INTERNAL MEDICINE BOARD REVIEW

1. INTERNAL MEDICINE BOARD REVIEW

2. My Advice • Have fun… seriously • Learning opportunity • Questions are reasonable • Preparation is key • Stick to a schedule • Practice questions

3. Question 1 • A 51-year-old woman with chronic low back pain is evaluated for a 2-week history of moderate low back pain radiating down her right leg to her right foot following a paroxysm of sneezing. She has no leg weakness or numbness. She takes no prescription medications. Her medical history is notable for a hysterectomy.

4. Question 1 • On physical examination, the temperature is 36.9 °C (98.5 °F). The lumbar paraspinal muscles are tender to palpation. A straight-leg-raising test is positive on the right. Her perineal sensation and rectal sphincter tone are intact. • She has difficulty extending her right great toe against resistance, but lower-extremity strength, sensation, and reflexes are otherwise normal. Radiography of the spine shows some degenerative changes in the lower lumbar spine but no disc narrowing or vertebral collapse.

5. Question 1 • Which of the following is the most appropriate initial management of this patient? A Referral to orthopedic surgeon B Bed rest for 7 days C MRI of the lumbar spine D NSAIDs E Back exercises

6. Question 1 Answer - D • Surgical intervention of patients with low back pain should be considered only if symptoms persist for more than 6 weeks or if progressive neurologic deficits develop • Controlled trials demonstrate that NSAIDs provide effective short-term symptom relief for patients with acute low back pain with or without sciatica

7. Question 2 • A 62-year-old man is evaluated for a 2-week history of dizziness. Episodes of dizziness occur several times per day, usually in the morning and at bedtime, and typically last about 15 to 30 seconds, particularly when he rolls over in bed. The dizziness is described as a spinning sensation and is associated with mild nausea but no vomiting. He had one previous episode of dizziness at the age of 28 years for which he went to the emergency department and received meclizine; that episode resolved in 3 days. The patient has hypertension and diabetes mellitus, and his current medications are hydrochlorothiazide, 50 mg daily, and glipizide, 10 mg daily.

8. Question 2 • On physical examination, supine pulse rate and blood pressure are 72/min and 120/80 mm Hg and values on standing are 76/min and 116/84 mm Hg. The head-hanging test (Hallpike maneuver) results in dizziness and mild nystagmus when the patient is recumbent with the left ear down but not with the right ear down. There are no focal neurologic findings, and the remainder of the physical examination is normal. • Laboratory studies • hemoglobin A1C of 9.6% • Non-fasting plasma glucose level of 170 mg/dL (9.44 mmol/L) • serum potassium level of 3.6 meq/L (3.6 mmol/L) • serum sodium concentration of 136 meq/L (136 mmol/L).

9. Question 2 • Which of the following is most appropriate for managing this patient's disorder? A CT scan of the head B Electronystagmography C Meclizine D Habituation exercises E Decreased hydrochlorothiazide dose

10. Question 2 Answer - D • The change of head position, particularly lying down, turning over in bed, and arising, is the usual trigger for brief spells of vertigo • Two types of nonpharmacologic treatments—habituation exercises and the canalolith repositioning (Epley's) maneuver—have proved beneficial for patients with BPV in small clinical trials

11. Question 3 • A 35-year-old man is evaluated for acute epistaxis. He denies any trauma, intranasal drug use, insertion of foreign bodies in the nose, symptoms of recent allergic or viral rhinitis, or recent use of aspirin or NSAIDs, and has not previously had bleeding difficulties. He is otherwise healthy. • On physical examination, the blood pressure is 150/90 mm Hg. There are several nasal blood clots that are easily removed and no obvious sources of bleeding. Bleeding stops with external pressure but then recurs in 30 minutes.

12. Question 3 • Which of the following is the best management approach in this patient? A Anterior packing B Posterior packing C Topical oxymetazoline D Silver nitrate cautery

13. Question 3 – Answer A • Epistaxis occurs commonly and the source is usually anterior. • Most cases of epistaxis occur in Kiesselbach's plexus, are idiopathic, or are due to trauma, hyperemia with allergic or viral rhinitis, intranasal drug use, foreign body, or antiplatelet or anticoagulant drugs. • The source of the nosebleed should be assumed to be anterior in patients with epistaxis in whom no bleeding site is obvious and fluid resuscitation and airway management are not needed

15. Question 4 • A 60-year-old man is evaluated for a 3-month history of persistent left lower facial pain in the mandibular region that has worsened and been unresponsive to treatment with acetaminophen, 4 g four times daily, over the past 3 weeks. He describes the pain as “electrical” in nature, often triggered by dental manipulation or extreme temperature exposure. His dentist found no oral or dental cause for the pain but treated him with a 14-day course of amoxicillin for presumptive sinusitis without improvement. • The physical examination, including a complete neurologic evaluation, is normal. Laboratory studies and CT of the sinuses are normal.

16. Question 4 • Which of the following is the most cost-effective and efficacious treatment for this patient? A Narcotic analgesia B Gabapentin C Tricyclic antidepressants D Carbamazepine E Tetrahydrocannabinol analogs

17. Question 4 – Answer D • Carbamazepine improves pain in patients with trigeminal neuralgia without any higher incidence of major adverse events compared with placebo • No other anticonvulsant agent has been adequately studied in randomized, placebo-controlled trials for treatment of this disorder. • Narcotic analgesia is only modestly effective at treating neuropathic pain and should be reserved only for patients whose pain is recalcitrant to non-narcotic treatments. • Although gabapentin is increasingly being used for patients with neuropathic pain, there is no clinical trial evidence for its efficacy in treating trigeminal neuralgia. • Compared with carbamazepine, gabapentin has not been found to be superior in treating other neuropathic syndromes and is more expensive • TCA’s are efficacious in treating several neuropathic pain syndromes, although these agents have not been studied in patients with trigeminal neuralgia. • Cannabinoids are currently being studied as treatment for chronic pain but have not yet been proved efficacious in patients with neuropathic pain

18. Question 5 A 75-year-old woman is evaluated for symptoms of urinary incontinence that have increased gradually over the past several months. She notes the frequent urge to urinate and has difficulty controlling her urine flow. She now wears pads in the daytime and at night. She lives alone and is able to care for herself. A few months ago, she was diagnosed with depression and began taking nortriptyline. Her medical history is significant for a hysterectomy for uterine fibroids, and hypertension well controlled with nifedipine and atenolol for several years.

19. Question 5 Which of the following is the most appropriate next step in the management of this patient? A Replace nortriptyline with another class of antidepressant B Replace atenolol with another class of antihypertensive agent C Replace nifedipine with another class of antihypertensive agent D Begin oxybutynin E Begin oral estrogen therapy

20. Question 5 – Answer A • Nortriptyline can cause symptoms of urge incontinence through its anticholinergic effects • Several classes of drugs are associated with an increase in symptoms of urinary incontinence • In most cases, discontinuation of the causative drug will lead to an improvement in the symptoms of incontinence. • Other drugs that can act on cholinergic receptors to cause symptoms of incontinence include antihistamines, antipsychotic agents, and TCA’s • Anticholinergic agents used to treat urge incontinence due to detrusor instability (oxybutynin and tolterodine) can also cause disorders of bladder filling and urinary storage and manifest with symptoms of urgency, nocturia, nocturnal enuresis, and incontinence.

21. Question 6 • A 22-year-old woman is evaluated during a routine physical examination. She has mild exercise-induced asthma. She does not smoke, drinks alcohol only socially, and does not use illicit drugs. She has had a total of four sexual partners, and currently is in a monogamous relationship with a serious boyfriend. She has no history of sexually transmitted infections and takes an oral contraceptive to prevent pregnancy. A recent HIV test was negative. She is due for a Pap smear. She has had baseline pulmonary function tests.

22. Question 6 • In addition to the Pap smear, which of the following is most appropriate for this patient? A Encourage use of sunscreen B Prescribe a multivitamin with folic acid daily C Screen for Chlamydia trachomatis D Measure fasting plasma glucose

23. Question 6 – Answer C • Annual chlamydial screening for sexually active women aged 25 years and younger and for other women at increased risk for Chlamydia trachomatis infection is recommended. • The Centers for Disease Control and Prevention recommend annual screening for sexually active women aged 25 years and younger and for other women at increased risk for Chlamydia trachomatis infection (women with new or multiple sex partners, history or current symptoms of sexually transmitted disease, or history of unprotected intercourse). • Untreated chlamydial infection can lead to pelvic inflammatory disease (PID) and subsequent infertility. Randomized controlled trials have shown that routine screening for C. trachomatis prevents PID. • Endocervical and urethral swab specimens for culture were the gold standard for diagnosis, but new amplified DNA assays (polymerase chain reaction [PCR], ligase chain reaction, and strand displacement assay) using first-void urine specimens have better test characteristics (PCR sensitivity, 82% to 100%; specificity, 98% to 100%). • Patients with high cumulative levels of sun exposure and those with prior skin cancers should be encouraged to wear sunscreen and protective clothing, although the benefit of such counseling is unknown.

24. Question 7 • A 37-year-old woman is evaluated for major depression that was diagnosed 1 month ago and treated with fluoxetine. Two weeks after treatment, she had no suicidal ideation, and her depressive symptoms had improved, with a 5-point decrease in her PHQ-9 score. During today's visit, she reports that her depressive symptoms have continued to improve, although she has experienced sexual dysfunction manifested by anorgasmia. Her medical history includes hypertension, for which she takes hydrochlorothiazide and lisinopril. • On physical examination, the BMI is 29, and blood pressure is 146/90 mm Hg. The remainder of the examination is normal.

25. Question 7 • Which of the following is the most appropriate alternative treatment option for this patient's depression? A Citalopram B Mirtazapine C Venlafaxine D Bupropion E Sertraline

26. Question 7 – Answer D • Bupropion has the least proclivity toward sexual dysfunction and does not cause weight gain. • Anorgasmia is a common side effect of selective serotonin reuptake inhibitors (SSRIs), including citalopram, and there is no good evidence suggesting one SSRI has fewer sexual side effects than another SSRI.

27. Question 8 • A 41-year-old woman is evaluated for a 3-week history of red, itchy eyelids. She wears contact lenses daily. She has not used any new cosmetics, soaps, or laundry detergents. She has no history of asthma or atopy. • Physical examination shows erythema and mild edema of the upper eyelids only. There is no blurred vision, purulent eye discharge, or dry skin around the eyes or lashes. The rest of her skin examination is normal. There is no lymphadenopathy or muscle weakness.

28. Question 8 • Which of the following is the most likely diagnosis? A Seborrheic blepharitis B Rosacea C Dermatomyositis D Lichen simplex E Contact dermatitis

29. Question 8 Answer - E • Contact dermatitis is an inflammatory response of the skin to an allergen or irritant. It can appear as an acute eczematous dermatitis with erythematous papules and vesicles and, occasionally, bullae. • The patient in this case has an acute presentation with a limited area of involvement and manifested by swelling and itching of the entire upper lid, including the inner canthus. • Eyelids are particularly sensitive to allergens in nail polish, shampoos, hair sprays, and other aerosolized products • When it involves the eyelid, contact dermatitis may be confused with seborrheic blepharitis because of the scaling and flaking. • Seborrheic blepharitis is a chronic condition that usually causes pain with blinking and burning eye irritation with watering. Frequently, scale is visible around the lashes, and sometimes there is crusting at the medial canthus. Occasionally, patients have decreased vision or photophobia.

30. Rosacea most often affects the nose, cheeks, and forehead. Its classic patchy, flushed discoloration mimics sunburn. Rosacea can involve the eyelids, and many patients have irritated eyes with a bloodshot appearance. Flushing is common, but itch is not a predominant symptom. • Dermatomyositis does not itch and is usually accompanied by proximal muscle weakness, although skin findings can precede muscular weakness. The typical eyelid finding in dermatomyositis is a heliotrope or violaceous discoloration around the eyes (raccoon-like). The heliotrope rash is generally not itchy and is associated with a more circumferential periorbital edema. It rarely involves scale. • Lichen simplex is known as the “scratch that itches.” It is a form of chronic dermatitis, in which inflammation causes the skin to become scaly, producing the sensation of itch. Chronic itching and scratching cause further changes in the skin, and the thickening epidermal layers and leather-like texture result in a persistent scratch-itch cycle. It is frequently exacerbated by stress and is more common in women.

31. Question 9 • A 75-year-old man undergoes postoperative evaluation after right hip-fracture surgical repair. His history includes mild dementia, coronary artery disease treated with intracoronary stenting to the left anterior descending artery 2 years ago, hypertension, hyperlipidemia, and type 2 diabetes mellitus.

32. Question 9 • Preoperative medications included atenolol, fosinopril, hydrochlorothiazide, simvastatin, glipizide, lorazepam as needed for sleep, and daily aspirin. • Preoperatively, the physical examination was notable for normal vital signs, distress due to pain, full orientation, nonfocal neurologic findings, and normal cardiopulmonary and abdominal examinations.

33. Question 9 • Hct 38%, CXR normal, EKG old inferior infarct. • On postoperative day 1, he is acutely confused, agitated, rambling, illogical in speech, and unable to focus attention on conversation. The temperature is normal, P 80 - 100/min depending on state of agitation, and BP is 130/76 mm Hg. The remainder of the examination, including neurologic examination, is unremarkable.

34. Question 9 • Which of the following is the optimal postoperative management strategy for this patient? A Haloperidol, patient restraints for safety, and CT of the head B Olanzapine and MRI of the head C Risperidone, empiric antibiotics, LP D CXR, EKG, metabolic profile, and haloperidol

35. Question 9 Answer - D • In addition to a physical examination, most patients with postoperative delirium should be evaluated with electrocardiography, chest radiography, and metabolic panel.

36. Question 10 • A 24-year-old man requests antibiotics during an evaluation for symptoms he has attributed to a sinus infection. He reports sinus congestion and clear nasal drainage that has persisted for 1 month after he developed a cold; he has no fever, sinus pain, purulent nasal drainage, sneezing, or nasal itching.

37. Question 10 • Since the onset of his symptoms, he has been using a nasal decongestant spray with only short-term symptomatic relief, but he states that antibiotics have been effective in the past for treating his sinus infections. His history includes allergic rhinitis, but his primary allergens are not in season.

38. Question 10 • Nasal examination shows congested nasal mucosa with a profuse watery discharge. The nasal septum appears normal, the turbinates are pale, and there are no polyps. The remainder of the physical examination is normal.

39. Question 10 • Which of the following is the most likely reason for this patient's symptoms? A Allergic rhinitis B Bacterial sinusitis C Nonallergic rhinitis D Rhinitis medicamentosa E Viral upper respiratory infection

40. Question 10 – Answer D

41. Question 11 • A 67-year-old woman is evaluated for a 6-week history of stiffness and pain, particularly around the shoulders and hips. She is unsure whether there are any exacerbating or alleviating factors or whether her pain worsens during certain times of the day but believes that it is worse in the morning. She does not have visual problems, scalp tenderness, temporal area pain, jaw claudication, or wrist or finger joint swelling. • On physical examination, she is afebrile. There are no rashes, and peripheral pulses are symmetrical and normal. There is no evidence of synovitis. On musculoskeletal examination, there is tenderness to palpation, particularly around the proximal upper and lower extremities, but muscle strength is normal. The remainder of the examination is unremarkable.On laboratory studies, hemoglobin is 11 g/dL (110 g/L) and erythrocyte sedimentation rate is 82 mm/h.

42. Which of the following is the most appropriate therapy? • A) Prednisolone, 15 mg/d • B) Prednisolone, 1 mg/kg/d • C) Methotrexate, 10 mg weekly • D) Etanercept, 25 mg subcutaneously • E) Hydroxychloroquine, 400 mg/d

43. PMR Treatment with prednisone, 15 mg/d Typically develops in patients >50 years of age Proximal pain Sense of weakness of the upper and lower extremities Higher doses of prednisone or a corticosteroid equivalent are indicated if features of giant cell arteritis (GCA), such as headache, visual disturbance, jaw claudication, or neck pain (carotidynia), are present. However, these symptoms are absent in this patient.

44. Prednisolone, 1 mg/kg/d, is useful for initial management of GCA but excessive for PMR; this dose would be equivalent to prednisone, 60 mg/d. • Methotrexate is beneficial in inflammatory arthritis, such as rheumatoid arthritis, but is not indicated in a patient without signs of synovitis on examination. Methotrexate also may be used as a steroid-sparing agent later in the course of certain inflammatory diseases but is not required in the treatment of PMR and may not be effective in GCA. • Etanercept can be used in rheumatoid and psoriatic arthritis. This patient lacks peripheral synovitis involving the small joints which excludes these conditions. • Hydroxychloroquine is an immunomodulator commonly used to treat arthritis and photosensitivity related to systemic lupus erythematosus and milder arthritis in rheumatoid arthritis but is not beneficial for PMR or GCA.

45. Question 12 • A 38-year-old woman with a 6-year history of systemic lupus erythematosus comes for a follow-up evaluation after starting therapy with hydroxychloroquine and ibuprofen for joint arthralgias 3 weeks ago. She feels modestly better and reports no difficulty with her new medications. She does not have rash, diarrhea, stomach pain, or heartburn.

46. Which of the following studies are routinely indicated for this patient to monitor for hydroxychloroquine toxicity? • A) Chest radiography • B) Ophthalmologic examination • C) Complete blood count • D) Urinalysis

47. Hydroxychloroquine is an antimalarial agent with lysosomotropic properties that affects immune regulation and inflammation. • Its use is associated with modest reduction in signs and symptoms of active rheumatoid arthritis and has been shown to reduce the likelihood of flares in patients with systemic lupus erythematosus. • This agent becomes beneficial after 2 to 6 months of use and is frequently used in combination regimens. • Hydroxychloroquine should be used with caution or not at all in patients with allergies to any antimalarial agents or who have glucose-6-phosphate dehydrogenase deficiency or retinal abnormality.

48. Because hydroxychloroquine is associated with retinal toxicity, all patients taking this agent should be monitored with an ophthalmologic examination every 6 to 12 months. • In addition, formal visual field testing should be performed at least once a year, because retinal toxicity associated with this agent causes visual field defects. • Chest radiography, complete blood count, and urinalysis are not useful for toxicity monitoring.

49. Question 14 • A 67-year-old man with newly diagnosed, widely metastatic prostate cancer is hospitalized for severe hip, chest wall, and shoulder pain. Acetaminophen, ibuprofen, and oxycodone–acetaminophen have not relieved his pain. Administration of intravenous morphine sulfate, 1 mg/h, is initiated, with a breakthrough dose of 2 mg/h, intravenously, as needed. His pain is well controlled after 2 days. Which of the following is the most appropriate drug regimen for this patient after hospital discharge to the home? • A) Controlled-released morphine sulfate twice daily and immediate-release morphine sulfate as needed • B) Oxycodone–acetaminophen as needed • C) Hydrocodone-acetaminophen as needed • D)Controlled-release morphine sulfate twice daily and oxycodone as needed

50. Question 15 • A 73-year-old man is evaluated for long-standing bilateral lower-extremity edema and a feeling of leg heaviness. Treatment with diuretics has not reduced the swelling. Medical history includes gastroesophageal reflux disease, emphysema, and hypertension treated with ranitidine, albuterol, furosemide, and lisinopril. • On examination, the pulse rate is 76/min, respiration rate is 12/min, and blood pressure is 144/84 mm Hg. There is no jugular venous distention. On cardiopulmonary examination, his heart rhythm is normal, and he has no murmurs or gallops and only a few scattered bibasilar crackles on auscultation. The lower legs are diffusely hyperpigmented, and there is pitting edema above the indurated tissue and over the feet, with no warmth, ulcerations, drainage, or toe involvement • BUN: 22 Cr: 1.4 TSH: 8.4