Board Review Questions in Internal Medicine

Tiffany Avery, MD, Premraj Makkuni, MD, Janani Rangaswami, MD, Michaela Schulte, MD, and Steven L. Sivak, MD, Albert Einstein Medical Center, Philadelphia

Published Online: June 6, 2007 - 1:19:45 PM (CDT)

Questions

► 1. A randomized trial of otherwise healthy individuals compares an active medication with placebo to determine its effect on preventing the incidence of a specific disease. The results show disease incidence of 123/10,000 in the study medication arm and 372/10,000 in the placebo arm. Approximately how many patients will need to receive the drug to prevent the disease in 1 person?

1. 4
2. 40
3. 400
4. 249
5. Cannot calculate without knowing the incidence of the disease in the study population

► 2. Which of the following values increases as the prevalence of a disease declines in a population?

1. Positive predictive value of a test
2. Negative predictive value of a test
3. Specificity
4. Sensitivity
5. None of the above

► 3. A 33-year-old otherwise healthy woman presents to her primary care physician complaining of a cough productive of thick, yellow sputum for the past 3 days. She had rhinorrhea with clear discharge, sore throat, myalgias, and mild headaches for 2 to 3 days before the onset of cough. Her 2 children, ages 5 and 8 years, have had similar symptoms during the past week. The cough is worse when she is active, and it interrupts her sleep at night. She has not had fevers, chills, sinus drainage, or chest pain. Physical examination shows her vital signs are unremarkable, with the exception of a few scattered wheezes at the base of each lung and coughing during the examination that produced thick, yellow sputum. She has tried some over-the-counter cold medications, with only minimal relief. What is the most appropriate next step in management?

1. Antibiotic treatment with a quinolone
2. Order a chest x-ray
3. Antibiotic treatment with a macrolide
4. Treatment with a beta₂-agonist inhaler and an antitussive for symptom control
5. Send sputum sample for culture and Gram's stain

► 4. A 27-year-old man presents to his primary care physician with complaints of chronic nasal congestion. About 2 months earlier, he had an upper respiratory tract infection with rhinorrhea, nasal congestion, and coughing. Since then he continues to have severe nasal congestion with minimal drainage, for which he uses oxymetazoline nasal spray (eg, Afrin, Dristan) twice daily. Physical examination reveals mild tenderness to percussion over his maxilla bilaterally. The nares are erythematous, with swollen but patent turbinates and no purulent discharge. What is the most appropriate treatment?

1. Antibiotics
2. Oral antihistamine
3. Discontinue oxymetazoline
4. Nasal saline spray
5. Nasal fluticasone (Flovent)

► 5. A 45-year-old woman presents to the emergency department with drooping of the left side of her face, which she first noticed when getting up in the morning. She is healthy, takes no medications, and has not had any recent viral illness, rashes, or tick bites. Physical examination reveals facial asymmetry, with drooping of the left angle of her mouth. She is unable to close her left eyelid; on attempt, the eye rolls upward. Furthermore, she is unable to wrinkle her forehead, inflate her left cheek, or show her teeth. What is the next step in management?

1. Urgent magnetic resonance imaging (MRI) of the brain
2. Computed tomography (CT) of the brain without contrast
3. Acyclovir (Zovirax) and corticosteroids
4. Immediate lumbar puncture
5. Urgent surgical decompression of the facial nerve

► 6. A 56-year-old man fell off the ramp of a truck he was unloading and hit the back of his head on the ground. His coworker noticed some muscle twitching right after the man fell. He remained unresponsive for about 1 minute and vomited twice upon awakening. Physical examination in the emergency department shows he is awake and fully oriented and only complains of a headache. His scalp has a small laceration and contusion at the site of impact. The neurologic examination is normal. The patient is otherwise healthy and does not take any medication. What would be the most appropriate next step in management?

1. CT of the head without contrast
2. Plain x-rays of the head to rule out fracture and admit for 24-hour observation
3. Discharge home and recommend rest for 48 hours
4. No imaging studies, but admit for 24-hour observation

► 7. A 68-year-old man undergoes colonoscopic evaluation as part of a workup for microcytic anemia. A friable mass is found in the descending colon, but the study could not be completed because of inadequate bowel preparation. The biopsy results confirm that the mass is an adenocarcinoma. The patient exhibits no signs or symptoms of obstruction from the mass. What is the most appropriate next step in management?

1. Full-body positron-emission tomography (PET) scanning
2. CT scan of the abdomen and pelvis and measurement of carcinoembryonic antigen level
3. Surgical resection
4. Repeat colonoscopy to evaluate the entire colon
5. Initiation of neoadjuvant chemotherapy

► 8. A 73-year-old black woman presents to your office complaining of dysphagia and a 20-lb weight loss during the preceding 6 months. She has a 40 pack-year smoking history, drinks 1 shot of bourbon daily, and has had a longstanding history of gastroesophageal reflux disease (GERD) but has not complied with proton pump inhibitor (PPI) therapy. She is obese and has tried to lose weight in the past, but her current weight loss is unintentional. Upon review of her chart, you discover that she also has a history of achalasia. You suspect that she may have esophageal cancer. In addition to her cigarette smoking and alcohol use, which of her risk factors suggest that she has a squamous-cell carcinoma rather than an adenocarcinoma?

1. Obesity
2. GERD symptoms
3. Noncompliance with PPI therapy
4. History of achalasia
5. Older age

► 9. A 22-year-old, otherwise healthy woman is referred to you by her gynecologist. She has had menorrhagia since menarche and was recently hospitalized by her gynecologist because of symptomatic anemia (hemoglobin, 5.8 g/dL), which caused her lightheadedness with palpitations. Laboratory tests in the hospital reveal her platelet count, prothrombin time, and international normalized ratio are normal; a slightly prolonged partial thromboplastin time; and a prolonged bleeding time. What is the most likely diagnosis?

1. Glanzmann's thrombasthenia
2. Von Willebrand's disease
3. Hemophilia A
4. Idiopathic thrombocytopenic purpura
5. Bernard-Soulier disease

► 10. A 72-year-old man presents to your office complaining of a 30-lb weight loss, shortness of breath with exertion, and cough productive of blood-tinged sputum for the past 2 months. He has a 60 pack-year smoking history. An initial chest radiograph reveals a mass in the upper lobe of the right lung. CT scan of the chest shows a 5-cm mass in the right upper lobe, with right-sided mediastinal adenopathy. PET scanning reveals uptake in 3 mediastinal nodes on the right side and 1 mediastinal lymph node on the left side. What should be your next step in management?

1. Biopsy of the mediastinal nodes
2. Neoadjuvant chemotherapy, followed by lobectomy of the right upper lobe
3. Pulmonary function testing, followed by lobectomy of the right upper lobe, then adjuvant chemotherapy
4. Radiation therapy
5. Radiation therapy, followed by lobectomy

► 11. An otherwise healthy 35-year-old nonsmoking white woman is evaluated for episodes of redness, warmth, and burning pain in both legs. The episodes start in the balls of her feet and progress rapidly to involve the entire circumference of her legs. The symptoms seem to be worse at night when her feet are covered by her bedclothes. Elevating her legs seems to alleviate the symptoms. Physical examination findings are normal. A complete blood cell count and basic chemistries, including serum calcium, phosphorus, and uric acid levels, are also normal. Which of the following therapies would help relieve her symptoms?

1. Calcium channel blocker
2. Aspirin
3. Long-acting opioid
4. Allopurinol (Zyloprim)

► 12. A 23-year-old man is evaluated for new-onset painful swallowing and retrosternal chest pain. He is otherwise healthy. The symptoms started 2 days earlier and have progressed to the point where swallowing is so painful that he has to spit out his saliva. He has no history of vomiting, hematemesis, or shortness of breath. His only current medication is a 2-week course of doxy-cycline for recurrent acne. Physical examination reveals a young man in mild distress. The oropharynx looks normal, and the rest of the examination is unremarkable. Which of the following approaches would be the most appropriate next step?

1. Barium swallow study to evaluate for a motility disorder
2. Upper endoscopy to evaluate for esophageal mucosal lesions
3. Instruct the patient to stop taking doxycycline
4. CT of the chest with contrast to rule out esophageal compression

► 13. A 28-year-old primigravida woman is evaluated in her second trimester for dysuria, frequent urination, and urgency for the past 2 days. A urine culture grows Escherichia coli, and the patient is treated with a course of nitrofurantoin (Macrodantin) for 7 days. A repeat urine culture 2 weeks later, when the patient is asymptomatic, is still positive for E coli. What is the next appropriate step?

1. Assure the patient that the culture result is insignificant, since she is asymptomatic, and that she has been adequately treated for her recent urinary tract infection
2. Treat with a 7- to 10-day course of ciprofloxacin (Cipro), because the nitrofurantoin did not eliminate the first infection
3. Treat with a 3-day course of TMP/SMX to improve patient compliance
4. Repeat the course of nitrofurantoin and order subsequent cultures to monitor for asymptomatic bacteruria

► 14. A 40-year-old woman is evaluated for recurrent urinary tract infections, which have occurred during the past several years, along with persistent microscopic hematuria. Physical examination is unremarkable. Serum blood urea nitrogen and creatinine levels are within normal limits. Ultrasound of the kidneys shows irregular enlargement of the papillary ducts bilaterally and multiple small medullary cysts. The size of both kidneys is normal. What is the most likely diagnosis?

1. Bilateral renal papillary necrosis
2. Adult polycystic kidney disease
3. Medullary sponge kidney
4. Adult medullary cystic disease

► 15. A 38-year-old woman is followed-up for new-onset, worsening disequilibrium. One year ago she was diagnosed with multiple sclerosis after presenting with optic neuritis. The initial episode was treated with pulse steroids, and her neurologic symptoms have been stable over the past year. She has no history of recent trauma or infection, and she is not taking any new medications. Physical examination reveals evidence of a chronic visual field defect from the optic neuritis. The patient also demonstrates signs of cerebellar dysfunction. A T2 MRI of the brain shows new lesions in the cerebellum compared with baseline images obtained 1 year ago. What is the next step in management?

1. Observation of her neurologic course, since this is her second neurologic deficit
2. Begin pulse steroids, and continue steroid therapy indefinitely to prevent further relapses
3. Institute plasmapheresis to reduce the severity of any relapse
4. After a short course of pulse steroids, institute therapy with interferon beta (Avonex, Rebif)

► 16. A 37-year-old man is brought to the emergency department by his neighbor, who found him about 3 hours ago lying outside his house, intoxicated. The neighbor helped him get inside his house and stayed with him for a while, but decided to call for an ambulance, because he was concerned that the man could not be aroused. On arrival in the emergency department, the patient responds to painful stimuli by weak withdrawal and wincing. His blood pressure is 100/60 mm Hg; heart rate, 112 beats/min; and respiratory rate, 10 breaths/min. Pulse oximetry is normal. A sweet-smelling breath is noted, and when asked, the neighbor confirms there was an empty 200-cc bottle of 70% rubbing alcohol on the living room floor. Laboratory studies show the presence of an osmolar gap, ketonemia, but no metabolic acidosis. The cause of his condition is believed to be isopropanol ingestion. What is the most appropriate therapy?

1. Activated charcoal treatment
2. Nasogastric lavage
3. Fomepizole (Antizol)
4. Supportive therapy
5. Immediate hemodialysis

► 17. A 45-year-old white woman is brought to the emergency department with mental status changes characterized by increasing confusion, somnolence, and lethargy. She was noted to drink large amounts of water on occasion recently and was urinating frequently. She has a history of schizoaffective disorder and mild mental retardation. Her medications include divalproex sodium (Depakote), lithium (Lithobid), risperidone (Risperdal), benztropine mesylate (Cogentin), quetiapine (Seroquel), and clonazepam (Klonipin). She is awake and alert. Physical examination reveals mild tachycardia, with a heart rate of 105 beats/min. Her mouth is dry. Laboratory test results show a serum sodium level of 147 mmol/L and a fasting blood glucose of 82 mg/dL. Serum osmolality is 304 mmol/kg. Which of the following tests would be most useful for the diagnosis?

1. Water-deprivation test
2. Hemoglobin (Hb) A_1c measurement
3. Measuring plasma vasopressin level
4. Dexamethasone suppression test

► 18. A 55-year-old male smoker with type 2 diabetes and emphysema presents to the hospital with community-acquired pneumonia in early November. Pneumococ-cus is identified in 2 blood cultures. The patient is treated with ceftriaxone sodium (Rocephin) and azithromycin (Zithromax) and makes an uneventful recovery. In addition to counseling on smoking cessation, which of the following approaches should be considered?

1. Pneumococcal and influenza vaccinations 2 weeks after discharge
2. Pneumococcal and influenza vaccinations now
3. Influenza vaccination now and pneumococcal vaccination in 4 weeks
4. Influenza vaccination now
5. Pneumococcal vaccination now

► 19. A 24-year-old respiratory therapist comes to your clinic for an emergency walk-in appointment after she was called at home and told that a patient she had managed on her night shift, which ended a few hours earlier, was found to have meningococcal meningitis. She had assisted in intubation and had managed the patient's endotracheal tube. She has no significant medical history, but she is 14 weeks pregnant. She was immunized against meningitis when she was in college 4 years ago. What is the best management for this patient?

1. Rifampin (Rifadin) 600 mg twice daily for 2 days
2. Ciprofloxacin 500 mg orally one time
3. Ceftriaxone 250 mg intramuscular injection one time
4. Reassurance that meningococcal vaccination is likely to provide adequate protection
5. Booster meningococcal vaccine and rifampin 600 mg twice daily for 2 days

► 20. A 36-year-old man was found unresponsive by his mother. Paramedics found empty bottles of zolpidem tartrate (Ambien) and dapsone in the man's room; both medications belonged to the mother. The man has a history of depression. On arrival at the emergency department, the patient is more alert but agitated. Perioral cyanosis is observed. Which of the following tests will probably help diagnose the underlying problem?

1. Pulse oximetry
2. Cooximetry
3. Arterial blood gas
4. High-resolution CT
5. Chest x-ray

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