Internal_Medicine_Medical_School_Crash_Course_Unabridged_17_A_T

Course test questions cover topics related to the management of patients with sepsis, trauma, and cardiac conditions. The best initial management for a patient with classical findings of septic shock is to start IV antibiotics and look for a source of infection. Patients with suspected sepsis and no immunodeficiency should be started on a third-generation cephalosporin until culture results are available. In a trauma patient with low blood pressure after fluid resuscitation, the next step is to give intravenous norepinephrine. Patients with burns are at risk for sepsis from Pseudomonas. In a motor vehicle accident with no external trauma, injury to the aorta should be suspected. Late deaths in trauma patients are often due to pneumonia. The ATLF system aims to provide standardized trauma care nationwide. Angiography is used to identify bleeding sources and can be used with arterial embolization. The first test in evaluating trauma patients is a PA x-ray of the chest. In Course test questions. Number one, you are evaluating a patient in the emergency department who has the acute onset of hypotension, decreased body temperature, and an alteration in their mental status. What is the best way to initially manage the patient's care? A. Obtain a CT scan of the head to rule out intracranial pathology. B. Obtain a bedside radiograph of the chest to rule out pneumonia. C. Send the patient to the intensive care unit and begin a thorough evaluation for sepsis. D. Start IV antibiotics and look for a source of infection. Answer D. The patient is presenting with classical findings typical of septic shock requiring aggressive workup and urgent treatment. The best way to initially manage the patient's care is to admit them to the intensive care unit for an urgent workup for sepsis. Number two, the patient you are seeing is showing evidence of sepsis but has no history of immunodeficiency. You obtain blood cultures as well as cultures of body fluids suspected of being the source of the infection. How should the patient be managed? A. Start them on at least two bactericidal antibiotics while awaiting culture. B. As the patient is immunocompetent, you can await the culture results before starting the patient on an appropriate antibiotic. C. Start the patient on a third-generation cephalosporin and await the results of the culture. D. Start the patient on an intravenous aminoglycoside and await the results of the culture. Answer C. The patient with suspected sepsis and no evidence of immunodeficiency can be begun on a course of single third-generation cephalosporin until the results of the cultures return. You can't use an aminoglycoside as this class of antibiotic doesn't provide enough bacterial coverage and the patient needs to be started on only a single antibiotic. Treatment with an empiric antibiotic needs to be started prior to the return of the cultures. Number 3. You are treating a hospitalized patient for suspected sepsis who still has low blood pressure readings after giving adequate intravenous fluids. What is the next step in the patient's treatment? A. Give the patient intravenous phenylephrine. B. Give the patient intravenous dopamine. C. Give the patient intravenous albumin. D. Give the patient intravenous norepinephrine. Answer D. The next step in treating the septic patient who doesn't respond to fluid resuscitation is to begin treating with a vasopressive agent. The initial vasopressive agent of choice should be norepinephrine. The other options are possible but are only given if norepinephrine doesn't work or causes negative side effects. The use of IV albumin won't work to improve the patient's blood pressure. Number 4. The patient you are treating is suffering from multiple end organ failure secondary to complications from burns. What organism should be suspected if the patient develops signs and symptoms of sepsis? A. Pseudomonas. B. Klebsiella. C. Staphylococcus. D. Streptococcus. Answer A. The patient is suffering from burns and is at a risk of secondary sepsis from Pseudomonas. The patient needs an antibiotic treatment that covers for this organism if he exhibits signs of sepsis. Number 5. The patient is the driver involved in a one-car motor vehicle accident. The victim was seat belted and struck a tree at a high velocity. Upon evaluating the patient at the scene, you find that the victim is pulseless without any cardiac activity but shows no sign of external trauma. What injury do you suspect the patient has suffered from given the findings? A. Blunt abdominal trauma. B. Head injury. C. Injury to the aorta. D. Cervical spine injury. Answer C. The patient has died suddenly at the scene of the accident without documentation of external trauma. Because of this, you suspect the patient has suffered cardiac trauma or trauma to the great vessels. Because the patient was found belted in the vehicle, the chance of an acute head injury is unlikely. Number 6. The patient is a multiple trauma victim who survives the initial management but dies later in the hospital. What is the most common cause of death late in the management of trauma? A. Hemorrhage of the pelvis. B. Pneumonia. C. Cervical spine injury. D. Open orthopedic injury. Answer B. Most late deaths in patients who survive the initial trauma and are admitted to the hospital die later from an infectious process such as pneumonia. Rarely would they succumb from an orthopedic injury or occult hemorrhage. Number 7. The patient you are seeing was involved in a multiple trauma situation and is found to have an intact airway and normal ventilation. In evaluating their circulatory status, you discover that the patient is hypotensive. When treating this patient for their condition, what do you do? A. Give typed and cross-matched blood as soon as it is available. B. Place two IVs in two peripheral veins and give Ringer's lactate solution until the blood pressure normalizes. C. Give IV fluids with albumin to diminish the chance of cerebral edema. D. Place a central line and give IV normal saline until the central venous pressure is normal. Answer B. The patient should be suspected of having an acute hemorrhage. To treat this, you need to place two peripheral IV lines and give them Ringer's lactate solution. Giving the patient a blood transfusion would take too long and albumin is not generally used in the acute phases of resuscitation. Placing a central catheter in this patient would take too long and shouldn't be attempted in a trauma patient unless a peripheral IV cannot be placed. Number 8. What is the general idea and goal behind the ATLF system? A. It helps get trauma patients to a trauma center faster. B. It has standardized trauma care for individuals in all parts of the country. C. It teaches advanced interventional techniques to ambulance personnel. D. It allows rural victims to have a better chance of survival. Answer B. The primary goal of the ATLF system is that it has resulted in standardized trauma care regardless of where the patient is treated so that victims from all parts of the country can receive proper trauma care. Indirectly, it does help rural trauma patients receive better trauma care so they have a good chance of surviving their trauma. Number 9. For what purpose is the use of angiography in the management of a trauma patient? A. It is the only way that arterial bleeding can be diagnosed. B. It is a fast way to identify bleeding sources. C. It can be used along with arterial embolization to control severe bleeding. D. It can confirm findings seen on an MRI evaluation. Answer C. Angiography can help find sources of active bleeding. It is not a fast way to diagnose active bleeding so it is primarily used when attempting to provide arterial embolization in cases of severe and uncontrollable bleeding. Number 10. Which imaging technique should be the first test done in the evaluation of trauma patients? A. CT scan of the head. B. CT scan of the cervical spine. C. AP x-ray of the cervical spine. D. PA x-ray of the chest. Answer D. The first imaging test performed on a patient with traumatic injuries is a PA x-ray of the chest to look for pneumothorax, hemothorax, and placement of tubes and lines. The other choices can be done but are not the first test of choice. Number 11. You are seeing a patient who is presented for emergency treatment after developing the signs and symptoms of a heart attack an hour ago. The initial EKG reveals no ST segment elevation. A serum troponin level is drawn and is found to be increased. What initial treatment should the patient be given? A. Aspirin therapy with serial cardiac enzymes to document myocardial necrosis. B. Emergency angiogram and possible angioplasty. C. Tissue plasminogen activator by intravenous means. D. Left ventricular assist device. Answer B. The patient most likely has had an acute myocardial infarction as documented by history and elevated troponin level even though the EKG has not changed. Because the patient has had the symptoms for less than 90 minutes, the initial treatment should be an angioplasty to potentially resolve any blockage that could lead to myocardial tissue death. Number 12. Interventional cardiology involves the placement of a catheter for the evaluation and treatment of heart conditions. Where is the catheter generally inserted? A. The radial artery. B. The left subclavian vein. C. The femoral artery. D. The femoral vein. Answer C. The catheters used for interventional cardiology are usually placed in the femoral artery. The second most common place a catheter is placed is the radial artery. Number 13. Which blood test is considered the most sensitive and specific for the diagnosis of cardiac muscle necrosis? A. CPKM-B. B. CPKM-M. C. SGOT. D. Troponin. Answer D. Each of these choices can be found to be increased in myocardial necrosis except the CPKM-M level which comes from striated muscle. The troponin test is considered the most sensitive and specific for coronary muscle necrosis and is the most often referred to test in cases of a suspected acute myocardial infarction. Number 14. What is the primary purpose of giving aspirin to patients suspected of having an acute myocardial infarction? A. It causes the blood to be thinner, decreasing clot formation. B. It helps dissolve coronary artery blood clots. C. It prevents platelet aggregation, decreasing further clot formation. D. It negatively feeds back on the coagulation system of the body. Answer C. Aspirin is used for the management of patients with suspected myocardial infarction because it prevents platelet aggregation, decreasing further clot formation. Number 15. Which finding on a standard EKG is positive evidence indicating cardiac necrosis? A. Frequent premature ventricular beats. B. Atrial fibrillation. C. ST segment elevation. D. ST segment depression. Answer C. Elevation of the ST segment on a standard EKG is positive evidence of cardiac necrosis. The other choices indicate EKG findings that may be present even when there is no necrosis of the heart muscle. Number 16. The management of patients in acute heart failure often involves giving the patient diuretic therapy. Why is this treatment used? A. It increases renal perfusion. B. It decreases blood volume, decreasing the work of the heart. C. It lowers blood pressure, which helps strengthen the heart. D. It decreases preload of the heart. Answer B. Diuretics are helpful in the treatment of heart failure because they decrease the patient's total blood volume, which decreases the work of the failing heart. Number 17. The treatment of patients in acute heart failure often involves giving them beta blocker therapy. When is beta blocker therapy not a good choice for heart failure? A. EKG evidence of ST segment elevation. B. First degree atrioventricular block. C. Tachycardia. D. Third degree atrioventricular block. Answer D. Beta blocker therapy is a good choice for heart failure in all of the choices except for third degree atrioventricular block. Beta blocker therapy is also not recommended when the patient shows evidence of second degree atrioventricular block or has a heart rate less than 50. Number 18. What imaging test is the most valuable in the management of patients with acute heart failure? A. CT scan of the chest. B. PA chest x-ray. C. Doppler echocardiogram. D. Angiogram. Answer C. A Doppler echocardiogram is the most valuable test in the management of acute heart failure because it can show if there are structural abnormalities of the heart and can evaluate the pump function of the heart. Number 19. Under what circumstances does a heart failure patient benefit from a left ventricular assist device? A. When their ejection fraction is extremely low. B. When their pump function is low enough to cause hypotension. C. When their heart failure is expected to reverse itself. D. When they have a valvular problem causing their heart failure. Answer C. Heart failure patients can most benefit from receiving a left ventricular assist device when the cause of their heart failure is not expected to last very long and when it is expected to reverse itself. Number 20. The patient you are seeing is an eight-year-old girl who has the acute onset of nausea, vomiting, and confusion. She has evidence of a recent history of weight loss, increased thirst, and increased urination. What is the best test to evaluate this child? A. Urine glucose level. B. Antipancreatic antibodies. C. Urine ketone level. D. Blood glucose level. Answer C. This child has history and clinical symptoms of diabetic ketoacidosis. A blood glucose level would be elevated but wouldn't indicate she has diabetic ketoacidosis. The only test that would positively make the diagnosis of diabetic ketoacidosis would be a urine or blood ketone level which should be elevated only if the patient has diabetic ketoacidosis. Number 21. A patient presenting with type 2 diabetes has evidence of hypertension and elevated glucose levels. What treatment modality should be considered in this patient? A. Start insulin to manage the elevated blood sugar. B. Decrease oral diabetic medications and start an ACE inhibitor. C. Start an angiotensin receptor blocker. D. Instruct the patient on dietary measures to reduce blood sugar which will secondarily reduce blood pressure. Answer B. The patient needs a combination of better blood sugar control and better blood pressure control. The blood sugar elevation can be managed with the addition of oral diabetic medications. The elevated blood pressure can be treated best with an ACE inhibitor which will also help preserve kidney function in the diabetic patient. They need both treatments in this situation. Number 22. You are seeing a patient without any particular symptoms who has evidence of an ulcer on the right foot and decreased peripheral pulses on the feet. In further looking into the cause of this ulcer, what initial test would most be helpful in identifying the cause? A. Blood glucose testing. B. Doppler flow study of the peripheral arteries. C. Electrocardiogram. D. Left leg angiogram. Answer C. This patient is showing findings indicative of peripheral vascular disease and is likely to have the ulcer of the foot, secondary to undiagnosed diabetes mellitus. Further evaluation of the cause of the ulcer can be done by doing a blood glucose test followed by a Doppler flow study of the peripheral arteries which would then be followed by a right leg angiogram to see if the patient has a reversible vascular condition that could be fixed to restore blood flow to the leg. Number 23. The patient you are seeing has the relatively acute onset of fever, tachycardia, sweating, anxiety and diarrhea. What endocrine condition is likely the cause of the patient's symptoms? A. Thyroid storm. B. Myxedema. C. Hashimoto's thyroiditis. D. Medullary thyroid cancer. Answer A. The patient has signs and symptoms highly suggestive of severe hyperthyroidism, also known as a thyroid storm. This is potentially life threatening and needs emergency medical treatment. Number 24. You are asked to evaluate a 30 year old woman who has recently had a child. She shows signs and symptoms of postpartum depression and gained some weight. She is very tired with any activity and indicates that she has constipation. What test would be the most helpful in evaluating the patient's problem? A. Serum ACTH level. B. Saliva cortisol level at midnight. C. Serum TSH level. D. Serum aldosterone level. Answer C. The patient has recently given birth which puts her at an increased chance of developing postpartum hypothyroidism which would explain each of her symptoms. Testing of a serum TSH level would be indicated. The serum TSH level would likely be high establishing the diagnosis of hypothyroidism. Number 25. You are seeing a woman who has developed increased fat deposits in the upper back, hypertension, hyperglycemia and purple striae on the abdomen over a short period of time. What endocrine problem would best explain her symptoms? A. Primary aldosteronism. B. Endogenous Cushing disease. C. Exogenous Cushing disease. C. Exogenous Cushing disease. D. Benign adrenal cortical tumor. Answer C. The endocrine finding that would most explain the woman's symptoms is the taking of exogenous glucocorticoids resulting in a diagnosis of exogenous Cushing disease. Endocrine conditions such as endogenous Cushing disease and benign cortical adrenal tumors can also have the same symptoms but are much less likely to explain the patient's symptoms. Number 26. The patient you are seeing in consultation has a history of acute pneumonia with coexisting findings of orthostatic hypotension, fainting spells, nausea, vomiting and diarrhea. The patient is evaluated for sepsis and is found to have nothing more than a serious case of acute pneumonia. What endocrine problem could explain the patient's unusual symptoms? A. The pneumonia is inadequately treated so the patient needs intravenous antibiotics. B. The patient has a lung tumor that secretes ACTH but that can't be seen on x-ray yet. C. The patient is having an Addisonian crisis secondary to illness. D. The patient is having a hypermetabolic state and should be checked for hyperthyroidism. Answer C. The patient has an acute infectious illness and additional symptoms which are suggestive of decreased functioning of the adrenal glands. Hyperthyroidism isn't the answer because it doesn't have clinical findings of hypotension. The patient needs to be further evaluated for the possibility of having Addison's disease. Number 27. You are the internist evaluating a nine-year-old male who has obesity, a history of increased thirst and a history of increased frequency of urination. How would you further evaluate this child? A. Serum TSH level. B. Serum ACTH level. C. Serum ketone level. D. Fasting glucose level. Answer D. The child has a good chance of having either type 1 diabetes or type 2 diabetes but doesn't show signs of having diabetic ketoacidosis. He is obese so he is at risk for type 2 diabetes. A good test to evaluate the child would be a fasting blood glucose level. As he is a child he should also have an evaluation for type 1 diabetes but more likely has type 2 disease. Number 28. The patient you are seeing is a 32 year old female who shows a history of night sweats, periods of feeling very hot and a menstrual history indicating oligomenorrhea. What endocrine disorder might she have? A. She has a pituitary adenoma impacting luteinizing hormone and follicle stimulating hormone levels. B. She has premature ovarian failure with decreasing ovarian output of estrogen and progesterone. C. She has hyperthyroidism with clinical evidence of hypermetabolism. D. She has evidence of a thyroid storm and needs urgent intervention. Answer B. The patient is at an age where she might have primary ovarian failure happening before menopause should occur. A serum estrogen and progesterone level can be drawn. These will be decreased revealing premature ovarian failure as the diagnosis. Number 29. You are the internist caring for a 45 year old male who presents with chest discomfort after meals, indigestion and an increase in pain while lying down. What is the best way to find out the patient's problem? A. Do an upper GI contrast study to rule out gastric pathology. B. Do an esophageal manometry study to evaluate esophageal pressure. C. Do an upper GI endoscopy to rule out Barrett's esophagus. D. Treat with proton pump inhibitors before doing any studies. Answer D. The patient is young and has no symptoms other than the symptoms of GERD. He can easily be managed with a simple trial of a proton pump inhibitor to see if this eases his symptoms without having to have a workup for GERD. Number 30. You are evaluating a 75 year old male who tells you he has chest pain after eating that has been ongoing for a long period of time. His symptoms are worse when he lies down and are worse when he eats foods that are spicy. He is taking aspirin every day for heart disease prevention but doesn't take anything else. How should he be managed? A. Have him take antacids after every meal and avoid spicy foods. B. Perform esophageal manometry. C. Perform an upper GI endoscopy. D. Have him take a histamine 2 blocker for 6 months and re-evaluate. Answer C. This is an older patient who has signs and symptoms suggestive of GERD. His symptoms have lasted a long time so he is at an increased chance of having precancerous changes in his lower esophagus. Prior to prescribing him a proton pump inhibitor, you need to do an upper GI endoscopy to make sure he doesn't have pathology in his lower esophagus that might suggest esophageal cancer. Number 31. You are evaluating a 12 year old female who presents with lower abdominal pain and fever without bowel habit changes. How do you further evaluate this child's symptoms? A. Do a colonoscopy to rule out inflammatory bowel disease before treating. B. Do an occult blood evaluation of the stool to rule out active Crohn's disease. C. Treat as an acute abdomen and do an ultrasound of the appendix and CBC. D. Do a swallow study with small bowel follow-through to rule out Crohn's disease of the terminal ileum. Answer C. This child is presenting with clinical evidence suggesting an acute abdomen. For this reason, she needs to have a full evaluation for infectious processes such as appendicitis before doing an evaluation for a chronic bowel condition. Number 32. You are the internist seeing a 24 year old woman who has symptoms of a sudden onset of pain in the left lower quadrant of the abdomen without any fever. Her pain is very severe and she also has symptoms of nausea. How would she be further evaluated in the emergency department? A. Do a digital rectal exam to check for occult blood. B. Further evaluate pain by doing a colonoscopy to biopsy the colonic mucosa for inflammation. C. Do a pelvic examination and pregnancy test to rule out ectopic pregnancy. D. Treat as an acute abdomen and rule out ruptured viscous or diverticulitis. Answer C. This is a woman who might have pain because of gastrointestinal pathology or a problem unassociated with a GI tract. She doesn't show signs of disease in the colon and carries a low chance of having a ruptured viscous or diverticulitis. She needs to have a workup for a gynecological problem such as a ruptured ectopic pregnancy before evaluating her for a gastrointestinal problem. Number 33. You are evaluating a 24 year old male patient with several months history of pain in his abdomen, weight loss, and diarrhea. What should be done to further evaluate the cause of this young man's gastrointestinal symptoms? A. He should be evaluated for irritable bowel syndrome using the Rome criteria. B. He should have a thorough workup for inflammatory bowel disease including colonoscopy and imaging studies. C. He should have an abdominal ultrasound to evaluate his spleen, liver, gallbladder, and appendix. D. He should be treated with antidiarrheal medication and worked up for more serious disease if the medication fails to control his symptoms. Answer. B. This is a young man with GI symptomology and a constitutional finding of weight loss which makes him a good candidate for having inflammatory bowel disease rather than irritable bowel syndrome. He needs a workup for inflammatory bowel disease before assuming he just has irritable bowel syndrome. Number 34. You are evaluating an 81 year old man who complains of diarrhea, crampy lower abdominal pain, and has an exam showing a positive test for occult blood in the stool. What might be the cause of his symptoms? A. His symptoms are suggestive of colon cancer. B. His symptoms are suggestive of irritable bowel syndrome. C. His symptoms are suggestive of ulcerative colitis. D. His symptoms are suggestive of ischemic colitis. Answer. D. As he is elderly, he is low risk for a new diagnosis of irritable bowel disease or ulcerative colitis. His symptoms don't indicate the possibility of colon cancer but instead are suggestive of ischemic disease in the intestinal tract or diverticulitis. Number 35. You are evaluating a patient with abdominal pain that feels crampy and symptoms of bloating and gas that get better after defecation. He has no symptoms indicating fever, nausea, vomiting, or weight loss. How should this patient be managed further? A. Apply the Rome criteria and do a baseline workup for colonic pathology. B. Provide him with symptomatic relief of bloating and gas with follow-up if the treatment fails. C. The patient should have an upper and lower GI x-ray with contrast before treating empirically. D. The patient should be treated as having an acute abdomen and should have a surgical consult. Answer. A. The patient has classic symptomology suggestive of irritable bowel syndrome with no high-risk GI symptomology so he should have the Rome criteria applied before having a simple workup for colon disease before giving him medical management for irritable bowel syndrome. Number 36. You are seeing an eight-year-old male patient who has developed an acute onset of nonspecific abdominal pain, nausea, and vomiting. How should this young man be further managed? A. Treat symptoms of nausea and vomiting with the presumptive diagnosis of gastroenteritis. B. Do a baseline CBC and treat as an acute abdomen if this is abnormal. C. Do serial x-rays of the abdomen looking for evidence of a ruptured viscous. D. Do an upper GI x-ray series with contrast to look at stomach and bowel for Crohn disease. Answer. B. The patient is a young male who may or may not have evidence of an acute abdomen. He should have a CBC drawn to see if this is elevated. If the CBC is normal, the child can be treated only with symptom relief. If this doesn't relieve his symptoms, he needs to be further monitored to see if he has an acute abdomen. Number 37. The patient is seen who has a test positive for a colt blood in the stool without abdominal symptoms. He is a 40 year old male. What is statistically the most likely cause of this finding? A. Crohn colitis. B. Chronic gastritis. C. C. Internal hemorrhoids. D. Colon cancer. Answer. C. In a young and healthy man who has no abdominal symptoms, a positive stool test for a colt blood is most likely secondary to benign disease like internal hemorrhoids. Even so, he needs a workup of his colon because he could have colon cancer at an early age. Number 38. You are evaluating a child who is 9 years old who presents with a subacute onset of crampy abdominal pain, fever, nausea, and vomiting. He has a stool test indicating a positive finding of a colt blood. He admits to having ongoing diarrhea. What should the patient be further evaluated for? A. Crohn colitis. B. Ulcerative colitis. C. Bacterial gastroenteritis. D. Viral gastroenteritis. Answer. C. This is a patient who might have structural gastrointestinal pathology as he has findings of a positive stool test but inflammatory bowel diseases such as ulcerative colitis or Crohn colitis are less commonly seen when compared to acute infectious process. An acute disease such as bacterial gastroenteritis would also give a positive a colt blood test and be a more likely diagnosis in a patient of this age. Number 39. You receive a phone call describing the new onset of pneumonia in a nursing facility resident with dementia. What thing would best help you provide the proper treatment for the patient's symptoms? A. A CBC taken at the bedside and sent to the local hospital for evaluation. B. The nursing home charge nurse's assessment of the resident's breath sounds. C. Visiting the patient urgently to evaluate their respiratory status. D. Reviewing the resident's advance directives to see if they have wishes around antibiotic use. Answer. D. The resident has clinical findings of dementia in the nursing home and might have left instructions in the advance directive about antibiotic use if an infection is found. This can guide you in making the proper clinical decision and ethical decision about how to manage the problem. Number 40. The nursing home staff is caring for an elderly resident. They find that the on doctor is the only doctor that can be contacted about a resident who presents with symptoms of a new urinary tract infection. What can the staff do in this situation? A. Wait until the primary care physician is back on duty to call the urinary results to. B. Call the on-call doctor and get a telephone order for an antibiotic. C. Call the on-call doctor and get a faxed order from the doctor for an antibiotic. D. Insist that the on-call doctor come to see the patient to evaluate their condition. Answer. C. For a condition like a urinary tract infection, a doctor doesn't have to see the resident as long as the clinical findings can be given to the doctor by phone. An on-call doctor is acceptable to treat the patient's problem. However, the doctor should send the antibiotic order by facsimile or electronically so there isn't any confusion about what is being ordered. Number 41. You are the attending physician managing a nursing home resident who, after a hip fracture, shows clinical signs suggesting pneumonia and respiratory distress. You are seeing the resident and recognize that she is in acute respiratory distress. She doesn't have an advanced directive and is too short of breath to speak. What should you do to treat the resident for her symptoms? A. Make contact with a geriatrician to see how best to handle this resident. B. Ask a family member what the resident would want to have done in this medical situation. C. Decide to admit the resident to the care of a hospitalist and send the medical record for the hospitalist to review. D. Decide to treat the resident with oral antibiotics and review the decision later with the ethics committee. Answer C. This is not a situation where ethics are part of the decision-making process. The resident is not at the nursing home because of a long-term problem. She needs to have acute respiratory treatment in the hospital unless she has an advanced directive or is able to say something about how she wants to be cared for. Number 42. You are evaluating a nursing home resident who has dementia and falls in the nursing facility because the nursing assistant didn't raise the resident's bed rails. The resident has a hip fracture because of the fall. How should you handle this problem? A. Even if the resident has dementia, they should be treated for their fracture and the report should be made to the continuous quality control committee. B. The resident had dementia and isn't expected to ambulate anyway, so they can receive supportive care only for their fracture. C. The resident should have an x-ray to confirm a fracture and should have an orthopedist see them at a later date to consult with the primary care doctor. D. The care should revert back to the geriatrician who is better equipped to handle fracture care in elderly residents. Answer A. The case should be presented to the continuous quality improvement committee because the fracture happened because of an error made by a staff member. As for the fracture care, the resident should be treated with maximal care unless there is evidence, such as an advanced directive, indicating that the resident would oppose maximal treatment. Number 43. You are sending a hospitalized patient to a nursing facility after they were treated for pulmonary edema. The patient is in the nursing home for both rehabilitation and medical treatment of fluid and electrolyte status. How should you manage the resident's health problems? A. Make daily phone contact with the charge nurse who can assess the resident's lung sounds and electrolyte status. B. Turn the care over to the geriatrician who can manage pulmonary edema in the elderly better than the internist. C. Arrange to make more frequent visits to the nursing facility until the resident stabilizes. D. Order daily x-rays of the resident's lungs and have the results faxed to the clinic as soon as they are available. Answer C. The resident isn't at the nursing facility as a long-term care resident who needs monthly visits, but is instead an acute care resident who requires frequent visits for clinical management until they resolve their acute problem. You need to see the resident more frequently with visits that are as frequent as if you were seeing the resident in the hospital. Number 44. You are the attending physician for a female nursing home resident without dementia or a mental status problem. She fills out an advance directive indicating she wants no heroic measures to save her life if she develops a life-threatening condition. She comes down with symptoms suggesting acute pulmonary edema and complains of shortness of breath. She wants something for the shortness of breath. How do you treat the patient? A. As the resident was lucid and ordered no heroic efforts, the doctor places the resident on oxygen for comfort and does no further intervention. B. The doctor admits the resident to the hospital because the only way to keep her comfortable is to use intravenous treatments unavailable at the nursing facility. C. Gives oral medication only to the resident even though they don't treat the resident's shortness of breath because the resident ordered no heroic efforts. D. As the resident was lucid at the time the advance directive was made, she should have understood that oxygen alone wouldn't treat the condition, so the doctor orders intramuscular diuretics to be given at the nursing home. Answer B. The woman has indicated that she wants the doctor to treat her without heroic treatment but still needs to be kept comfortable. In this severe pulmonary condition, giving her oxygen without any other treatment probably won't help her shortness of breath. For this reason, she needs to be treated with more than just oxygen. IV diuretics are necessary to treat the resident's shortness of breath and these things aren't able to be used in a nursing home setting, so she needs to be hospitalized. Number 45. You are the attending physician for a patient who is being managed for terminal lung cancer and who only requests palliative care. What management decision would be the most appropriate in the care of this patient? A. Liberal use of nebulizer treatments to keep the airways only. B. Liberal use of morphine and continuous oxygen supplementation. C. Oxygen by mask when cyanosis is evident and liberal use of morphine. D. Morphine when pain is present and liberal use of oxygen. Answer B. The patient has lung cancer and is dying of the disease. The patient will likely have problems in both pain and shortness of breath. An order for the liberal use of morphine can be given to treat both the shortness of breath and pain. Oxygen should be used on a regular basis for shortness of breath. Number 46. You are managing a terminally ill patient who develops a bowel obstruction that can't be treated using surgery. How do you treat this patient? A. Tell the patient they can no longer eat anything as this will worsen the bowel obstruction. B. Treat the patient's bowel pain and order a diet to be as tolerated. C. Give the patient parenteral feedings as this will improve skin integrity and keep nutrition up in a situation where the patient can't eat. D. Provide the patient with the option of having a colostomy to avoid the bowel obstruction so they can continue to eat what they want in their last remaining days without discomfort. Answer B. If the patient has a terminal illness and isn't expected to live very long, the little bit of food they eat probably won't worsen their bowel obstruction. They need medical management for their bowel obstruction pain but rather than deny them food, they should be allowed to eat anyway. Invasive procedures are not in keeping with the goal of palliative care and forcing the patient to avoid eating in a terminal state would not be a comfort measure. Number 47. You are the attending physician for a terminally ill patient who has brain cancer and is being managed by hospice. They are lucid some of the time and unconscious at other times. How should you go about managing their pain? A. Provide them with morphine rectally on a routine schedule regardless of their mental status. B. Provide them with subcutaneous morphine only when they are awake even if they don't complain of pain. C. Provide them with oral morphine when they are awake and tell their family member they have a headache. D. Provide them with oral morphine on a regular schedule regardless of their mental status. Answer A. The patient is terminally ill with cancer and might or might not have pain with a decreased level of consciousness. Because of this, they need to have care for their pain and shortness of breath care using rectal morphine that is independent of their mental status. An order for morphine to be given orally would be less invasive but can't be used when the patient is unconscious. Number 48. You are the primary physician treating a 15 year old female who has menorrhagia. She tells you that bleeding disorders run in her family but she can't recall what type of bleeding disorder her family has. How should she be further managed? A. Obtain a hemoglobin and serum iron level. If the iron level is low, recommend supplemental iron. B. Obtain a CBC and bleeding time. To screen for a bleeding disorder. C. Obtain a hemoglobin, bleeding time, protein, and partial thromboplastin time. D. Obtain levels of all the clotting factors to define what bleeding disorder she has. Answer C. She may or may not have a bleeding disorder so she can be simply screened by drawing blood for a hemoglobin, bleeding time, protein, and partial thromboplastin time. If she has laboratory evidence of a bleeding disorder with these tests, she can be evaluated further with clotting factor levels. Number 49. You are the primary care physician caring for a one-year-old male patient who presents with spontaneous bleeding in his knee joint. He doesn't have a positive family history of any type of bleeding disorder. What do you think is the patient's diagnosis? A. Hemophilia B with autosomal recessive inheritance that hasn't yet been discovered in the family. B. Hemophilia A that is a new mutation so it won't have a family history. C. Spontaneous mutation causing type 1 von Willebrand disease. D. Acquired von Willebrand disease. Answer B. The patient is male and shows evidence consistent with a serious bleeding disorder rather than a minor problem with bleeding. The most likely diagnosis in this patient's case is hemophilia A with a spontaneous mutation. Less likely diagnoses would be von Willebrand's disease type 3 because this also causes severe bleeding. He has a low risk for acquired von Willebrand disease and the diagnosis of type 1 von Willebrand disease is incorrect because this condition is usually mild and wouldn't present with spontaneous joint bleeding. Number 50. You are the internist for a 65 year old man who presents with the acute onset of shortness of breath. Laboratory testing reveals he has a hemoglobin of 7 milligrams per deciliter, platelet count of 60,000 and a white blood cell count of 40,000. What do you think is going on with this patient? A. He has evidence of a bleeding disorder and anemia so he probably has blood loss anemia. B. He has an elevated white blood cell count which could represent leukemia with crowding out of the red blood cell line production and platelet production. C. He has evidence of early bone marrow failure suggestive of a plastic anemia. D. He has fibrosis in his bone marrow that has impacted his red blood cell production and platelet production. Answer B. He has a markedly elevated white blood cell count which indicates a high likelihood for a diagnosis of acute leukemia that has crowded out his red blood cell production and platelet production. Number 51. You are the attending physician managing the care of a 33 year old male with signs and symptoms of anemia and a bleeding problem. A CBC is drawn which reveals a hemoglobin of 6 milligrams per deciliter, a platelet count of 45,000 and a WBC of 1,000. How should you manage these findings? A. Set him up for platelet transfusion, white blood cell transfusion and packed red blood cell transfusions. B. Find out what toxic exposures he has come in contact with and remove those toxins in the blood. C. Obtain a thorough family history and attempt to find a matched donor relative for a bone marrow transplant. D. Look through the bone marrow registry to find a suitable donor for the patient. Answer C. You feel that this patient has a diagnosis of aplastic anemia which is probably not secondary to any kind of toxic exposure. The only way you can manage this patient so he can have a long-lasting resolution of his problem is to suggest a matched bone marrow transplant with a related donor. Transplants of the bone marrow using an unrelated donor have a low chance of success so this is not a good recommendation. Number 52. You are the attending physician for a man showing laboratory evidence of a low hemoglobin, a low white blood cell count and a low platelet count. A bone marrow biopsy is not able to be obtained from his hip because he doesn't have an abundance of red marrow in his hip bone. What do you think is wrong with this patient? A. Early leukemia that hasn't yet resulted in an elevated white blood cell count. B. Fanconi's anemia with involvement of the bone marrow. C. Myelofibrosis. D. Kidney failure with lack of erythropoietin. Answer C. This is a patient who doesn't have very much red marrow which is responsible for making all of the blood cell lines. Because he has a difficult bone marrow aspiration study, the most likely problem in this patient's condition is myelofibrosis that has caused a decrease in the total of red marrow in the bone. Kidney failure isn't the answer because this would only result in red blood cell loss. Fanconi's anemia would only have red blood cell loss as well. Early leukemia isn't the answer because a bone marrow biopsy would be easier to do and would show evidence of leukemia in the bone marrow. Number 53. You are the attending physician for a 34 year old female with a laboratory test showing a hemoglobin of 11 milligrams per deciliter. What test would be most helpful in finding the cause of the low hemoglobin level? A. A bone marrow biopsy. B. A serum iron level. C. A serum B12 level. D. Kidney function studies. Answer B. The most likely diagnosis in a menstruating woman without other findings would be iron deficiency anemia secondary to menstrual blood loss. You can do a serum iron level and do more testing only if the serum iron doesn't seem to be decreased. Number 54. You are the attending physician for a 70 year old female patient with diabetes and hypertension who also has labs showing a hemoglobin of 10.5 milligrams per deciliter. What do you expect the patient's anemia is due to in this case? A. Blood loss anemia with low iron stores. B. Macrocytic anemia with low B12 absorption. C. Chronic renal failure with decreased erythropoietin. D. Macrocytic anemia with low folate intake. Answer C. This patient has a history and clinical findings suggestive of chronic disease which probably means she has diabetic neuropathy. This results in kidney disease and a deficiency of erythropoietin which would normally stimulate red blood cell growth. With kidney disease she has secondary anemia. Number 55. You are the attending physician managing the care of a 72 year old male who has peptic ulcer disease and laboratory evidence of macrocytic anemia. What do you think is the mechanism behind his anemia? A. Anemia of chronic disease. B. Anemia secondary to low folate intake. C. Anemia secondary to B12 deficiency. D. Anemia secondary to lack of B12 absorption. Answer. D. The patient is a man who has peptic ulcer disease. With this disease there is an increased chance of a reduction in the gastric production of intrinsic factor. This will secondarily result in poor absorption of vitamin B12 and macrocytic anemia. Number 56. You are the attending physician caring for a 57 year old alcoholic male who has a laboratory test revealing a hemoglobin of 10 milligrams per deciliter with a high MCV value. What do you think is the cause of this patient's low hemoglobin value? A. Anemia of chronic disease. B. Folate deficiency anemia. C. B12 absorption problems. D. Anemia secondary to alcoholic gastritis and occult blood loss. Answer. B. The most likely cause of a low hemoglobin value in a patient with alcoholism is folate deficiency which can be further evaluated by drawing a blood level for folate. Number 57. Which area of the body is most injured when a patient is given chemotherapy drugs? A. The urinary system. B. The reproductive system. C. The gastrointestinal system. D. The central nervous system. Answer. C. The cells of the gastrointestinal system divide rapidly in the same way that cancer cells divide so they are greatly injured when chemotherapy is given. This is why chemotherapy patients have a lot of gastrointestinal symptoms. Number 58. What can be done to help the radiotherapist precisely direct the external radiation beam to the tumor site every time radiation treatments are given? A. The patient is scanned prior to every treatment to find the right place to direct the beam. B. Patients are marked with permanent ink so the radiotherapist can direct the beam at the same place every time. C. The radiation beam is wide enough so that slight fluctuations in placement still affect the tumor. D. The patient is x-rayed before treatments so tumors are identified before treatment. Answer. B. The tumor can be precisely targeted each time radiation is given because the patient can be marked using permanent ink that shows the exact place to give the radiation on the body. Number 59. Why is brachytherapy such a helpful way to give a patient with cancer radiation therapy? A. It directs radiation at tumor cells and doesn't affect healthy cells. B. It uses a type of radiation that is particularly detrimental to cancer cells. C. It avoids any chance of having a secondary malignancy from radiation exposure. D. It places radiation in close proximity to the tumor in solid form. Answer. D. Brachytherapy is helpful in treating certain types of cancer because it allows the radiation source to be near the cancer cells without giving the patient systemic side effects. Number 60. Naked monoclonal antibodies are used in some forms of cancer treatment. How do they work to fight cancer? A. They carry a radioactive particle to the tumor site and bind to the proteins on the cancer cell. B. They bind to the cancer cell marking it for destruction by the patient's own immune system. C. They bind to the tumor and to T cells placing T cells in close proximity to tumor cells. D. They carry chemotherapy drugs directly to the cell surface of the tumor cell. Answer. B. Naked monoclonal antibodies are just antibodies directed toward tumor cells without a drug or radiation source attached to them. They are able to attach to receptors on cancer cells causing them to be marked for immune activation and secondary cell death by the patient's own immune system. Number 61. What is the biggest problem with the use of immunotherapy in the management of patients with cancer? A. It depends on the patient having an intact immune system. B. It has more side effects than chemotherapy treatments. C. It doesn't work on every type of cancer. D. It often takes several months to see any effect on the tumor growth. Answer. A. The biggest problem with the use of immunotherapy is that it can only work when the patient has a well-functioning immune system which isn't found in all patients who have cancer treatments. Number 62. In what way do bispecific monoclonal antibodies work to fight cancer cells? A. They bind to more than one receptor on the tumor cell membrane. B. They bind to the tumor and to the patient's T cell. C. They carry chemotherapy drugs to the tumor directly. D. They carry radiation particles directly to the site of the tumor. Answer. B. Bispecific monoclonal antibodies work against cancer cells because they are able to bind to both the tumor cell and to the patient's T cell so the immune cell is placed very near to the cancerous cell allowing it to kill the cancer. Number 63. What nutritional issue is the biggest problem in the care of the patient with cancer? A. Poor absorption of nutrients. B. Poor appetite. C. Insulin resistance. D. Oral stomatitis. Answer. B. The biggest nutritional issue in patients suffering from cancer is poor appetite which can be secondary to the cancer or to the treatments given to fight the cancer. Number 64. You are treating a septic patient who is found to be hypotensive. What type of therapy is best used in this situation? A. The administration of blood products. B. Intravenous colloidal solutions. C. Intravenous albumin. D. Vasopressive agents. Answer. B. A patient with sepsis and low blood pressure should initially be treated with intravenous colloidal solutions first with the use of other treatments only if this fails. Number 65. Which part of the body tends to fail first when a patient is suffering from septicemia? A. The kidneys. B. The liver. C. The heart. D. The lungs. Answer. D. The gas exchange function in the alveoli of the lungs is the part of the body that fails first in septicemia which results in damage to the heart and heart failure. This causes the low blood pressure seen in these patients. Number 66. Which statement is the most correct when it comes to patients with sepsis? A. Cases of sepsis are due to an uncontrolled bacterial infection. B. Septic patients suffer from hypotension. C. The body temperature is elevated in sepsis. D. Sepsis is more common in immunocompromised hosts. Answer. D. The patient with sepsis is likely to be immunocompromised. Because of this, you may find that the patient's body temperature will be high or low, their blood pressure may be normal or low, and the patient can suffer from sepsis unrelated to infection. Number 67. Which kind of vasopressive agent is the treatment of choice in the management of the septic patient with hypotension? A. norepinephrine. B. epinephrine. C. dobutamine. D. dopamine. Answer. A. The vasopressive agent of choice in the management of the patient with sepsis is norepinephrine. Epinephrine can be used as a second-line treatment. Number 68. Which drug classification is always necessary when caring for the patient who has sepsis? A. Vasopressor therapy. B. Corticosteroids. C. Antibiotics. D. Proton pump inhibitors. Answer. C. The drug classification that must be used in septic patients is antibiotics, which need to be used in all patients, even when you can't find a source for the infection, and even if the blood cultures are negative. Number 69. Which of the following patients is more likely to have pneumonia secondary to, and infection with, pneumocystitis? A. An elderly patient living in the community. B. An infant living in the community. C. A ventilator-dependent patient. D. A patient with AIDS. Answer. D. Pneumocystis pneumonia is almost exclusively seen in patients suffering from AIDS. It is rare to be seen in any patients without the finding of AIDS. Number 70. You are the primary caregiver for a patient who has evidence of community-acquired pneumonia by x-ray evaluation, which reveals a lober consolidation. How can you further manage this patient's care? A. Sputum cultures are obtained and the patient is treated after the culture returns. B. Antiviral agents are given as the source is likely viral in nature. C. Empiric antibiotic therapy is started. D. Antifungal agents are started until cultures return. Answer. C. The patient has signs and x-ray evidence suggesting community-acquired pneumonia. They can be easily managed by giving them empiric antibiotic therapy. The findings of a lober pneumonia indicate that the source of the infection is most likely to be bacterial. Number 71. Which finding on a patient's blood evaluation would lead you to further evaluate the patient's kidney function? A. Glucose level of 300 milligrams per deciliter. B. Sodium level of 134. C. WBC of 14,000. D. HGB of 12 milligrams per deciliter. Answer. A. The finding of a blood glucose level as high as 300 milligrams per deciliter would lead you to believe that the patient is suffering from diabetes mellitus. Because of this, they should have their kidney function evaluated as they are at a high risk for developing chronic kidney disease. Number 72. Which type of drug is primarily used in the management of patients who have chronic kidney disease? A. Beta blockers. B. Calcium channel blockers. C. ACE inhibitors. D. Vasodilators. Answer. C. ACE inhibitors are used in most patients with chronic kidney disease because they are able to lower the blood pressure and can protect the kidneys from being damaged by the patient's diabetes or other disease affecting the kidneys. Number 73. You are treating a patient who is suffering from shock and has evidence for also having acute renal failure. Why would such a patient develop acute renal failure? A. Inflammatory markers impair the function of the tubules. B. Infection causes damage to lung tissue. C. Blood flow to the kidneys is diminished. D. Medications used to treat shock can impair kidney function. Answer. C. The patient suffering from shock often suffers from acute kidney failure because of a decrease in the overall blood flow to the kidneys, causing kidney damage. Number 74. Why should patients with chronic kidney disease have evaluation and treatment of elevated cholesterol levels? A. Cholesterol can block the tubules of the kidneys. B. Cholesterol needs to be filtered by the kidneys and too much cholesterol can overtax the kidneys. C. Cholesterol can raise blood pressure levels. D. Cholesterol can block the arteries leading to the kidneys. Answer. D. Patients with chronic kidney disease need management of high cholesterol levels because cholesterol plaques can block the arteries leading to the kidneys, leading to macrovascular disease that can decrease the renal arterial blood flow. Number 75. You are treating a patient with prostate disease. How can this patient also have clinical findings suggestive of chronic renal failure? A. The prostate gland can cause decreased blood flow to the kidneys if it is enlarged. B. The prostate gland can release factors into the blood that cause kidney damage. C. The prostate gland can secrete factors into the urine that result in kidney damage. D. The prostate gland can block urine outflow damaging the kidneys. Answer. D. The prostate gland can cause a patient to develop chronic renal failure if it becomes enlarged resulting in urine outflow obstruction and secondary damage to the kidneys. Number 76. The patient has documented evidence of strep throat. How can this condition sometimes lead to the development of acute renal disease? A. The kidneys can become infected with the streptococcus virus. B. The kidneys are damaged by inflammation associated with a streptococcal infection. C. Streptococcal infections cause decreased blood flow to the kidneys. D. Streptococcal infections raise blood sugar levels which damage the kidneys. Answer. B. Strep throat sometimes causes systemic inflammation that can secondarily cause acute kidney damage. Number 77. You are the primary internist managing the care of a 40-year-old patient who has chronic renal insufficiency. What aspect of their health needs monitoring and optimization the most to keep their kidney function stable? A. Blood hemoglobin A1c. B. Blood pressure. C. Serum albumin level. D. Serum electrolytes. Answer. B. Monitoring and maintaining a blood pressure in chronic renal insufficiency patients is the most important part of their management. Number 78. You are the primary internist caring for a 55-year-old patient suffering from stage 1 renal failure. What type of medication would you prescribe for this patient who has this stage of renal failure? A. Antibiotics. B. A. ACE inhibitors. B. Oral diabetic medications. C. Angiotensin 2 receptor blockers. D. No medications are recommended. Answer. D. A patient who has evidence of stage 1 renal failure doesn't need any medications. Instead of medications, the patient just needs to be advised to eat a healthy diet and avoid risk factors for worsened renal insufficiency. Number 79. What is the treatment of choice for a patient you are treating who has stage 5 renal failure? A. ACE inhibitors. B. Angiotensin 2 receptor blockers. C. Hemodialysis. D. Thiazide diuretics. Answer. C. The treatment most helpful in a patient who has stage 5 renal failure is hemodialysis. At this stage of renal failure, the use of any type of medication won't be helpful in improving the kidney function. Number 80. You are the primary internist managing the care of a 70-year-old male who describes the gradual onset of frequent cough that is productive of clitoris. He shows no evidence of fever, but tells you he is mildly short of breath with exertion. What do you think is most likely wrong with the patient? A. Acute bronchitis. B. Chronic bronchitis. C. Emphysema. D. Chronic obstructive pulmonary disease. Answer. B. This is a patient who has a history and clinical evidence suggesting chronic bronchitis. He doesn't have any symptoms indicating a case of acute bronchitis and doesn't really have any symptoms of emphysema. The most likely diagnosis then is chronic bronchitis. Number 81. You are managing the treatment of a 78-year-old male who is found to be in stage 1 renal failure. You are managing the treatment of a 78-year-old male who is found to be in stage 1 chronic obstructive pulmonary disease. What type of treatment would you prescribe for this patient? A. Inhaled corticosteroid treatment. B. Oral corticosteroid treatment. C. Inhaled bronchodilator treatment. D. Oral antibiotic treatment. Answer. C. For a patient who only has stage 1 chronic obstructive pulmonary disease, the treatment you would prescribe would involve only inhaled bronchodilator therapy. The other choices tend to be prescribed in patients who have greater stage disease. Number 82. You are the primary internist for a patient who has chronic obstructive pulmonary disease. What is the most likely thing that has caused this patient's condition? A. Air pollution. B. Cigarette smoking. C. Secondhand smoke. D. Chronic infections. Answer. B. The most common reason a person has chronic obstructive pulmonary disease would be cigarette smoking. The other answers are more rare causes of the disease. Number 83. You are the attending internist caring for a 35-year-old man who has a 5-year history of emphysema. What could be the cause of the early onset of this patient's condition? A. Secondhand smoke inhalation. B. Alpha-1 antitrypsin deficiency. C. Chronic cigarette smoking. D. Chronic respiratory infections. Answer. B. This patient has emphysema at an extremely young age. This makes him have a clinical suspicion of having a genetic cause for the emphysema. Alpha-1 antitrypsin deficiency should be suspected in this case. Number 84. You are the attending internist evaluating a 60-year-old male who has symptoms suggestive of possible emphysema. The chest x-ray isn't helpful in making the diagnosis and you want to do additional testing to further evaluate the man's symptoms. A. Pulmonary function test. B. Arterial blood gases. C. CT scanning of the chest. D. Lung biopsy. Answer. C. If the chest x-ray can't show that the patient has emphysema, you can go on with the evaluation by doing a CT scan of the chest, which can help you make the diagnosis of emphysema. Number 85. Why would you treat your patients who have chronic obstructive pulmonary disease with therapy that involves giving both bronchodilators and corticosteroids? A. Both types of treatments are necessary to fight small airway disease. B. The patient has elements of both obstructive airway disease and chronic inflammation. C. The patient will be less short of breath if a corticosteroid is part of their therapy. D. The patient will have less bronchoconstriction on corticosteroid therapy. Answer. B. Patients who have chronic obstructive pulmonary disease are often prescribed both bronchodilators and corticosteroids because they have lung disease that involves both obstructive airway disease and chronic inflammation, requiring two types of medication. Number 86. You are the internist managing a patient suffering from stage 4 chronic obstructive pulmonary disease. What should be used at this stage to help the patient have maximal improvement of their symptoms? A. Long-term bronchodilator therapy. B. Lung transplant. C. Oral corticosteroid therapy. D. Oxygen therapy. Answer. B. In a patient suffering from stage 4 chronic obstructive pulmonary disease, the only course of action that can maximally improve their symptoms for a long period of time is a lung transplant. Number 87. You are the attending internist caring for a 75-year-old woman who has both osteoarthritis of the knee and peptic acid disease, making her a poor candidate for NSAID therapy. What treatment can you give her for her knee pain that won't have systemic side effects? A. Narcotic pain relief of joint pain. B. Total knee replacement. C. Hyaluronic acid injections. D. Proton pump inhibitors and NSAID therapy. Answer. C. There are many things that can be done to help a patient with osteoarthritis who also has peptic acid disease. One safe treatment for this patient is hyaluronic acid injections that can be injected into the joint without a risk for systemic side effects. Number 88. How can you best identify osteoarthritis in your patient? A. Blood tests showing autoantibodies to joint tissue. B. CT scan of the vertebral column. C. Physical exam and x-ray of painful joints. D. Joint aspiration showing inflammation of the joints. Answer. C. Osteoarthritis is best identified by doing a thorough examination of the patient's joints and by doing a plain x-ray of at least one affected joint which shows characteristic joint space narrowing and bony abnormalities. Number 89. You are evaluating a 65-year-old female with possible rheumatoid arthritis. How do you go about evaluating this patient if you suspect this disease? A. Aspiration of joint fluid showing inflammatory cells. B. Blood tests for erythrocyte sedimentation rate and rheumatoid factor. C. Blood tests showing anemia of chronic disease. D. Biopsy of synovial tissue showing acute inflammation. Answer. B. The diagnosis of rheumatoid arthritis can be done through the use of blood testing looking for a positive rheumatoid factor and by evaluating the patient's overall inflammation through the use of an erythrocyte sedimentation rate test. Number 90. You are the primary internist treating a patient who only has symptoms involving a loss of pigmentation of the skin. What autoimmune disease do you think the patient is suffering from? A. Scleroderma. B. Dermatomyositis. C. Sjogren's disease. D. Vitiligo. Answer. D. Vitiligo is the only autoimmune disease that would give you these symptoms without any other symptoms. Number 91. You are evaluating a young patient who has signs and laboratory evidence of chronic liver insufficiency and probable autoimmune disease. Which autoimmune disease do you think is causing this patient's liver disease? A. Systemic lupus erythematosus. B. Celiac disease. C. Polymyositis. D. Primary biliary cirrhosis. Answer. D. The most common autoimmune disease listed that would result in liver insufficiency is primary biliary cirrhosis. Number 92. You are treating a 55-year-old woman who is believed to have an autoimmune disease affecting the thyroid gland. How do you further evaluate this patient? A. The patient can have thyroid function tests done to evaluate the function of the gland. B. The patient can have antithyroid antibodies evaluated. C. The patient can have an erythrocyte sedimentation rate checked. D. The patient can have a biopsy of the thyroid gland showing inflammation. Answer. B. Autoimmune diseases affecting the thyroid gland will show evidence of antithyroid antibodies in a blood test. The finding of antithyroid antibodies in the blood will prove an autoimmune-related thyroid disease. Number 93. You are the primary health care provider to a patient with laboratory studies showing extremely high liver enzymes and who has a history of intravenous drug use. What laboratory value is most likely to be found to be positive and helpful in diagnosing this patient given their history? A. Alanine aminotransferase levels. B. Hepatitis C IgM antibody. B. Hepatitis B IgM antibody. D. Hepatitis A IgM antibody. Answer. C. The most common blood test that would help identify the cause of the patient's elevated liver enzymes is a hepatitis B IgM antibody test, which will be elevated in acute cases of viral hepatitis. Number 94. You are the internist managing the care of a patient with a long history of chronic alcohol use. What test can you do to prove the patient has alcoholic cirrhosis? A. Ultrasound of the liver. B. AST and ALT levels in the blood. C. MRI scan of the abdomen. D. Biopsy of the liver tissue. Answer. D. The only way to accurately show that the patient has cirrhosis of the liver is a liver biopsy. The other tests may suggest cirrhosis, but won't prove it. Number 95. You are managing the care of a patient who presents with enlarged esophageal veins, but no history of upper GI bleeding episodes. How can you treat this patient? A. Routine paracentesis to draw ascitic fluid off the abdomen. B. Propranolol to decrease portal hypertension. C. Avoidance of nonsteroidal anti-inflammatory agents. D. Proton pump inhibitors. Answer. B. You can help the patient with esophageal varices by decreasing the portal blood pressure through the use of propranolol. Another treatment you can give involves treating the varices with banding or sclerotherapy. Number 96. You are managing the care of a patient with cirrhosis and secondary splenomegaly. How do you follow this patient to identify secondary complications of their condition? A. Routine paracentesis to draw off ascitic fluid. B. Routine ultrasounds to follow splenic size. C. Routine CBCs to monitor for low cell counts. D. Routine CT scans to monitor splenic size. Answer. C. The main secondary problem in patients who have cirrhosis and splenomegaly is low cell counts due to splenic sequestration. The size of the spleen is not important. However, blood needs to be drawn periodically for monitoring of low counts. Number 97. The best way to prove the diagnosis of cirrhosis is a liver biopsy. However, it is not often performed. Why is it not often done? A. The diagnosis can easily be made using non-invasive techniques. B. The risk of bleeding is high with liver biopsies. C. Liver biopsies often fail to detect advanced disease. D. The liver is shrunk in cirrhosis, making it hard to access for biopsy. Answer. B. Even though a liver biopsy is the only way to prove a patient has cirrhosis of the liver, it is not usually performed when diagnosing the disease because the risk of bleeding during a procedure is high. Number 98. How do you manage high-risk cirrhosis patients to find liver cancer at the earliest possible time? A. Yearly CT scans of the abdomen. B. Yearly MRI scans of the abdomen. C. Twice yearly alpha-fetoprotein levels. D. Twice yearly liver transaminase levels. Answer. C. Patients who have cirrhosis and a high risk for having secondary liver cancer can be monitored by having twice yearly liver ultrasounds and measurements of the serum alpha-fetoprotein level. Number 99. You are caring for a cirrhotic patient with chronic abdominal ascites. What is the best way to manage this patient's problem? A. Thiazide diuretic therapy. B. Low potassium diets. C. Propranolol to decrease portal pressures. D. Spironolactone therapy. Answer. D. While there are several good treatments for ascites, including following a low-salt, low-fluid diet, most patients still have ascites after this and usually require diuretic therapy. Spironolactone is a typical diuretic therapy used in the management of ascites. Number 100. You are caring for an otherwise healthy young female patient who has clinical evidence suggesting she has acute hepatic insufficiency. What test can best assess the cause of her acute hepatic failure, given her history? A. Antinuclear antibody and anti-smooth muscle antibody titers. B. Liver biopsy. C. Viral screening for hepatitis A. D. Ultrasound of the liver. Answer. A. A healthy young female showing clinical evidence of hepatic inflammation and insufficiency of the liver should be screened for autoimmune hepatitis. Hepatitis A will result in inflammation of the liver but won't be a cause for her liver failure. An ultrasound of the liver will not help in diagnosing the cause of her liver failure, and performing a liver biopsy would be done only as a follow-up. This is not the last result, because it would be risky in a patient who has liver insufficiency.