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Board Review
Question 1 <ul><li>40 year old male landscaper in PA  </li></ul><ul><li>Rash left thigh  </li></ul><ul><li>Mild headache  ...
What should you do next? <ul><li>A.  If IgM lyme titer is (+), begin treatment </li></ul><ul><li>B.  Begin treatment now a...
Question 1 <ul><li>Begin antibiotics regardless of titer results  </li></ul><ul><li>Recognize relationship between serolog...
Question 2 <ul><li>68yo with cervical cancer s/p extensive surgery  </li></ul><ul><li>On broad spectrum antibiotics post-o...
Which of following is most likely causing infection in this patient?   <ul><li>A.  Cryptococcus neoformans </li></ul><ul><...
Question 2 <ul><li>Candida parapsilosis </li></ul><ul><li>Recognize fungal pathogens associated with vascular catheter inf...
Question 3 <ul><li>50yo poultry farmer with CLL </li></ul><ul><li>Fever, HA, vomiting, diarrhea, MS changes  </li></ul><ul...
Appropriate empiric antibiotic therapy for this patient is: <ul><li>A.  Ceftriaxone </li></ul><ul><li>B.  Doxycycline </li...
Question 3 <ul><li>Ceftriaxone, vancomycin and ampicillin </li></ul><ul><li>Treat a patient with meningitis who is at risk...
Question 4 <ul><li>33-year old woman presents to Emergency Department with one week history of fever, malaise, myalgias, s...
Question 4 <ul><li>Past medical history: </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Social history: </li></ul><ul><...
Question 4 <ul><li>Physical Examination in ED </li></ul><ul><ul><li>T 40 o C. BP 104/76 P 108   R 20 </li></ul></ul><ul><u...
 
 
Question 4 <ul><li>Laboratory data in ED </li></ul><ul><li>H/H 16/48 </li></ul><ul><li>WBC 3100 (46 segs, 19 bands, 25 lym...
The most likely causative agent of the patient’s symptoms is: <ul><li>A.  HIV </li></ul><ul><li>B.  Arcanobacterium haemol...
Question 4 <ul><li>HIV </li></ul><ul><li>Consider differential for acute pharyngitis with rash  </li></ul>
Question 5 <ul><li>34yo female from Nantucket  </li></ul><ul><li>Inguinal LAD and constitutional sx without rash or h/o ti...
The most appropriate therapy for this patient is: <ul><li>A.  Oral penicillin </li></ul><ul><li>B.  Doxycycline </li></ul>...
Question 5 <ul><li>Intravenous ceftriaxone  </li></ul><ul><li>Select the most appropriate treatment for later-stage (early...
Question 6 <ul><li>50yo male with elevated LFTs and (+) hepatitis C antibody test  </li></ul><ul><li>H/O IVDU in 1960s </l...
What further testing is indicated  to   confirm  his hepatitis C infection? <ul><li>A.  Third generation enzyme immunoassa...
Question 6 <ul><li>No further testing indicated  </li></ul><ul><li>Understand testing for the diagnosis of hepatitis C and...
Question 7 <ul><li>24 yo G1P0, in 2 nd  month of pregnancy </li></ul><ul><li>5d h/o vulvar itching and vaginal d/c </li></...
Which should be the next step in management? <ul><li>A.  Treat with one dose of oral fluconazole </li></ul><ul><li>B.  Tre...
Question 7 <ul><li>Treat with 7-day course of metronidazole po (500mg bid) </li></ul><ul><li>Recognize the clinical pictur...
Question 8 <ul><li>27yo with HIV, CD4 ct 175, on daily TMP-SMX </li></ul><ul><li>Seizure, weeks of stumbling </li></ul><ul...
The best approach to management would be: <ul><li>A.  2 weeks of empiric therapy with TMP-SMX followed by repeat CT </li><...
Question 8 <ul><li>(CSF for EBV PCR) </li></ul><ul><li>CT-guided needle biopsy </li></ul><ul><li>Select the most appropria...
Question 9 <ul><li>85yo nursing home resident with ruptured diverticular abscess and fever </li></ul><ul><li>S/P open drai...
In addition to contact isolation, the appropriate treatment of this pt is to: <ul><li>A.  Treat VRE empirically, and test ...
Question 9 <ul><li>Continue the piperacillin/tazobactam </li></ul><ul><li>Distinguish between colonization and infection d...
Question 10 <ul><li>44yo with 3 week h/o fever, purulent cough and wt loss </li></ul><ul><li>SZ d/o s/p seizure 1 month ag...
What is the most appropriate therapeutic step? <ul><li>A.  Culture sputum for anaerobic bacteria and begin treatment with ...
Question 10 <ul><li>Send sputum for gram stain and AFD and treat empirically with piperacillin/tazobactam  </li></ul><ul><...
Question 11 <ul><li>55yo man with fever, chills, tachypnea 2 days after squeezing a facial furuncle </li></ul><ul><li>H/O ...
Which of the following would be the best treatment? <ul><li>A.  Aztreonam, 1g every 8 hours </li></ul><ul><li>B.  Cefazoli...
Question 11 <ul><li>Vancomycin 1gm IV bid </li></ul><ul><li>Select appropriate substitution therapy in the presence of PCN...
Question 12 <ul><li>34yo man planning a trip to Kenya </li></ul><ul><li>Needs malaria prophylaxis </li></ul>
Which medication should he receive? <ul><li>A.  Chloroquine </li></ul><ul><li>B.  Chloroquine followed by primaquine </li>...
Question 12 <ul><li>Mefloquine </li></ul><ul><li>Select appropriate chemoprophylaxis for malaria. </li></ul>
Question 13 <ul><li>24yo pregnant woman with vaginal d/c </li></ul><ul><li>Cervical culture is (+) for  Neisseria gonorrho...
Appropriate therapy for this patient is: <ul><li>A.  Ciprofloxacin 500mg po x 1 </li></ul><ul><li>B.  Doxycycline, 100mg p...
Question 13 <ul><li>Ceftriaxone IM x 1 </li></ul><ul><li>Treat uncomplicated gonorrhea in a pregnant woman. </li></ul>
Question 14 <ul><li>35yo with AML and chemotherapy-induced neutropenia </li></ul><ul><li>On day 6 of neutropenia, she deve...
The most likely diagnosis is: <ul><li>A.  Streptococcal cellulitis with bacteremia </li></ul><ul><li>B.  Disseminated cand...
Question 14 <ul><li>Pseudomonas aeruginosa  bacteremia </li></ul><ul><li>Diagnose  Pseudomonas  bacteremia with skin lesio...
Question 15 <ul><li>19yo with urethral d/c and GS with gram-negative intracellular diplococci </li></ul><ul><li>Given IM c...
The reason for symptoms is likely: <ul><li>A. Treatment failure </li></ul><ul><li>B.  Non-compliance with medication </li>...
Question 15 <ul><li>Failure to take doxycycline </li></ul><ul><li>Recognize reasons for treatment failure in urethritis. <...
Question 16 <ul><li>85yo in ED b/c daughter found a bat in his bedroom </li></ul><ul><li>Man does not recall bite or c/o p...
The most appropriate course of action is: <ul><li>A.  Give rabies immune globulin and initiate rabies vaccine series </li>...
Question 16 <ul><li>Give rabies immune globulin and initiate rabies vaccine series </li></ul><ul><li>Assess the need for r...
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Internal Medicine Board Review

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  • Transcript of "Internal Medicine Board Review"

    1. 1. Board Review
    2. 2. Question 1 <ul><li>40 year old male landscaper in PA </li></ul><ul><li>Rash left thigh </li></ul><ul><li>Mild headache </li></ul><ul><li>Temp = 100 </li></ul><ul><li>Rash – circular, macular with central clearing </li></ul><ul><li>Lyme serologies are pending </li></ul>
    3. 3. What should you do next? <ul><li>A. If IgM lyme titer is (+), begin treatment </li></ul><ul><li>B. Begin treatment now and discontinue if lyme titers are (-) </li></ul><ul><li>C. Begin treatment now regardless of results of lyme titers </li></ul><ul><li>D. If IgM lyme titer is (-), repeat in 2 weeks and treat if (+) </li></ul>
    4. 4. Question 1 <ul><li>Begin antibiotics regardless of titer results </li></ul><ul><li>Recognize relationship between serologic testing and empiric treatment for early Lyme disease. </li></ul>
    5. 5. Question 2 <ul><li>68yo with cervical cancer s/p extensive surgery </li></ul><ul><li>On broad spectrum antibiotics post-op </li></ul><ul><li>On TPN </li></ul><ul><li>5d post-op fever to 102.2 </li></ul><ul><li>CXR, urine and sputum cx are neg </li></ul><ul><li>Vancomycin added, pt remains febrile </li></ul><ul><li>Blood cx and cath tip are positive for fungus </li></ul>
    6. 6. Which of following is most likely causing infection in this patient? <ul><li>A. Cryptococcus neoformans </li></ul><ul><li>B. Aspergillus fumigatus </li></ul><ul><li>C. Candida parapsilosis </li></ul><ul><li>D. Mucor species </li></ul><ul><li>E. Blastomyces dermatitidis </li></ul>
    7. 7. Question 2 <ul><li>Candida parapsilosis </li></ul><ul><li>Recognize fungal pathogens associated with vascular catheter infections and hyper- alimentation </li></ul>
    8. 8. Question 3 <ul><li>50yo poultry farmer with CLL </li></ul><ul><li>Fever, HA, vomiting, diarrhea, MS changes </li></ul><ul><li>20yo daughter with recent miscarriage due to infection </li></ul><ul><li>Disoriented, fever to 101.8, photophobia, meningismus </li></ul><ul><li>CSF: protein 120, glucose 60, 1200 wbcs (70% pmns), GS with no orgs </li></ul>
    9. 9. Appropriate empiric antibiotic therapy for this patient is: <ul><li>A. Ceftriaxone </li></ul><ul><li>B. Doxycycline </li></ul><ul><li>C. Ceftriaxone and vancomycin </li></ul><ul><li>D. Ceftriaxone, vancomycin and ampicillin </li></ul><ul><li>E. Vancomycin and gentamicin </li></ul>
    10. 10. Question 3 <ul><li>Ceftriaxone, vancomycin and ampicillin </li></ul><ul><li>Treat a patient with meningitis who is at risk for infection with Listeria monocytogenes </li></ul>
    11. 11. Question 4 <ul><li>33-year old woman presents to Emergency Department with one week history of fever, malaise, myalgias, sore throat </li></ul><ul><li>Five days PTA noted onset of new rash, non-pruritic, on face, torso, extremities </li></ul><ul><li>Two days PTA developed mouth sores that were so painful she was unable to eat or drink </li></ul>
    12. 12. Question 4 <ul><li>Past medical history: </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Social history: </li></ul><ul><ul><li>Single, grad student, no tobacco, no IVDA </li></ul></ul><ul><li>Family history: </li></ul><ul><ul><li>DM, HTN </li></ul></ul>
    13. 13. Question 4 <ul><li>Physical Examination in ED </li></ul><ul><ul><li>T 40 o C. BP 104/76 P 108 R 20 </li></ul></ul><ul><ul><li>Appears unwell; clinically dehydrated </li></ul></ul><ul><ul><li>HEENT: Multiple oral ulcerations </li></ul></ul><ul><ul><li>Non-exudative pharyngitis </li></ul></ul><ul><ul><li>Multiple cervical nodes ( + tender) </li></ul></ul><ul><ul><li>Rash </li></ul></ul>
    14. 16. Question 4 <ul><li>Laboratory data in ED </li></ul><ul><li>H/H 16/48 </li></ul><ul><li>WBC 3100 (46 segs, 19 bands, 25 lymphs, 6 atyp lymphs, 4 monos) </li></ul><ul><li>Platelets 41,000 </li></ul><ul><li>ALT 124, AST 75 </li></ul><ul><li>Urine drug screen negative </li></ul><ul><li>Monospot negative </li></ul><ul><li>HIV test negative </li></ul>
    15. 17. The most likely causative agent of the patient’s symptoms is: <ul><li>A. HIV </li></ul><ul><li>B. Arcanobacterium haemolyticum </li></ul><ul><li>C. Streptococcus pyogenes </li></ul><ul><li>D. Cytomegalovirus </li></ul><ul><li>E. Epstein-Barr virus </li></ul>
    16. 18. Question 4 <ul><li>HIV </li></ul><ul><li>Consider differential for acute pharyngitis with rash </li></ul>
    17. 19. Question 5 <ul><li>34yo female from Nantucket </li></ul><ul><li>Inguinal LAD and constitutional sx without rash or h/o tick bite </li></ul><ul><li>6 weeks later - migratory polyarthralgia, sore throat, left facial palsy and HA </li></ul><ul><li>PE with peripheral facial cranial neuropathy </li></ul><ul><li>CSF: mild pleocytosis </li></ul><ul><li>Lyme ELISA is positive </li></ul>
    18. 20. The most appropriate therapy for this patient is: <ul><li>A. Oral penicillin </li></ul><ul><li>B. Doxycycline </li></ul><ul><li>C. Intravenous ceftriaxone </li></ul><ul><li>D. High-dose parenteral glucocorticoids </li></ul>
    19. 21. Question 5 <ul><li>Intravenous ceftriaxone </li></ul><ul><li>Select the most appropriate treatment for later-stage (early disseminated) Lyme Disease </li></ul>
    20. 22. Question 6 <ul><li>50yo male with elevated LFTs and (+) hepatitis C antibody test </li></ul><ul><li>H/O IVDU in 1960s </li></ul><ul><li>Normal physical exam </li></ul>
    21. 23. What further testing is indicated to confirm his hepatitis C infection? <ul><li>A. Third generation enzyme immunoassay </li></ul><ul><li>B. Recombinant immunoblot assay (RIBA) </li></ul><ul><li>C. Reverse transcriptase PCR </li></ul><ul><li>D. No further testing indicated </li></ul>
    22. 24. Question 6 <ul><li>No further testing indicated </li></ul><ul><li>Understand testing for the diagnosis of hepatitis C and interpretation of results </li></ul>
    23. 25. Question 7 <ul><li>24 yo G1P0, in 2 nd month of pregnancy </li></ul><ul><li>5d h/o vulvar itching and vaginal d/c </li></ul><ul><li>Exam with thin, malodorous, white d/c and mildly inflamed vulva </li></ul><ul><li>Rare wbc’s microscopically with granulated vaginal epithelial cells </li></ul>
    24. 26. Which should be the next step in management? <ul><li>A. Treat with one dose of oral fluconazole </li></ul><ul><li>B. Treat with a 7-day course of oral metronidazole, 500mg bid </li></ul><ul><li>C. Treat with one dose of oral metronidazole, 2g </li></ul><ul><li>D. Withold antibiotics due to fetal risk </li></ul>
    25. 27. Question 7 <ul><li>Treat with 7-day course of metronidazole po (500mg bid) </li></ul><ul><li>Recognize the clinical picture of bacterial vaginosis and understand how to treat this in a pregnant patient </li></ul>
    26. 28. Question 8 <ul><li>27yo with HIV, CD4 ct 175, on daily TMP-SMX </li></ul><ul><li>Seizure, weeks of stumbling </li></ul><ul><li>Toxo serology (-) 2 years ago </li></ul><ul><li>Head CT with 2 large parietal lesions with surrounding edema and midline shift </li></ul>
    27. 29. The best approach to management would be: <ul><li>A. 2 weeks of empiric therapy with TMP-SMX followed by repeat CT </li></ul><ul><li>B. 2 weeks of empiric TMP-SMX + dexamethasone, followed by CT </li></ul><ul><li>C. CT-guided needle biopsy </li></ul><ul><li>D. LP to evaluate CSF for EBV PCR </li></ul><ul><li>E. Open brain biopsy </li></ul>
    28. 30. Question 8 <ul><li>(CSF for EBV PCR) </li></ul><ul><li>CT-guided needle biopsy </li></ul><ul><li>Select the most appropriate management for a patient with HIV and a CNS mass lesion. </li></ul>
    29. 31. Question 9 <ul><li>85yo nursing home resident with ruptured diverticular abscess and fever </li></ul><ul><li>S/P open drainage </li></ul><ul><li>On piperacillin/tazobactam </li></ul><ul><li>Blood cultures with pan-sensitive E. coli </li></ul><ul><li>Pt is now afebrile and recovering </li></ul><ul><li>Abscess culture grows E. coli, Enterobacter, Bacteroides and VRE </li></ul>
    30. 32. In addition to contact isolation, the appropriate treatment of this pt is to: <ul><li>A. Treat VRE empirically, and test susceptibility </li></ul><ul><li>B. Test susceptibility and treat accordingly </li></ul><ul><li>C. Continue piperacillin/tazobactam </li></ul><ul><li>D. Discontinue all antibiotics and send the patient back to the nursing home </li></ul>
    31. 33. Question 9 <ul><li>Continue the piperacillin/tazobactam </li></ul><ul><li>Distinguish between colonization and infection due to VRE and recognize significance of VRE colonization. </li></ul>
    32. 34. Question 10 <ul><li>44yo with 3 week h/o fever, purulent cough and wt loss </li></ul><ul><li>SZ d/o s/p seizure 1 month ago </li></ul><ul><li>CXR with 2.5cm cavity in superior segment RLL with A/F level </li></ul><ul><li>(+) ppd </li></ul>
    33. 35. What is the most appropriate therapeutic step? <ul><li>A. Culture sputum for anaerobic bacteria and begin treatment with clindamycin </li></ul><ul><li>B. Send sputum for AFB stain and culture and begin treatment with INH, RIF, PZA and ETB </li></ul><ul><li>C. Begin treatment with metronidazole and schedule bronchoscopy </li></ul><ul><li>Send sputum for gram stain and AFB and </li></ul><ul><li>treat empirically with piperacillin/tazobactam </li></ul>
    34. 36. Question 10 <ul><li>Send sputum for gram stain and AFD and treat empirically with piperacillin/tazobactam </li></ul><ul><li>Identify the clinical presentation of a lung abscess and select appropriate therapy. </li></ul>
    35. 37. Question 11 <ul><li>55yo man with fever, chills, tachypnea 2 days after squeezing a facial furuncle </li></ul><ul><li>H/O anaphylaxis to PCN </li></ul><ul><li>BC (+) for GPC in clusters </li></ul>
    36. 38. Which of the following would be the best treatment? <ul><li>A. Aztreonam, 1g every 8 hours </li></ul><ul><li>B. Cefazolin, 1g every 8 hours </li></ul><ul><li>C. Ceftriaxone, 1g every 12 hours </li></ul><ul><li>D. Vancomycin, 1g every 12 hours </li></ul><ul><li>E. Imipenem, 500mg every 6 hours </li></ul>
    37. 39. Question 11 <ul><li>Vancomycin 1gm IV bid </li></ul><ul><li>Select appropriate substitution therapy in the presence of PCN allergy. </li></ul>
    38. 40. Question 12 <ul><li>34yo man planning a trip to Kenya </li></ul><ul><li>Needs malaria prophylaxis </li></ul>
    39. 41. Which medication should he receive? <ul><li>A. Chloroquine </li></ul><ul><li>B. Chloroquine followed by primaquine </li></ul><ul><li>C. Mefloquine </li></ul><ul><li>D. Quinine plus doxycycline </li></ul><ul><li>E. Clindamycin </li></ul>
    40. 42. Question 12 <ul><li>Mefloquine </li></ul><ul><li>Select appropriate chemoprophylaxis for malaria. </li></ul>
    41. 43. Question 13 <ul><li>24yo pregnant woman with vaginal d/c </li></ul><ul><li>Cervical culture is (+) for Neisseria gonorrhoeae </li></ul><ul><li>Chlamydia screen of cervical secretions is (-) </li></ul>
    42. 44. Appropriate therapy for this patient is: <ul><li>A. Ciprofloxacin 500mg po x 1 </li></ul><ul><li>B. Doxycycline, 100mg po bid x 7 days </li></ul><ul><li>C. Amoxicillin, 3g po x 1 </li></ul><ul><li>D. Ceftriaxone 125mg IM x 1 </li></ul>
    43. 45. Question 13 <ul><li>Ceftriaxone IM x 1 </li></ul><ul><li>Treat uncomplicated gonorrhea in a pregnant woman. </li></ul>
    44. 46. Question 14 <ul><li>35yo with AML and chemotherapy-induced neutropenia </li></ul><ul><li>On day 6 of neutropenia, she develops skin lesion with a rise in temp to 102.2 </li></ul><ul><li>The skin lesion progresses </li></ul>
    45. 47. The most likely diagnosis is: <ul><li>A. Streptococcal cellulitis with bacteremia </li></ul><ul><li>B. Disseminated candidiasis </li></ul><ul><li>C. Meningococcemia </li></ul><ul><li>D. Pseudomonas aeruginosa bacteremia </li></ul><ul><li>E. Staphylococcal endocarditis with metastatic abscesses </li></ul>
    46. 48. Question 14 <ul><li>Pseudomonas aeruginosa bacteremia </li></ul><ul><li>Diagnose Pseudomonas bacteremia with skin lesions in a neutropenic patient. </li></ul>
    47. 49. Question 15 <ul><li>19yo with urethral d/c and GS with gram-negative intracellular diplococci </li></ul><ul><li>Given IM ceftriaxone and prescription for doxycycline </li></ul><ul><li>1 week later returns with persistent d/c and GS with only wbcs </li></ul>
    48. 50. The reason for symptoms is likely: <ul><li>A. Treatment failure </li></ul><ul><li>B. Non-compliance with medication </li></ul><ul><li>C. Re-exposure to infected partner </li></ul><ul><li>D. Herpes simplex infection </li></ul><ul><li>E. Syphilis </li></ul>
    49. 51. Question 15 <ul><li>Failure to take doxycycline </li></ul><ul><li>Recognize reasons for treatment failure in urethritis. </li></ul>
    50. 52. Question 16 <ul><li>85yo in ED b/c daughter found a bat in his bedroom </li></ul><ul><li>Man does not recall bite or c/o pain </li></ul><ul><li>Skin exam is unremarkable </li></ul>
    51. 53. The most appropriate course of action is: <ul><li>A. Give rabies immune globulin and initiate rabies vaccine series </li></ul><ul><li>B. Give rabies immune globulin but not the rabies vaccine </li></ul><ul><li>C. Observe and initiate rabies immune globulin if the patient behaves abnormally </li></ul><ul><li>D. Reassure the patient and the daughter; prophylaxis is not required because a puncture wound was not evident </li></ul>
    52. 54. Question 16 <ul><li>Give rabies immune globulin and initiate rabies vaccine series </li></ul><ul><li>Assess the need for rabies prophylaxis after a bat exposure. </li></ul>
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