291 - 41st Annual Intensive Review of Internal Medicine Post Test

S.No. Questions

1. Which one of the statements from the US Preventive Health Services is correct regarding screening for chronic
kidney disease?

A. Measurement of BUN and serum creatinine are the preferred measures for screening of CKD
B. Use of cystatin C is preferred to serum creatinine for CKD screening
C. Use of the MDRD prediction glomerular filtration equation is recommended for CKD screening
D. Measurement of hemoglobin should be used as an adjunctive test in CKD screening
E. Screening for CKD is not recommended in asymptomatic individuals

2. Which of the following does not apply to the metabolic acidosis of chronic renal failure?

A. Decreased ammonium excretion prevents excretion of the daily acid load

B. Correction of the acidosis with sodium bicarbonate may minimize the progression of renal osteodystrophy
C. Sodium citrate (citrate is rapidly metabolized in the body to bicarbonate) is preferred because it is more
palatable than sodium bicarbonate
D. The metabolic acidosis is typically characterized by an elevated anion gap, particularly in patients with severe
renal failure

3. A 52-year-old white female presents to the emergency room with unstable angina. She is noted to have a past
medical history of mild chronic renal insufficiency and type 2 diabetes mellitus (NIDDM). She is transferred to the
coronary care unit and therapy for her unstable angina is initiated. A cardiac catheterization is planned for the next
day. Risk factors that would predispose this woman to contrast nephrotoxicty include all of the following except:

A. Diabetes mellitus
B. Pre-existing renal insufficiency
C. The volume of IV contrast utilized in the procedure
D. Presence of extracellular volume contraction
E. A history of coronary artery disease

4. A 62-year-old white male with end-stage renal disease who has recently been started on chronic hemodialysis is
noted on routine monthly laboratory blood draw to have serum calcium of 8.8 mg/dL and a serum phosphorous of
7.2 mg/dL. His serum albumin is 4.2 g/L. An intact PTH measurement is 420 pg/ml. The patient is currently taking
calcium acetate 1 capsule (667 mg) orally three times each day with meals, and oral 1, 25 dihydroxy vitamin D 0.50
micrograms/day daily. He says that he is compliant with his medications.
The next best strategy would include which of the following?

A. Change his calcium acetate to calcium carbonate (TUMS) 1 capsule with meals each day
B. Arrange for a parathyroidectomy to treat his hyperparathyroidism
C. Perform a bone biopsy to rule out aluminum toxicity
D. Increase his dose of calcium acetate to 2 caps with meals each day and add 2 caps of capsules before bedtime
E. Substitute 2-3 capsules of sevelemar three times each day with meals for the calcium acetate and temporarily
hold the vitamin D, until his calcium –phosphorous product is < 55

5. A 78-year-old black female with type 2 diabetes who has retinopathy and nephropathy is referred to you from the
ambulatory screening clinic. He gives you a 3-month history of nausea, difficulty sleeping at night, and
progressively worsening appetite with a weight loss of 15 lbs over the past 6 months. His examination is notable for
a blood pressure of 140/92 mmHg, heart rate of 68 bpm, afebrile, and a sallow appearance. He also has scratch
marks over his trunk and lower extremities. Laboratory values are remarkable for:
Which of the following would be the next best steps in management?

A. Make an appointment for the patient to be seen in the hematology clinic for work-up of his anemia
C. Refer
D.
E. Arrange
thefor
patient
the patient
for a routine
to receive
appointment
intravenous
subcutaneous
with
iron
your
erythropoietin
local vascular
and arrange
surgeon for
for dialysis
evaluation of dialysis access
Page 1 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

5. A 78-year-old black female with type 2 diabetes who has retinopathy and nephropathy is referred to you from the
ambulatory screening clinic. He gives you a 3-month history of nausea, difficulty sleeping at night, and
progressively worsening appetite with a weight loss of 15 lbs over the past 6 months. His examination is notable for
a blood pressure of 140/92 mmHg, heart rate of 68 bpm, afebrile, and a sallow appearance. He also has scratch
marks over his trunk and lower extremities. Laboratory values are remarkable for:
Which of the following would be the next best steps in management?

A. Make an appointment for the patient to be seen in the hematology clinic for work-up of his anemia
B. Start the patient on an angiotensin converting enzyme inhibitor, if he is not already on one, for better control of
his blood pressure
C. Arrange for the patient to receive intravenous iron
D. Arrange for the patient to receive subcutaneous erythropoietin and arrange for dialysis
E. Refer the patient for a routine appointment with your local vascular surgeon for evaluation of dialysis access
options

6. A 67-year-old man presents with 1-week history of anorexia, nausea, lassitude, and pedal edema. He has
longstanding hypertension, which has been well controlled with hydrochlorothiazide and amlodipine. He has been
taking fenoprofen for osteoarthritis of the hip for the past 3 months. Physical examination shows a blood pressure
of 167/93mm Hg, heart rate of 82 beats per minute, and a temperature of 97.8OF. He has a jugular venous
pressure of 8 cm; normal cardiac and pulmonary examinations; and 2+ pitting edema. Urinalysis showed a specific
gravity of 1.017, protein 4+, 1+ blood, and negative for glucose. Microscopic examination of the sediment showed
2-4 erythrocytes and 15-20 leukocytes per high-power field, and occasional granular casts. Results of initial
laboratory tests showed: blood urea nitrogen, 93 mg/dL; creatinine, 7.8 mg/dL; sodium, 137 mEq/L; potassium, 4.4
mEq/L; chloride, 95 mEq /L; bicarbonate, 21 mEq/L; calcium, 9.2 mg/dL; phosphorus, 7.8 mg/dL; uric acid, 7.7 mg/
dL; aspartate aminotransferase, 42 U/mL; bilirubin, 0.8 mg/dL; albumin, 2.9 g/dL; and total protein, 5.9 g/dL. His
hematocrit was 32%. ANCA is negative. Antinuclear antibodies were detected at a 1:40 titer. His anti-dsDNA
antibody level was 0. Twenty-four hour urinary protein excretion is 7.7 g. A renal ultrasound showed normal sized
kidneys bilaterally without obstruction. Three months previously his serum creatinine was 1.7 mg/dL.
The nephrotic-range proteinuria and renal failure are most likely the result of:

A. Lupus nephritis
B. Multiple myeloma
C. Systemic small vessel vasculitis
D. Fenoprofen-induced nephrotic syndrome and interstitial nephritis
E. Renal vein thrombosis secondary to membranous nephropathy

7. A previously healthy 24-year-old Japanese-American man becomes ill with fever (temperature, 38ºC [100.4º]),
malaise, myalgias, and a sore throat. Approximately 8 hours later, gross hematuria and flank pain begin. His past
medical history is notable for several prior episodes of gross hematuria. Urinalysis shows protein, 3+ and
erythrocyte casts. His blood urea nitrogen (BUN) is 28 mg/dL, serum creatinine is 1.3 mg/dL. Electrolytes are within
normal limits. Serological testing reveals normal complements, a negative ANA, and negative ASLO and ANCA
titers. His anti-GBM titers are also negative. Which of the following is the most likely diagnosis?

A. Lupus nephritis
B. IgA nephropathy
C. Rapidly progressive glomerulonephritis secondary to Wegener’s granulomatosis
D. Goodpasture’s syndrome
E. Post-streptococcal glomerulonephritis

8. Which of the following may produce clinically significant bleeding without prolongation of the PT or aPTT?

A. Hypodysfibrinogenemia
D. Plasminogen
E. Factor XIII deficiency
deficiency
Page 2 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

8. Which of the following may produce clinically significant bleeding without prolongation of the PT or aPTT?

A. Hypodysfibrinogenemia
B. Factor IX deficiency
C. Factor XII deficiency
D. Factor XIII deficiency
E. Plasminogen deficiency

9. Desmopressin acetate (DDAVP) has been shown to be effective in the treatment of bleeding associated with each
of the following disorders except:

A. Immune thrombocytopenia purpura (ITP)

B. Hemophilia A
C. Uremia
D. Platelet storage pool disease
E. Von Willebrand’s disease

10. Antithrombin III deficiency is associated with which of the following conditions:

A. Heparin therapy
B. Warfarin therapy
C. Major surgery
D. Chemotherapy
E. Inflammatory states

11. A 65-year-old white male complains of progressive difficulty in swallowing. The difficulty was initially worse for solid
than liquids. Hot or cold liquids do not exacerbate his dysphagia. Over the past 6 months he complains of difficulty
with both liquids and solids. He has also had an approximately 10 Kg weight loss. There are no associated
symptoms of reflux. Social history is notable for a 20-pack year history. Physical examination is unremarkable. The
next step should be:

A. Endoscopy and biopsy

B. Esophageal manometry
C. Ambulatory esophageal pH monitoring
D. Barium swallow
E. Acid perfusion (Bernstein test)

12. All of the following are true about Helicobacter pylori, except:

A. H.pylori is gram negative bacterium

B. H.pylori transmission appears to be person-to-person
C. Most H.pylori infections occur in childhood
D. The best initial test to diagnose H.pylori infection is by endoscopy and biopsy
E. Active peptic ulcer disease secondary to H.pylori should be treated

13. A 44-year-old white female with alcoholic pancreatitis was admitted 14 days ago with severe acute pancreatitis
complicated by organ failure. Dynamic contrast-enhanced CT scan showed considerable pancreatic necrosis. The
pancreatic head and proximal body enhance reasonably well. There is a considerable amount of low attenuation
material replacing the tail of the pancreas and extending into the lesser sac displacing the stomach anteriorly. At
present, the white blood count is 10,000, temperature 98.5ºF daily. She remains intubated with assisted ventilation.
CT-guided percutaneous aspiration of fluid shows no organisms on Gram’s stain and no growth. What is the best
course of treatment?

A. Surgical debridement
B. Percutaneous catheter drainage of fluid
C. Continuation of medical
D. Endoscopic cyst-gastrostomy
E. Therapy with antibiotics effective for gram negative and anaerobic organisms

14. A 46-year-old white male develops idiopathic acute pancreatitis. Three weeks later, he is continuing to experience
abdominal pain that precludes intake of food. CT scan reveals a low attenuation area replacing the distal body and
tail of the pancreas displacing the stomach. Which of the following choices would you recommend?
B. Continued
C.
D.
E. ERCP
Percutaneous
Surgical
with
drainage
medical
insertion
catheter
therapy
of adrainage
stent in the main pancreatic duct
Page 3 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

14. A 46-year-old white male develops idiopathic acute pancreatitis. Three weeks later, he is continuing to experience
abdominal pain that precludes intake of food. CT scan reveals a low attenuation area replacing the distal body and
tail of the pancreas displacing the stomach. Which of the following choices would you recommend?

A. Endoscopic drainage with cyst-gastrostomy

B. ERCP with insertion of a stent in the main pancreatic duct
C. Percutaneous catheter drainage
D. Surgical drainage
E. Continued medical therapy

15. A 63-year od white male is admitted to the hospital with evidence of cirrhosis on examination and is found to have
large ascites, a low-grade fever and an ascitic fluid cell count of 984, of which 51% are PMN’s. The patient is
hemodynamically stable. The patient appears well and has a normal peripheral WBC count. The ascites total
protein concentration is < 1.0 g/dL, and albumin gradient (serum-ascites albumin concentration) is 1.8 g/dL. The
most appropriate intervention at this point is:

A. Begin empiric ampicillin, gentamicin, and metronidazole while awaiting culture results
B. Await culture results and begin antibiotics if a positive culture is obtained or patient shows evidence for clinical
deterioration
C. Obtain abdominal CT scan to exclude evidence of bowel perforation
D. Treat with cefotaxime IV while awaiting culture results, discontinue antibiotics if not growth after 72 hours
E. Treat with cefotaxime IV. Once clinically stable, discharge on oral quinolone even if cultures were negative

16. A 74-year-old white male with a prior history of alcohol-induced cirrhosis is experiencing persistent hepatic
encephalopathy as manifest by day/night reversal, mild confusion and asterixis on examination. There is no
evidence of occult infection, SBP or intravascular volume depletion. Serum electrolytes are unremarkable. Current
medications are limited to spirinolactone and furosemide. The most appropriate therapeutic recommendation is:

A. Recommend 25 gram dietary protein restriction

B. Begin Ambien to assist with sleep
C. Arrange for head CT to exclude intracranial edema
D. Titrate lactulose to 2-3 bowel movements per day
E. Begin lactulose 1 tablespoon po bid and neomycin 3 grams po per day

17. A 66-year-old white male with cirrhosis presents with large ascites and peripheral edema to the knees bilaterally.
Previous work-up has confirmed the presence of a wide serum-ascites albumin gradient. Renal function has
remained normal on a dose of spironolactone 100 mg per day and furosemide 40 mg per day, but these
medications have been ineffective in promoting a diuresis. The patient reports following a reasonable sodium
restriction. There is no history of encephalopathy. The most appropriate intervention at this point is?

A. Refer to interventional radiology for TIPS evaluation

B. Retap ascites for cytology to exclude intraperitoneal infection
C. Increase spironolactone to 200 mg per day
D. Refer to a surgeon for placement of a peritoneovenous shunt
E. Discontinue diuretics and management with large volume paracentesis on a prn basis

18. Each of these anticancer agents may produce cardiac toxicity except:

A. Doxorubicin
B. Cyclophosphamide
C. 5-fluorouracil
D. Idarubicin
E. Vinblastine

19. All of the following statements about myelodysplastic syndrome (MDS) are true except:

A. Chemotherapy and radiation therapy are increasingly common causes of MDS.

B. Clinical features of MDS often include: anemia, thrombocytopenia, and neutropenia
C. Marrow infiltration needs to be ruled in the differential diagnosis of MDS
D. < 20% of MDS patients have cytogenetic abnormalities
E. 30% die from transformation to AML and its complications.

A. Tyrosine
B.
C.
D.
E. Splenectomy
Hydroxyurea
Bone marrow
Busulfan kinase
therapy
transplantation
inhibitors (imatinib)
Page 4 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

20. A 67-year-old woman is found to have a WBC=23,000/mm3 at a routine visit. Her Hct=29% and the platelet count is
650,000/mm3. The WBC differential reveals 50% neutrophils, 10% bands, 10% lymphs, 15% myelocytes, 5%
promyelocytes, 5% basophils, 5% eosinophils. On examination her temperature is 100.5 F and her spleen is 3 FB
below the left costal margin. The leukocyte alkaline phosphatase is very low and chromosomal analysis of her bone
marrow shows a t (19, 22).
When discussing her diagnosis and management with her, she asks which therapeutic options will be curative:

A. Tyrosine kinase inhibitors (imatinib)

B. Splenectomy
C. Bone marrow transplantation
D. Busulfan therapy
E. Hydroxyurea

21. A 74-year-old white male is found to have a white blood count of 94,000/mm3 on routine blood work. The
differential shows 96% mature appearing lymphocytes and 4% neutrophils. His hematocrit is 41% and the platelet
count is 210,000/mm3.
On further questioning he tells you that he has been fully active. He denies fevers, sweats, weight loss or fatigue.
He has had no infections. His physical examination is remarkable for scattered lymph nodes of 1-1.5 cm. The
spleen is barely palpable at the left costal margin.

The best therapy for this man at this time is:

A. No therapy
B. Allogeneic bone marrow transplantation
C. Aggressive multiagent chemotherapy consisting of cyclophosphamide, Adriamycin, vincristine and prednisone
D. Oral chlorambucil and prednisone
E. Prednisone alone

22. Which one of the following statements about Hodgkin’s disease is correct:

A. Hodgkins affects patients predominantly in their 70s and 80s

B. Most commonly the bone marrow is the primary organ that is affected
C. The risk of secondary malignancies is negligible
D. The liver is the most common site for infradiaphragmatic involvement
E. Hodgkin’s disease is potentially curable

23. A 27-year-old man comes to your office complaining of a 25 lb weight loss, fevers, and night sweats. Physical
examination is remarkable for 10 cm nodal masses in both supraclavicular areas. Chest X-ray shows a large
mediastinal mass. Biopsy of the supraclavicular lymph nodes shows nodular sclerosis Hodgkin’s disease. A bone
marrow biopsy shows involvement with Hodgkin’s disease.
The best therapy at this point should include:

A. Bone marrow transplantation

B. No therapy-the patient has stage IV disease and is incurable
C. Aggressive chemotherapy with ABVD
D. Radiation to areas of apparent lymph node enlargement
E. Use of an anti-CD20 monoclonal antibody (Rituximab)

24. The treatment options for advanced prostatic cancer (stage IV) include all of the following, except:

A. Prostatectomy
B. Leuprolide or diethylstilbestrol (DES)
C. Orchiectomy
D. Peripheral androgen blockade using enzalutamide
E. None of the above

25. A 66-year-old woman is admitted to the hospital with acute pulmonary edema. She has a history of moderately
severe hypertension controlled with diuretics. Her physical examination reveals a heart rate of 110 beats/minute
and blood pressure of 170/90 mmHg. Rales are heard over both lung fields to the level of the mid scapulae. Neck
veins are distended to 12 cm H20. A dynamic left ventricular impulse is infero-laterally displaced. Heart sounds are
brisk and accompanied by a prominent fourth heart sound but no murmurs. Her electrocardiogram is remarkable
only for left ventricular hypertrophy, a small left ventricular cavity size, and hyperdynamic wall motion. In addition to
diuretic therapy, the best long-term therapy for this patient would be:

C. Long-acting
D.
E. A beta
An arterial
blocker
vasodilator
nitrates alone
alone
Page 5 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

25. A 66-year-old woman is admitted to the hospital with acute pulmonary edema. She has a history of moderately
severe hypertension controlled with diuretics. Her physical examination reveals a heart rate of 110 beats/minute
and blood pressure of 170/90 mmHg. Rales are heard over both lung fields to the level of the mid scapulae. Neck
veins are distended to 12 cm H20. A dynamic left ventricular impulse is infero-laterally displaced. Heart sounds are
brisk and accompanied by a prominent fourth heart sound but no murmurs. Her electrocardiogram is remarkable
only for left ventricular hypertrophy, a small left ventricular cavity size, and hyperdynamic wall motion. In addition to
diuretic therapy, the best long-term therapy for this patient would be:

A. Digoxin and arterial vasodilator

B. Digoxin and long-acting nitrates
C. A beta blocker
D. An arterial vasodilator alone
E. Long-acting nitrates alone

26. A 63-year-old white male reports an 18-month history of stable exertional chest pain typical for angina. The
discomfort occurs once a week during the warm-up phase of his Sunday morning tennis game. On exercise testing,
the patient completes stage IV of a standard Bruce protocol, at which time he complains of chest pain that worsens
slightly in recovery and slightly abates. This is accompanied by 1 mm ST depression in leads II and V6, which
resolve with the pain between 1 and 3 minutes post-exercise. Coronary angiography demonstrates 90% narrowing
of the mid right coronary artery and90% narrowing of the of the mid left anterior descending coronary artery beyond
the septal and diagonal branches. Left ventriculography reveals intact contraction with no regional wall motion
abnormalities.
Which one of the following statements is correct regarding this patient?

A. Coronary artery bypass surgery can be expected to reduce his chance of suffering a myocardial infarct in the
next 10 years
B. Coronary artery bypass surgery can be expected to improve his life expectancy
C. If coronary artery bypass surgery is performed with saphenous venous grafts there is a 60-70% chance that the
grafts will have flow-limiting lesions within 10 years
D. If coronary artery bypass surgery is performed with internal mammary arterial grafts there is a 50% chance that
the grafts will be occluded within 10 years
E. If coronary artery bypass surgery is successful the native lesions will regress

27. You are called to the dialysis unit to assist with a 54-year-old man who is suffering from acute hypotension. He is in
the middle of the third hour of his dialysis run, and three liters have been removed so far. He tolerated his previous
two dialysis runs poorly with transient hypotension. On physical examination his heart rate is irregularly irregular at
110-125 beats/minute, and his supine blood pressure is 85/70 mmHg with 20 mmHg of a paradoxical pulse. His
lungs are clear, but his neck veins are full and collapse with expiration. His heart sounds are distant.
Electrocardiography confirms atrial fibrillation and shows low voltage QRS throughout.
After fluid resuscitation the next best step involves:

A. Admission to the coronary care unit for rule-out myocardial infarction

B. Adjustment of his dialysate bath
C. Echocardiography
D. Electrical cardioversion
E. Intravenous dopamine

28. A 72-year-old woman presents with left calf discomfort of 9 months’ duration. She describes a cramping sensation
after walking approximately three blocks. Symptoms resolve after she stops walking. Heart rate is 72/min and blood
pressure is 160/90 mmHg. A bruit is audible over the left carotid artery. Cardiac examination is normal. The left
femoral pulse is diminished. The left popliteal, dorsalis pedis and posterior tibial pulses are absent. The right
femoral, popliteal, dorsalis pedis, and posterior tibial are present. Laboratory studies are noteworthy for a plasma
glucose of 110 mg/dL and a total cholesterol 260 g/dL.
What is the most appropriate initial diagnostic test to evaluate this patient’s symptoms?

A. Radiography of the lumbosacral spine

B. Leg segmental pressure measurements
C. Carotid duplex ultrasound imaging
D. Arteriography
E. Magnetic Resonance Angiogram (MRA)

29. A 68-year-old male complains about severe right foot pain that has been present for 2 weeks. This pain has been
preventing him from sleeping comfortably, so he sits in a chair most of the night for relief. For the past year he has
been experiencing right calf discomfort whenever he walks one block. He has diabetes mellitus, hypertension and
smokes one pack of cigarettes each day. Examination of the extremities shows a cool and swollen right foot. When
A. Skin
B.
C.
D.
E. Venous
Pulse
Contrast
Nervebiopsy
volume
conduction
ultrasonography
arteriography
recording
study (PVR)
Page 6 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

29. A 68-year-old male complains about severe right foot pain that has been present for 2 weeks. This pain has been
preventing him from sleeping comfortably, so he sits in a chair most of the night for relief. For the past year he has
been experiencing right calf discomfort whenever he walks one block. He has diabetes mellitus, hypertension and
smokes one pack of cigarettes each day. Examination of the extremities shows a cool and swollen right foot. When
the foot is elevated, it becomes pale; when it is dependent, rubor develops. The right femoral pulse is diminished.
The right popliteal, dorsalis pedis and posterior tibialis pulses are absent. The left femoral and popliteal pulses are
present and normal. The left pedal pulses are absent.
What diagnostic test will confirm this patient’s diagnosis and guide the treatment?

A. Venous ultrasonography
B. Pulse volume recording (PVR)
C. Contrast arteriography
D. Nerve conduction study
E. Skin biopsy

30. A 53-year-old white male is noted to have an irregular pulse on elective physical examination. He is asymptomatic
and unaware of his condition. His electrocardiogram demonstrates normal sinus rhythm with normal intervals and
QRS morphology. Occasional unifocal premature ventricular contractions are noted on a rhythm strip.
Echocardiography is performed with no demonstrable abnormalities of valves, chamber size or pump function. 24-
hour ambulatory monitoring records 8542 isolated, but multiform, premature ventricular contractions, 842 couplets,
and 2 three-beat runs of ventricular tachycardia. After 48 hours of amiodarone therapy, the number of premature
ventricular contractions is reduced in half, no couplets are noted, and only a single triplet is observed. You asked to
provide an additional opinion by the family physician.
After obtaining a history and examining the patient you recommend one of the following:

A. Discontinuing amiodarone
B. Maintaining amiodarone
C. Increasing the dose of the amiodarone
D. Adding digoxin
E. Replacing the amiodarone with sotalol

31. Palpitations followed by syncope develop suddenly in a 17-year-old boy with known Wolff-Parkinson-White
syndrome. In the emergency room the patient is alert when supine with a blood pressure of 85/50 mmHg, but is
nearly syncopal if he tries to sit up. A rhythm strip demonstrates a wide QRS tachyarrhythmia at 260 beats/minute.
The best initial treatment is:

A. Intravenous procainamide
B. Intravenous verapamil
C. Intravenous dopamine
D. Electrical cardioversion
E. Intravenous digoxin

32. What advice will you provide to the following patient regarding Coumadin Therapy?
65 year-old man with increasingly evident dementia complicated by falls on Coumadin started after a single
episode of atrial fibrillation

A. Increase dose
B. Decrease dose
C. Stop therapy

33. What advice will you provide to the following patient regarding Coumadin Therapy?
48 year-old woman with a hematological disorder who starts antibiotics for a urinary tract infection

A. Increase dose
B. Decrease dose
C. Stop therapy

34. What advice will you provide to the following patient regarding Coumadin Therapy?
Initiation of amiodarone therapy in an older man on long term Coumadin for paroxysmal atrial fibrillation

A. Increase dose
B. Decrease dose
C. Stop therapy

A. Decrease
B.
C. Increase
Stop therapy
dose
dose
Page 7 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

35. What advice will you provide to the following patient regarding Coumadin Therapy?
Initiation of cholestyramine therapy for hypercholesterolemia in a woman who was begun on Coumadin after an
apical clot was documented weeks after a significant myocardial infarction

A. Increase dose
B. Decrease dose
C. Stop therapy

36. What advice will you provide to the following patients regarding Coumadin Therapy?
A young woman from India who begins TB prophylaxis with rifampin and is on Coumadin having had a mechanical
mitral valve replacement for mitral stenosis.

A. Increase dose
B. Decrease dose
C. Stop therapy

37. Which of the following statements is a main clinical consideration when planning the placement of an inferior vena
caval filter?

A. Perforation is a common problem

B. The filter often spontaneously embolizes to the superior vena cava or to the right atrium
C. Filters frequently get infected and must be removed when this occurs
D. Filters reduce the mortality rate assessed 2 years after initial placement
E. The DVT rate during the two years following filter placement is actually higher in patients who receive IVC filters
compared with patients who do not receive IVC filters

38. A 48 year-old white male is bitten by a skunk that was not captured after the attack. What are appropriate steps in
his treatment?

A. Cleansing of the wound with soap and water

B. Administration of rabies vaccine
C. Administration of rabies immune globulin
D. Administration of a tetanus booster
E. All of the above

39. A 38-year-old black male develops severe pain in his anterior thigh and fever to 102o. On examination, there is
extreme tenderness over the thigh, with erythema, tense edema, and crepitus. There is no evidence of an injury or
break in the skin. Blood cultures grow Clostridium septicum. After the patient recovers from this infection, what test
should be performed?

A. Chest CT
B. Colonoscopy
C. Echocardiogram
D. Culture of oropharyngeal secretions
E. C.difficile assay

40. A 55 year-old woman who is two years status post renal transplant presents with mental status changes and
headache. Head CT reveals 4 hypodense lesions 1-2 cm in diameter. Aspirate of a lesion demonstrates purulent
material with thin Gram-positive branching rods. What antibiotics should be used in this case?

A. Ampicillin and gentamicin

B. Penicillin and metronidazole
C. Trimethoprim and sulfamethoxazole
D. Ceftazidime and gentamicin
E. Amphoterecin B

41. A 42 year-old white male becomes ill two hours after eating dinner at a seafood restaurant. He develops
generalized flushing, urticaria, and headache. The most likely cause of his illness is:

A. Ciguatera fish poisoning

B. Clostridium perfringens infection
C. Scombroid fish poisoning

Page 8 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

41. A 42 year-old white male becomes ill two hours after eating dinner at a seafood restaurant. He develops
generalized flushing, urticaria, and headache. The most likely cause of his illness is:

A. Ciguatera fish poisoning

B. Clostridium perfringens infection
C. Scombroid fish poisoning
D. Vibrio vulnificus infection
E. Salmonella

42. A 26 year-old white male presents with three days of fever and bloody diarrhea. He notes no ill contacts, but
recently acquired a new puppy. What organism is most likely to be found on stool culture?

A. Clostridium difficile
B. Salmonella enteritidis
C. Shigella flexneri
D. Campylobacter jejuni
E. Clostridium septicum

43. A 74-year-old woman with a history of metastatic breast cancer on experimental chemotherapy is exposed to a
child with varicella infection. The adult has not been vaccinated in the past, and does not recall having had chicken
pox as a child. She is VZV antibody negative on testing. Which of the following is the best method of preventing
active varicella infection in this patient?

A. Administer varicella vaccine

B. Administer varicella immune globulin (VZIG)
C. Administer both vaccine and immune globulin
D. Treat the patient prophylactically with acyclovir 800 mg 5 times/day
E. None of these

44. The major health benefits of oral contraceptives are all of the following, except:

A. Regularization of the menstrual cycle

B. Decrease in ovarian cancer risk
C. Decrease in pelvic inflammatory disease (PID)
D. Decrease in endometrial cancer
E. Decrease in risk of breast cancer

45. Oral contraceptives (OCPs) are contraindicated in all of the following, except:

A. Family history of breast cancer

B. History of pulmonary embolism
C. History of coronary artery disease
D. History of undiagnosed genital bleeding
E. Age > 35 years and a smoker

46. Adverse consequences of inhaled corticosteroids include all of the following EXCEPT:

A. Open-angle glaucoma
B. Cataracts
C. Adrenal insufficiency
D. Thrush
E. Ocular hypertension

47. An 80-year-old man with a history of severe COPD is noted on routine chest X ray to have a solitary pulmonary
nodule in the peripheral aspect of the left upper lobe. A chest computed tomography (CT) scan is done and shows
only the single pulmonary nodule and it is free of calcium and has a low Hounsfield unit. The hilar and mediastinal
lymph nodes are normal in appearance and size. The CT is compared to a prior CT performed 2 years previously.
Which one of the following features suggests that this is a benign nodule?

A. The nodule is less than 3 cm in diameter

B. 2The nodule has changed in size over the past 2 years
C. There is no calcification

Page 9 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

47. An 80-year-old man with a history of severe COPD is noted on routine chest X ray to have a solitary pulmonary
nodule in the peripheral aspect of the left upper lobe. A chest computed tomography (CT) scan is done and shows
only the single pulmonary nodule and it is free of calcium and has a low Hounsfield unit. The hilar and mediastinal
lymph nodes are normal in appearance and size. The CT is compared to a prior CT performed 2 years previously.
Which one of the following features suggests that this is a benign nodule?

A. The nodule is less than 3 cm in diameter

B. 2The nodule has changed in size over the past 2 years
C. There is no calcification
D. The nodule was not seen on the prior CT scan
E. The older age of the patient

48. All of the following are true statements regarding a pleural effusion except:

A. A pleural fluid protein/serum protein ratio of > 0.5 is suggestive of an exudate

B. A pleural fluid LDH/serum LDH ratio of > 0.6 is suggestive of an exudate
C. A low pleural fluid glucose concentration (< 60 mg/dL, or pleural fluid/serum glucose ratio <0.5) is compatible
with a malignant exudative effusion
D. Pleural fluid lymphocytosis suggests tuberculous pleurisy

49. A 68-year-old woman who is a non-smoker presents with a history of progressive dyspnea and cough over an 18-
month period. She denies wheezing. Physical examination reveals clubbing and bibasilar fixed rales. Review of
symptoms reveals no systemic symptomatology. PFTs show a total lung capacity of 57%, a vital capacity of 62%,
residual volume of 65%, and FEV1 of 85%, maximum voluntary ventilation of 108%, and a DLCO of 8. The most
likely diagnosis is:

A. Chronic bronchitis
B. Severe neuromuscular disease
C. Pulmonary hypertension
D. Idiopathic pulmonary fibrosis
E. Emphysema

50. An 18- year-old boy is seen in your office with a history of snoring. Which one of the following would favor a sleep
study?

A. A history suggestive of gastro esophageal reflux disease (GERD)

B. A propensity to sleep long hours
C. A blood pressure of 120/80 mm Hg
D. A body mass index of 22 kg/m2
E. A history suggesting waking hyper somnolence

51. All of the following statements are true regarding consciousness, except:

A. Cognitive content is modulated by the cerebral cortex, whereas arousal is a vegetative function maintained by
the brain stem/medial diencephalic structures
B. Coma implies lack of both wakefulness and awareness
C. Brain death is the absence of both cerebral cortex and brain stem function
D. Persistent vegetative state is the absence of cerebral function with normal brain stem function
E. Locked-in syndrome is normal brain stem function but absent cerebral cortex function

52. A 28-year-old black male presents with bacterial meningitis, and CSF culture reveals Neisseria meningitidis. He
recovers from his illness, but 2 years later presents with a second episode of meningococcal meningitis. A possible
explanation for this recurrence is:

A. Subdural empyema
B. Carriage of Neisseria in the oropharynx
C. HIV infection
D. Deficiency of complement
E. History of alcoholism

53. What is the most cost effective radiology procedure for diagnosis of suspected subarachnoid hemorrhage?

C. Echocardiogram
D.
E. Ultrasound
Chest X-ray
Page 10 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

53. What is the most cost effective radiology procedure for diagnosis of suspected subarachnoid hemorrhage?

A. CT
B. MRI
C. Ultrasound
D. Chest X-ray
E. Echocardiogram

54. What is the most cost effective radiology procedure for diagnosis of suspected cholecystitis?

A. CT
B. MRI
C. Ultrasound
D. Chest X-ray
E. Echocardiogram

55. What is the most cost effective radiology procedure for diagnosis of evaluation of liver for metastatic disease?

A. CT
B. MRI
C. Ultrasound
D. Chest X-ray
E. Echocardiogram

56. What is the most cost effective radiology procedure for diagnosis of evaluation of liver for pancreatitis?

A. CT
B. MRI
C. Ultrasound
D. Chest X-ray
E. Echocardiogram

57. What is the most cost effective radiology procedure for diagnosis of evaluation of liver for suspected brain tumor?

A. CT
B. MRI
C. Ultrasound
D. Chest X-ray
E. Echocardiogram

58. What is the most cost effective radiology procedure for diagnosis of evaluation of liver for adnexal mass?

A. CT
B. MRI
C. Ultrasound
D. Chest X-ray
E. Echocardiogram

59. A 26-year-old man is admitted to the ICU with a severe asthma exacerbation and requires intubation and
mechanical ventilation. The ventilator settings are as follows: assist-control mode, rate 22/min, FI02 0.40, VT 800
ml, no PEEP. His ABGs show a pH of 7.32, pC02 49, pO2 88. He becomes hypotensive. Chest X-ray shows
marked hyperinflation. Which one of the following is the next best step?

A. Increase his FI02

B. Increase minute ventilation
C. Add PEEP
D. Decrease respiratory rate
E. Decrease inspiratory flow

60. Complications of mechanical ventilation include all of the following, except:

C. Hypertension
D.
E. Oxygenulceration
Stress toxicity
Page 11 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

60. Complications of mechanical ventilation include all of the following, except:

A. Barotrauma
B. Nosocomial pneumonia
C. Oxygen toxicity
D. Stress ulceration
E. Hypertension

61. All of the following statements about Clostridium difficile colitis (“C. difficile colitis”) are true except:

A. The vast majority of diarrhea in critically ill patients is due to C. difficile colitis
B. Toxin A and Toxin B mediate the clinical syndromes associated with C. difficile
C. The laboratory diagnosis of C. Difficile colitis is based on the detection of Toxin B
D. The cytotoxic assay has a sensitivity of 94-100%, whereas the ELISA for Toxin A or B is 69-87%
E. 1-5% of normal adults carry toxigenic C. difficile

62. A 28-year-old woman is found to have a 2x2 cm nodule in the left lobe of her thyroid gland on a routine physical
examination. She has no symptoms and no history of head or neck irradiation. Her serum thyrotropin concentration
is normal. The next step in her evaluation should be:

A. Thyroid ultrasound
B. Fine-needle aspiration of the nodule
C. Thyroxine therapy to suppress nodule growth
D. Surgical neck exploration
E. Nuclear medicine scan of her thyroid

63. Which of the following conditions can be associated with a sensitive TSH assay result that is <0.1 mU/L?

A. Recently treated Graves disease with a normal free T4 index

B. Normal pregnancy
C. Accelerated bone loss
D. None of the above
E. All of the above

64. A 52-year-old male with a newly diagnosed squamous cell lung cancer (solitary nodule, regional nodes negative)
has an abdominal CT scan as a staging test. A two cm nodule is discovered in the left adrenal gland; the right
adrenal gland is normal. Other staging studies are negative. Physical examination and blood pressure are normal.
The next test that you would recommend would be which of the following?

A. Needle biopsy of the adrenal nodule

B. An overnight dexamethasone suppression test
C. 24 hour urine collection for catecholamines
D. 24 hour urine 17-ketosteroids
E. Octreotide scan

65. A 42-year-old female who presented to the hematology clinic for easy bruisability was clinically felt to be
Cushingnoid in appearance. An overnight 1 mg dexamethasone suppression was performed (plasma cortisol at
8am, 18 µg/dl; normal < 5 µg/dl). Physical examination: blood pressure 150/95 mmHg; heart rate 80 beats per
minute, skin: no hirsutism, striae or hyperpigmentation. Proximal muscle wasting was evident. The next step in your
diagnostic work-up would be:

A. Obtain additional history to rule out pseudo-Cushing’s syndrome

B. 24 hour urine for free cortisol
C. Pituitary MRI
D. Plasma ACTH level
E. Plasma DHEA sulfate

66. A 42-year-old female, who has been an oral steroid-dependent asthmatic since the age of 12 is treated with the
high dose potent inhaled steroid, Flovent. Her asthma improves and her physician attempts to taper and withdraw
her oral prednisone treatment. Over the subsequent 18 months, every time she is tapered fewer than 10 mg she
becomes nauseated and complains of profound weakness. As her physician, you raise the possibility that, in
addition to, HPA axis suppression she could also have underlying Addison’s disease. To resolve this issue what one
A. ACTH
B.
C.
D.
E. Plasma
8
Abdominal
am cortisol
(cortrosyn)
test-0,
DHEA
CT-adrenal
level
60sulfate
min
test-0,
aldosterone
images
60 min cortisol
levels levels
Page 12 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

66. A 42-year-old female, who has been an oral steroid-dependent asthmatic since the age of 12 is treated with the
high dose potent inhaled steroid, Flovent. Her asthma improves and her physician attempts to taper and withdraw
her oral prednisone treatment. Over the subsequent 18 months, every time she is tapered fewer than 10 mg she
becomes nauseated and complains of profound weakness. As her physician, you raise the possibility that, in
addition to, HPA axis suppression she could also have underlying Addison’s disease. To resolve this issue what one
of the following tests would you order?

A. Plasma DHEA sulfate

B. ACTH (cortrosyn) test-0, 60 min cortisol levels
C. ACTH test-0, 60 min aldosterone levels
D. Abdominal CT-adrenal images
E. 8 am cortisol level

67. A 67-year-old Caucasian woman who is 26 years past menopause comes to your office for evaluation of new T11
and T12 fractures. The patient first developed sharp unremitting back pain two weeks earlier when she opened a
window. She relates a history of losing 2 inches of height since she was in college. Physical examination reveals a
thin woman weight 40 kg with a BP of 130/82 mmHg pulse of 80. She has no exophthalmus, lid lag, or stare.
Thyroid examination shows a small multinodular gland. Her reflexes are 2+, and she does not have a tremor. The
patient has tenderness on percussion and palpation of the mid and lower thoracic spine. All of the following are
appropriate tests in the evaluation of this patient except:

A. Sensitive TSH level

B. Calcium level
C. Serum and urine protein electrophoresis
D. Estrone level
E. 25-hydroxyvitamin D

68. A 64-year-old white male is evaluated for bone pain in his legs and lower spine. The patient relates a history of an
increasing hat size over several years. Physical examination shows bowing and deformity of the bones in his lower
extremities and increased warmth of the skin overlying his tibias. Laboratory evaluation reveals the following:
Calcium 10.4 mg/dL, Phosphate 3.6 mg/dL. Which one test would most likely support your diagnosis in this patient?

A. Bone biopsy
B. 25-hydroxyvitamin D
C. Alkaline phosphatase
D. Growth hormone
E. Parathyroid hormone (PTH) level

69. A 58-year-old white male with an 8-year history of type 2 diabetes comes in for a follow up appointment. His
medications include Metformin 1000mg twice a day and hydrochlorothiazide 25 mg daily. Recent laboratory tests
show: a urine micro albumin of 82 mg/g creatinine, total cholesterol of 212 mg/dl, LDL 82; fasting triglyceride of 486
mg/dl; and a hemoglobin A1C of 8.2 %. Your recommendations to modify his treatment are:

A. Discontinue metformin, initiate insulin and gemfibrozil

B. Continue metformin, add an ACE-inhibitor or an angiotensin receptor blocker, and recommend gemfibrozil along
with dietary changes for the hypertriglyceridemia
C. Continue metformin, initiate sitaglipitin and add an ACE-inhibitor or an angiotensin receptor blocker
D. Continue metformin, Start Glipizide, a statin, and add an ACE-inhibitor
E. Discontinue metformin, start Glipizide and gemfibrozil

70. A 77-year-old woman, a day-care center owner, complains of symmetric polyarthritis involving the wrists,
metacarpophalangeal joints, and knees of 1 year’s duration. Work-up shows that latex tests for rheumatoid factor
are positive at a titer of 1:320. X-rays of her hands show periarticular demineralization, erosions, and joint space
narrowing of the metacarpophalangeal joints and wrists. Which would be the next best option?

A. Begin Etanercept
B. Recommend intensive physical therapy
C. Suggest that she use wrist splints
D. Begin methotrexate
E. Maintain her on prednisone 15 mg/day, with NSAIDs

71. A 28-year-old black woman with a history of systemic lupus erythematosus (SLE), diagnosed 2 years previously,
consults with you about whether she should get pregnant. Her SLE with fatigue, a malar rash, mild arthralgias, and
Raynaud’s. She is currently receiving plaquenil but continues to have mild arthralgias and fatigue. This would be
A. 100%
B.
C.
D.
E. 30%
70%
< 1%
3-5%
Page 13 of 14 9/7/2018
 291 - 41st Annual Intensive Review of Internal Medicine Post Test
S.No. Questions

71. A 28-year-old black woman with a history of systemic lupus erythematosus (SLE), diagnosed 2 years previously,
consults with you about whether she should get pregnant. Her SLE with fatigue, a malar rash, mild arthralgias, and
Raynaud’s. She is currently receiving plaquenil but continues to have mild arthralgias and fatigue. This would be
her first pregnancy. The laboratory data that you request is remarkable for:
Which one of the following most closely approximates the chance of her delivering a fetus with neonatal lupus and
congenital heart disease?

A. 30%
B. 70%
C. < 1%
D. 3-5%
E. 100%

Page 14 of 14 9/7/2018