Steven L. Sivak, MD Paul L. Johnson Chairman of Medicine
Internal Medicine Albert Einstein Medical Center Philadelphia, Pa
1. A 54-year-old homeless man with a history of chronic alcoholism was admitted to the hospital after a fall. He was diagnosed with a hip fracture but was otherwise well. The repair of the fracture and his immediate postsurgery course were unremarkable. On day 4 of hospitalization, he developed myalgia and weakness. Laboratory evaluation revealed elevated serum creatinine, and urinalysis showed a large amount of blood and no red blood cells (RBCs). Which of the following laboratory tests will probably reveal the cause of his symptoms? A. Serum haptoglobin B. Serum lactate dehydrogenase (LDH) C. Serum phosphate D. Serum sodium
2. An 18-year-old woman presents with a cough of 3 weeks’ duration. She describes it as paroxysmal, dry, and hacking, with particularly strong paroxysms of cough early in the morning. There is no sputum production or fever. She has occasional posttussive emesis. The cough occurs both during the day and at night and frequently awakens her from a sound sleep. She has no exertional dyspnea, symptoms of heartburn, or allergies. She does not smoke and has had all appropriate vaccinations since infancy. She is a college student who baby-sits a 3-year-old boy on weekends. Results of an earlier pulmonary function test with bronchoprovocation challenge were normal. Following this test, a trial of a proton-pump inhibitor and an antihistamine did not improve the symptoms. One week ago, when she visited the emergency department with the same complaints, her chest x-ray showed no infiltrates. A course of amoxicillin/clavulanate potassium (Augmentin) was prescribed, but her symptoms did not improve. What is the next step in management? A. Obtain a nasopharyngeal culture, and prescribe erythromycin (Ery-Tab, PCE Dispertab), regardless of the result B. Obtain a sputum culture, and prescribe antibiotics according to sensitivities of the isolated organism C. Refer to otolaryngology services for evaluation of her vocal cords and larynx D. Order a computed tomography (CT) scan of the chest
3. A 65-year-old woman was recently diagnosed with lymphoma and is being treated with a chemotherapy regimen of cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), vincristine sulfate (Vincasar), prednisone (eg, Deltasone, Orasone, Meticorten), and rituximab (Rituxan). She presents with a 2-week history of vague abdominal pain, fevers, and chills. She emigrated from Jamaica 20 years ago and has never returned. She reports no changes in bowel habits. Her temperature is 38.5°C. The only significant physical examination finding is diffuse abdominal tenderness, with no guarding or rebound. Bowel sounds are normal. Laboratory studies reveal a white blood cell (WBC) count of 3.6 x 109/L. Results of an electrolyte panel and renal function testing are normal. Blood cultures are positive for Bacteroides species, Escherichia coli, and Klebsiella pneumoniae. Which of the following tests will confirm the diagnosis? A. Colonoscopy B. Stool examination for ova and parasites C. CT of the abdomen, with and without contrast D. Upright abdominal x-ray E. Abdominal Doppler ultrasound
4. A 72-year-old woman with a history of hypertension, diabetes, and chronic kidney disease comes to the emergency department because of 2 days of shortness of breath. She has no chest pain. Physical examination reveals: heart rate, 120 beats/min; blood pressure (BP), 115/76 mm Hg; jugular venous pressure, elevated; rales in the lower lung fields; and pitting edema of the legs. Her electrocardiogram (ECG) is shown (Figure 1).
Which of the following treatments should be instituted emergently? A. Electrical cardioversion B. Intravenous (IV) loading dose of amiodarone (Cordarone), 150 mg over 10 minutes, followed by amiodarone infusion C. IV bolus of 10% calcium chloride solution, 5 mL D. IV bolus of procainamide HCl, 100 mg E. IV bolus of adenosine (Adenocard), 6 mg
5. A 46-year-old man with a history of end-stage renal disease secondary to glomerulonephritis has been receiving hemodialysis for 5 years. He presents with bleeding around the site of his tunneled dialysis catheter. The bleeding started after the catheter was changed. Application of localized pressure to the site for 30 minutes did not stop the bleeding. Physical examination shows his heart rate is 110 beats/min and BP 93/57 mm Hg. The exit site of the tunneled catheter is oozing bright red blood, but no isolated lesion can be seen. The patient does not take any antiplatelet or anticoagulant medications. His prothrombin time (PT) and partial thromboplastin time (PTT) are normal. Hemoglobin concentration is 11 g/dL, and platelet count is 233 x 109/L. What is the next step in management? A. Administer fresh frozen plasma B. Administer vitamin K subcutaneously C. Administer IV desmopressin acetate (DDAVP) D. Observation and pressure dressing E. Platelet transfusion
6. A 51-year-old black man presents with increasing abdominal girth and leg edema. His medical history is significant for extensive IV and subcutaneous drug abuse, resulting in multiple skin abscesses. Physical examination reveals ascites, 3+ pitting edema on both legs, and multiple needle track marks and smaller superficial scars caused by “skin popping” (ie, subcutaneous injection of drugs). There is no evidence of active skin infection. Serum creatinine is 2.1 mg/dL. Renal ultrasound reveals 14-cm kidneys bilaterally, with no hydronephrosis. Urine protein excretion is 9 g/24 h. Tests for HIV infection and hepatitis B and C virus infections are negative. Urine electrophoresis shows no evidence of a monoclonal protein. What is the most likely cause of his nephrotic syndrome? A. HIV nephropathy B. Diabetes mellitus C. Minimal change disease D. Focal segmental glomerulosclerosis E. Amyloidosis
7. A healthy 53-year-old black man undergoes routine screening colonoscopy. He has no family history of colon cancer and no symptoms of any gastrointestinal illness. A single 0.7-cm polyp found at the rectosigmoid junction is successfully removed. Pathologic examination shows a tubular adenoma with low-grade dysplasia. What is the most appropriate follow-up? A. None; schedule repeat colonoscopy in 10 years B. Flexible sigmoidoscopy in 1 year C. Colonoscopy in 1 year D. Colonoscopy in 3 years E. Colonoscopy in 5 years
8. A 64-year-old man with end-stage renal disease who is on hemodialysis complains of chronic knee pain and swelling. A radiograph of his knee (Figure 2) reveals features that are pathognomonic of which condition? A. Rheumatoid arthritis B. Osteoarthritis C. Gout D. Pseudogout E. Calciphylaxis
9. In a study on the use of antibiotic therapy to prevent the occurrence of febrile neutropenia during chemotherapy, 760 patients were randomly assigned to either oral levofloxacin (Levaquin) or to placebo beginning at the time that chemotherapy was initiated and continuing until the neutropenia resolved. Febrile neutropenia developed in 65% of patients who received levofloxacin and 85% of those who received placebo. Mortality rates and side effect profiles were similar in both groups. What is the number of patients needed to treat to prevent 1 episode of febrile neutropenia? A. 50 patients B. 20 patients C. 10 patients D. 5 patients E. 2 patients
10. You are seeing a 58-year-old Korean woman for a follow-up visit. Four years earlier she was diagnosed with osteoporosis based on a bone mineral density (BMD) T score of –2.6 at the lumbar spine and –1.8 at the hip. She was prescribed calcium (1200 mg/d) and vitamin D (800 IU/d) supplementation, along with alendronate sodium (Fosamax), 70 mg weekly. She entered menopause at the age of 48. She has never had a fragility fracture but has a family history of osteoporosis. Her body mass index is 20 kg/m2. She is tolerating treatment well, and her latest bone densitometry scan showed a T score of –1.0 at the vertebrae and –0.8 at the hip. She tells you that her health insurance has stopped paying for the bisphosphonate therapy, because she no longer has osteoporosis. She asks for your advice. What would you tell her? A. Continue the calcium/vitamin D supplements, and stop the alendronate B. Continue the alendronate at 70 mg weekly C. Measure markers of bone turnover to stratify her risk of fragility fracture D. Replace alendronate with raloxifene (Evista), a selective estrogen receptor modulator E. Prescribe a generic low-dose conjugated estrogen
11. A 90-year-old nursing home resident is admitted to the hospital with a productive cough, shortness of breath, and fever. She is diagnosed with health care–associated pneumonia and is given cefepime HCl (Maxipime) and gatifloxacin (Tequin). Her condition improves, but, on the fourth day of hospitalization, she develops profuse, watery diarrhea; low-grade fever; and mild abdominal distension. A stool test for Clostridium difficile toxin is positive, and the patient is treated with a 10-day course of oral metronidazole (Flagyl). Her diarrhea and fever resolve, and she is discharged back to the nursing home. A week later she is brought to the emergency department because of diarrhea, fever, leukocytosis, and abdominal pain. Physical examination reveals: temperature, 38.3°C; heart rate, 80 beats/min; BP, 110/67 mm Hg. Her abdomen is diffusely tender, but there is no rebound or guarding. Bowel sounds are present. Stool examination is guaiac negative. A second C difficile toxin assay is again positive. Besides putting the patient in contact isolation, what would be the most appropriate management? A. Await stool culture results for sensitivity testing B. Start oral metronidazole C. Start oral vancomycin (Vancocin) D. Start IV vancomycin (Vancoled) E. Colonoscopy and biopsy
12. A 28-year-old woman who is 14 weeks pregnant comes to your office for routine follow-up. She is taking appropriate folic acid supplementation. A screening test for gestational diabetes is negative. Urinalysis shows a WBC count of 3 per high-power field and no RBCs, protein, or glucose. Urine culture grows 105 colony-forming units/mL of E coli, which is sensitive to all antibiotics. The patient is asymptomatic. What is the most appropriate next step? A. No treatment; reassurance B. A second urinalysis and culture in the third trimester C. Ciprofloxacin (Cipro) for 3 days D. Double-strength trimethoprim/sulfamethoxazole (TMP/SMX; Bactrim DS, Septra DS) for 3 days, followed by prophylactic TMP/SMX until the time of delivery E. Nitrofurantoin (Macrobid, Macrodantin) for 7 days, followed by frequent screening for recurrence
13. A 48-year-old HIV-infected man presents to the clinic with a 6-month history of a dry, hacking cough, weight loss, and night sweats. Chest radiography shows cavitary lesions in both upper lung fields. Sputum is positive for acid-fast bacilli, and the patient is started on antituberculosis (anti-TB) therapy with rifampin (Rifadin), isoniazid (Nydrazid), pyrazinamide, and ethambutol HCl (Myambutol). He returns to the clinic 3 months later, complaining of progressive blurry vision. He is also having difficulty distinguishing the color of traffic lights and is afraid to continue driving. Which drug is probably the culprit? A. Rifampin B. Isoniazid C. Pyrazinamide D. Ethambutol
14. A 32-year-old man comes to your office for a routine checkup. He is healthy, has no known medical conditions, and does not smoke, drink, or use illicit drugs. He exercises at a health club 3 to 4 times weekly. He has no family history of diabetes mellitus or colon cancer. He says he is homosexual and has been living with the same man for 3 years. They use condoms during sexual activity. Results of an HIV test he had 6 months ago were negative. Aside from routine screening appropriate for his age, what other measure is indicated? A. Influenza vaccination B. Pneumococcal vaccination C. Hepatitis A vaccination D. Prostate cancer screening E. Colon cancer screening
15. A 25-year-old man presents to the office for a routine preemployment physical examination. His only complaint is occasional leg cramps. He has no known medical conditions and does not take any prescribed or over-the-counter medications. He does not smoke or use illicit drugs and only occasionally drinks alcoholic beverages. His family history is unremarkable. Physical examination reveals a well-built young man, with a BP of 120/75 mm Hg and heart rate of 70 beats/min. Blood test results are: sodium, 138 mEq/L; potassium, 3.0 mEq/L; bicarbonate, 34 mEq/L; chloride, 91 mEq/L; blood urea nitrogen (BUN), 14 mg/dL; creatinine, 1.0 mg/dL; glucose, 80 mg/dL. Urinary chloride level is elevated, and urinary calcium is low. What is the most likely diagnosis? A. Bartter’s syndrome B. Liddle’s syndrome C. Gitelman’s syndrome D. Primary hyperaldosteronism E. Surreptitious vomiting
16. You are called to evaluate a nurse who had a needlestick injury while attempting to draw blood from a patient. The source patient is known to be infected with hepatitis B virus (HBV) but is hepatitis C- and HIV-negative. The nurse recalls having one 3-dose series of hepatitis B vaccinations before she started working at the hospital. She also remembers having a positive antibody response. What would you recommend? A. Hepatitis B immune globulin (BayHep B, Nabi-HB) B. Hepatitis B immune globulin and hepatitis B vaccine (Engerix-B, Recombivax HB) booster C. Hepatitis B immune globulin and begin a new hepatitis B vaccine series D. No treatment
17. A 50-year-old man presents to the office complaining of a “creepy-crawly” sensation in his legs, mostly at night when he is about to go to sleep. He says the sensation is temporarily relieved by moving his legs or getting up to walk. His symptoms have been worsening over the past few months, and he now has difficulty sleeping. He has never been told that he was a loud snorer nor does his wife report any periods of apnea when he is asleep. What is the next best step in management? A. Refer for a sleep study B. Electromyography with nerve conduction studies on his legs C. Measure serum ferritin level and iron saturation D. Measure thyroid-stimulating hormone level
18. A 32-year-old man is being evaluated for bilateral leg edema that has been worsening over the past month. Laboratory test results show: BUN, 18 mg/dL; serum creatinine, 1.1 mg/dL; urine protein-to-creatinine ratio, 8; serum albumin, 2.8 mg/dL; total cholesterol, 300 mg/dL. HIV, hepatitis B, and hepatitis C tests are negative. A biopsy of the left kidney shows subepithelial immune complexes along the glomerular basement membrane. Two days later, the patient complains of severe right-sided flank pain with gross hematuria. Urinalysis shows numerous RBCs but no casts. Creatinine level has increased to 3.0 mg/dL, and serum LDH is 1000 U/L. Ultrasonography shows an enlarged right kidney, but no renal calculi are found. What is the most likely explanation? A. Development of rapidly progressive glomerulonephritis B. Acute renal vein thrombosis C. Capsular hematoma secondary to renal biopsy D. Renal calculi are not seen on ultrasonography
19. A 68-year-old woman presents with a 2-day history of fever, malaise, and abdominal pain. She has end-stage renal disease secondary to type 2 diabetes and is on continuous ambulatory peritoneal dialysis. In the past 24 hours, she has noticed that the dialysate effluent was cloudy. She recalls having had 2 bouts of peritonitis in the past year. Physical examination reveals: BP, 100/70 mm Hg; heart rate, 110 beats/min; temperature, 38.5°C. She has diffuse tenderness over her abdomen, but the peritoneal dialysis catheter site looks clean. The effluent is sent for analysis and shows a WBC count of 500/mL, with 80% neutrophils and a negative gram stain. Empiric antibiotic therapy with IV cefepime and vancomycin is initiated. Three days later, the patient is still febrile, and culture of the effluent has grown Candida. What is the next appropriate step? A. Continue current antibiotic therapy; culture results may have been caused by a contaminant B. Add amphotericin (Amphocin, Fungizone) and flucytosine (Ancobon) to current antibiotic treatment C. Discontinue cefepime and vancomycin, and start amphotericin and flucytosine D. Arrange to have the peritoneal dialysis catheter removed immediately, and then start amphotericin and flucytosine
20. A 55-year-old man with Barrett’s esophagus undergoes surveillance upper endoscopy. Multiple biopsies are taken, and pathologic examination reveals low-grade dysplasia. What would be appropriate management? A. Repeat endoscopy in 1 year B. Repeat endoscopy in 3 years C. Repeat endoscopy in 5 years D. Recommend esophagectomy
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