ITE General Internal Medicine 5 — Questions and Answers
Question 1: A 66-year-old man with known COPD presents with worsening dyspnea and increased sputum production. Spirometry shows FEV1/FVC of 0.58 and FEV1 55% predicted. His current regimen is a LABA alone. The next best step is:
- Add a LAMA (tiotropium) (Correct answer)
- Start systemic corticosteroids long-term
- Add theophylline
- Start inhaled corticosteroids alone
Correct answer: Add a LAMA (tiotropium)
GOLD guidelines recommend combining LABA and LAMA for symptomatic COPD patients inadequately controlled on monotherapy to reduce exacerbations.
Question 2: A 44-year-old woman presents with a 3-week history of pleuritic chest pain, facial rash worsened by sun, and joint pain. ANA is 1:640. Which antibody is most specific for systemic lupus erythematosus?
- Anti-dsDNA antibody (Correct answer)
- Anti-SSA (Ro) antibody
- Anti-Scl-70 antibody
- Anti-CCP antibody
Correct answer: Anti-dsDNA antibody
Anti-dsDNA antibodies are highly specific for SLE (>95%) and correlate with disease activity and lupus nephritis.
Question 3: A 78-year-old woman with osteoporosis takes alendronate. After 5 years of therapy, a DXA scan shows T-score of -2.4. She denies new fractures. What is the most appropriate next step?
- Drug holiday (discontinue bisphosphonate for 1-2 years) (Correct answer)
- Switch to teriparatide
- Continue alendronate indefinitely
- Add denosumab to alendronate
Correct answer: Drug holiday (discontinue bisphosphonate for 1-2 years)
A drug holiday after 5 years of bisphosphonate therapy is recommended for low-risk patients as the drug remains in bone and continues to work.
Question 4: A 52-year-old man with hypertension presents with unprovoked DVT confirmed by duplex ultrasound. He has no family history of clotting disorders and no prior VTE. How long should anticoagulation be continued?
- At least 3 months, then reassess for indefinite therapy (Correct answer)
- 6 weeks only
- Lifelong anticoagulation without reassessment
- No treatment needed for first DVT
Correct answer: At least 3 months, then reassess for indefinite therapy
Unprovoked DVT should be treated for at least 3 months; the decision for indefinite anticoagulation depends on bleeding risk and patient preference.
Question 5: A 60-year-old man with cirrhosis presents with acute upper GI bleeding. Endoscopy reveals esophageal varices with active oozing. In addition to endoscopic band ligation, which medication should be started immediately?
- Octreotide (Correct answer)
- Proton pump inhibitor (pantoprazole)
- Propranolol
- Vasopressin
Correct answer: Octreotide
Octreotide (somatostatin analogue) reduces portal pressure by causing splanchnic vasoconstriction and is given alongside endoscopic therapy for variceal bleeding.
Question 6: A 35-year-old woman with Graves' disease and exophthalmos presents with palpitations and heat intolerance. TSH is suppressed and free T4 is markedly elevated. She desires rapid control of symptoms. Which agent provides the fastest symptomatic relief?
- Propranolol (beta-blocker) (Correct answer)
- Methimazole
- Radioactive iodine
- Thyroidectomy
Correct answer: Propranolol (beta-blocker)
Beta-blockers rapidly control adrenergic symptoms (palpitations, tremor, anxiety) of hyperthyroidism within hours, while antithyroid drugs take weeks to reduce hormone levels.
Question 7: A 48-year-old man with no cardiac history presents with syncope preceded by dizziness while standing. On exam, systolic BP drops from 140 to 95 mmHg after 3 minutes of standing. Heart rate does not compensate appropriately. The most likely diagnosis is:
- Autonomic dysfunction (orthostatic hypotension) (Correct answer)
- Vasovagal syncope
- Cardiac arrhythmia
- Hypovolemia
Correct answer: Autonomic dysfunction (orthostatic hypotension)
Orthostatic hypotension with inadequate heart rate response suggests autonomic neuropathy; common causes include diabetes, Parkinson's disease, and certain medications.
ITE General Internal Medicine 5
A 66-year-old man with known COPD presents with worsening dyspnea and increased sputum production.
Spirometry shows FEV1/FVC of 0.58 and FEV1 55% predicted.
His current regimen is a LABA alone.
The next best step is: