Medpass Exam 4 – Internal

A 70-year-old male with no significant medical history who does not take any medication has
a negative fecal occult blood test taken one year ago. He is now complaining of general
malaise and exertion intolerance. Labs include Hb=7.1, MCV=78, RDW=20. What should be
the next step?

A 60-year-old male is admitted to the intensive care unit with systemic candidiasis. Which of
the following is a risk factor for the development of such severe candidemia?

Which of the following criteria is not included in the definition of the “metabolic
syndrome”?

Which of the following is not considered a physical sign of COPD?

A 40-year-old male that has untreated AIDS presents with shortness of breath. His physical
exam is significant for respiratory distress and O2 saturation of 88% in room air. Chest X-ray
shows bilateral opacities. His labs demonstrate CD4<40. Sputum Silver stain is positive. How
would you treat this patient?

A 55-year-old woman with a history of mitral valve replacement with a mechanical
prosthesis, presents with 2-week long fever, malaise and shortness of breath. Blood cultures
are positive for Methicillin resistant Staph Aureus (MRSA). Transesophageal
echocardiography (TEE) shows a 5 mm vegetation on the anterior leaflet of the mitral valve.
What is the correct antibiotic treatment?

An 84-year-old woman presented to the emergency department two weeks after initiation
of SSRI therapy, with extreme malaise and general deterioration in her condition. Despite
deterioration she continued to take her usual prescription medication. On the day of her
admission, she experienced loss of consciousness and tonic-clonic seizure, without focal
neurological deficits. Brain CT scan was without evidence of bleeding or any other acute
findings. Plasma osmolality=250, calcium=8.5, Na=110. Urine osmolarity=250, and urine
sodium>20. How should this patient be treated?

A 30-year-old male presents with a burning sensation during urination and a small but
increasing amount of discharge from his penis. Urine dipstick showed evidence of
leukocytes, and Gram staining revealed Gram negative solitary and paired cocci. What is the
preferred treatment for this patient?

A 35-year-old male is complaining of shortness of breath. Pulmonary function tests (PFT)
demonstrated: TLC=73%, RV=110%, FVC=72%, FEV1=80%, FEV1/FVC=75%, DLCO was
normal. Which of the following diagnoses can explain the above PFT?

A 56-year-old woman has been suffering from a rash and fatigue in the past several months.
Her physical exam showed scratch marks on her skin, normal heart sounds and normal
breathing, her abdomen was soft without organomegaly. Her limbs are without edema nor
signs of DVT. Lab results:

What is the best treatment?

Which of the following is true regarding acute kidney injury caused by IV contrast dye?

A 62-year-old male with medical history of hyperlipidemia, diabetes and smoking, was
admitted to the internal medicine unit due to a pressing chest pain radiating to his left
shoulder, along with shortness of breath and cold sweat, lasting for 30 minutes. ECG on
admission was without signs of ischemia and his troponin was negative. Which of the
following is correct regarding a stress test for this patient?

A combat soldier presents to the emergency room after 8 days of high temperature -up to
41◦C, chills, headache, muscle aches and nausea without vomiting. There was a several-day
relief from the fever followed by repeat rise exceeding 40◦C. The patient noted that other
soldiers in his unit have similar complaints. Labs were normal including a normal white blood
cell count. Antibiotic therapy with penicillin was initiated in the ER, and two hours later the
patient developed rigors, his body temperature rose to 42◦C and blood pressure was 70/40.
Which of the following describes this patient`s condition most accurately?

A 77-year-old male with multiple admissions for urinary tract infection, is now hospitalized
due to diarrhea, and was diagnosed with clostridium difficile infection. The patient
completed 10 days of treatment with oral metronidazole, with clinical improvement. Two
days after the completion of treatment the diarrhea recurred. Labs showed rising
leukocytosis up to 14,000 and creatinine of 1.3. Repeat stool test for clostridium toxin came
back positive. Choose the best statement regarding treatment of this patient.

A 25-year-old female who suffers from nephrotic syndrome presents to the emergency
department with a swollen leg. Sonography of the deep veins of her leg demonstrates
thrombosis in the superficial femoral vein. Which of the following situations does not
contribute to hypercoagulability syndrome in this patient?

A 30-year-old male presents to the emergency room with fever, dry cough and malaise. His
chest X-ray demonstrates interstitial infiltrates. His blood test shows WBC=11,000, Hb=11,
LDH is high and there is evidence of cold agglutinins. What is the pathogen?

A 60-year-old male was admitted to the internal medicine department to investigate
hyponatremia. The initial diagnosis was Syndrome of inappropriate antidiuretic hormone
secretion (SIADH). Therefore, to investigate whether the cause could be a neoplastic
process, a CT scan of the chest and abdomen was performed, discovering a space occupying
lesion (SOL) in the lungs. What is the most probable pathology of this SOL?

A 65-year-old female presented to the emergency room with chest pain radiating to her
back- between her shoulder blades, in addition to general malaise and shortness of breath.
Her vital signs included blood pressure of 220/120 and a regular heart rate of 70 beats per
minute. Her chest X-ray demonstrated a wide mediastinum, without pulmonary congestion.
What is the next step?

A 43-year-old male suffers from epigastric pain, heart burn and diarrhea. Gastroscopy found
an ulcer in the second part of the duodenum. H. Pylori test was negative. There is no history
of NSAIDS use. Treatment for the ulcer was initiated without symptom improvement. Repeat
gastroscopy showed no cure of the ulcer. What should be the next test?

Which of the following does not cause QT elongation and Torsades de Pointes?

A 65-year-old male was recently diagnosed with NASH cirrhosis. Screening gastroscopy
showed very large, grade 3 esophageal varices without signs of bleeding. Which of the
following is the preferred treatment?

A 30-year-old male was referred to the emergency room due to sudden syncope. On his
admission his blood pressure was 120/70 with regular pulse of 80 beats per minute. Heart
auscultation revealed a fourth heart sound (S4) and a systolic murmur 4/6, maximal at the
apex, radiating to the axilla, increasing with Valsalva maneuver. Following is his ECG:

Which of the following is true regarding this patient?

A 46 year old male with a history of drug and alcohol abuse and chronic HBV, presents with
abdominal pain, nausea and malaise in the past several days. His physical examination is
noted for icteric sclerae and tenderness in the right upper abdominal quadrant. The
following labs are attached:

Abdominal sonography demonstrates hepatomegaly, without focal findings. What is the
most likely diagnosis?

A 30-year-old female is known to have had asthma since childhood. She presented to the
emergency room with shortness of breath for the last two days. Which of the following
findings in her physical exam is not indicative of a life threatening severe asthmatic attack?

A 59-year-old male, with a history of diabetes and hypertension, presented to the
emergency room with chest pain radiating to the left shoulder, that started at rest 30
minutes ago, together with shortness of breath and cold sweat. An ECG was performed as
follows:

The patient was immediately brought to the catheterization suite. Which artery is expected
to be occluded?

In which of the following cases thrombolytic therapy for pulmonary embolism (PE) is
indicated?

A 60-year-old heavy smoker is complaining about bilateral calf aches that appear after
walking for 200 meters and subside after rest, for the past 3 months. In his physical
examination there is no increased jugular venous pressure, his heart sounds are normal
without murmurs or additional heart sounds, there is no limb edema, he has normal
palpable peripheral pulses and his ankle-brachial index=0.7. Which of the following
treatments would you recommend to the patient?

Which of the following patients that recently experienced deteriorating kidney function
would you refer to kidney biopsy?

Which of the following is considered a criterion of acute respiratory distress syndrome
(ARDS)?

A 60-year-old male with a history of hypertension, diabetes and smoking presented to the
emergency room with pressing chest pain in the front area of his chest, that started 30
minutes ago, together with shortness of breath and cold sweat. His vital sign on admission
were a heart rate of 60 beats per minute and blood pressure of 85/60 with evidence of
increased jugular venous pressure (JVP). An ECG was performed as follows:

A 30-year-old male with a history of type I diabetes mellitus is presenting with two days of
diarrhea and vomiting. His labs on admission were: Glucose=240, pH=7.22, HCO3-=13,
PCO2=26, Cl-=113, Na+=134, how should we proceed with the diagnosis and treatment?

A 70-year-old male with a history of hypertension, diabetes and chronic atrial fibrillation is
regularly treated with warfarin. He was referred to the emergency room due to INR value of
6. What should be done?

A 35-year-old female presented to the emergency department with extreme malaise. Her
lab results showed hemoglobin level of 6, MCV=102, Reticulocytes=14%, platelets=190,000,
WBC=7800, LDH=800. How would you proceed with the diagnosis process?

A 70-year-old female tourist from South-East Asia is complaining about dysphagia. At first it
was difficult to swallow solid food only, and now it is difficult to swallow liquids as well.
Symptoms have progressed rapidly in the past several months and she had lost 7 kg of her
weight. Imaging of her esophagus is attached. Which of the following is correct?

A 34-year-old female is complaining for quite some time about pain in the joints of her
fingers, a rash on her face, hair loss and weight loss. She currently underwent an abortion in
the 13th week of pregnancy. She had abortions in the past, in week 12 and week 14 of
pregnancy. Which of the following conditions does she most probably have?

A 46-year-old male with a history of hypertension was treated with ACE. Since he was
discontent with this treatment it was changed to a beta blocker 3 months ago. Lately he has
been complaining about joint pain, mild rash on his nasal bridge and cheeks and chest pain
that was relieved by leaning forward. What is he probably suffering from?

A 48-year-old male with a history of asthma is complaining of cough for the last several
weeks, now with hemoptysis. He is also complaining about left leg weakness and hand
paresthesia His physical exam was significant for diffuse purpuric rash. Complete Blood
Count found 10,000 leukocytes, normal creatinine, PMN=60%, EOS=20%. Which test would
you perform next?

A 40-year-old male is suffering from scaly skin in his naval and joint pain. His blood tests are
negative for Rheumatoid factor (RF). Which of the following is likely to be found in this
physical exam?

A 30-year-old female, without significant medical history presented with abdominal pain and
ascites. Sonography demonstrated a non-cirrhotic liver and signs of hepatic vein occlusion.
Which of the following tests should be performed?

A usually healthy 36-year-old male is presenting with 3 days of diarrhea with frequency of 7-
8 times during the day and 1-2 times during the night. He also has fever and abdominal pain.
He was treated with fluids and electrolytes. How should we proceed?

A Crohn`s patient with diarrhea and weight loss is presenting with gum and skin bleeding. A
deficiency in which of the following can explain this presentation?

A 70-year-old male is presenting with pruritis and fatigue for a long period of time. In
addition, he has several enlarged lymph nodes in his neck and axilla. A biopsy of the nodes
revealed the following picture. What is his diagnosis?

A usually healthy 40-year-old male, is presenting with confusion, fever and the following
laboratory tests:

 Platelets=80,000
 Hemoglobin=10 gr/dL
 Creatinine 1.8 mg/dL
 LDH=700
 Total bilirubin=3.5
 Direct bilirubin=0.3
 Low haptoglobin
What should be done?

A 60-year-old female is presenting with chronic fatigue. Her blood test is significant for
30,000 leukocytes, mostly polymorphonuclear cells (PMN) and mild anemia. Chromosomal
investigation showed 22:9 translocation. What is the treatment?

In a patient suffering from lower back pain for the past two weeks, which of the following
will be the most helpful in ruling out osteomyelitis?

An 85-year-old nursing home resident suffered from a cough and shortness of breath and
was diagnosed with pneumonia; attached please find a chest X-ray and CT scan that were
obtained. She was primarily treated with Augmentin for a week with no improvement, then
Clindamycin was initiated, without improvement after two days of treatment.

What should we do?

You were called to tend to a person that collapsed in the hospital hallway, with no palpable
pulse. What should you do immediately besides chest compressions?

A 70-year-old lady with known hypertension presents to the emergency room with blood
pressure of 220/80 mmHg and mild headache. Examination by an ophthalmologist
demonstrates mild retinopathy, without disc edema. She is otherwise asymptomatic, and
her blood tests are normal. How should she be treated?

A 34-year-old male with a history of hypertension and hypokalemia is suspected to have
hyperaldosteronism. Aldosterone/renin ratio was found to be high. How can a diagnosis of
primary aldosteronism be verified?

A 32-year-old female with a history of Grave`s disease is breastfeeding, two months
postpartum. Treatment with methimazole was initiated, and then she came down with fever
of 38°C and a sore throat. Her CBC was significant for 20,000 neutrophils. How should she be
treated after recovering from the acute phase?

A 60-year-old male with a history of COPD is hospitalized due to exacerbation in cor-
pulmonale. He is treated with diuretic medication. His blood gas test showed: Na+=140, Cl-
=88, K+=4, HCO3-=42, PCO2=67, pH=7.45. What is the disruption in acid-base equilibrium?

Which of the following is not a side effect of Amiodarone?

The Following is a hand image of a 72-year-old male, who presents with right knee pain for the
last 6 weeks. Assuming the cause of his complaint it similar to the one affecting his hands,
what would his complaints probably be?

A 78-year-old female with a history of heavy smoking and heart failure resulting from ischemic heart disease, presents to the emergency room with progressive shortness of breath for the last two weeks. She denies chest pain, cough and weight loss. She has normal body temperature and O2 saturation; she is tachypneic, without respiratory distress, breathing 18 breaths per minute and has decreased breath sounds on the left. Her labs show no leukocytosis, Hb=13, creatinine=1.2mg/L, protein=7 gr/L, albumin=4.2 gr/L, LDH=220mg/dL. Her chest X-ray is attached below.

Which of the following is correct regarding management of this case?

A 28-year-old female is hospitalized due to fever, hemoptysis and shortness of breath that started 10 days prior to her admission. She had several episodes of otitis and sinusitis with purulent discharge in the past several months, with negative cultures. Her labs were significant for leukocytosis with neutrophilia, positive anti-PR3 ANCA and normal creatinine. A chest X-ray is attached.

Which of the following treatments is correct?

A 70-year-old male presents with ascites for the first time in his life. He undergoes diagnostic
paracentesis, and in the ascites fluid albumin level is 2 gr/dL, while in the blood it is 3.5
gr/dL. Protein in the ascites fluid is 1.5 gr/dL. Which of the following is a possible cause of
ascites in this patient?

A 50-year-old male undergoes endoscopy of the upper GI due to dyspepsia and weight loss,
that demonstrates mucosa-associated lymphoid tissue (MALT) limited to the stomach that is
verified by biopsy, which is also positive for H. Pylori. What is the first step of treatment in
this patient?