Internal Medicine Flashcards

Question

A 49-year-old man came with one day history of severe shortness of breath, cough and confusion. He is a known asthmatic patient with irregular follow-up and not adherent to medications. On examination, his blood pressure is 140/90 mmHg, respirations are 40/min and SPO2 is 70percent at room air. The patient was admitted with emergency treatment protocol. What is the best initial treatment for this patient? a. Long acting beta agonists • b. Systemic steroids • c. Short acting beta agonists • d. Magnesium sulphate

Answer 1

The best initial treatment for this patient with severe shortness of breath, cough, and confusion, who is a known asthmatic in acute distress, is: c. Short acting beta agonists Explanation: This patient is likely experiencing a severe asthma exacerbation or asthma attack, as evidenced by: • Severe shortness of breath, • Respiratory distress (high respiratory rate of 40/min), • Low oxygen saturation (SpO2 of 70%), and • Confusion, which can be a sign of hypoxia. The first-line treatment for an acute asthma exacerbation involves the following: • Short-acting beta agonists (SABA) (e.g., albuterol), which are bronchodilators that rapidly relieve bronchospasm and improve airflow. They work quickly to dilate the airways and relieve symptoms of wheezing, shortness of breath, and cough. Why not the other options? • a. Long acting beta agonists (LABAs): LABAs are used for maintenance therapy in asthma and are not suitable for acute exacerbations. They take longer to act and do not provide rapid relief in emergency situations. • b. Systemic steroids: Systemic steroids (e.g., prednisone) are often used in moderate to severe asthma exacerbations to reduce airway inflammation, but they are not the first step in treatment. They are typically used after the initial relief of bronchospasm with SABA therapy. • d. Magnesium sulfate: Magnesium sulfate may be used in cases of severe asthma exacerbations if the patient does not respond to initial treatments, as it can help relax the smooth muscle of the airways. However, it is not the first-line therapy and would typically be considered after SABA and steroids. Initial Treatment Sequence: 1. Administer short-acting beta agonists (SABA) via nebulizer or inhaler to rapidly relieve bronchospasm. 2. Systemic steroids should be started shortly after to reduce inflammation. 3. Consider additional treatments like magnesium sulfate if the patient does not respond adequately to the initial therapies. Key Takeaway: The best initial treatment for acute asthma exacerbation involves short-acting beta agonists (SABA) to relieve bronchospasm, followed by systemic steroids to reduce inflammation.

Answer 2

The most likely diagnosis for this patient is: b. COPD (Chronic Obstructive Pulmonary Disease) Explanation: This patient presents with symptoms that are highly suggestive of COPD, particularly: • Chronic cough: The patient has a productive cough of two years duration with tenacious whitish sputum, which is characteristic of the chronic bronchitis component of COPD. • Exertional dyspnea and fatigue: These are common symptoms of COPD as airflow limitation progressively worsens. • Chest tightness: This can also occur in COPD, particularly in the presence of bronchospasm. • History of wood smoke exposure: This is a significant risk factor for COPD, especially in individuals who do not smoke but are exposed to indoor air pollution from cooking with wood or biomass fuels. Additionally, the chest x-ray showing hyperinflated lungs and flattening of the diaphragm further supports the diagnosis of COPD, particularly the emphysema component, which is common in advanced stages. Why not the other options? • a. Bronchiectasis: This condition typically presents with a persistent cough and copious sputum production, often with a history of recurrent respiratory infections. However, bronchiectasis is less likely in the absence of a history of infections or significant inflammation causing airway dilation. • c. Obliterative bronchiolitis: This is a rare form of small airway disease that is associated with exposure to inhaled toxic agents or organ transplantation. It is less likely in this case because the patient’s symptoms and chest x-ray findings are more consistent with COPD. • d. Bronchial asthma: Although asthma can present with wheezing and cough, it typically occurs in younger individuals, with a history of episodic symptoms and reversible airway obstruction. This patient has chronic symptoms lasting for two years, making asthma less likely. The absence of a clear pattern of asthma triggers and the physical exam and radiologic findings are more consistent with COPD. Key Takeaway: Given the patient’s chronic cough, exertional dyspnea, history of wood smoke exposure, and chest x-ray findings of hyperinflated lungs, COPD (likely a combination of chronic bronchitis and emphysema) is the most likely diagnosis.

Answer 3

The most appropriate initial management for this patient is: c. Resuscitate with double IV line and prepare cross-matched blood Explanation: This patient presents with signs of gastrointestinal (GI) bleeding, which is supported by: • Vomiting of coffee ground matter (suggestive of upper GI bleeding), • Dark tarry stool (indicating melena, which typically occurs due to digested blood from the upper GI tract), • Low hemoglobin level (7 g/dL, indicating significant blood loss), • Hypotension (85/60 mmHg) and tachycardia (120/min), which suggest hypovolemic shock due to blood loss. The most critical initial steps are: 1. Resuscitation: The patient needs immediate volume resuscitation to stabilize his blood pressure and improve tissue perfusion. This can be achieved by administering IV fluids (normal saline or Ringer’s lactate) and cross-matched blood if needed. 2. Secure IV access: Double IV lines should be established to ensure that there is adequate access for fluid resuscitation and blood transfusion if necessary. 3. Prepare for potential blood transfusion: Given the low hemoglobin and clinical signs of shock, blood transfusion may be required. Cross-matched blood should be prepared in case transfusion becomes necessary. After initial resuscitation, the patient should be evaluated further for the source of bleeding, likely through upper GI endoscopy, but this is not the first step in management. The priority is to stabilize the patient before diagnostic procedures. Why not the other options? • a. Resuscitate and prepare for emergency laparotomy: While this may be needed if the bleeding is from a surgical cause (like perforation or massive hemorrhage that requires surgical intervention), it is not the first-line approach in this scenario. The priority is stabilization, and an emergency laparotomy is typically not the initial step unless there is a clear surgical emergency. • b. Secure IV line and send for upper GI endoscopy immediately: While upper GI endoscopy is important to identify the source of bleeding, it should not be done immediately before resuscitation. The patient is in hypovolemic shock, and the first priority is to stabilize the patient with IV fluids and blood transfusion, if necessary, before any diagnostic procedures. • d. Put him on maintenance fluid and do NG: Nasogastric (NG) tube placement can be helpful in assessing the volume and type of bleeding (e.g., presence of blood), but the priority here is aggressive resuscitation and stabilization. Maintenance fluids are not sufficient in this setting, as the patient needs immediate resuscitation with large volumes of IV fluids and potential blood transfusion. Key Takeaway: For a patient with upper GI bleeding and hypovolemic shock, the immediate priority is to resuscitate with IV fluids, establish double IV access, and prepare for blood transfusion if necessary. Diagnostic procedures, like upper GI endoscopy, should follow after the patient is stabilized.

Answer 4

The most appropriate next step in the patient’s care is: a. Do brain CT Explanation: The patient has a sudden loss of consciousness and a neurologic deficit (left-sided weakness with 0/5 power on the left upper and lower extremities), which raises concern for an acute cerebrovascular event, such as a stroke. Given that the patient has: • A history of diabetes (which is a risk factor for stroke), • Sudden loss of consciousness, • Unilateral weakness (hemiparesis), and • Elevated blood pressure (160/100 mmHg, which may be indicative of an ischemic or hemorrhagic stroke), It is crucial to rapidly assess the type of stroke (ischemic or hemorrhagic) to determine the appropriate treatment. Brain CT: • CT of the brain is the initial imaging modality of choice in the acute setting (within the first few hours) because it can quickly distinguish between ischemic and hemorrhagic stroke. A CT scan is more readily available and faster than MRI in the emergency setting. • In hemorrhagic stroke, a CT scan will quickly reveal bleeding, whereas, in ischemic stroke, it may take several hours for changes to appear, but it is still useful to rule out hemorrhage. Why not the other options? • b. Do brain MRI: While MRI is superior in detecting ischemic strokes, especially in the early stages, it is not the first-line test in the emergency setting. CT is quicker and more readily available, making it the preferred initial imaging study. • c. Start Atorvastatin: While statins like atorvastatin may be beneficial in the long-term management of cardiovascular risk and prevention of further strokes, they are not the first intervention for a patient with acute stroke. Immediate evaluation with brain imaging is the priority. • d. Start Aspirin: Aspirin is commonly used for ischemic stroke to prevent further clot formation, but it should not be given in the case of a hemorrhagic stroke, as it can worsen bleeding. The first step is to determine the type of stroke using brain CT before initiating antiplatelet therapy. Key Takeaway: In a patient with a suspected acute stroke, brain CT is the most appropriate initial step to determine the presence of hemorrhagic stroke or ischemic stroke. Only after determining the type of stroke can appropriate treatment, including medications like aspirin or interventions like thrombolysis, be considered.

Answer 5

The most effective management for this patient is: a. IV fibrinolytic therapy Explanation: The patient’s presentation with: • Shortness of breath, • Right-sided chest pain, • Hypotension (80/50 mmHg), • Raised JVP (jugular venous pressure), • Dullness to percussion (which may suggest pleural effusion), • And a CT angiography showing pulmonary artery thrombosis, indicates a diagnosis of massive pulmonary embolism (PE). In massive pulmonary embolism, there is a high-risk for cardiovascular collapse, and the primary treatment goal is to rapidly resolve the obstruction in the pulmonary vasculature to restore normal circulation and prevent hemodynamic collapse. Management of Massive Pulmonary Embolism: • IV fibrinolytic therapy (also called thrombolytics, e.g., alteplase) is the first-line treatment for massive PE with hemodynamic instability (i.e., shock or hypotension). Fibrinolytics help dissolve the clot rapidly, improving pulmonary circulation and hemodynamics. Why not the other options? • b. Systemic glucocorticoids: While glucocorticoids can be used for inflammatory conditions (such as asthma or autoimmune disorders), they have no role in managing pulmonary embolism. PE is a thrombotic event, not an inflammatory condition requiring steroids. • c. High-dose Furosemide: Although furosemide (a loop diuretic) can be used to manage fluid overload and symptoms of heart failure or pulmonary edema, it does not address the underlying cause of pulmonary embolism, which is a clot in the pulmonary arteries. Furosemide would not be effective in managing the acute thromboembolic event. • d. Oral anti-platelet: While antiplatelet drugs (like aspirin) are useful for prevention of thrombotic events (such as myocardial infarction), they are not effective in treating acute pulmonary embolism. Pulmonary embolism is primarily treated with anticoagulation (such as heparin), and in cases of massive PE, fibrinolytics are the most appropriate therapy. Key Takeaway: For a patient with massive pulmonary embolism with hemodynamic instability (hypotension, raised JVP, tachypnea), the most effective treatment is IV fibrinolytic therapy to rapidly dissolve the thrombus and restore circulation.

Answer 6

The answer is ACE inhibitor In this patient, with periorbital and leg edema and a serum creatinine of 2.5 mg/dL, there may be signs of fluid overload, which can be seen in the context of diabetic nephropathy with renal impairment. Fluid overload can result from the kidneys’ reduced ability to excrete excess fluid, leading to edema and potential heart failure if left untreated. Management of Fluid Overload: The treatment of fluid overload includes: 1. Diuretics: • Furosemide (a loop diuretic) is commonly used to treat fluid overload and edema. It helps the kidneys eliminate excess sodium and water. In patients with renal impairment, the dose may need to be adjusted carefully. • Thiazide diuretics (e.g., Hydrochlorothiazide) may be used as adjuncts in combination with loop diuretics if necessary, especially if there is significant fluid retention. 2. Fluid Restriction: • In some cases, especially with severe fluid overload, fluid intake may need to be restricted to prevent further accumulation of fluids. 3. ACE Inhibitors or ARBs: • While these agents (e.g., Enalapril) are primarily used to reduce proteinuria and control blood pressure, they may also have a mild diuretic effect, but they are not a substitute for specific diuretics. 4. Electrolyte Monitoring: • It’s important to closely monitor serum electrolytes (especially potassium levels) when using diuretics, as they can lead to imbalances like hypokalemia (from furosemide) or hyperkalemia (if ACE inhibitors are used in combination with other medications). Initial Management: Given the patient’s edema and renal impairment, initial management should focus on fluid removal while also addressing the underlying diabetic nephropathy. The patient can be managed with: 1. Furosemide (loop diuretic): This would help to manage fluid overload and reduce edema. 2. Enalapril (ACE inhibitor): For proteinuria, blood pressure control, and nephroprotection. 3. Close monitoring of renal function and electrolytes: Since the patient has renal impairment, monitoring renal function (creatinine, BUN) and electrolytes is crucial during diuretic therapy. In summary, while Enalapril is important for managing the underlying nephropathy and proteinuria, furosemide would be the first-line therapy to address the fluid overload in this patient.

Answer 7

The best management for this scenario is: d. Give single dose of HBIG and full course of HBV vaccine. This is the recommended post-exposure prophylaxis for a healthcare worker who has sustained a needlestick injury from a patient who is positive for hepatitis B surface antigen (HBsAg) and has a negative hepatitis B serology (i.e., the nurse is not immune). Rationale: • Hepatitis B Immunoglobulin (HBIG): A single dose of HBIG provides immediate passive immunity to protect against potential infection from the needlestick injury. • HBV Vaccination: The nurse should also receive a full course of the hepatitis B vaccine (usually 3 doses over 6 months) as active immunization to ensure long-term protection. Even though the nurse’s baseline serology is negative, the vaccination will help in case of any future exposures. The combination of HBIG and HBV vaccine is the standard and most effective approach for post-exposure prophylaxis in this situation.

Answer 8

Stg -cloxacilin +culture so C

Answer 9

The most likely diagnosis for this patient is: d. Peripheral arterial disease (PAD) Rationale: • Peripheral arterial disease (PAD) is a common complication of diabetes and typically presents with claudication (pain in the calf or thigh that is exacerbated by walking and relieved by rest). The pain is due to reduced blood flow to the muscles during activity, causing ischemia. Why the other options are less likely: • a. Diabetic neuropathy: This typically causes numbness, tingling, or burning pain in the feet and lower legs, not intermittent pain with exertion. • b. Deep vein thrombosis (DVT): DVT usually presents with swelling, redness, and tenderness in the affected leg, not pain specifically related to walking and rest. • c. Varicose veins: Varicose veins can cause aching or heavy feeling in the legs, but they are not typically associated with pain that is relieved by rest during walking, as in PAD. Thus, the pattern of pain aggravated by walking and relieved by rest is characteristic of Peripheral arterial disease.

Answer 10

The correct answer is c. Pulse rate. Rationale: Propranolol is a non-selective beta-blocker that is commonly used in patients with chronic liver disease (CLD) and varices for primary prophylaxis of variceal bleeding. The goal of propranolol therapy is to reduce portal pressure by decreasing the heart rate and reducing cardiac output. • Pulse rate is the most important clinical parameter to monitor when adjusting the propranolol dose. The target heart rate for propranolol therapy is typically between 55-60 beats per minute (bpm), as this has been shown to be effective in reducing the risk of variceal bleeding without causing excessive side effects. Why the other options are less relevant: • Platelet count: While platelet count is an important marker for liver function and bleeding risk, it does not directly guide propranolol dosing. • Hemoglobin: This is important for evaluating anemia or bleeding, but it does not directly influence the dosing of propranolol. • Blood pressure: While hypotension could be a concern with beta-blockers, the dose of propranolol is primarily titrated based on the heart rate. Blood pressure should be monitored but is not the primary parameter for optimizing the propranolol dose in this case. Thus, pulse rate is the key clinical parameter for titrating the propranolol dose.

Answer 11

The most appropriate next step is: c. Enhanced adherence support for 3 months Explanation: This patient on HAART (TDF + 3TC + DTG) presents with symptoms suggestive of opportunistic infection (productive cough, night sweats, loss of appetite) and has a detectable viral load of 2400 copies/mL, indicating possible virological failure or suboptimal adherence. However, switching the regimen immediately is not recommended without addressing adherence first. 1. Viral load threshold: • A viral load >200 copies/mL suggests poor control, and the first step is to evaluate and improve adherence to therapy. 2. Enhanced adherence support: • Patients with detectable viral loads should undergo enhanced adherence counseling for at least 3 months. • Adherence issues are a common cause of virological failure, especially in patients with low-to-moderate viral load elevation like this. 3. Further steps after 3 months: • Repeat the viral load test after adherence support. • If the viral load remains elevated (>1000 copies/mL), evaluate for drug resistance and consider switching to a second-line or third-line regimen. Other options: • a. Repeat viral load after a month: Inadequate without addressing adherence, as the underlying issue may persist. • b. Switch to 2nd or 3rd line ART regimen: Premature without confirming treatment failure after adherence support and resistance testing. • d. Discontinue HAART: Discontinuing ART is not appropriate, as it would worsen the patient’s condition and increase the risk of opportunistic infections. Additional considerations: • Investigate for tuberculosis (TB) given the respiratory symptoms and night sweats. Sputum testing and chest imaging are recommended. • Treat the erythematous tongue, possibly indicating oral candidiasis, with antifungal therapy.

Answer 12

The most likely diagnosis is: b. Esophageal cancer Explanation: The patient’s symptoms and barium swallow findings strongly suggest esophageal cancer: 1. Progressive dysphagia: • Initially for solids and later for liquids indicates a mechanical obstruction, commonly seen in esophageal cancer. 2. Significant weight loss: • Suggests a malignant process causing both difficulty swallowing and systemic effects. 3. Barium swallow findings: • Distal esophageal narrowing with shouldering is a classic finding in esophageal cancer, indicating an irregular mass causing obstruction. Other options: • a. Gastroesophageal reflux disease (GERD): • GERD can cause dysphagia but usually does not lead to progressive symptoms or significant weight loss. • Barium swallow would typically show reflux, not the characteristic narrowing and shouldering. • c. Esophageal stricture: • Strictures from GERD or other causes (e.g., caustic injury) usually cause non-progressive dysphagia. • Barium swallow would show a smooth narrowing without shouldering. • d. Achalasia: • Achalasia causes dysphagia for solids and liquids from the onset, not progressively worsening dysphagia. • Barium swallow typically shows a bird’s beak appearance at the lower esophageal sphincter. Next Steps: • Perform an upper endoscopy with biopsy to confirm the diagnosis. • Staging with CT or PET scans to evaluate the extent of the disease.

Answer 13

The best cardiovascular risk reduction measure to be taken in this case is: c. Rosuvastatin Explanation: This patient has multiple cardiovascular risk factors, including: 1. Diabetes (even with controlled HbA1C, he remains at increased risk). 2. Hypertension (although not severely elevated). 3. Obesity (BMI 29 kg/m², waist circumference >102 cm). 4. Elevated LDL (110 mg/dL). Why Rosuvastatin? • LDL management is crucial: For diabetic patients, the recommended LDL target is <70 mg/dL for high-risk individuals or at least <100 mg/dL. • Statins (e.g., Rosuvastatin or Atorvastatin) are first-line therapies to lower LDL cholesterol and significantly reduce cardiovascular events in diabetic patients. • Rosuvastatin is particularly effective in lowering LDL and stabilizing plaques. Other options: • a. Enalapril: Not indicated unless the patient has hypertension >140/90 mmHg, proteinuria, or evidence of diabetic nephropathy. • b. Add Insulin: Unnecessary, as the patient has good glycemic control with HbA1C of 6.2% on Metformin and Liraglutide. • d. ASA (Aspirin): Recommended for secondary prevention or very high-risk patients. This patient is not yet in the secondary prevention category (no prior CV events). Key Cardiovascular Risk Reduction Steps: 1. Start a statin (e.g., Rosuvastatin 10–20 mg daily). 2. Continue managing diabetes and weight with lifestyle changes and current medications. 3. Monitor blood pressure and glycemic control regularly. 4. Consider low-dose aspirin if future cardiovascular risk increases.

Answer 14

The most likely underlying cause of this patient’s illness is: b. Rheumatic heart disease Explanation: The patient’s presentation is consistent with mitral stenosis (MS), most likely secondary to rheumatic heart disease (RHD): 1. Key findings suggestive of mitral stenosis: • Diastolic murmur at the apex: A classic finding in MS, caused by turbulent blood flow across a narrowed mitral valve during diastole. • Mitral valve area (MVA) of 1.5 cm²: Indicates moderate mitral stenosis (normal MVA is 4–6 cm²). • Thickened and shortened mitral valve leaflets: Typical echocardiographic finding in RHD-related MS. 2. Signs of heart failure: • Left ventricular ejection fraction (LVEF) of 35% indicates systolic dysfunction, possibly due to chronic volume overload or sequelae of mitral stenosis. • Symptoms of dyspnea, palpitation, and generalized swelling (suggesting pulmonary congestion and right-sided heart failure). 3. RHD as the most common cause of MS: • RHD is the primary cause of mitral stenosis, especially in younger patients from regions where rheumatic fever remains prevalent. Other options: • a. Atherosclerosis: • Atherosclerosis does not cause mitral valve thickening or stenosis. It is associated with coronary artery disease. • c. Carcinoid tumor: • Carcinoid syndrome affects right-sided heart valves (e.g., tricuspid and pulmonary valves), not the mitral valve. • d. Dilated cardiomyopathy: • Can cause systolic dysfunction and heart failure but does not explain the diastolic murmur, mitral valve thickening, or stenosis. Conclusion: The most likely cause of this patient’s mitral stenosis and subsequent heart failure is rheumatic heart disease.

Answer 15

The most appropriate initial management for this patient is: c. Apply three-way dressing Explanation: The patient has a sucking chest wound, which is a type of open pneumothorax. This condition causes air to flow into the pleural cavity with each breath, leading to a collapsed lung and respiratory distress. Immediate management focuses on: 1. Sealing the sucking chest wound: • A three-way (occlusive) dressing is applied to temporarily seal the wound. This dressing allows air to escape from the pleural cavity (preventing tension pneumothorax) while stopping further air entry. 2. Further steps after stabilization: • Once the wound is sealed, definitive management includes placing a chest tube to re-expand the lung. Why not the other options? • a. Suck out the secretion: • Clearing the airway is essential, but the priority in this case is addressing the life-threatening sucking chest wound. Suction can be done after stabilizing the chest wound. • b. Insert chest tube: • While a chest tube is necessary, it is not the initial step. Air entry through the wound must be controlled first with a three-way dressing. • d. Putting her on oxygen: • Administering oxygen is supportive but not the initial priority. The sucking chest wound must be addressed immediately to restore proper lung function. Conclusion: The initial priority is to control the sucking chest wound with a three-way dressing to stabilize the patient, followed by further interventions such as chest tube placement and suctioning as needed.

Answer 16

The most specific antibody associated with this disease is: b. Anti-dsDNA Explanation: The patient has symptoms suggestive of systemic lupus erythematosus (SLE): 1. Key clinical features: • Photosensitivity: Reddish discoloration of the skin exacerbated by sunlight. • Malar rash: Raised erythematous rash on her cheeks. • Arthralgia/arthritis: Symmetrical joint pain and swelling, commonly seen in SLE. 2. Laboratory findings: • Anemia, leukopenia, and thrombocytopenia: Common in SLE due to autoimmune destruction or bone marrow suppression. 3. Anti-dsDNA antibody: • Highly specific for SLE (although not the most sensitive). • Associated with disease activity, particularly lupus nephritis. Why not the other options? • a. Rheumatoid factor: • Seen in rheumatoid arthritis, not specific to SLE. • c. Anti-Ro (SSA): • Associated with subacute cutaneous lupus erythematosus, Sjögren’s syndrome, and neonatal lupus but is less specific for SLE. • d. Antihistone: • Commonly seen in drug-induced lupus, not in systemic lupus erythematosus. Conclusion: The presence of anti-dsDNA antibodies is the most specific finding for systemic lupus erythematosus (SLE) in this patient.