inches, weight is 210 pounds, blood pressure is 135/85 mmHg, and pulse is regular at 76. Auscultation reveals his chest is clean and free of cardiac rubs or murmurs. The overall evaluation is unfavorable. He has a normal electrocardiogram. What logical step would result in the best chance of a diagnosis?
Explanation:
Technetium Tc99m Sestamibi stress test. The primary objective is to determine if the patient has coronary artery disease (CAD). His history of smoking, high blood pressure, and possibly diabetes already elevates his risk. A lipid profile would only corroborate his risk for CAD. An EGD endoscopy would rule out an upper gastrointestinal cause of his symptoms, such as gastroesophageal reflux or esophageal spasm. Many patients have both coronary artery disease and gastrointestinal reflux. An elevated troponin level may indicate recent myocardial damage but is likely to be normal or equivocal in this patient. Since he is presently stable and pain-free, an isotopic stress test is preferable to immediate angiography. Consider angiography, and possible angioplasty and stenting, after reviewing the results of his stress test.
You are meeting a 20-year-old male who has complained for the previous two months about "puffy eyes" and "swollen ankles." Additionally, he says that his pee "sort of looks frothy and foamy." His vital signs during the examination are within normal ranges, and the funduscopy is uneventful save for minor bilateral edema 2+ in the bilateral feet to the ankle. He has never experienced any health issues or operations. His tests show an average serum creatinine level; a considerable 4-plus protein level without blood or bacteria is found in the urine. He has had a kidney biopsy, which on light microscopy appears normal but, on electron microscopy, reveals diffuse podocyte effacement. Negative immunofluorescence results. Which medical intervention is ideal for this patient?
Explanation:
This patient most likely has Minimal Change Disease. Minimal Change Disease is most common in very young children but does commonly occur in older children and young adults as well. Minimal change disease is unique in that it lacks visible evidence of pathology on light microscopy alone. Characteristic findings on electron microscopy include podocyte effacement, vacuolation, and growth of microvilli on the visceral epithelial cells. Corticosteroids are the initial treatment of choice. A typical initial regimen is oral prednisone in a daily dosage of 1 mg/kg of body weight for 8-16 weeks (or until 1 wk after remission is achieved) followed by an alternate-day single-dose and then tapered if proteinuria disappears of falls to a very low level. Even after remission, relapses are common (only approximately 1/3 of patients have a single episode). If the patient is found to be resistant to steroids (as approximately 25% are), then tacrolimus, cyclosporine, or cyclophosphamide would be used. These are also used in patients with frequent relapses.
