Internal Medicine Questions Flashcards
23 yo pt with hx of ileal resection for Crohn’s disease presents with a 1 cm kidney stone in the renal pelvis. What is it most likely made of?
A. Cystine B. Oxalate C. Phosphate D. Struvite E. Uric acid
B. Oxalate
Bile acids are absorbed by terminal ileum. Bile salt malabsorption leads to fat malabsorption. With fat malabsorption, calcium in the bowel lumen is bound by fatty acids instead of precipitating with oxalate, which is left free for excessive absorption, leading to oxalate stones
Starts out with multiple lesions, may be over trunk, buttocks, or extremities. Described as papules that become vesicles and may even develop hemorrhagic crusts
Most likely dx?
A. Pityriasis alba B. Pityriasis lichenoides C. Pityriasis rosea D. Pityriasis rubra pilaris E. Tinea versicolor
B. Pityriasis lichenoides
Which of the following is outpatient therapy for pyelo?
A. TMP/SMX
B. Nitrofurantoin
C. Amoxicillin-clav
D. Ciprofloxacin
D. Ciprofloxacin
A positive Nikolsky’s sign refers to sloughing and separation of the epidermis upon gentle pressure to the lesions. Four diseases are associated with this sign. Which of the following is NOT one of them?
a. Bullous pemphigoid
b. Pemphigus vulgaris
c. Toxic epidermal necrolysis
d. Stevens Johnson syndrome
e. Staphylococcal scalded skin syndrome
a. Bullous pemphigoid
Which of the following is tx for severe fistulizing crohns disease?
A. Mesalamine and prednisone
B. Infliximab
C. Azathioprine
D. Cyclosporine
B. Infliximab
Which of the following is associated with hyperkalemia as a side effect?
A. Chlorthalidone B. Furosemide C. Lisinopril D. Metoprolol E. Nifedipine
C. Lisinopril
HLP medication associated with hyperuricemia and predisposing to gout attacks
A. Cholestyramine B. Ezetimibe C. Gemfibrozil D. Niacin E. Simvastatin
D. Niacin
Pt with history of multiple episodes of DVT. Her father had similar episodes. What hereditary disorder is most likely?
A. Activated protein C resistance B. Antithrombin deficiency C. Hyperhomocysteinemia D. Protein C deficiency E. Prothrombin gene mutation G20210A
A. Activated protein C resistance
Aka Factor V Leiden mutation
Characterized by diffusely erythematous skin rash, fever above 38 C, lymphadenopathy, hematologic abnormalities, hepatitis, and involvement of at least 1 organ; carries mortality rate of 10-20% with most fatalities due to liver failure
A. DRESS syndrome B. Red man syndrome C. Stevens-Johnson syndrome D. Toxic epidermal necrolysis E. Toxic shock syndrome
A. DRESS syndrome
Manage with supportive therapy, steroids, and antihistamines
Which of the following treatment regimens is used in AML?
A. Fludarabine, cyclophosphamide, and rituximab
B. Imatinib
C. Vincristine, prednisone, doxorubicin
D. Cytarabine (Ara-C), daunorubicin, cladribine
D. Cytarabine (Ara-C), daunorubicin, cladribine
Pt presents with gastric varices and a thrombus in the splenic vein. What is the most common etiology?
A. Chronic pancreatitis B. Ductal adenocarcinoma of the pancreas C. Factor V leiden D. Intraductal papillary mucinous tumor E. Pancreatic pseudocyst
A. Chronic pancreatitis
Splenic v thrombosis most commonly occurs d/t chronic pancreatitis. This can result in gastric varices without elevation in portal pressures. The tx for isolated gastric variceal bleeding secondary to splenic v thrombosis is splenectomy
A child is suspected to have lead poisoning. In addition to blood lead level, what other study should be done at this time?
A. Capillary blood toxin levels B. EMG C. MRI brain D. Plain film of abdomen E. Radiographs of long bones
D. Plain film of abdomen
This looks for lead-containing objects which may need to be removed. Note that chelation therapy with DMSA or EDTA should be initiated for BLLs greater than 45 ug/dL
Pt presents with palpitations, chest pain associated with painful respiration, temperature of 100.5, O2 sat of 98%. PE reveals normal CV, resp, and abdominal exam. ECG shows ST-elevation in leads I, aVL, II, III, aVF, and V2-6. PR depression is present in lead II and PR elevation in aVR. What is the next step in management?
A. ceftriaxone B. heparin C. indomethacin D. levofloxacin E. percutaneous coronary intervention
C. indomethacin
Diffuse ST-elevation, low-grade fever, and pleuritic chest pain indicate acute pericarditis. Treat with ASA 2-4 g/day, ibuprofen 400-600 mg TID, or indomethacin 25-50 mg TID. Colchicine may also be given or even glucocorticoids if tx has been refractory
HIV pt with CD4 count of 100 presents with AMS, cough, SOB, and headache for several months. He also has blurry vision and vomiting. PE reveals rales, papilledema, and multiple red papules on arms and chest. Most likely organism?
A. Cryptococcus neoformans B. Histoplasma capsulatum C. Mycobacterium tuberculosis D. Neisseria meningitidis E. Cytomegalovirus
A. Cryptococcus neoformans
Consider this dx in any pt presenting with s/s of chronic meningitis. Pts with underlying HIV should be tx with amphotericin B, flucytosine, AND fluconazole.
CMV can cause CNS sxs, but not usually until CD4 is less than 50. Also presents with more GI sxs including bloody diarrhea
Presents as pulmonary-renal syndrome with nonspecific symptoms like fever, myalgias, and arthralgias. Pts have a history of asthma and present with eosinophilia
A. Churg Strauss B. Goodpastures C. Microscopic polyangiitis D. Wegener’s granulomatosis E. Rheumatoid arthritis
A. Churg Strauss
Otitis media is an infection of middle ear cavity common in children. Common pathogens are strep pneumo, H. influenzae, and M. catarrhalis. What is the treatment of choice?
Amoxicillin 80-90 mg/kg/day for 10 days
Presents with hemoptysis and hematuria; often triggered by infections like streptococci or drugs like penicillin. P-ANCA positive.
A. Churg Strauss B. Goodpastures C. Microscopic polyangiitis D. Wegener’s granulomatosis E. Rheumatoid arthritis
C. Microscopic polyangiitis
Note: Churg strauss is also p-anca positive. Also note that presentation of microscopic polyangiitis is almost identical to wegener’s, but wegener’s is c-anca positive
A 78 y/o male presents for routine checkup. PMH significant for HTN, dyslipidemia, and obesity. He is found to be in afib. What is his CHADS2-VaSc score?
A. 1 B. 2 C. 3 D. 4 E. 5
C. 3
CHF = 1 HTN = 1 Age > 75 = 2 Diabetes = 1 Stroke or TIA = 2 Vascular disease = 1 Age 65-74 = 1 Sc (sex) = 1 if female
This guy gets 1 for HTN and 2 for age >75 = 3 points
Which of the following is most likely to be found in a braindead patient?
A. Corneal reflex B. Oculocephalic reflex C. Reactive pupils D. Spinal reflexes to pain E. Spontaneous respiration
D. Spinal reflexes to pain
13 y/o male immigrant from China dx with congestive cardiomyopathy
What is the deficiency?
A. Calcium B. Selenium C. Vitamin B1 D. Vitamin B3 E. Zinc
B. Selenium
Pt presents with complaint of vertigo, nausea, vomiting, and tinnitus in the setting of recent viral illness. Pt has mild hearing loss and positive Dix Hallpike. Dx?
A. BPPV B. Labyrinthitis C. Meniere’s disease D. Vascular insufficiency E. Vestibular neuritis
B. Labyrinthitis
If there were NO hearing loss, this would be vestibular neuritis. Meniere’s disease presents with triad of vertigo, tinnitis, and hearing loss - but is NOT associated with recent URI
Which of the following is a Duke’s major criteria for infective endocarditis?
a. Fever of 102.2 F
b. History of IV drug use
c. Evidence of endocardial involvement on TEE or other imaging
d. Long standing myalgias
e. Cavitary lesions on CXR
c. Evidence of endocardial involvement on TEE or other imaging
Major criteria = Positive blood culture (typically S.viridans, S.gallolyticus, HACEK, or S.aureus); Evidence of endocardial involvement
Minor criteria = predisposing condition (heart damage, hx IV drug use), fever, vascular phenomena, immunologic phenomena, microbiologic evidence (positive blood culture, but not of typical bug associated with endocarditis)
Characterized by flushing, erythema, and pruritis, usually affecting upper body, face, and neck. Pain and muscle spasms of back and chest, dyspnea, and hypotension may also occur; commonly due to vancomycin
A. DRESS syndrome B. Red man syndrome C. Stevens-Johnson syndrome D. Toxic epidermal necrolysis E. Toxic shock syndrome
B. Red man syndromeq
Which of the following is characterized by sudden death and is associated with one of several ECG patterns characterized by incomplete RBBB and ST-elevations in the anterior precordial leads?
a. Wolf Parkinson White
b. Brugada syndrome
c. Orthostatic hypotension
d. Postural tachycardia syndrome
e. Vasovagal events
b. Brugada syndrome
Pt presents with asymptomatic hypotonic hyponatremia. A TSH is normal, her urine does not have evidence of renal tubular acidosis, and her cortisol is normal. What is the next best step in management?
A. 3% normal saline B. CT scan chest C. Water restriction D. MRI brain E. Normal saline infusion
B. CT scan chest
She has SIADH — CT chest to look for small cell cancer. DDx for euvolemic hypotonic hyponatremia is RATS: Renal tubular acidosis, Addison’s disease, thyroid disease, and SIADH.
Antibodies found in systemic scleroderma/systemic sclerosis
A. Antihistone Abs B. Anticentromere Abs C. Anti-Jo1 Abs D. Anti-smith Abs E. Anti-topoisomerase Abs
E. Anti-topoisomerase Abs
A young female presents with abrupt onset nausea, vomiting, wheezing, and lethargy. Vitals reveal HR 120, BP 150/90, RR 25, and O2 sat 87% RA. PE reveals obtunded female with pinpoint pupils, rhinorrhea, and twitching of the face. Lung exam reveals diffuse expiratory wheezes. The most likely etiologic agent is
A. anthrax B. phosgene C. ricin toxin D. sarin E. sulfur mustard
D. sarin
Sarin is an acetylcholinesterase inhibitor that causes miosis, rhinorrhea, bronchospasm, diaphoresis, nausea, vomiting, and urinary incontinence
Sulfur mustard exposure causes skin irritation followed by fluid filled blisters; eye exposure leads to miosis, conjunctivitis, and temporary blindness. If inhaled in high concentrations can cause bleeding, blistering, and pulmonary edema
Which of the following is used to diagnose autoimmune hemolytic anemia?
a. ADAMTS-13 assay
b. Bone marrow biopsy
c. D-dimer assay
d. Direct Coombs test
e. stool culture for E.coli O157:H7
d. Direct Coombs test
ADAMTS-13 is for TTP. E.coli stool culture is for HUS.
_______ is used for patients with penicillin allergy for gram negative rod infections. Think of using this for PCN allergic patients to cover for pseudomonas. MOA is inhibition of cell wall synthesis by binding to penicillin-binding proteins
A. Amoxicillin B. Aztreonam C. Nafcillin D. Piperacillin/tazobactam E. Vancomycin
B. Aztreonam
Presents as multiple erythematous patches usually on the face. Evolve into hypopigmented areas that eventually resolve over time
Most likely dx?
A. Pityriasis alba B. Pityriasis lichenoides C. Pityriasis rosea D. Pityriasis rubra pilaris E. Tinea versicolor
A. Pityriasis alba
Antibodies specific to limited scleroderma
A. Antihistone Abs B. Anticentromere Abs C. Anti-Jo1 Abs D. Anti-smith Abs E. Anti-topoisomerase Abs
B. Anticentromere Abs
Pt presents with perioral burning, abdominal pain, and bloody diarrhea after ingesting unusual brown speckled beans. PE reveals dry mucous membranes, scleral icterus, and abdominal tenderness. LFTs are elevated, BUN is 43 and Cr is 4.8. What is the etiologic agent
A. Anthrax B. Ebola C. Ricin D. Smallpox E. Tularemia
C. Ricin
What is the hallmark electrolyte disturbance associated with refeeding syndrome?
A. Hyperkalemia B. Hypermagnesemia C. Hypochloremia D. Hyponatremia E. Hypophosphatemia
E. Hypophosphatemia
Complete absence of behavioral self or environmental awareness. Pt has preserved capacity for spontaneous or stimulus-induced arousal, such as sleep-wake cycle. Pt postured or withdrawals to noxious stimuli.
A. Brain death B. Locked in syndrome C. Coma D. Minimally conscious state E. Vegetative state
E. Vegetative state
Patients present with rapidly progressive glomerulonephritis with elevated creatinine, hematuria, RBC casts, and renal failure. Pulmonary hemorrhage with hemoptysis is present in almost half of patients.
A. Churg Strauss B. Goodpastures C. Microscopic polyangiitis D. Wegener’s granulomatosis E. Rheumatoid arthritis
B. Goodpastures
Aka anti-glomerular basement membrane disease
Antibodies specific to drug induced lupus
A. Antihistone Abs B. Anticentromere Abs C. Anti-Jo1 Abs D. Anti-smith Abs E. Anti-topoisomerase Abs
A. Antihistone Abs
Which of the following treatment regimens is used in CLL?
A. Fludarabine, cyclophosphamide, and rituximab
B. Imatinib
C. Vincristine, prednisone, doxorubicin
D. Cytarabine (Ara-C), daunorubicin, cladribine
A. Fludrabine, cyclophosphamide, and rituximab
Best initial tx for malignant otitis externa
A. Dexamethasone drops B. Oral amoxicillin-clavulanate C. Surgical debridement D. Oral ciprofloxacin E. Neomycin drops
D. Oral ciprofloxacin
Carcinoid syndrome can result in which of the following vitamin deficiencies?
A. Calcium B. Vitamin A C. Vitamin B1 D. Vitamin B2 E. Vitamin B3
E. Vitamin B3
Carcinoid manifests with diarrhea, flushing, wheezing, and heart murmurs as a result of serotonin producing tumor that converts niacin to tryptophan to serotonin. Thus it can result in niacin deficiency
What is the hallmark ECG finding associated with hypocalcemia?
A. Osborne J waves B. Prolonged PR interval C. Prolonged QT interval D. Prominent U wave E. Widened QRS
C. Prolonged QT interval
Which of the following is the most common electrolyte abnormality seen in DKA?
A. Hypercalcemia B. Hyperkalemia C. Hypernatremia D. Hypokalemia E. Hyponatremia
E. Hyponatremia
The most common eletrolyte abnormality in DKA is hyperosmolar hyponatremia. This hyponatremia is not due to primary sodium loss but due to plasma dilutional effect of hyperglycemia.
Red rash that looks like a sunburn with rough texture like sandpaper, most often starting on the chest and stomach then spreading to rest of body. The rash may last 2-7 days and is associated with red, swollen lips and tongue. Skin may peel on hands and feet after rash fades.
A. Erythema infectiosum B. Exanthema subitum C. Exanthematous drug eruption D. Rubella E. Scarlet fever
E. Scarlet fever
A 64 yo male with no PMH is hospitalized after a fall. On hospital day 4 he is transferred to ICU for UTI. Which of the following is most appropriate empiric tx?
A. Ampicillin and gentamicin B. Azithromycin and TMP-SMX C. Ceftriaxone and cefepime D. Ciprofloxacin and nitrofurantoin E. Vancomycin and metronidazole
A. Ampicillin and gentamicin
This pt needs abx that cover gram-negative bacteria including E.coli, proteus, Klebsiella, enterobacter, and pseudomonas, as well as gram positives like enterococci. The ampicillin will cover for enterococci and the aminoglycoside will cover enterobacter and pseudomonas
Pt presents with salmon colored spot on her back with a red outline. This new skin lesion is identified as a herald patch.
Most likely dx?
A. Pityriasis alba B. Pityriasis lichenoides C. Pityriasis rosea D. Pityriasis rubra pilaris E. Tinea versicolor
C. Pityriasis rosea
Starts out as single lesion (herald patch) usually on trunk. Several other lesions often develop over period of weeks that are macules or papules with scaling texture and wrinkling
Presents as a descending rash that is described as redness and scaliness. Found on face and descends to where pt may have thickening of skin on soles of hands and feet
Most likely dx?
A. Pityriasis alba B. Pityriasis lichenoides C. Pityriasis rosea D. Pityriasis rubra pilaris E. Tinea versicolor
D. Pityriasis rubra pilaris
Which of the following is characteristic of prerenal azotemia?
A. FeNa of 3% B. Urine:plasma urea <3 C. Urine creatinine:plasma creatinine ratio <20 D. Urine osmolality of 285 mosm E. Urine Na <20 mosm/L
E. Urine Na <20 mosm/L
Prerenal acute renal failure stimulates release of aldosterone which leads to resorption of sodium from the collecting ducts. This results in fall in urine sodium to <20 mOsm/L and FeNa <1%. The urine becomes more concentrated than plasma
__________ is the most common cause of of isovolemic hypotonic hyponatremia. It should be considered in any pt who presents with chronic hyponatremia without edema, decreased arterial volume, or renal insufficiency
A. Adrenal insufficiency B. Hyperglycemia C. Pseudohyponatremia D. RTA type 4 E. Syndrome of inappropriate ADH
E. Syndrome of inappropriate ADH
SIADH will result in a low serum osmolality (<280) and high urine osmolality (>100) secondary to fluid retention and volume expansion. Edema is not seen in SIADH due to increased ANP and decreased proximal tubular sodium absorption leading to appropriate sodium excretion (urine Na >20)
Other labs that support the dx are low serum uric acid, low BUN, normal or slightly decreased Cr, and normal thyroid and adrenal function
Conditions associated with SIADH include: cancer, stroke, head trauma, meningitis, encephalitis, COPD, TB, and pneumonia.
_______________ is indicated with severe aortic valve stenosis with valve area less than 1 cm presenting with sxs, left ventricular dysfunction (EF <50%), or aneurysmal/rapidly expanding aortic root
A. Lisinopril to decrease afterload B. Limitation of physical activity C. Metoprolol D. Simvastatin E. Valve replacement
E. Valve replacement
Pt tests positive for syphilis and has allergy to penicillin. UPT is negative. What is next best step?
A. Penicillin B. Ceftriaxone C. Doxycycline D. Erythromycin E. Penicillin desensitization
C. Doxycycline
Which of the following is the most appropriate first step in management for acute hepatitis B?
A. Liver bx B. Observation with liver enzyme monitoring C. Pegylated interferon D. Ribavirin E. Tenofovir
E. Tenofovir
[pegylated interferon and ribavirin are for hep C]
Which of the following types of kidney stones can be prevented with acidification of the urine?
A. Ammonium uric acid B. Calcium ammonium phosphate C. Calcium oxalate D. Calcium phosphate E. Sodium uric acid
D. Calcium phosphate
These and struvite stones (magnesium ammonium phosphate) form in alkaline urine
32 y/o female presents with new rash on palms. 2 weeks ago she had sore throat, fatigue, cough, chills, and chest pain. 3 days ago she was dx with URI and proceeded with conservative tx. Symptoms have since persisted, and she now has this new rash. On exam she has multiple raised, target-shaped macules on her palms with dusky purple centers. The rash is not present anywhere else. Most likely dx?
A. Rocky mountain spotted fever B. Secondary syphilis C. Erythema multiforme D. Erythema nodosum E. Hand foot and mouth disease
C. Erythema multiforme
In addition to correcting electrolyte abnormalities in refeeding syndrome, the pt should also receive
A. Calcium carbonate B. Insulin C. Metoclopramide D. Sodium bicarbonate E. Thiamine
E. Thiamine
Complete failure of arousal system with a positive auditory brain response but no response in eye-opening, verbal, or motor response to stimuli
A. Brain death B. Locked in syndrome C. Coma D. Minimally conscious state E. Vegetative state
C. Coma
What causes hypocalcemia in end stage renal disease?
A. Elevated PTH B. Inadequate intake C. Low serum phosphate D. Dialysis E. Vitamin D deficiency
E. Vitamin D deficiency
Gut absorption of calcium is decreased when there is a deficiency in renal vitamin D metabolism
Incidental finding on chest CT showing 7 mm pulmonary nodule with popcorn like calcification
A. Hamartoma B. Hydatid cyst C. Lung adenocarcinoma D. Progressive fibrosis E. Tuberculosis
A. Hamartoma
[hydatid cysts don’t calcify; popcorn calcification = hamartoma]
Which of the following treatment regimens is used in ALL?
A. Fludarabine, cyclophosphamide, and rituximab
B. Imatinib
C. Vincristine, prednisone, doxorubicin
D. Cytarabine (Ara-C), daunorubicin, cladribine
C. Vincristine, prednisone, doxorubicin
Presents as raised red rash that first appears on cheeks. A lace-like rash starts on the torso and arms after 1-4 days then spreads to the rest of the body. Flu like sxs may be present up to 7 days before the rash. Caused by human parvovirus B19
A. Erythema infectiosum B. Exanthema subitum C. Exanthematous drug eruption D. Rubella E. Scarlet fever
A. Erythema infectiosum
Aka fifth disease
Antibodies found in inflammatory myopathies
A. Antihistone Abs B. Anticentromere Abs C. Anti-Jo1 Abs D. Anti-smith Abs E. Anti-topoisomerase Abs
C. Anti-Jo1 Abs
Pt with hx of alcoholism presents with hypocalcemia unresponsive to calcium gluconate replacement therapy. What is the most likely additional finding?
A. Hyperalbuminemia B. Hypernatremia C. Hypokalemia D. Hypomagnesemia E. Hypophosphatemia
D. Hypomagnesemia
18 y/o with dysgeusia, anosmia, and growth retardation
What is the deficiency?
A. Calcium B. Selenium C. Vitamin B1 D. Vitamin B3 E. Zinc
E. Zinc
Chronic zinc def can result in stunted growth, hypopigmented hair, night blindness, decreased spermatogenesis, diarrhea, alopecia, pustular dermatitis, decreased immunity
Patient presents with swelling in bilateral lower extremities 1 week after starting new medication for HTN. What med was he likely started on?
A. Chlorthalidone B. Furosemide C. Lisinopril D. Metoprolol E. Nifedipine
E. Nifedipine
This is a DHP CCB - the most common AE is peripheral edema.
Empiric coverage of meningitis in immunocompetent adult?
A. Ceftriaxone, vancomycin, ampicillin, and dexamethasone
B. Ceftriaxone, vancomycin, and dexamethasone
C. Ceftriaxone and vancomycin
D. Vancomycin and Pip/tazo
E. Await culture/sensitivity
B. Ceftriaxone, vancomycin, and dexamethasone
Add ampicillin in immunocompromised
With little or no prodrome, pts develop a low grade fever with swollen and tender lymph nodes. The rash following the fever is a raised, red, pinpoint rash that starts on the face and spreads downward. The rash can itch and last up to 3 days
A. Erythema infectiosum B. Exanthema subitum C. Exanthematous drug eruption D. Rubella E. Scarlet fever
D. Rubella
Aka german measles
Patients first develop a fever, usually greater than 103 F, with rash dveloping as fever is resolving. The rash is rosy pink, blanchable, and develops first on the neck and chest before spreading to rest of body. Caused by HHV6.
A. Erythema infectiosum B. Exanthema subitum C. Exanthematous drug eruption D. Rubella E. Scarlet fever
B. Exanthema subitum
Aka Roseola infantum or sixth disease
