Internal Medicine Jeopardy

General Internal Medicine

100

A 17-year-old teenager is evaluated during an office visit. She is brought in by her mother who is concerned about her focus on diet and weight. The patient states that she believes that she is obese and feels as though she needs to diet to achieve a more appropriate body weight. She also reports exercising on a daily basis to help her lose weight. Dietary history suggests that most of the time she consumes very little food, but at least twice per week she will eat large amounts of high-calorie desserts over the course of 1 to 2 hours. She describes feeling guilty after doing so and will make herself vomit. Medical history is otherwise unremarkable, although she indicates that her menstrual periods are highly irregular. On physical examination, vital signs are normal. BMI is 23. The parotid glands are enlarged, but the remainder of the examination is unremarkable. Which of the following is the most likely diagnosis? a-Anorexia, purging subtype b-Anorexia, restricting subtype c-Binge eating disorder d-Bulimia nervosa

Correct Answer: D Educational Objective: Diagnose bulimia nervosa. Key Point Bulimia nervosa is characterized by frequent episodes (≥1 per week) of binge eating followed by inappropriate compensatory behaviors (self- induced vomiting or misuse of laxatives, diuretics, and enemas) due to fear of weight gain

200

A 58-year-old woman is evaluated during a routine examination. She is asymptomatic. Medical history is unremarkable. She smoked cigarettes socially in her 20s but is currently a nonsmoker. Family history is significant for her mother who had a hip fracture in her 70s and two cousins who have hypothyroidism. She takes no medications. On physical examination, temperature is normal, blood pressure is 118/72 mm Hg, and pulse rate is 72/min. BMI is 24. The remainder of the physical examination is normal. A lipid panel and fasting plasma glucose level obtained 1 year ago were normal. Pap smear and human papillomavirus testing performed 3 years ago were negative. Her Fracture Risk Assessment Tool (FRAX) score indicates a 13% risk for major osteoporotic fracture over the next 10 years. Which of the following is the most appropriate screening test for this patient? a-Dual-energy x-ray absorptiometry scan b-Fasting lipid panel c-Fasting plasma glucose level d-Pap smear e-Thyroid-stimulating hormone level

Correct Answer: A Educational Objective: Screen for osteoporosis in a patient with risk factors. Key Point Women aged 65 years and older and younger women who have a fracture risk of 9.3% or higher should be screened for osteoporosis. This patient should be screened for osteoporosis with dual-energy x-ray absorptiometry (DEXA). The U.S. Preventive Services Task Force (USPSTF) recommends screening for osteoporosis by measurement of bone mineral density in women aged 65 years and older and in younger women who have a fracture risk equal to or higher than a 65-year-old white woman (9.3%).

300

An 86-year-old woman is evaluated in her assisted-living facility for pain. Four weeks ago, she developed herpetic lesions on her right posterior thorax in a T7 distribution. She was treated with acyclovir, and the lesions healed; however, she has persistent severe burning pain. The pain is so severe that she is unable to leave her bed to attend meals. Medical history is remarkable for hypertension, mild cognitive impairment, and osteoporosis. She ambulates short distances but uses a walker for longer distances. Medications are amlodipine and as-needed acetaminophen. She cannot tolerate opioid medications because they have caused delirium in the past. On physical examination, the patient is afebrile, blood pressure is 140/86 mm Hg, pulse rate is 62/min, and respiration rate is 14/min. BMI is 18. Examination of the back reveals allodynia and hyperalgesia in the right posterior T7 dermatome. All zoster skin lesions have resolved. On neurologic examination, she exhibits short-term memory impairment, which her family reports is her baseline. The remainder of the examination is unremarkable. Which of the following medications is the most appropriate pharmacologic therapy for this patient's pain? a-Fentanyl patch b-Oral gabapentin c-Oral tramadol d-Topical lidocaine

orrect Answer: D Educational Objective: Treat a patient with neuropathic pain. Key Point Topical lidocaine is effective in the treatment of postherpetic neuralgia. Fentanyl is a potent opioid that is indicated only in patients who are opioid tolerant due to chronic treatment, and this patient has not been taking opioids regularly. Gabapentin is first-line therapy for systemic neuropathic pain conditions that affect large portions of the body that are difficult to treat topically. Tramadol binds to opioid receptors in the central nervous system and can cause adverse reactions similar to those of other opioid medications, which this patient does not tolerate.

400

A 77-year-old man is evaluated in follow-up for prostate cancer. He is asymptomatic and feels well. He was diagnosed with high-grade prostate cancer 3 years ago and was treated with external-beam radiation therapy. Since that time, he has undergone regular surveillanceHis most recent serum prostate-specific antigen level rose from undetectable to 120 ng/mL (120 μg/L). A subsequent abdominopelvic CT scan showed an increase in regional lymphadenopathy and multiple sclerotic bony lesions in the visualized pelvis and spine. The patient has been actively engaged in his medical care and has expressed a desire to be made aware of all information about his health status. The patient has scheduled this visit to discuss the results of his prostate cancer surveillance testing, and the physician indicates to the patient that, unfortunately, he has bad news to convey. Which of the following is the most appropriate approach to conveying this news to the patient? a-Explain that the planned surveillance has done what was intended and that it has led to the finding of possible recurrent tutors b-Indicate that there are several abnormal lesions in his bones that will require further evaluation c-Note that the cancer has likely returned but that hormonal therapy and chemotherapy are usually effective treatments d-State that the cancer has returned

Correct Answer: D Educational Objective: Manage breaking bad news to a patient. Key Point The SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, Strategize) protocol can be used to break bad news to patients while maintaining patient hope. The physician should state that the cancer has returned. Physicians often have difficulty imparting bad news to patients and worry that they will diminish patient hope or leave patients emotionally inconsolable. The SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, Strategize) framework provides a schema for disclosing critical information in a way that allows patients to hear information while supporting their emotional reactions, thereby maintaining hope. In this case, the provider has already addressed the S, P, and I steps of the SPIKES protocol and is at the point of imparting knowledge (K). When delivering the news, it is important for the physician to use short, declarative sentences without jargon or euphemisms.

500

An 88-year-old man is evaluated at an assisted-living facility. Staff members have noticed that the patient seems more withdrawn than usual, is less interactive with other residents, and no longer attends social functions. At times, he seems confused and answers questions nonsensically or has difficulty navigating simple conversations. At other times, he seems normal and cheerful. The staff has not observed any crying spells. He appropriately manages his own medications and finances. There have been no recent changes in his medications. He has had no recent falls, illness, or fever. On physical examination, vital signs are normal. The patient is appropriately conversant. The general medical examination is unremarkable. On neurologic examination, Mini-Mental State Examination score is 25/30, which is unchanged over the past 18 months. A two-question depression screen is negative. The remainder of the neurologic examination is unremarkable. Which of the following is the most appropriate management of this patient? a-Donepezil b-PHQ-9 depression assessment c-Whispered voice test d-Clinical observation

Correct Answer: C Educational Objective: Diagnose hearing loss in an older patient. Key Point Older patients who present with symptoms of a mood disorder or cognitive dysfunction should be screened for hearing loss. This older patient should be evaluated for hearing loss with the whispered voice test. Hearing loss is common in older adults, and it results in significant impairment in quality of life and potentially leads to depression and social isolation. Because patients may experience difficulties in understanding and communication, hearing loss is frequently misdiagnosed as cognitive dysfunction. There is some evidence that hearing aids in older patients improve not only hearing but also quality of life; therefore, patients who have cognitive or affective concerns that may be related to hearing should be screened for hearing loss. No one screening test has been shown to be superior to another. Whispered voice test, finger rub test, hearing loss questionnaire, and hand-held audiometry are all reasonable screening tests.

Cardiology

100

A 64-year-old woman is evaluated during a routine examination. She has no symptoms. Medical history is significant for hypertension and type 2 diabetes mellitus. Medications are amlodipine, losartan, atorvastatin, and metformin. On physical examination, she is afebrile, blood pressure is 154/77 mm Hg and equal on both sides, pulse rate is 82/min, and respiration rate is 16/min. BMI is 28. Cardiac examination shows a grade 1/6 decrescendo diastolic murmur heard best over the apex. There are no changes with a Valsalva maneuver or change in position. Peripheral pulses are normal. Electrocardiogram shows sinus rhythm with nonspecific ST changes. Which of the following is the most appropriate diagnostic test to perform next? a-Chest CT b-Exercise echocardiography stress testing c-Transthoracic echocardiography d-No further testing

Correct Answer: C Educational Objective: Evaluate a patient with a diastolic murmur. Key Point Transthoracic echocardiography is indicated for asymptomatic patients with a systolic murmur that is grade 3/6 or higher, a late or holosystolic murmur, or a diastolic or continuous murmur and for patients with a murmur and accompanying symptoms.

200

A 58-year-old woman is evaluated during a routine physical examination. She has a history of atrial fibrillation and had an atrial fibrillation ablation procedure 6 months ago. Before her ablation, she had persistent atrial fibrillation with palpitations and dyspnea. Since her ablation, she has been asymptomatic with no palpitations. Ambulatory electrocardiographic monitoring at 3 and 6 months after the ablation demonstrated no atrial fibrillation. Medical history is also significant for a transient ischemic attack, hypertension, and hyperlipidemia. Her medications are warfarin, metoprolol, candesartan, and simvastatin. On physical examination, the patient is afebrile, blood pressure is 130/80 mm Hg, pulse rate is 64/min, and respiration rate is 16/min. BMI is 30. Heart rate and rhythm are regular. An electrocardiogram shows normal sinus rhythm. Which of the following is the most appropriate management? a-Continue warfarin b-Continue warfarin and add aspirin c-Discontinue warfarin d-Discontinue warfarin and start aspirin e-Discontinue warfarin and start aspirin and clopidogrel

Correct Answer: A Educational Objective: Manage thromboembolic risk following atrial fibrillation ablation. Key Point Stroke prevention therapy after catheter ablation of atrial fibrillation should be based upon risk stratification, not heart rhythm status. This patient should continue taking warfarin. She has a history of symptomatic atrial fibrillation and is now symptom-free without evidence of recurrent atrial fibrillation after catheter ablation. However, patients with successful ablation and elimination of symptoms may have transient asymptomatic atrial fibrillation with continued risk for atrial fibrillation–associated thromboembolic disease.

300

A 32-year-old man is evaluated during an initial office visit. He has no symptoms and no significant medical history. He takes no medications. On physical examination, blood pressure is 120/70 mm Hg in both arms, pulse rate is 64/min, and respiration rate is 12/min. Cardiac examination reveals a grade 1/6 decrescendo diastolic murmur heard best at the left lower sternal border. Femoral pulses are equal. Which of the following is the most likely cause of the patient's murmur? a-Aortic coarctation b-Atrial septal defect c-Bicuspid aortic valve d-Mitral stenosis

Correct Answer: C Educational Objective: Diagnose bicuspid aortic valve. Key Point A bicuspid aortic valve is often discovered incidentally; the murmur depends on the degree of valve dysfunction, with a systolic ejection murmur that may range from a minimal flow disturbance to findings

400

71-year-old man is evaluated in the emergency department for severe pain in the chest and back that was abrupt in onset and has persisted for 3 hours. He has no abdominal pain, leg pain, or neurologic symptoms. His medical history is notable for hypertension. Medications are amlodipine and lisinopril. On physical examination, the patient is afebrile, blood pressure is 180/100 mm Hg in both arms, pulse rate is 98/min, and respiration rate is 18/min. Oxygen saturation is 96% on ambient air. Cardiac auscultation discloses an S4 gallop but no murmur. Pulmonary examination is normal. Pulses are symmetric and equal in all extremities. Laboratory studies show a D-dimer level of 1.2 μg/mL (1.2 mg/L) and a serum creatinine level of 1.0 mg/dL (88.4 μmol/L). Initial serum cardiac troponin I level is not elevated. Electrocardiogram shows left ventricular hypertrophy with repolarization abnormalities. Chest radiograph shows an enlarged cardiac silhouette. Chest CT scan with intravenous contrast demonstrates a focal penetrating ulcer in the thoracic descending aorta (shown). Which of the following is the most appropriate immediate next step in management? a-Heparin followed by warfarin b-Endovascular stenting c-Intravenous β-blockade followed by intravenous sodium nitroprusside d-Open surgical repair

Correct Answer: C Educational Objective: Treat a penetrating atherosclerotic ulcer in the descending aorta. Key Point Uncomplicated type B acute aortic injury is best treated medically,initially with β-blockade followed by a parenteral arterial vasodilator to control blood pressure. The most appropriate management for this patient is intravenous β- blockade followed by intravenous sodium nitroprusside. The CT scan(shown) reveals a focal penetrating atherosclerotic ulcer (PAU) in the proximal descending aorta (arrow), a type B acute aortic syndrome. PAU is a focal defect or lesion occurring at the site of an intimal atherosclerotic plaque. Patients tend to be older and with greater cardiovascular comorbidity. PAU occurs most commonly in the descending aorta, which may reflect a greater burden of atheromatous disease at this site. Elevation of the D-dimer level frequently accompanies acute aortic syndromes. Uncomplicated type B acute aortic injury is best treated medically, initially with β-blockade to decrease the heart rate to below 60/min followed by a parenteral arterial vasodilator as needed to control blood pressure.

500

A 66-year-old woman is evaluated at the hospital for 6 hours of chest pressure and shortness of breath. Earlier this day, the patient's husband was diagnosed with lung cancer. Medical history is otherwise unremarkable.On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 110/62 mm Hg, and pulse rate is 98/min. BMI is 25. Cardiac examination shows a normal S1 and S2 without S3, S4, murmur, or rub. Lung examination is normal. Serum troponin T level is 2.0 ng/mL (2.0 μg/L). Electrocardiogram is show consistent with anterior and/or lateral ST- segment elevation The patient is administered aspirin, clopidogrel, and unfractionated heparin. Emergency coronary angiography shows normal coronary anatomy. Diastolic (left panel) and systolic (right panel) images from left ventriculography are show the presence of hypokinesis of the mid and apical left ventricle. Which of the following is the most appropriate management? a-Endomyocardial biopsy b-Intra-aortic balloon pump c-Metoprolol and captopril d-Thrombolytic therapy

Correct Answer: C Educational Objective: Diagnose stress cardiomyopathy (takotsubo cardiomyopathy). Key Point Stress cardiomyopathy presents similarly to myocardial infarction, with ST-segment elevation and, often, elevated cardiac biomarkers; howevercoronary angiography demonstrates an absence of significant obstructive coronary artery disease. This patient's clinical history and presentation are consistent with stress cardiomyopathy (takotsubo cardiomyopathy). The absence of coronary artery stenosis and the presence of hypokinesis of the mid and apical left ventricle on ventriculography confirm this diagnosis. This patient with takotsubo cardiomyopathy without evidence of cardiogenic shock should be administered metoprolol and captopril. The treatment of stress cardiomyopathy is supportive, including the use of β-blockers and ACE inhibitors, and most patients have resolution of symptoms and recovery of left ventricular function within 7 days.

Infectious Disease

100

A 40-year-old woman is evaluated for a 1-month history of cough, fever, night sweats, and weight loss. Pulmonary tuberculosis is strongly suspected, and the community has no reported cases of drug-resistant tuberculosis. She takes no medications. On physical examination, temperature is 37.9 °C (100.2 °F), blood pressure is 130/70 mm Hg, pulse rate is 95/min, and respiration rate is 15/min. BMI is 21. Crackles are heard in the lung apices bilaterally. Chest radiograph shows bilateral apical fibrocavitary disease. A sputum smear reveals acid-fast bacilli. The initial phase of four-drug tuberculosis therapy with isoniazid, rifampin, pyrazinamide, and ethambutol is planned. In addition to liver function testing, which of the following baseline studies should be obtained in this patient as part of monitoring for potential adverse drug effects? a-Audiogram b-CD4 cell count c-Vestibular testing d-Visual acuity and color vision

Correct Answer: D Educational Objective: Manage a patient receiving ethambutol for treatment of tuberculosis. Key Point Before starting ethambutol, patients should be evaluated for color discrimination and visual acuity because an adverse effect of the drug is a retrobulbar neuritis manifesting as decreased green-red color discrimination or decreased visual acuity.

200

A 33-year-old woman is evaluated in the emergency department for a 2- month history of fever, lethargy, weight loss, and headache. She moved to the United States from India 4 years ago. Her father died of tuberculosis 20 years ago. Medical history is otherwise unremarkable, and she takes no medications. On physical examination, temperature is 38.6 °C (101.5 °F), blood pressure is 114/70 mm Hg, pulse rate is 94/min, and respiration rate is 18/min. BMI is 20. Except for lethargy, neurologic examination is unremarkable. No abnormalities are noted on ophthalmologic, cardiac, or pulmonary examinations or in the remainder of the physical examination. Cerebrospinal fluid (CSF) studies: Leukocyte count 275/μL (275 × 106), with 98% lymphocytes Glucose -30 mg/dL (1.7 mmol/L) Protein- 250 mg/dL (2500 mg/L) CSF opening pressure-150 mm H2O The remainder of a complete blood count and comprehensive metabolic panel are normal. Acid-fast bacilli smear of CSF is negative, but polymerase chain reaction is positive for Mycobacterium tuberculosis. Minimal basilar meningeal enhancement is seen on CT scan of the head without any evidence of cisternal or ventricular abnormalities, midline shift, or mass lesion. In addition to four-drug antituberculous therapy, which of the following is the most appropriate additional treatment? a-Acetazolamide b-Dexamethasone c-Furosemide d-Ventriculoperitoneal shunt

Correct Answer: B Educational Objective: Treat a patient with tuberculous meningitis. Key Point Patients with tuberculous meningitis should receive a glucocorticoid in addition to antituberculous therapy. This patient has tuberculous meningitis and should receive glucocorticoid therapy in addition to antituberculous therapy. Dexamethasone is recommended for adults with tuberculous meningitis because limited data show some mortality benefits. The recommended dose of dexamethasone is 12 mg/d for 3 weeks, with gradual tapering during the following 3 weeks. Some experts use prednisone instead of dexamethasone, and others recommend a slightly longer duration of glucocorticoid therapy (approximately 8 weeks). The recommendations for duration of treatment of extrapulmonary tuberculosis are generally the same as for pulmonary tuberculosis (6-9 months).

300

A 22-year-old woman is evaluated during a routine office visit. She is pregnant at 38 weeks' gestation. She reports no dysuria, urgency, fever, or chills. Medical history is unremarkable. Her only medication is a prenatal vitamin. On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 100/70 mm Hg, pulse rate is 80/min, and respiration rate is 16/min. Abdominal examination is consistent with her stage of pregnancy; no costovertebral angle tenderness is noted. The remainder of the examination is unremarkable.Urine dipstick is positive for nitrites and leukocyte esterase. Urine culture grows greater than 100,000 colony-forming units/mL of Escherichia colisusceptible to ampicillin, nitrofurantoin, and trimethoprim-sulfamethoxazole. Which of the following is the most appropriate treatment? a-Amoxicillin b-Nitrofurantoin c-Trimethoprim-sulfamethoxazole d-No treatment

Correct Answer: A Educational Objective: Treat asymptomatic bacteriuria in a pregnant woman. Key Point Asymptomatic bacteriuria should be treated in patients who are pregnant, and amoxicillin is safe to use in the third trimester of pregnancy. This patient is pregnant and has asymptomatic bacteriuria caused byEscherichia coli susceptible to multiple antibiotics, so she should begin a course of amoxicillin. Asymptomatic bacteriuria during pregnancy increases the risk of pyelonephritis and has been associated with preterm birth and low-birthweight infants.

400

A 57-year-old woman is evaluated for blood cultures growing yeast during long-term intravenous antibiotic therapy. She has completed 4 weeks of a planned 6-week course of intravenous antibiotics for methicillin-sensitiveStaphylococcus aureus infective endocarditis. A peripherally inserted central venous catheter (PICC) was placed at the beginning of her treatment. She developed a high fever 3 days ago, and blood cultures drawn peripherally and through the catheter at that time grew Candida species; further identification is pending. Medical history is otherwise negative, and her only medication is nafcillin. On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 126/80 mm Hg, pulse rate is 82/min, and respiration rate is 16/min. The eye grounds are clear. Chest examination is unremarkable. Cardiac auscultation reveals a grade 2/6 crescendo-decrescendo murmur at the right upper sternal border. She has no spinal tenderness. The right brachial PICC site is without erythema, drainage, or tenderness. In addition to continuing intravenous antibiotic therapy, which of the following is the most appropriate management? a-Continue PICC use b-Continue PICC use and add antifungal therapy c-Remove PICC d-Remove PICC and add antifungal therapy

Correct Answer: D Educational Objective: Manage a central line–associated fungal bloodstream infection. Key Point In patients with candidemia associated with an intravenous catheter, the catheter should be removed and empiric antifungal therapy initiated. Removal of the peripherally inserted central venous catheter and initiation of antifungal therapy is the most appropriate management in this patient.

500

A 46-year-old man is evaluated in the emergency department for fever and altered mental status. Five days ago he underwent replacement of a ventriculoperitoneal shunt used to manage congenital hydrocephalus. The procedure was unremarkable, and he did well postoperatively until the rapid onset of confusion and fever over the past several hours. Medical history is otherwise unremarkable, and he takes no medications. On physical examination, the patient is confused and mildly agitated. Temperature is 39.7 °C (103.5 °F), blood pressure is 142/87 mm Hg, pulse rate is 110/min, and respiration rate is 16/min. The general medical examination shows healing surgical incisions on the scalp, neck, and upper abdomen that are clean and dry. Marked nuchal rigidity is noted. Neurologic examination reveals altered sensorium but is otherwise nonfocal. Head CT shows the ventriculoperitoneal shunt in proper position and no hydrocephalus or other focal lesions. Laboratory evaluation of the cerebrospinal fluid shows a leukocyte count of 4660/μL (4660 × 106/L) with neutrophilic predominance, glucose level of 15 mg/dL (0.8 mmol/L), and protein level of 480 mg/dL (4800 mg/L). Gram stain and culture results are pending. Which of the following is the most appropriate empiric antibiotic treatment? a-Ampicillin, vancomycin, and ceftriaxone b-Meropenem and vancomycin c-Moxifloxacin d-Vancomycin and ceftriaxone

Correct Answer: B Educational Objective: Provide empiric antimicrobial therapy with meropenem and vancomycin for a patient with nosocomial bacterial meningitis. Key Point Empiric antimicrobial therapy for nosocomial meningitis must cover a broad spectrum of pathogens, including gram-negative organismsand Staphylococcus aureus, particularly methicillin-resistant S. aureus.This patient should begin empiric antimicrobial therapy with intravenous meropenem and vancomycin. He developed fever, nuchal rigidity, and altered mental status after a neurosurgical intervention, and analysis of the cerebrospinal fluid is consistent with bacterial meningitis following an invasive central nervous system (CNS) surgical procedure. In the setting of nosocomial meningitis, empiric antimicrobial therapy must cover a broad spectrum of pathogens, including gram-negative organisms (including Pseudomonas aeruginosa, Acinetobacterspecies, and Enterobacteriaceae) and Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA]). Meropenem, a monobactam, is a broad-spectrum, bactericidal β-lactam with excellent coverage of gram- positive and gram-negative organisms that effectively penetrates the CNS, making it an excellent agent for empiric treatment of nosocomial meningitis.

Neurology

100

A 35-year-old man is evaluated in the emergency department for a 7- hour history of midback pain and bilateral leg numbness. He was in a bar fight immediately before symptom onset and sustained forceful kick injuries to the back, head, and limbs; he did not lose consciousness. On physical examination, temperature is 36.6 °C (97.8 °F), blood pressure is 110/70 mm Hg, pulse rate is 108/min, and respiration rate is 18/min; BMI is 32. The patient is alert without any apparent cognitive deficits. Lacerations on the face, scalp, and extremities are noted, as are hematomas on the midback and chest. No tremors or significant swelling or hematomas on the scalp are detected. Muscle strength is 3/5 in the lower extremities, and muscle tone in the legs is reduced. Muscle tone in the arms is normal, and anal sphincter tone is reduced. Pinprick testing shows a sensory level below T8. Which of the following is the most appropriate next step in management? a-CT of the head b-High-dose methylprednisolone c-MRI of the thoracic spine d-Phenytoin

Correct Answer: B Educational Objective: Treat acute spinal cord injury. Key Point High-dose methylprednisolone administered within 8 hours of a traumatic spinal cord injury has been shown to improve motor function recovery.

200

A 42-year-old man is evaluated in the emergency department for a 1- week history of bilateral leg weakness and numbness. He has an 8-year history of multiple sclerosis (MS) that is currently well controlled with natalizumab; he has had no MS exacerbations since beginning treatment 2 years ago after unsuccessful trials of interferon beta and glatiramer acetate. The patient also has chronic fatigue and depression. Medications are monthly natalizumab, twice daily amantadine and extended-release bupropion, a daily multivitamin, and a calcium–vitamin D supplement that he rarely takes. On physical examination, temperature is 36.7 °C (98.1 °F), blood pressure is 124/58 mm Hg, pulse rate is 74/min, and respiration rate is 14/min. Muscle strength is 4/5 in the bilateral hip flexors, knee flexors, and foot dorsiflexors. Decreased pinprick sensation is noted just below the umbilicus. Laboratory studies performed 3 weeks ago showed no evidence of elevated serum antibody titers against the JC virus. Results of current complete blood count, liver chemistry studies, and a urinalysis show no abnormalities. An MRI of the brain shows white matter hyperintensities consistent with MS and is unchanged from an MRI obtained 1 year ago. In addition to a 5-day infusion of intravenous methylprednisolone, which of the following is the most appropriate next step in management? a-Discontinuation of natalizumab b-Measurement of serum 25-hydroxyvitamin D level c-MRI of the lumbar spine d-Oral trimethoprim-sulfamethoxazole for 5 days

Correct Answer: B Educational Objective: Diagnose vitamin D deficiency in a patient with multiple sclerosis. Key Point Vitamin D supplementation as an adjunctive treatment in multiple sclerosis (MS) has been shown to be superior to disease-modifying therapy alone and has become a standard of care for patients with MS, especially those who are vitamin D deficient.Accumulating evidence suggests that disease activity in MS is highly linked with serum vitamin D levels, with less frequent relapses and fewer new MRI lesions in patients with higher levels. This patient's serum 25-hydroxyvitamin D level should thus be measured to determine if he is vitamin D deficient.

300

A 72-year-old woman is evaluated for a 6-month history of gradually worsening, nonsuppressible involuntary movements. The patient first noticed twitching movements of the lower part of the face, with occasional unintended thrusting of the tongue through the lips and biting of the cheeks inside the mouth. She further reports pressure and a pulling sensation at the back of the neck that causes her head to pull backward suddenly and the occasional tendency to drop objects from her hands secondary to uncontrollable jerking movements. The patient has chronic gastroparesis that is treated with metoclopramide and bipolar disorder that is well controlled with lamotrigine and quetiapine. She has no family history of a movement disorder or any neurologic disease. On physical examination, temperature is 37.5 °C (99.5 °F), blood pressure is 145/76 mm Hg, and pulse rate is 80/min. Frequent stereotyped pursing movements of the lips, occasional tongue protrusion and forceful jaw closure, continual slow and nonrhythmic movements of the fingers, and recurrent cervical retrocollis are noted. Occasional rapid jerking movements of the arms and infrequent facial grimacing also are present. Gait is slow and marked by short steps and reduced arm swing.Which of the following is the most appropriate next step in management? a-Change quetiapine to risperidone b-Discontinue metoclopramide c-Start carbidopa-levodopa d-Start tetrabenazine

Correct Answer: B Educational Objective: Treat drug-induced tardive dyskinesia. Key Point The most appropriate treatment of medication-related tardive dyskinesia is discontinuation of the causative dopamine blocker agent. The most appropriate next step is to discontinue the dopamine receptor antagonist metoclopramide. This patient has prominent craniofacial features of chorea and dystonia that are characteristic of tardive dyskinesia. She most likely has medication-related dyskinesia, and discontinuation of the causative dopamine blocker agent is required.

400

A 40-year-old man is evaluated in the emergency department for a headache that started 1 day ago while he was lifting weights. He first experienced a severe, sharp, right periorbital pain associated with nausea and ipsilateral neck pain. Although the pain has lessened in intensity, it has persisted, and this morning he had an episode of right monocular visual loss resolving spontaneously after several minutes. The patient has a history of monthly migraine without aura that typically lasts 6 hours and is characterized by bilateral frontotemporal throbbing, pain associated with photophobia, and nausea. He says that his current headache pain is “different” from the pain he experiences during migraine episodes and that the neck pain is new. His only medication is naproxen as needed. On physical examination, blood pressure is 130/86 mm Hg and pulse rate is 72/min. Palpation of the neck elicits pain. Right ptosis and miosis are noted, but all other physical examination findings are unremarkable. A CT scan of the head shows normal findings. Which of the following is the most likely diagnosis? a-Carotid artery dissection b-Cluster headache c-Migraine d-Vertebral artery dissection

Correct Answer: A Educational Objective: Diagnose carotid artery dissection. Key Point Carotid artery dissection should be suspected in a patient with acute headache and neck pain associated with Horner syndrome. The patient most likely has had a carotid artery dissection. Despite his migraine history, the report of a different type of headache should raise suspicion of a secondary headache. Cervicocephalic dissection is an uncommon but important cause of stroke, especially in persons younger than 50 years. The presence of ipsilateral neck pain and ischemic complications, such as transient monocular visual loss and Horner syndrome (miosis, ptosis, and anhidrosis), is characteristic of carotid artery dissection and may not be associated with preceding trauma.

500

A 45-year-old man is evaluated in the emergency department for a 3- week history of headache and impaired vision on the right side. He has not previously had frequent headaches, but the current pain has been constant and worsening since onset. The patient thinks that something is wrong with his eyesight because he has been running into or tripping over objects on the right side. He has no significant medical history and takes no medication. On physical examination, vital signs are normal. No papilledema is noted on funduscopic examination. A slit lamp examination shows no cells in the vitreous humor. Other findings from the general medical examination are unremarkable. Neurologic examination reveals the presence of right homonymous hemianopia. An MRI of the brain shows a lesion in the left occipital lobe that is highly suspicious for central nervous system lymphoma. Results of laboratory studies include a normal leukocyte count and differential and no evidence of HIV antibodies. Cytologic analysis of cerebrospinal fluid shows no malignant cells. Which of the following is the most appropriate next step in management? a-Bone marrow biopsy b-Surgical biopsy of the brain lesion c-Surgical resection of the brain lesion d-Treatment with dexamethasone e-Treatment with photon-beam radiation

Correct Answer: B Educational Objective: Diagnose a primary central nervous system lymphoma. Key Point Pathologic analysis, usually of a brain biopsy specimen, to confirm primary central nervous system lymphoma is required before beginning treatment with methotrexate-based chemotherapy and possible whole- brain radiation. This patient should undergo surgical biopsy of the brain lesion without resection. The MRI is suggestive of primary central nervous system lymphoma (PCNSL), a non-Hodgkin lymphoma that can affect any part of the central nervous system but commonly presents as a focal supratentorial lesion; visual symptoms are common because the tumor often involves the optic radiations.

Gastroenterology

100

A 40-year-old man is evaluated for a 6-month history of intermittent episodes of two to four loose stools per day. When he has diarrhea, he also notices crampy abdominal pain and bloating. He has not had nausea, vomiting, anorexia, fever, melena, hematochezia, recent travel, or any new medications, including antibiotics. He is overweight but has been exercising and watching his diet for the past 6 months, and he has intentionally lost 6.8 kg (15.0 lb). The main change in his diet has been switching to diet soda and using sugar-free sweeteners. He takes no medications. On physical examination, vital signs are normal. The abdomen is obese but soft with normal bowel sounds and no distention or tenderness. Which of the following is the most appropriate management? a-Abdominal CT scan Colonoscopy with biopsies b-Discontinuation of sugar-free sweeteners c-Gluten-free diet d-Tissue Transglutaminase IgA antibody testing

Correct Answer: C Educational Objective: Manage chronic diarrhea caused by malabsorption of sugar-free sweeteners. Key Point Artificial sweeteners have little or no absorption in the small intestine and, when taken in excess, can cause symptoms of carbohydrate malabsorption. The most appropriate management is discontinuation of sugar-free sweeteners. The appearance of this patient's diarrhea coincided with healthy lifestyle changes that include the ingestion of artificial sweeteners

200

A 58-year-old man is evaluated for a 6-month history of episodic epigastric abdominal pain. In addition, his wife was recently diagnosed withHelicobacter pylori infection, and she is concerned that he may be infected as well. His epigastric pain occurs on most days and may occur several times during the day. He characterizes it as a vague discomfort that does not affect most activities. The discomfort is not closely related to eating, but he has been eating less. The discomfort typically resolves spontaneously within 30 to 60 minutes, but it has been occurring more frequently. He has also noted occasional nausea without vomiting. His weight is 2.3 kg (5.0 lb) lower than it was 1 year ago at his last appointment. Family history is negative for gastrointestinal malignancy. On physical examination, blood pressure is 138/79 mm Hg, and pulse rate is 80/min. Other vital signs are normal. BMI is 35. Abdominal examination reveals generalized tenderness to deep palpation but no palpable mass. Laboratory studies reveal a hemoglobin level of 12.5 g/dL (125 g/L) and a mean corpuscular volume of 94 fL. Which of the following is the most appropriate management? a-Empiric treatment of H. pylori b-Empiric trial of omeprazole c-H. pylori serologic testing d-Upper endoscopy

Correct Answer: D Educational Objective: Evaluate dyspepsia with alarm features. Key Point Upper endoscopy is recommended for the exclusion of upper gastrointestinal structural causes of dyspepsia; it should be performed in patients who have alarm features. The most appropriate management is further investigation with upper endoscopy. Guidelines recommend upper endoscopy for patients with dyspepsia and alarm features. Alarm features include onset after age 50 years; anemia; dysphagia; odynophagia; vomiting; weight loss; family history of upper gastrointestinal malignancy; personal history of peptic ulcer disease, gastric surgery, or gastrointestinal malignancy; and abdominal mass or lymphadenopathy on examination.

300

A 53-year-old woman is evaluated in follow-up after a recent hospitalization for right flank pain. Ultrasound performed in the hospital showed a dilated right renal collecting system and a 12-mm gallbladder polyp. Two hours after admission, she passed a stone in the urine and the right flank pain resolved. Since her hospitalization, she has had no other episodes of pain and otherwise feels well. On physical examination, vital signs are normal; BMI is 34. Abdominal examination reveals a normal liver and spleen, no tenderness, and a negative Murphy sign. Laboratory studies, including a complete blood count, alkaline phosphatase, alanine aminotransferase, and bilirubin, are normal. Which of the following is the most appropriate management? a-Abdominal CT b-Cholecystectomy c-Endoscopic retrograde cholangiopancreatography d-Magnetic resonance cholangiopancreatography e-Ultrasound in 1 year

Correct Answer: B Educational Objective: Manage gallbladder polyps. Key Point The finding of a gallbladder polyp larger than 1 cm is an indication for cholecystectomy, even if the patient is asymptomatic. The most appropriate management is cholecystectomy. The finding of a gallbladder polyp larger than 1 cm is an indication for cholecystectomy, even if the patient is asymptomatic. Gallbladder polyps are found in approximately 5% of ultrasound examinations. Although only a small percentage of gallbladder polyps are neoplastic (adenoma oradenocarcinoma), the risk for neoplasia increases as polyp size increases. In the absence of gallstones, a gallbladder polyp smaller than 1 cm can be followed with serial ultrasound examinations unless the patient is symptomatic or has primary sclerosing cholangitis. For patients with gallstones and any size polyp, cholecystectomy is usually recommended

400

A 22-year-old woman is evaluated for a flare of Crohn disease. A colonoscopy performed 6 months ago showed moderate, patchy, left- sided colitis extending from the descending colon to the splenic flexure. She responded to therapy with prednisone but declined maintenance therapy in advance of conceiving. She is now 12 weeks pregnant and for the past 2 weeks has experienced bloody diarrhea and left-sided abdominal pain. On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 110/66 mm Hg, and pulse rate is 76/min. Abdominal examination reveals left-sided abdominal tenderness without guarding or rebound. Flexible sigmoidoscopy shows recurrent left-sided patchy colitis, and stool studies are negative for Clostridium difficile infection. Which of the following is the most appropriate treatment? a-Certolizumab b-Ciprofloxacin and metronidazole c-Controlled ileal-release budesonide d-Mesalamine d-Methotrexate

Correct Answer: A Educational Objective: Treat Crohn disease in a pregnant patient. Key Point Treatment with an anti–tumor necrosis factor agent is effective for induction and maintenance of remission in Crohn disease and is generally considered to be safe during pregnancy (FDA pregnancy category B).

500

A 65-year-old man is evaluated for a 4-week history of worsening reflux and heartburn. He has a 10-year history of heartburn that was previously well controlled with omeprazole. Recently he noticed that the medication is less effective, and he is experiencing heartburn in the afternoon. He has no dysphagia, nausea, vomiting, or weight loss. He takes no other medications. On physical examination, vital signs are normal. The remainder of the examination, including abdominal examination, is unremarkable. Upper endoscopy shows a small hiatal hernia and salmon-colored mucosa in the distal esophagus. Pathology results reveal a diagnosis of Barrett esophagus with high-grade dysplasia. Which of the following is the most appropriate next step in management? a-Endoscopic ablation b-Esophagectomy c-Fundoplication d-Repeat upper endoscopy in 1 year

Correct Answer: A Educational Objective: Treat Barrett esophagus with high-grade dysplasia with endoscopic ablation. Key Point Treatment to remove Barrett esophagus is recommended for patients with confirmed high-grade dysplasia and can be done with endoscopic therapies that include radiofrequency ablation, photodynamic therapy, or endoscopic mucosal resection.