Board Review Questions in Internal Medicine

Jeanny Aragon-Ching, MD, Chief Medical Resident, Albert Einstein Medical Center; Mark Morginstin, DO, Chief Medical Resident, Albert Einstein Medical Center; Daniel Salerno, MD, Chief Medical Resident, Albert Einstein Medical Center; Steven L. Sivak, MD, The Paul J. Johnson Chairman of Medicine, Albert Einstein Medical Center, Clinical Professor of Medicine at Jefferson Medical College, Philadelphia, Pa

1. You are the physician taking care of residents at a local nursing home during the winter season. You hear about a recent outbreak of influenza in another nursing home and are concerned about a similar outbreak in the facility where you work. There was a delay in the administration of the influenza vaccine, and the nursing home residents have not received their flu shots. What is your next step?

1. administer amantadine HCl (Symmetrel) only to elderly patients with comorbidities
2. administer zanamivir (Relenza) to those with chronic lung conditions
3. administer influenza vaccine to all residents
4. wait for the outbreak to reach your facility, then administer amantadine
5. do nothing; none of the patients has influenza

2. A 56-year-old woman comes in complaining of easy fatigability. Her medical history is significant for primary hyperparathyroidism diagnosed 1 year ago. A dual-energy x-ray absorptiometry (DEXA) scan obtained after she had fractured her ankle showed a T-score of -2.5 SD on the hip and forearm. Laboratory tests show a serum calcium level of 11.6 mg/dL (previously, 10.9 mg/dL) and a phosphorus level of 2.6 mg/dL. A follow-up parathyroid hormone (PTH) level was elevated, 110 pg/mL (normal, 10-65 pg/mL). What is the next step in your management?

1. observation
2. yearly follow-up measurements of serum calcium, with referral to surgery for parathyroidectomy if the calcium level increases
3. recommend vitamin D and calcium supplementation for treatment of osteoporosis
4. referral for parathyroidectomy
5. prescribe alendronate sodium (Fosamax), 10 mg/d, for treatment of osteoporosis

3. A 34-year-old white woman comes to your office for an initial visit. She says she has not been diagnosed with any medical conditions and does not have any symptoms, but she recalls being told that she had "some kind of hepatitis" a few months earlier, during screening for a blood donation. She denies drinking alcohol but admits to intravenous (IV) drug use in the past. Her vital signs and physical findings are unremarkable, and results of laboratory and liver function tests are within normal limits. What should management be at this time?

1. lamivudine (Epivir) therapy
2. recommend ultrasound examinations every 6 months
3. peg-interferon alfa (Pegasys, PEGIntron) and ribavirin (Copegus, Rebetol) therapy
4. hepatitis A and B vaccination
5. measurement of alpha-fetoprotein level every 6 months

4. You are in the outpatient clinic seeing a 45-year-old woman who is receiving warfarin sodium (Coumadin, Jantoven) because of a history of deep venous thrombosis followed by pulmonary embolism. She now has new-onset retinal bleeding and an international normalized ratio (INR) of 8.4. What should your management be?

1. withhold warfarin and switch to low-molecular-weight heparin (LMWH) and fresh frozen plasma
2. withhold warfarin and administer subcutaneous vitamin K, 10 mg
3. withhold warfarin and administer IV vitamin K, 10 mg, and fresh frozen plasma
4. withhold warfarin, then restart it at a lower dose after 3 to 4 days when her INR is between 2.0 and 3.0
5. withhold warfarin and administer oral vitamin K, 10 mg

5. A 23-year-old woman sees you for an initial visit after her 35-year-old brother was diagnosed with colon cancer. She is unaware of any other family history of cancer and denies any symptoms. She has heme-negative stools on examination. Laboratory tests show no significant findings. You refer her to a gastroenterologist, who performs a colonoscopy and finds multiple (>100) adenomatous polyps throughout the colon, ranging in size from 2 to 15 mm. What would be the best management for this patient?

1. celecoxib (Celebrex) or sulindac (Clinoril) to reduce the size of the polyps
2. polypectomy of the largest lesions (>1 cm), then biopsy the remaining polyps every 6 months
3. prophylactic colectomy
4. sigmoidoscopic surveillance and ablation of polyps every 6 months
5. continue yearly colonoscopy examinations and perform colectomy only if colorectal cancer develops

6. A 22-year-old African American woman comes to see you because of increasing shortness of breath for several months that is worse with exercise and a dry cough. She denies fever, edema, chest pain, recent travel, smoking, sick contacts, or any significant family history. Screening laboratory tests show a hemoglobin level of 12 g/dL and serum calcium level of 11.1 mg/dL. Chest x-ray shows no infiltrates but fullness of the mediastinum suggestive of bilateral hilar adenopathy. The mechanism of her hypercalcemia is:

1. increased PTH secretion
2. increased macrophage production of circulating 1,25-dihydroxy vitamin D
3. increased circulating PTH-related protein
4. failure of calcium-sensing receptors
5. increased set-point for calcium suppression of PTH

7. A 44-year-old man presents to the emergency department complaining of acute right colicky flank pain with radiation to the right testicle. A plain abdominal film shows no acute disease but a noncontrast computed tomography (CT) scan shows a 2-mm radiolucent stone in the right ureteropelvic region. Serum calcium was 8.9 mg/dL. Aside from pain management and increasing his fluid intake to more than 2 L/d, what is the most appropriate next step in management?

1. prescribe urease inhibitors (acetohydroxamic acid)
2. refer to urology for shock wave lithotripsy
3. prescribe colchicine
4. prescribe oral sodium citrate and citric acid solution (Bicitra, Oracit) or potassium citrate (Urocit-K)
5. refer to urology for ureteroscopy

8. A 24-year-old woman presents for medical clearance for her job as a nursing assistant. She had been healthy all her life except for some episodes of gum bleeding when she brushes her teeth "too vigorously." She denies any family history of bleeding disorders, HIV risk factors, or use of drugs, alcohol, or over-the-counter (OTC) medications. Physical examination is normal except for some notable petechiae on her arms, which she says have been there on and off for the past year. You order a complete blood cell count, which shows an isolated thrombocytopenia (platelet count, 55 x 10⁹/L) without any other abnormality on the peripheral smear. All other serum chemistries and coagulation profile are normal. The mechanism of her thrombocytopenia is:

1. failure of cleavage of von Willebrand factor (vWF) multimers
2. presence of circulating platelet factor IV antibodies
3. presence of autoimmune antibodies to platelet membrane antigens
4. mutation defect of vWF binding to factor VIII
5. quantitative decrease or absence of vWF

9. A 24-year-old woman comes to the clinic for medical evaluation after her obstetrician noted a murmur on prenatal examination. She is in her 21st week of pregnancy and denies any symptoms. She has a history of penicillin allergy with an immediate hypersensitivity reaction. Physical examination showed blood pressure (BP) is 128/68 mm Hg and pulse is 89 beats per minute (bpm). Cardiac examination reveals a systolic click followed by a 2/6 late crescendo-decrescendo murmur at the apical area that diminishes with squatting and worsens with Valsalva maneuver. Which of the following is appropriate endocarditis prophylaxis in this patient?

1. amoxicillin (Amoxil, Trimox) 1 hour before a cesarean delivery
2. vancomycin (Vancocin, Vancoled), 1 g, 30 minutes before cesarean delivery
3. azithromycin (Zithromax), 500 mg orally, before vaginal delivery
4. no antibiotic prophylaxis regardless of the type of delivery
5. cephalexin (Biocef, Keflex), orally, before vaginal delivery

10. You are a hospitalist admitting an 81-year-old woman from the nursing home who sustained a right femoral neck fracture after a fall. The orthopedic surgeon is planning a reduction and internal fixation pending your medical clearance. Her medical history includes type 2 diabetes mellitus, cerebrovascular accident with residual right hemiparesis, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and hypertension. She denies any pain except locally over the right groin. She cannot tell you much about her functional status, since she claims to spend most of the time in her wheelchair or bed, and it was her attempt to get up that resulted in her fall. Vital signs are stable, with a BP of 140/80 mm Hg. Electrocardiography (ECG) reveals normal sinus rhythm with a rate of 89, left ventricular hypertrophy, and nonspecific T-wave changes. Screening laboratory test results are within normal limits, except for a slightly elevated creatinine concentration of 1.7 mg/dL (her baseline). Chest xray reveals slight cardiomegaly but no cephalization or fluid overload. What is your recommendation for medical clearance?

1. proceed immediately to surgery and give perioperative betablockers
2. proceed to surgery, since the procedure is low risk
3. perform angiography before surgery
4. schedule a dobutamine stress echocardiogram or nuclear imaging study
5. cancel surgery; her risk for perioperative death is too high

11. A 65-year-old man complains of cough, which he thought was the flu, for 1 month. He denies any significant medical history and has not traveled recently. He denies hemoptysis, night sweats, or any other significant symptoms. He has a 50 pack-year smoking history. Physical examination is unremarkable and pulmonary function tests show a forced expiratory volume in 1 second of 3 L. You order a chest x-ray, which reveals a 3.5-cm right middle-lobe lung mass near the periphery. No previous x-rays can be found. A subsequent CT scan of the chest confirms the presence of the 3.5-cm lesion, which has an irregular and spiculated border without calcification. No obvious adenopathy can be seen. What is the next step in management?

1. refer the patient for thoracic surgery or video-assisted thoracoscopy for resection of the lesion
2. follow-up with annual repeat chest x-rays
3. start chemotherapy
4. start radiation therapy with concurrent chemotherapy
5. obtain a needle-guided biopsy

12. A 68-year-old African American nonsmoking man presents for a routine visit. His medical history includes hypertension, which is well controlled with a calcium channel blocker. During your review of systems, he admits to having nightly episodes of urination "more than usual." He feels that his bladder does not fully empty after voiding and that his urine stream has slightly diminished. He says these symptoms are disrupting his lifestyle. He has had no associated fever, weight loss, hematuria, or pain with voiding. Digital rectal examination is significant for moderate enlargement of the prostate but is otherwise normal. Results of urinalysis and kidney functions are normal. His prostate-specific antigen (PSA) level is 1 ng/mL. What is the appropriate therapy for this patient?

1. surgery
2. referral for surgical prostatectomy
3. saw palmetto
4. alpha-blocker therapy
5. watchful waiting

13. A 36-year-old man with AIDS (CD4 cell count <20/μL) presents with right upper-quadrant pain, mild jaundice, and diarrhea and vomiting for 3 days. Liver function tests show a significantly elevated alkaline phosphatase of 821 U/L, total bilirubin of 1.4 mg/dL, and mildly elevated AST (95 U/L) and ALT (84 U/L). Amylase and lipase levels are elevated. Right upper-quadrant ultrasound shows gallbladder distention, with thick sludge, as well as intra- and extrahepatic ductal dilatation. Treatment with percutaneous biliary drainage relieves his symptoms. What is the most likely diagnosis?

1. gallstone pancreatitis
2. pancreatic carcinoma
3. HIV cholangiopathy
4. alcoholic hepatitis
5. cholangiocarcinoma

14. A 73-year-old healthy woman presents to your office for the first time for a regular checkup. She has osteoarthritis, which is controlled with OTC acetaminophen (Tylenol). She has had an appendectomy in the past. She has no symptoms and feels well and reports she has had a Pap smear in the past but cannot remember exactly when or what the results were. You obtain her records from her previous provider, which show that she has had 4 Pap smears in the past 10 years, all completely normal. Based on these results, she asks if she needs a Pap smear today. What is the appropriate course of action?

1. perform the Pap smear and, if normal, another one in 1 year, then stop screening
2. refer her to a gynecologist for further evaluation
3. assure her that she no longer needs screening for cervical cancer
4. obtain a pelvic ultrasound

15. A 63-year-old African American woman comes for a follow-up evaluation for hypertension. She is taking a diuretic for hypertension, has no history of coronary artery disease, is asymptomatic, but her BP in the office is 160/85 mm Hg. She also has diabetes, which is controlled with metformin HCl (Glucophage). She has microalbuminuria and a creatinine level of 1.5 mg/dL, which is increased from 1 year ago. Which of the following treatments is indicated in this patient?

1. continue the current drug regimen; this is stage 1 hypertension
2. prescribe an angiotensin-converting enzyme (ACE) inhibitor, with the goal of lowering BP to less than 130/85 mm Hg, as she has stage 2 hypertension
3. start an ACE inhibitor, with the target BP of less than 140/80 mm Hg
4. start a beta-blocker, with the target BP of less than 140/80 mm Hg
5. increase the dose of the diuretic to treat her stage 2 hypertension

16. An 80-year-old woman comes from her home with a complaint of shortness of breath for the past 5 days. She also claims to have low-grade fever, cough with greenish sputum, and pleuritic chest pain related to the cough. Her medical history is only positive for hypertension, which is under control with hydrochlorothiazide (eg, Esidrix, Hydro-Par). Physical examination shows she is alert and oriented to place and time. Her respiratory rate is 24 breaths per minute, and temperature is 100.8°F. Pulse oxymetry shows an oxygen saturation of 96% on room air. Lung examination reveals dullness and inspiratory crackles in the left lung base. The rest of the examination is unremarkable. Basic laboratory test results are also normal. Chest x-ray confirms the presence of a left lower base infiltrate, without any effusion. What is the next step in management?

1. she must be admitted to the intensive care unit and receive IV antibiotics
2. she must be observed for at least 72 hours in the general medical floor while receiving oral antibiotics
3. she must be observed for at least 72 hours in the general medical floor while receiving IV antibiotics
4. she is a safe candidate for discharge and management with oral antibiotics and subsequent follow-up by her primary care physician
5. she can be discharged with symptomatic treatment and follow-up with her physician; if symptoms persist, she will need oral antibiotics

17. A 52-year-old African American man comes to the emergency department with a 3-day history of malaise, fever, and posterior neck pain. After questioning, he says the pain radiates to his arms and he admits being an active IV drug user. His vital signs are significant for a temperature of 100.4°F and sinus tachycardia at 110 bpm. Examination shows significant inflammation in his posterior neck area and persistent flexion of his neck with limited lateral movement. Neurologic examination is normal. He is alert but in distress because of the pain in the cervical area. Initial laboratory tests show an erythrocyte sedimentation rate of 37 mm/h and a white blood cell count of 7 x 10⁹/L. How will you manage this patient?

1. immediate incision and drainage of the inflamed area and no antibiotics
2. admit him to the hospital and treat with a first-generation cephalosporin for his neck cellulitis
3. discharge the patient and treat with a first-generation cephalosporin for his neck cellulitis
4. obtain cervical spine x-rays; do not prescribe antibiotics until you see the results
5. admit him and order a gadolinium-enhanced magnetic resonance imagining (MRI) scan of the cervical spine, consult orthopedics and/or neurosurgery, and start antibiotic therapy with gram-positive and gram-negative coverage

18. Which of the following statements about acute pancreatitis is false?

1. 10% to 15% of patients develop systemic inflammatory response syndrome, leading to a fulminant course with pancreatic necrosis and multiorgan failure
2. gallstones are the leading cause in developed countries
3. a rise in concentration of serum amylase is expected but not always seen
4. patients should not be fed by mouth for at least 1 week
5. the standard of care dictates that patients with acute pancreatitis complicated by necrosis should receive a prophylactic, broadspectrum antibiotic, typically imipenem-cilastin (Primaxin)

19. A 42-year-old man presents to the emergency department with a 1-day history of dizziness. He says the symptoms appeared suddenly yesterday after waking up and included repeated vomiting and nausea and persistent vertigo that is still present. He denies other symptoms, such as dysarthria, lack of coordination, numbness, weakness, or any other neurologic focal deficit. On further interrogation, he remembers having some "cold" symptoms 1 week ago that resolved spontaneously. Once in the emergency department, his vital signs are stable. He has a left beating horizontal nystagmus that does not change in direction with changes in the position of the gaze. Otherwise, his neurologic examination is completely normal, and there is no hearing loss with tuning fork tests. What will you need to do before you can make a diagnosis and start treatment?

1. order an audiogram
2. order an electronystagmographic test
3. order a gadolinium-enhanced MRI of the brain or a thin-cut CT scan of the head with emphasis in the cerebellar area
4. a, b, and c
5. nothing; history and physical examination findings are sufficient to make a diagnosis

20. A 62-year-old Asian man presents to your office with a concern about changes in the shape of his fingers and nails. He is a longtime smoker with a documented history of COPD. He was told by another physician that the changes in his fingers are related to the COPD and that there is no need for further workup. Your physical examination confirms that the changes in his fingers are compatible with clubbing. Which of the following statements is false?

1. clubbing and hypertrophic pulmonary osteoarthropathy share features but are not the same entity
2. COPD is a common cause of clubbing
3. generation of the changes that cause clubbing may be related to platelet clumps that escaped the filtration in the pulmonary bed and entered into the systemic circulation, releasing growth factors at the nail bed
4. some specific conditions may cause clubbing in only one hand
5. the "Scharmroth sign" is positive in patients with clubbing

ANSWERS

1—C. The primary method for prevention is still annual vaccination. Outbreaks in long-term care facilities can involve a significant number of residents with high mortality rates. Antiviral drugs are useful when outbreaks occur and are an adjunct to the influenza vaccine; however, these agents are not a substitute for vaccination. Four licensed influenza antiviral agents are available in the United States—amantadine, rimantadine HCl (Flumadine), zanamivir, and oseltamivir phosphate (Tamiflu). Amantadine and rimantadine are effective for the treatment of influenza A, provided that they are administered during the first 2 days of illness. Amantadine stimulates the release of catecholamines and rimantadine does not, which presumably accounts for the prominent central nervous system side effects of amantadine. Therefore, amantadine should be used cautiously in elderly patients living in a nursing home. Zanamivir and oseltamivir are related antiviral drugs with a similar mechanism of action and rate of effectiveness against both influenza A and B viruses. Zanamivir should be used cautiously in patients with chronic respiratory disease because it can cause bronchospasm and reductions in airflow. Both zanamivir and oseltamivir are approved for the treatment of influenza only in persons who have been symptomatic for fewer than 2 days. In 2000, oseltamivir was approved for chemoprophylaxis of influenza in persons aged 13 years and older.

Source

MMWR Recomm Rep

Bridges CB, Harper SA, Fukuda K, et al. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). . 2003;52 (RR-8):1-34.

2—D. This patient has primary hyperparathyroidism, which has become increasingly more common since the advent of routine testing of serum calcium levels. Symptoms may include fatigue, weakness, exhaustion, depression, increased thirst, polyuria, nocturia, constipation, and musculoskeletal aches and pains. Associated conditions and complications include hypertension, nephrolithiasis, osteopenia and osteoporosis, gout, peptic ulcer disease, and pancreatitis. Indications for surgery have been the topic of debate in recent years. It is generally agreed that if the patient is symptomatic, parathyroid exploration is indicated. Considerable controversy remains concerning the most appropriate treatment for patients with mild or asymptomatic primary hyperparathyroidism, since the symptoms and complications do not appear to progress during a 10-year period in about 73% of patients. The 1990 National Institutes of Health (NIH) criteria for parathyroidectomy include (1) a serum calcium concentration more than 1.0 to 1.6 mg/dL above the upper limit of normal, (2) age under 50 years, (3) osteoporosis (Z-score, less than -2.0 in the forearm), (4) decreased renal function (>30%), (5) 24-hour urine calcium excretion greater than 400 mg per 24 hours, (6) nephrolithiasis, (7) severe psychoneurologic problems, or (8) a history of life-threatening hypercalcemia. More recent guidelines are similar, but the serum calcium level criteria is now reduced to 1 mg above the upper limit of normal, and bone density now includes patients with a T-score less than -2.5 at any site. Treating the osteoporosis without addressing the underlying cause of bone loss would lead to continuous and rapid bone loss. Hence, it is one of the indications for parathyroidectomy.

Sources

J Clin Endocrinol Metab

1. Bilezikian JP, Potts JT Jr, Fuleihan Gel-H, et al. Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century. . 2002;87:5353-5361.

Ann Intern Med

2. NIH Conference. Diagnosis and management of asymptomatic primary hyperparathyroidism: consensus development conference statement. . 1991;114:593-597.

JAMA

3. Irvin GL III, Carneiro DM. Management changes in primary hyperparathyroidism. . 2000;284:934-936.

N Engl J Med

4. Silverberg SJ, Shane E, Jacobs TP, et al. A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery. . 1999;341:1249-1255.

3—D. All patients with chronic hepatitis C virus (HCV) infection should be considered potential candidates for antiviral therapy. However, treatment is recommended for those who are at increased risk for progression to cirrhosis. Patients with chronic HCV infection without evidence of liver dysfunction do not require treatment. The NIH Consensus Development Conference Panel recommended reserving therapy for patients with histologic evidence of progressive disease. Thus, all patients with fibrosis or moderate- to-severe degrees of inflammation and necrosis on liver biopsy should be treated, and those with less severe histologic disease should be managed on an individual basis. This patient has normal aminotransferase levels, and therapy is inadvisable outside of controlled trials for individuals with normal aminotransferase levels; clinically decompensated cirrhosis; kidney, liver, heart, or other solid-organ transplant; or the presence of any specific contraindications to either monotherapy or combination therapy. If treatment was indicated, a combination of peg-interferon and ribavirin is recommended, which results in sustained response rates of 40% to 80%. Lamivudine is used to treat hepatitis B virus (HBV) infection. Screening for hepatocellular carcinoma is appropriate and more costeffective for patients with cirrhosis. This patient currently has HCV infection but no clinical evidence of cirrhosis. Patients with HCV infection would succumb more easily to other viral hepatitis infections, thus vaccination against hepatitis A is appropriate. Patients with HCV infection who belong to risk groups for whom HBV vaccine is recommended should also be vaccinated against HBV. Risk groups include health care workers, injection drug users, recipients of blood products (ie, hemodialysis patients), travelers to endemic areas, individuals who are incarcerated, household contacts, and sexual partners of HBV carriers.

Sources

Hepatology.

1. National Institutes of Health. National Institutes of Health Consensus Development Conference Statements: management of hepatitis C: 2002—June 10-12, 2002. 2002;36(suppl 1):S3-S20.

MMWR Recomm Rep

2. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. . 1998;47(RR-19):1-39.

4—C. This patient presents with serious bleeding secondary to warfarin treatment. Treatment should include withholding warfarin therapy and administering IV vitamin K with concurrent administration of either fresh frozen plasma or prothrombin concentrate. Oral vitamin K has been found to be effective in lowering the INR and is preferred unless rapid reversal of the INR is considered to be critical, in which case vitamin K is administered by slow IV infusion, since response to subcutaneous administration may be delayed or unpredictable. Switching to LMWH in the presence of a supratherapeutic INR is inappropriate. If the INR is above 5.0 but below 9.0 and the patient does not have clinically significant bleeding, 2 options are available. The warfarin dose can be omitted and reinstituted at a lower dose when INR falls to the therapeutic range. Or, the next dose of warfarin can be omitted and oral vitamin K (1.0-2.5 mg) given for patients at risk of bleeding.

Sources

Chest

1. Hirsh J, Dalen J, Guyatt G, American College of Chest Physicians. The sixth (2000) ACCP guidelines for antithrombotic therapy for prevention and treatment of thrombosis. . 2001;119(suppl):1S-2S.

Chest

2. Hirsh J, Dalen JE, Anderson DR, et al. Oral anticoagulants: mechanism of action, clinical effectiveness, and optimal therapeutic range. . 1998;114(suppl):445S-469S.

Chest

3. Ansell J, Hirsh J, Dalen J, et al. Managing oral anticoagulant therapy. . 2001;119(suppl):22S-38S.

Chest

4. Wilson SE, Douketis JD, Crowther MA. Treatment of warfarin-associated coagulopathy: a physician survey. . 2001;120:1972-1976.

5—C. This patient has familial adenomatous polyposis, an autosomal dominant syndrome caused by a germ-line mutation of the adenomatous polyposis coli gene. The disorder is characterized by the development of hundreds of colorectal adenomas during adolescence and colorectal cancer in nearly all affected persons by the sixth decade of life or earlier if prophylactic colectomy is not performed. A full colonoscopy and an initial upper endoscopic examination should be performed to evaluate the extent of the colonic polyposis in a gene carrier or at-risk member of a familial adenomatous polyposis family. The decision to perform colectomy and its timing depend on the number, size, and worst histology of the colonic adenomas. For patients with multiple large (>1 cm) adenomas or adenomas with villous histology and/or high-grade dysplasia, colectomy at the time of diagnosis is strongly recommended and is the safest approach, especially for those with profuse polyposis. Patients in the second decade of life with only a few small (<5 mm) adenomas can usually be followed endoscopically, with surgery scheduled to accommodate school and work schedules. Colonoscopy cannot identify polyps with advanced pathology or detect early cancers because the presence of multiple polyps precludes adequate sampling, and too many colonic polyps may be present for adequate and safe colonoscopic polypectomy or ablation. Cyclooxygenase (COX)-2 inhibitors and nonsteroidal anti-inflammatory drugs (NSAIDs) have been used to reduce the number of polyps. Although the NSAID sulindac can cause regression of colorectal adenomas, the regression is incomplete and does not influence the progression of polyps toward a malignant pattern. Thus, prophylactic colectomy remains the treatment of choice to prevent colorectal cancer in patients with this disorder. Sulindac has been used in some centers to delay new polyp formation in the rectum after subtotal colectomy.

Sources

N Engl J Med

1. Giardiello FM, Yang VW, Hylind LM, et al. Primary chemoprevention of familial adenomatous polyposis with sulindac. . 2002;346:1054-1059.

N Engl J Med

2. Steinbach G, Lynch PM, Phillips RK, et. al. The effect of celecoxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis. . 2000;342:1946-1952.

6—B. This patient's history is compatible with sarcoidosis. She had an insidious onset of dyspnea, typical radiologic findings, and multisystem involvement with compatible demographics. Hypercalcemia in sarcoidosis is usually a manifestation of disseminated disease; hence, pulmonary involvement is usually evident. Chest x-ray may reveal a diffuse fibronodular infiltrate and/or prominent hilar adenopathy. Hypercalcemia is believed to be secondary to an abnormally high level of circulating 1,25-dihydroxyvitamin (OH) D produced by mononuclear phagocytes in the granulomas. Macrophages obtained from granulomatous tissue convert 25(OH)D₃ to 1,25(OH)D₂ at an increased rate. The PTH level would also be suppressed. The incidence of primary hyperparathyroidism increases in persons over the age of 60. Such individuals may present with subtle symptoms, such as mental changes or with recurrent nephrolithiasis, peptic ulcers, or extensive bone resorption. Clinical suspicion that malignancy is the cause of the hypercalcemia should be heightened when symptoms associated with neoplasia, such as weight loss, fatigue, or muscle weakness are present—none of which is seen in this patient.

Source

Harrison's Principles of Internal Medicine

Potts JT. Diseases of the parathyroid gland and other hyper- and hypocalcemic disorders. In: Braunwald E, Fauci AS, Kasper DL, et al, eds. . 15th ed. New York, NY: Mc-Graw-Hill;2001:2205-2225.

7—D. This patient has acute renal colic secondary to a uric acid calculus. He has a radiolucent stone with characteristic pleomorphic rhombic crystals in acidic urine. Another radiolucent stone that should be considered in the appropriate clinical setting if there is evidence of infection is matrix stone, which is made of organic material and is occasionally seen in patients with ureaseproducing bacteria. The absence of any evidence of infection precludes the use of urease inhibitors. Uric acid stones can be treated medically, making shock wave lithotripsy or ureteroscopy unnecessary at this time, especially with a small stone when the likelihood of spontaneous passage is high and the chances that an intervention will be eventually required are only about 3%. Treatment should focus on increasing urine output, alkalinization of the urine, and administration of allopurinol in patients who excrete >1000 mg (5.4 mmol) of uric acid/day and who do not respond to hydration and alkali therapy. Uric acid is poorly soluble at a pH of <5.5, and alkalinizing the urine by means of sodium citrate, potassium citrate, or sodium bicarbonate to achieve urinary alkalinization to pH of 6.5 to 7.0 would be appropriate for dissolution of uric acid stones.

Source

N Engl J Med

Teichman JM. Clinical practice. Acute renal colic from ureteral calculus. . 2004;350:684-693.

8—C. This patient has the typical presentation of adult idiopathic thrombocytopenic purpura, a condition that usually affects young women. The onset is often insidious, and history and physical examination findings are normal except for a history of epistaxis, gingival bleeding, or purpura and other manifestations of platelet disorders. Laboratory examination showed isolated thrombocytopenia as the only abnormality. Marrow megakaryocytes are present in normal or increased numbers but no other abnormalities are seen. Bone marrow examination may be unnecessary for a young, asymptomatic patient with typical signs and symptoms compatible with a diagnosis of idiopathic thrombocytopenic purpura. Other differential diagnoses include drug use, HIV, or myelodysplasia in older patients. Heparin-induced thrombocytopenia is associated with platelet factor IV antibodies and is seen in individuals with past exposure to heparin. Thrombotic thrombocytopenic purpura presents with fever, neurologic symptoms, and abnormalities in the smear suggestive of microangiopathy other than isolated thrombocytopenia, with a mechanism of deficiency of a protein (ADAMTS 13) that cleaves the unusually large multimers of vWF antigen. von Willebrand disease is one of the most common bleeding disorders, and a typical history in a patient with mild-to-moderate disease includes epistaxis in childhood, lifelong easy bruising, and bleeding with dental extractions or other invasive dental procedures.

Sources

N Engl J Med

1. George JN, el-Harake MA, Raskob G. Chronic idiopathic thrombocytopenic purpura. . 1994;331:1207-1211.

N Engl J Med

2. Moake JL. Thrombotic microangiopathies. . 2002;347:589-600.

9—D. Recommendations for antibiotic prophylaxis depend on the degree of risk associated with the actual cardiac abnormality and the potential of the procedure to cause bacteremia. This patient has mitral valve prolapse with a murmur, which places her at moderate risk, and she would require antibiotic prophylaxis for procedures that involve bleeding from dental extraction or manipulation, respiratory tract procedures such as tonsillectomy, genitourinary procedures such as cystoscopy or prostatic surgery, and gastrointestinal (GI) procedures that involve the intestinal mucosa, biliary tract, or stricture dilatation and sclerotherapy. Vaginal and cesarean delivery are genitourinary procedures for which endocarditis prophylaxis is not recommended, except for high-risk patients in whom it would be optional. If antibiotic prophylaxis was indicated, the type of procedure or the presence of allergies would determine the drug of choice. This patient has a penicillin allergy, which is an immediate hypersensitivity reaction, precluding the use of cephalosporins. Azithromycin would be an option unless the patient was undergoing a high-risk genitourinary or GI procedure, in which case vancomycin would be the appropriate choice.

Source

JAMA

Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. . 1997;277:1794-1801.

10—D. Preoperative assessment of coronary risk is a common clinical challenge faced by practicing internists and hospitalists. An algorithm developed by the American College of Cardiology/American Heart Association Task Force on Practice Guidelines includes factors such as (1) the urgency of noncardiac surgery, (2) presence and severity of preexisting heart disease, (3) presence of major, intermediate, or minor clinical predictors, and (4) functional capacity. This patient has a host of intermediate clinical predictors, including diabetes mellitus, mild renal insufficiency, and compensated CHF, as well as minor clinical predictors, including advanced age, left ventricular hypertrophy, poor functional capacity, and a history of stroke. However, she denies any chest pain and has no clinical evidence of unstable or severe angina, decompensated heart failure, or severe valvular disease, making immediate angiography inappropriate, as it is not without risk, especially in the presence of renal insufficiency. Noninvasive testing with stress echocardiography or nuclear imaging to assess her coronary risk would be warranted, since the orthopedic procedure is considered of intermediate risk and her functional status is poor. Results of the noninvasive testing can then be used to determine additional perioperative management. Canceling surgery altogether without further testing and evaluation would be inappropriate in the setting of a necessary procedure. Proceeding immediately to the operating room while optimizing perioperative and postoperative cardiac risk would be appropriate only for emergency surgery.

Source

Circulation

Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). . 2002;105:1257-1267.

11—A. This patient has a solitary lung mass that is highly suspicious for malignancy. He is 65 years old, with an extensive smoking history and a characteristic irregular and spiculated mass, which increases the probability of malignancy. Yearly follow-up examinations with chest x-ray in this high-risk setting would be inappropriate. Proceeding with chemotherapy or chemoradiation without a tissue diagnosis is also inappropriate. Management of a patient with a solitary lung nodule (if the lesion is <3 cm) begins with a detailed history and physical examination and an attempt to obtain old xrays. If a lesion has been stable for more than 2 years in a young patient at low risk for malignancy, careful follow-up can be recommended. Because of a low diagnostic yield, a negative finding in a patient at risk for malignancy would not preclude further diagnostic testing. The likelihood of malignancy in a lung lesion larger than 3 cm is so great that all such lesions should be surgically resected unless medically contraindicated. Safer and less invasive procedures, such as thoracoscopy or video-assisted thoracoscopy, are important for the diagnosis and excision of peripheral solitary pulmonary nodules.

Source

Chest

Tan BB, Flaherty KR, Kazerooni EA, et al. The solitary pulmonary nodule. . 2003;123(suppl):89S-96S.

12—D. This patient has benign prostatic hyperplasia (BPH), one of the most common diseases of aging men. By the age of 60, more than 50% of men will have microscopic evidence of the disease; by age 85, as many as 90% will be affected. The initial evaluation of a man with lower urinary tract symptoms includes obtaining a thorough medical history to identify alternative causes for voiding dysfunction (eg, antihistamines or anticholinergics) and comorbidities (eg, diabetes or CHF) that may complicate treatment; a thorough physical examination, including a digital rectal examination; urinalysis to screen for hematuria and PSA for men with a life expectancy of more than 10 years; and cytologic examination of the urine in men with irritating symptoms and a history of smoking. Although this patient had an abnormal prostate examination, his PSA level was low, so prostate cancer is unlikely. Because his symptoms are bothersome, medical therapy with an alphablocker, not surgery, is the best choice. Alpha-blockers reduce prostatic stromal and bladder neck tone by inhibiting the alpha-adrenergic receptors that reside in these locations. These medications, which have been used for over a decade in men with BPH, include terazosin HCl (Hytrin), doxazosin mesylate (Cardura), tamsulosin HCl (Flomax), and most recently alfuzosin HCl (Uroxatral). They improve the symptoms without altering the natural history of the disease, unlike 5 alpha- reductase inhibitors, which reduce the size of the prostate by decreasing the amount of metabolically active intraprostatic androgens. Herbal medications, such as saw palmetto, are being used with increasing frequency throughout the world but are not approved by the Food and Drug Administration for the treatment of BPH, and their mechanism of action is unknown. Watchful waiting would be appropriate if this patient's symptoms were not bothersome.

Source

N Engl J Med

McConnell JD, Roehrborn CG, Bautista OM, et al, for the Medical Therapy of Prostatic Symptoms (MTOPS) Research Group. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. . 2003;349:2387-2398.

13—C. This patient has HIV cholangiopathy, which is caused by opportunistic infections (cytomegalovirus and cryptosporidium account for up to 97% of cases). Most patients present with right upperquadrant or epigastric pain that is often severe enough to require narcotics. The pain is usually sharp and may radiate to the back, confusing the diagnosis with pancreatitis. Half of all patients will have severe nausea and vomiting as well as fever. An anicteric cholestatic liver enzyme profile is typical. Alkaline phosphatase concentration is elevated to a mean of 5 times the upper limit of normal. Serum transaminase levels are only moderately elevated (2-3 times above normal). Despite what appears to be a severe cholangiographic abnormality, serum bilirubin concentration is usually normal or only mildly elevated. Four distinct patterns can be seen on imaging studies— papillary stenosis, sclerosing cholangitis, long strictures of the extra hepatic bile ducts, and combined stenosis and cholangitis.

Sources

Clin Liv Dis

Mahajani RV, Uzer MF. Cholangiopathy in HIV-infected patients. . 1999;3:66-684, x.

Am J Med

Cello JP. Acquired immunodeficiency syndrome cholangiopathy: spectrum of disease. . 1989;86:539-546.

14—C. Evidence suggests that there is a very low risk of cervical cancer in women aged 50 and older in countries with organized screening programs. No data support screening over the age of 65 to 70 in women who have been regularly screened. Since screening has been shown to affect mortality rates, there is a rationale to screen elderly persons who have not been screened. Women who are age 70 and older with an intact cervix and who have had 3 or more documented, consecutive, technically satisfactory normal/negative cervical cytology tests and no abnormal/positive cytology tests within the 10-year period before age 70 may elect to cease cervical cancer screening. Screening is recommended if a woman has not been previously screened, if information about previous screening is unavailable, or if past screening is unlikely. Women who have had cervical cancer, in utero exposure to diethylstilbestrol (DES), or who are immunocompromised (including HIV-positive) should continue cervical cancer screening as long as they are in reasonably good health and do not have a life-limiting chronic condition. Until more data are available, women aged 70 and older who have tested positive for human papillomavirus DNA should continue screening at the discretion of their physician.

Source

CA Cancer J Clin

Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. . 2002;52:342-362.

15—B. The JNC 7 guidelines have been simplified by designating fewer categories. The new classification shifts the entire range considered abnormal to lower levels. Normal BP is now less than 120/80 mm Hg. Systolic BP levels between 120 and 139 mm Hg and diastolic levels between 80 and 89 mm Hg are considered prehypertension. Stage 1 hypertension is defined as a systolic pressure of 140 to 159 mm Hg or a diastolic pressure of 90 to 99 mm Hg. Stage 2 is defined as systolic BP ≥160 mm Hg or a diastolic pressure ≥100 mm Hg. Treatment for this patient with stage 2 hypertension and diabetes would be an ACE inhibitor, titrated to bring her BP below 130/85 mm Hg. Another compelling reason for ACE inhibitor therapy is her chronic underlying kidney disease.

Source

JAMA

Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report: . 2003;289:2560-2572.

16—D. Disease-specific prediction rules are available that can be used to assess the initial severity of pneumonia and predict risk of death. Such instruments can help determine whether to hospitalize a patient. The most widely used and rigorously studied prediction rule, the Pneumonia Severity Index, has been validated in more than 50 000 individuals from a variety of inpatient and outpatient populations. This index, which is based on data commonly available at presentation, stratifies patients into 5 risk categories, with 30-day mortality rates ranging from 0.1% to 27.0%. The higher the score, the greater likelihood of admission to an intensive care unit, readmission, a longer hospital stay, and death. Easy-to-use versions of the index are now available on the Internet and for handheld computers. This patient is in risk class II, with a 30-day mortality risk of 0.6%, and is a safe candidate for outpatient treatment.

Source

N Engl J Med

Halm EA, Teirstein AS. Management of community-acquired pneumonia. . 2002;347:2039-2045.

Staphylococcus aureus

17—E. The incidence of spinal epidural abscess is estimated at 0.2 to 2.8 cases per 10 000 a year. Nevertheless, a high clinical suspicion is needed to allow for quick treatment of this potentially devastating condition. The most efficient approach includes adequate antibiotic coverage for 4 to 6 weeks combined with surgical decompression. The most common single agent responsible for this condition is . However, in this case, the history of IV drug use should raise the possibility of gram-negative bacilli, and the antibiotic of choice should have coverage for that as well. Immediate incision and drainage of the inflamed area is not appropriate; given the patient's symptoms and history, a deep collection is highly possible. A first-generation cephalosporin will miss the gramnegative bacilli associated with IV drug use. Cervical spine x-rays are not sensitive enough to rule out the diagnosis of an epidural abscess and the findings will not affect the decision to start antibiotics. Gadolinium-enhanced MRI is the imaging modality of choice and is useful in distinguishing epidural abscess from the adjacent compressed thecal sac and other potentially compressive lesions.

Source

Am Fam Physician.

Chao D, Nanda A. Spinal epidural abscess: a diagnostic challenge. 2002;65:1341-1346.

18—D. From 10% to 15% of patients with acute pancreatitis develop systemic inflammatory response syndrome, leading to a fulminant course with pancreatic necrosis and multiorgan failure. Gallstones are the leading cause of acute pancreatitis in developed countries; including microlithiasis, gallstones account for more than 90% of cases worldwide. A rise in serum amylase concentration is expected, but not always seen, in acute pancreatitis. Patients with mild acute pancreatitis can usually begin oral refeeding within a few days of pain onset. In severe disease associated with reduced oral intake and the presence of a catabolic state, poor nutrition is a common and serious problem. Early nutritional support may aid recovery. One of the goals of therapy is to avoid stimulation of the pancreas. In contrast, enteral feeding has been shown to be safe, as effective as total parenteral nutrition, and well tolerated in patients with severe acute pancreatitis. Use of antibiotics remains controversial. There is concern that routine use is leading to a rise in drug-resistant or unusual organisms in pancreatic sepsis and possibly even increased mortality when antibiotics are used inappropriately. In severe disease, secondary infection of necrotic pancreatic parenchyma is the leading cause of late mortality. Hence, antibiotic therapy is appropriate in severe acute necrotizing pancreatitis.

Source

Lancet

Mitchell RM, Byrne MF, Baillie J. Pancreatitis. . 2003;361:1447-1455.

19—E. The prodrome of viral symptoms plus the acute onset and persistence of vertigo with a classical peripheral nystagmus and otherwise normal neurologic examination make vestibular neuritis the most likely diagnosis. This condition is apparently caused by selective inflammation of the vestibular nerve, probably by a virus; therefore, in this patient, symptomatic treatment with anticholinergics, antiemetics, or benzodiazepines and close follow-up will probably be adequate. An audiogram in a case such as this should be normal. A perilymph fistula is also a possibility, but the history will be different, with the onset of vertigo following head trauma, barotrauma, or sudden strain. Electronystagmography will show unilateral caloric hypoexcitability in this case but will not add any important information for the differential diagnosis. Brain imaging will be appropriate if central vertigo is suspected, such as in a patient with a history or risk factors for cerebrovascular disease, with some other neurologic deficit confirmed by examination, and with the presence of a central nystagmus. Brain imaging will also be useful in a more subacute or chronic case to determine if a mass is compressing cranial nerve VIII. Performing all of these tests is unnecessary, delays diagnosis, and increases patient anxiety and cost without improving the diagnostic accuracy in a patient such as this.

Source

N Engl J Med

Baloh RW. Clinical practice. Vestibular neuritis. . 2003;348:1027-1032.

20—B. Clubbing is not usually seen in COPD. Because patients with COPD have risk factors for lung cancer, any patient with COPD who presents with new clubbing should have a workup to rule out pulmonary malignancy. Of the objective criteria that have been proposed for diagnosis, the best documented and most practical is an increase in the ratio of the distal phalangeal depth to the interphalangeal depth of the index finger to 1.0 or more. Clubbing of the nails is a thickening of the soft tissue beneath the proximal nail plate that results in sponginess of the proximal plate and thickening in that area of the digit. Hypertrophic pulmonary osteoarthropathy is a syndrome that includes digital clubbing but also includes chronic proliferative periostitis of the long bones and synovitis. The cause of clubbing is poorly understood. In clubbing, the angle between the finger proximal to the nail and the proximal nail plate is straightened, creating the "Schamroth sign," an obliteration of the normally diamond-shaped space formed when dorsal sides of the distal phalanges of corresponding right and left digits are opposed.

Source

Am Fam Physician

Fawcett RS, Linford S, Stulberg DL. Nail abnormalities: clues to systemic disease. . 2004;69:1417-1424.