Free Internal Medicine Questions and Answers — Questions and Answers
Question 1: With complaints of restlessness, agitation, palpitations, sweating, and considerable weight loss of 8 pounds (without any food or exercise intervention), a 34-year-old woman who is a mother of three visits her general care physician. She also complains of fine trembling and heat sensitivity. She vehemently denies 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 a pre-tibial myxedema, lid lag, and distinctive gaze in addition to a fine tremor. The thyroid gland is lobular and diffusely enlarged upon palpation. On auscultation, a bruit is audible over the surface of the gland. TSH levels are extremely low, and radioactive iodine uptake is boosted, according to lab tests. Graves disease is identified, and potential therapies are addressed. What long-term risks are there if the patient chooses radioactive iodine therapy?
- Hypothyroidism (Correct answer)
- Cholestasis
- Recurrent laryngeal nerve damage
- Carcinoma of thyroid gland
Correct answer: Hypothyroidism
Radioactive iodine therapy (RAI) for Graves' disease works by destroying overactive thyroid cells, reducing the production of thyroid hormones. A common long-term consequence is that too much thyroid tissue is destroyed, leading to insufficient hormone production. This results in iatrogenic hypothyroidism, which then requires lifelong thyroid hormone replacement therapy.
Question 2: After a car accident five years prior, a 46-year-old man with non-alcoholic cirrhosis and a history of splenectomy presented to the emergency room with 102 F fever, nausea, weakness, stomach discomfort, and myalgia. The patient and his dog had gone trekking on Cape Cod two weeks prior. Arrival values were 103°F, 108°HR, 12°RR, and 98% SaO2 in RA. The patient appears unwell, is feeble, febrile, and tachycardic during the examination. WBC 14.6; Platelets 218000; Hb 10.0; Na 136; K 4.0; BUN 22; Cr 1.3; in the lab. Additional labs are pending. Below is a blood smear. Intravenous fluids and supportive treatment are initiated for the patient after admission to the MICU. What specific therapy is being used?
- Atovaquone+ Doxycycline
- Clindamycin + Quinine+ Doxycycline (Correct answer)
- Clindamycin + Doxycycline
- Clindamycin + Atovaquone
Correct answer: Clindamycin + Quinine+ Doxycycline
The patient's symptoms (fever, myalgia, weakness, splenectomy history, Cape Cod trekking, blood smear with intraerythrocytic parasites) are highly suggestive of Babesiosis, a tick-borne parasitic infection. For severe Babesiosis, especially in immunocompromised or asplenic patients, the recommended treatment regimen is a combination of clindamycin and quinine. Doxycycline is often added if co-infection with Lyme disease or Anaplasmosis is suspected, which is common in endemic areas like Cape Cod.
Question 3: 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 noteworthy medical history. She owns a woman's clothes store, which keeps her busy yet stressful. 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. Over the diseased femur on an x-ray, there is a lucent, lytic lesion. Which diagnosis is more likely?
- Osteoarthritis
- Chondrosarcoma
- Osteogenic sarcoma
- Giant cell tumor of the bone (Correct answer)
Correct answer: Giant cell tumor of the bone
The patient's presentation of ongoing right knee pain, pain on palpation of the distal femur, reduced mobility, and a lucent, lytic lesion on X-ray in a young to middle-aged adult is characteristic of a giant cell tumor of the bone (GCT). GCTs are typically benign but locally aggressive tumors that commonly affect the epiphysis/metaphysis of long bones, particularly around the knee. Other options are less likely given the specific age and X-ray findings.
Question 4: A 63-year-old woman with a major past medical history of breast cancer arrives at the hospital with a three-day history of a sore throat, lethargy, and a petechial rash throughout the anterior abdominal wall and both lower extremities. A white blood cell count of 115.5 cells/ul (normal: 3.5-10.5 cells/ul), of which 77% are blasts, a hemoglobin level of 6.1 g/dl (normal: 12–16 g/dl), and a platelet count of 22,000/ul (normal: 150–400 thousand/ul) are all revealed by laboratory tests. She receives induction therapy while being treated at the hospital. The following statement is true:
- Anthracyclines are associated with cardiomyopathy but are there is no association between their use and secondary leukemias
- Prior treatment with doxorubicin (an anthracycline) for breast cancer has increased her risk of developing leukemia (Correct answer)
- Leukemias associated with prior chemotherapy are associated with an unfavorable prognosis (Correct answer)
- All of the above
Correct answer: Prior treatment with doxorubicin (an anthracycline) for breast cancer has increased her risk of developing leukemia
The patient's history of breast cancer treated with doxorubicin (an anthracycline) is a significant risk factor for developing secondary acute myeloid leukemia (AML). Anthracyclines are known to be topoisomerase II inhibitors, which can cause DNA damage and lead to specific chromosomal translocations associated with therapy-related AML. This type of secondary leukemia often carries an unfavorable prognosis.
Question 5: A 25-year-old man is treated for a severe asthma attack in 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, and they have been getting worse ever since. 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 they were at baseline. Which medication from the list below needs to be added to the patient's treatment plan in order to help him with his present symptoms?
- Oral prednisone
- Disodium cromoglycate
- Intravenous hydrocortisone (Correct answer)
- Theophylline
Correct answer: Intravenous hydrocortisone
The patient is experiencing a severe asthma attack, indicated by a long history of severe asthma, previous intubation, worsening symptoms despite home nebulizers, and significantly reduced peak flow rates. In such a severe exacerbation, systemic corticosteroids are crucial to reduce airway inflammation. Intravenous hydrocortisone is preferred over oral prednisone in acute, severe cases due to faster onset of action and reliable absorption, especially given his reported nausea, diarrhea, and vomiting which could impair oral absorption.
Question 6: Having a history of hypertension, hyperlipidemia, and alcoholism, a 50-year-old patient arrives at the emergency room with a strong cough, a fever, chills, and generalized weakness. Her family adds that she has been acting confused as well, and she claims that she has had those symptoms for more than a week. She recently resumed drinking and is currently taking Lipitor and Atenolol. Vital signs include a temperature of 102.5°F, a blood pressure of 110/75, a heart rate of 105 beats per minute, a respiratory rate of 22, and reduced breath sounds in the right lower lobe (RLL). What is your prevailing medical opinion?
- Sepsis (Correct answer)
- Severe sepsis
- Septic shock
- Systemic Inflammatory Response System
Correct answer: Sepsis
The patient presents with a strong cough, fever (102.5°F), chills, generalized weakness, and confusion, along with reduced breath sounds in the RLL, suggesting pneumonia. Her vital signs show a temperature >100.4°F and heart rate >90 bpm, meeting two criteria for Systemic Inflammatory Response Syndrome (SIRS). With a suspected infection (pneumonia) and SIRS criteria, the prevailing medical opinion is sepsis.
Question 7: A 66-year-old guy who has smoked 59 packs over the course of 59 years arrives at the emergency room complaining of a productive cough and worsening chronic shortness of breath. Over the past two weeks, he has also experienced multiple instances of blood-tinged sputum. His son claims that he has seemed hoarser than usual for the last three weeks. He shows soft dispersed rhonchi in both lung fields with a prolonged expiratory phase, along with dense rhonchi in the right mid-lung field, according to a physical examination. An irregular 6-cm tumor in the right middle lobe of the chest, together with accompanying lobar consolidation, is seen on the chest x-ray film. Which of the following would be the strongest indication that the patient has lung cancer that is surgically incurable?
- Worsening dyspnea
- Hemoptysis
- Increasing hoarseness (Correct answer)
- A post obstructive pneumonia
Correct answer: Increasing hoarseness
In a patient with a significant smoking history, worsening dyspnea, hemoptysis, and a lung mass, increasing hoarseness is a strong indicator of surgically incurable lung cancer. Hoarseness in this context often signifies involvement of the recurrent laryngeal nerve, which can be compressed or invaded by a tumor in the mediastinum. Recurrent laryngeal nerve paralysis indicates advanced disease that has spread beyond the lung, making surgical resection unlikely to be curative.
Free Internal Medicine Questions and Answers
With complaints of restlessness, agitation, palpitations, sweating, and considerable weight loss of 8 pounds (without any food or exercise intervention), a 34-year-old woman who is a mother of three visits her general care physician.
She also complains of fine trembling and heat sensitivity.
She vehemently denies 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 a pre-tibial myxedema, lid lag, and distinctive gaze in addition to a fine tremor.
The thyroid gland is lobular and diffusely enlarged upon palpation.
On auscultation, a bruit is audible over the surface of the gland.
TSH levels are extremely low, and radioactive iodine uptake is boosted, according to lab tests.
Graves disease is identified, and potential therapies are addressed.
What long-term risks are there if the patient chooses radioactive iodine therapy?