FREE Internal Medicine Questions and Answers
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 is an infection-related Systemic Inflammatory Response System (SIRS). Based on her history of alcohol use and a chest x-ray finding, this patient has sepsis that is 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.
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?
As much as 70% of patients who receive radioactive iodine therapy go on to develop hypothyroidism within 10 years of treatment. Complications like cholestasis and granulocytopenia are linked to anti-thyroid therapeutic alternatives like prophylthiouracil. Surgery for the thyroid, such as a sub-total thyroidectomy, increases the danger of harming the recurrent laryngeal nerve. Hemorrhage, hypoparathyroidism, and hypothyroidism are further problems. No proof exists that radioactive iodine therapy can raise the risk of developing cancer.
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:
Please select 2 correct answers
The number of cancer survivors has increased as a result of advancements in cancer therapy. Many of these survivors deal with a variety of lifelong issues like melancholy, worry about recurrence or relapse, infertility, toxic side effects from treatment such neuropathy, and secondary cancers. An anthracycline was used to treat the patient in this case, which is known to increase the risk of myelodysplastic syndrome and acute leukemia. According to one series (Campone et al. Annals of Oncology 2005), the risk applied to only 1% of all treated individuals. 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.
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?
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 resemblance in appearance. Babesiosis is transmitted by ticks and can be fatal, especially in those who have had their spleen removed. Babesiosis, Lyme disease, and Human Granulocytic Anaplasmosis can all be seen together since all three diseases are spread by the deer tick (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 very 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, due to his splenectomy, he is at a significant risk for decompensation.
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?
Bone tumors known as giant cell tumors (GCT) are often benign yet complicated. Years after the original diagnosis, they frequently spread to the lymph nodes or lungs and are known to be locally harmful. In about 10% of instances, local recurrence following therapy is a problem. Despite making up less than 10% of all primary tumors, GCTs tend to affect younger persons (ages 25 to 40) and women more frequently than other populations. One of the common complaints is a pain that slowly becomes worse near the tumor's site. A pathological fracture triggers a diagnosis in 15% of circumstances. Upon inspection, there can be a palpable enlargement that is warm, sensitive, or has a restricted range of motion. A well-defined, lucent "soap bubble" look is a distinctive feature of radiographs. Surgery, specifically intralesional excision by "extended" curettage, is the basis of treatment. Recurrence locally is frequent.
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?
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. In a patient with chronic obstructive pulmonary disease (COPD), recent changes in the change of voice suggest lung carcinoma (the hoarseness is due to metastatic disease involving recurrent laryngeal nerve, which indicates extra pulmonic spread and incurability by surgical means. Patients who have malignant pleural effusions, evidence of contralateral lymphadenopathy or lung involvement, or any extra pulmonic spread are not considered surgically curable (although chemotherapy and radiation therapy in patients with oat cell carcinoma of the lung can cause remission, these therapies are not curative).
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?
It would be best to supplement the effects of bronchodilators by lowering inflammation around the airways using an intravenous steroidal drug, such as hydrocortisone.