Internal Medicine Board Review

Question 1 40 year old male landscaper in PA Rash left thigh Mild headache Temp = 100 Rash – circular, macular with central clearing Lyme serologies are pending

What should you do next? A. If IgM lyme titer is (+), begin treatment B. Begin treatment now and discontinue if lyme titers are (-) C. Begin treatment now regardless of results of lyme titers D. If IgM lyme titer is (-), repeat in 2 weeks and treat if (+)

Question 1 Begin antibiotics regardless of titer results Recognize relationship between serologic testing and empiric treatment for early Lyme disease.

Question 2 68yo with cervical cancer s/p extensive surgery On broad spectrum antibiotics post-op On TPN 5d post-op fever to 102.2 CXR, urine and sputum cx are neg Vancomycin added, pt remains febrile Blood cx and cath tip are positive for fungus

Which of following is most likely causing infection in this patient? A. Cryptococcus neoformans B. Aspergillus fumigatus C. Candida parapsilosis D. Mucor species E. Blastomyces dermatitidis

Question 2 Candida parapsilosis Recognize fungal pathogens associated with vascular catheter infections and hyper- alimentation

Question 3 50yo poultry farmer with CLL Fever, HA, vomiting, diarrhea, MS changes 20yo daughter with recent miscarriage due to infection Disoriented, fever to 101.8, photophobia, meningismus CSF: protein 120, glucose 60, 1200 wbcs (70% pmns), GS with no orgs

Appropriate empiric antibiotic therapy for this patient is: A. Ceftriaxone B. Doxycycline C. Ceftriaxone and vancomycin D. Ceftriaxone, vancomycin and ampicillin E. Vancomycin and gentamicin

Question 3 Ceftriaxone, vancomycin and ampicillin Treat a patient with meningitis who is at risk for infection with Listeria monocytogenes

Question 4 33-year old woman presents to Emergency Department with one week history of fever, malaise, myalgias, sore throat Five days PTA noted onset of new rash, non-pruritic, on face, torso, extremities Two days PTA developed mouth sores that were so painful she was unable to eat or drink

Question 4 Past medical history: None Social history: Single, grad student, no tobacco, no IVDA Family history: DM, HTN

Question 4 Physical Examination in ED T 40 o C. BP 104/76 P 108 R 20 Appears unwell; clinically dehydrated HEENT: Multiple oral ulcerations Non-exudative pharyngitis Multiple cervical nodes ( + tender) Rash

Question 4 Laboratory data in ED H/H 16/48 WBC 3100 (46 segs, 19 bands, 25 lymphs, 6 atyp lymphs, 4 monos) Platelets 41,000 ALT 124, AST 75 Urine drug screen negative Monospot negative HIV test negative

The most likely causative agent of the patient’s symptoms is: A. HIV B. Arcanobacterium haemolyticum C. Streptococcus pyogenes D. Cytomegalovirus E. Epstein-Barr virus

Question 4 HIV Consider differential for acute pharyngitis with rash

Question 5 34yo female from Nantucket Inguinal LAD and constitutional sx without rash or h/o tick bite 6 weeks later - migratory polyarthralgia, sore throat, left facial palsy and HA PE with peripheral facial cranial neuropathy CSF: mild pleocytosis Lyme ELISA is positive

The most appropriate therapy for this patient is: A. Oral penicillin B. Doxycycline C. Intravenous ceftriaxone D. High-dose parenteral glucocorticoids

Question 5 Intravenous ceftriaxone Select the most appropriate treatment for later-stage (early disseminated) Lyme Disease

Question 6 50yo male with elevated LFTs and (+) hepatitis C antibody test H/O IVDU in 1960s Normal physical exam

What further testing is indicated to confirm his hepatitis C infection? A. Third generation enzyme immunoassay B. Recombinant immunoblot assay (RIBA) C. Reverse transcriptase PCR D. No further testing indicated

Question 6 No further testing indicated Understand testing for the diagnosis of hepatitis C and interpretation of results

Question 7 24 yo G1P0, in 2 nd month of pregnancy 5d h/o vulvar itching and vaginal d/c Exam with thin, malodorous, white d/c and mildly inflamed vulva Rare wbc’s microscopically with granulated vaginal epithelial cells

Which should be the next step in management? A. Treat with one dose of oral fluconazole B. Treat with a 7-day course of oral metronidazole, 500mg bid C. Treat with one dose of oral metronidazole, 2g D. Withold antibiotics due to fetal risk

Question 7 Treat with 7-day course of metronidazole po (500mg bid) Recognize the clinical picture of bacterial vaginosis and understand how to treat this in a pregnant patient

Question 8 27yo with HIV, CD4 ct 175, on daily TMP-SMX Seizure, weeks of stumbling Toxo serology (-) 2 years ago Head CT with 2 large parietal lesions with surrounding edema and midline shift

The best approach to management would be: A. 2 weeks of empiric therapy with TMP-SMX followed by repeat CT B. 2 weeks of empiric TMP-SMX + dexamethasone, followed by CT C. CT-guided needle biopsy D. LP to evaluate CSF for EBV PCR E. Open brain biopsy

Question 8 (CSF for EBV PCR) CT-guided needle biopsy Select the most appropriate management for a patient with HIV and a CNS mass lesion.

Question 9 85yo nursing home resident with ruptured diverticular abscess and fever S/P open drainage On piperacillin/tazobactam Blood cultures with pan-sensitive E. coli Pt is now afebrile and recovering Abscess culture grows E. coli, Enterobacter, Bacteroides and VRE

In addition to contact isolation, the appropriate treatment of this pt is to: A. Treat VRE empirically, and test susceptibility B. Test susceptibility and treat accordingly C. Continue piperacillin/tazobactam D. Discontinue all antibiotics and send the patient back to the nursing home

Question 9 Continue the piperacillin/tazobactam Distinguish between colonization and infection due to VRE and recognize significance of VRE colonization.

Question 10 44yo with 3 week h/o fever, purulent cough and wt loss SZ d/o s/p seizure 1 month ago CXR with 2.5cm cavity in superior segment RLL with A/F level (+) ppd

What is the most appropriate therapeutic step? A. Culture sputum for anaerobic bacteria and begin treatment with clindamycin B. Send sputum for AFB stain and culture and begin treatment with INH, RIF, PZA and ETB C. Begin treatment with metronidazole and schedule bronchoscopy Send sputum for gram stain and AFB and treat empirically with piperacillin/tazobactam

Question 10 Send sputum for gram stain and AFD and treat empirically with piperacillin/tazobactam Identify the clinical presentation of a lung abscess and select appropriate therapy.

Question 11 55yo man with fever, chills, tachypnea 2 days after squeezing a facial furuncle H/O anaphylaxis to PCN BC (+) for GPC in clusters

Which of the following would be the best treatment? A. Aztreonam, 1g every 8 hours B. Cefazolin, 1g every 8 hours C. Ceftriaxone, 1g every 12 hours D. Vancomycin, 1g every 12 hours E. Imipenem, 500mg every 6 hours

Question 11 Vancomycin 1gm IV bid Select appropriate substitution therapy in the presence of PCN allergy.

Question 12 34yo man planning a trip to Kenya Needs malaria prophylaxis

Which medication should he receive? A. Chloroquine B. Chloroquine followed by primaquine C. Mefloquine D. Quinine plus doxycycline E. Clindamycin

Question 12 Mefloquine Select appropriate chemoprophylaxis for malaria.

Question 13 24yo pregnant woman with vaginal d/c Cervical culture is (+) for Neisseria gonorrhoeae Chlamydia screen of cervical secretions is (-)

Appropriate therapy for this patient is: A. Ciprofloxacin 500mg po x 1 B. Doxycycline, 100mg po bid x 7 days C. Amoxicillin, 3g po x 1 D. Ceftriaxone 125mg IM x 1

Question 13 Ceftriaxone IM x 1 Treat uncomplicated gonorrhea in a pregnant woman.

Question 14 35yo with AML and chemotherapy-induced neutropenia On day 6 of neutropenia, she develops skin lesion with a rise in temp to 102.2 The skin lesion progresses

The most likely diagnosis is: A. Streptococcal cellulitis with bacteremia B. Disseminated candidiasis C. Meningococcemia D. Pseudomonas aeruginosa bacteremia E. Staphylococcal endocarditis with metastatic abscesses

Question 14 Pseudomonas aeruginosa bacteremia Diagnose Pseudomonas bacteremia with skin lesions in a neutropenic patient.

Question 15 19yo with urethral d/c and GS with gram-negative intracellular diplococci Given IM ceftriaxone and prescription for doxycycline 1 week later returns with persistent d/c and GS with only wbcs

The reason for symptoms is likely: A. Treatment failure B. Non-compliance with medication C. Re-exposure to infected partner D. Herpes simplex infection E. Syphilis

Question 15 Failure to take doxycycline Recognize reasons for treatment failure in urethritis.

Question 16 85yo in ED b/c daughter found a bat in his bedroom Man does not recall bite or c/o pain Skin exam is unremarkable

The most appropriate course of action is: A. Give rabies immune globulin and initiate rabies vaccine series B. Give rabies immune globulin but not the rabies vaccine C. Observe and initiate rabies immune globulin if the patient behaves abnormally D. Reassure the patient and the daughter; prophylaxis is not required because a puncture wound was not evident

Question 16 Give rabies immune globulin and initiate rabies vaccine series Assess the need for rabies prophylaxis after a bat exposure.

Internal Medicine Board Review

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Internal Medicine Board Review