Free Internal Medicine Board Review Questions and Answers — Questions and Answers
Question 1: A 34-year-old mother of three brings concerns of restlessness, agitation, palpitations, sweating, and a dramatic 8-pound weight loss to her primary care physician (without any dietary or exercise intervention). She also complains of fine trembling and heat sensitivity. She categorically denied using any form of tobacco, alcohol, or caffeine. Her vital signs are as follows: 37 °C (98.6 °F), 120 beats per minute for her heartbeat, 140/80 mmHg for her blood pressure, and 20 beats per minute for her breathing. During a physical examination, the doctor noted pre-tibial myxedema, lid lag, a distinctive gaze, and fine tremors. The thyroid gland is lobular and diffusely enlarged when palpated. On auscultation, a bruit is audible over the surface of the gland. According to lab tests, TSH levels are deficient, and radioactive iodine uptake is boosted. Graves disease is identified, and potential therapies are addressed. What long-term risks are there if a patient chooses radioactive iodine therapy?
- Cholestasis
- Recurrent laryngeal nerve damage
- Hypothyroidism (Correct answer)
- Carcinoma of thyroid gland
- Granulocytopenia
Correct answer: Hypothyroidism
Radioactive iodine therapy (RAI) for Graves' disease works by destroying overactive thyroid cells, effectively treating hyperthyroidism. However, the most common and significant long-term risk of this treatment is the development of hypothyroidism, as the destruction of thyroid tissue can lead to insufficient hormone production, requiring lifelong thyroid hormone replacement.
Question 2: An ER visit for a 46-year-old male with non-alcoholic cirrhosis and a history of splenectomy following a car accident five years prior reveals a 102 F fever, nausea, weakness, stomach discomfort, and myalgia. The patient and his dog had trekked on Cape Cod two weeks earlier. Temperatures upon arrival were 103°F, 108°F, RR 12, Sa02 98% in RA, and BP 90/70. During the examination, the patient appears sickly and is feeble, febrile, and tachycardic. WBC 14.6; Platelets 218000; Hb 10; Na 136; K 4.0; BUN 22; Cr 1.3; are the results of the lab tests. Additional labs are pending. The image below shows a blood smear. Intravenous fluids and supportive treatment are initiated for the patient after admission to the MICU. What specific therapy is being used?
- Clindamycin + Quinine+ Doxycycline (Correct answer)
- Clindamycin + Doxycycline
- Clindamycin + Atovaquone
- Atovaquone+ Doxycycline
- Clindamycin
Correct answer: Clindamycin + Quinine+ Doxycycline
The patient's history of splenectomy, travel to an endemic area (Cape Cod), fever, anemia, and the presence of intraerythrocytic parasites on the blood smear (consistent with Babesia) strongly indicate severe babesiosis. For severe cases, especially in asplenic patients, the recommended treatment regimen is a combination of quinine and clindamycin, often with doxycycline for broader coverage.
Question 3: An obese 32-year-old woman arrives with ongoing right knee pain. She rejects any claims of injury, bruising, fever, rash, or general ill health. She has never experienced anything like this. She doesn't have any unique medical history. She owns a women's clothing store, which keeps her busy but stressed. The knees are symmetrical and show no erythema, effusion, edema, or warmth. When felt, the distal femur is painful. On the right, there is less room for mobility. On the diseased femur, on an x-ray, there is a lucent, lytic lesion. Which diagnosis is more likely?
- Osteogenic sarcoma
- Ewing’s sarcoma
- Giant cell tumor of the bone (Correct answer)
- Osteoarthritis
- Chondrosarcoma
Correct answer: Giant cell tumor of the bone
Giant cell tumors of the bone typically affect young adults (20-40s) and commonly occur in the epiphysis/metaphysis of long bones, especially around the knee, presenting as a painful, lytic lesion on X-ray. The patient's age, symptoms, and X-ray findings are highly consistent with this diagnosis. Other options like osteosarcoma or Ewing's sarcoma are less likely given the age and specific presentation, while osteoarthritis would not present with a lytic lesion in a 32-year-old.
Question 4: A 63-year-old woman with a significant past medical history of breast cancer arrives at the hospital with a three-day history of sore throat, exhaustion, and a petechial rash throughout the anterior abdominal wall and lower extremities. A white blood cell count of 115.5 cells/ul (average: 3.5-10.5 cells/ul), of which 77% blasts, a hemoglobin level of 6.1 g/dl (average: 12–16 g/dl), and a platelet count of 22,000/ul (average: 150–400 thousand/ul) are all revealed by laboratory tests. She receives induction therapy while being treated at the hospital. Which of these statements is accurate:
- Leukemias associated with prior chemotherapy are associated with an unfavorable prognosis
- Prior treatment with doxorubicin (an anthracycline) for breast cancer has increased her risk of developing leukemia
- All of the above are true (Correct answer)
Correct answer: All of the above are true
The patient's history of breast cancer treated with doxorubicin (an anthracycline) significantly increases her risk of developing therapy-related acute myeloid leukemia (t-AML). Anthracyclines are known leukemogenic agents. Furthermore, t-AML, particularly following chemotherapy, is generally associated with an unfavorable prognosis due to specific cytogenetic abnormalities and resistance to treatment. Therefore, both statements regarding increased risk and unfavorable prognosis are accurate.
Question 5: A 25-year-old man with a severe asthma attack is admitted to the emergency room. He also feels queasy and reports having diarrhea and vomiting. With many hospitalizations and one intubation five years ago, the patient has a long history of severe asthma. He started having breathing problems two days ago, which have worsened. He attempted home nebulizers for ipratropium, cromolyn treatment, and albuterol, but nothing helped his symptoms. Peak flow rates in the hospital are over 50% lower than the baseline. Which medication from the list below must be added to the patient's treatment plan to help him with his present symptoms?
- Intravenous hydrocortisone (Correct answer)
- Disodium cromoglycate
- Inhaled beclomethasone
- Oral prednisone
- Theophylline
Correct answer: Intravenous hydrocortisone
This patient is experiencing a severe asthma exacerbation, unresponsive to initial bronchodilator therapy, indicated by his history of severe asthma, previous intubation, and significantly reduced peak flow rates. Systemic corticosteroids are essential for reducing airway inflammation in such severe cases. Given his severe presentation and inability to tolerate oral medications due to nausea, vomiting, and diarrhea, intravenous hydrocortisone is the most appropriate and rapidly acting systemic corticosteroid to administer.
Question 6: A 50-year-old patient with a history of hypertension, hyperlipidemia, and alcoholism arrives at the emergency room with a strong cough, a fever, chills, and generalized weakness. Her family adds that she has been acting confused, and she claims that she has had those symptoms for over a week. She recently resumed drinking and is currently taking Lipitor and Atenolol. Vitals: temperature is 102.5 degrees Fahrenheit, heart rate is 105 beats per minute, blood pressure is 110/75, and respiratory rate is 22. During a physical examination, the right lower lobe (RLL) exhibits diminished breath sounds correlated with an RLL infiltrate on a chest x-ray. What is your prevailing medical opinion?
- Multiple Organ Dysfunction Syndrome
- Sepsis (Correct answer)
- Septic shock
- Multiple Organ Dysfunction Syndrome
- Systemic Inflammatory Response System
Correct answer: Sepsis
The patient presents with an infection (pneumonia, indicated by cough, fever, and RLL infiltrate) and meets criteria for Systemic Inflammatory Response Syndrome (SIRS) with a fever, tachycardia, and tachypnea. The new onset of confusion signifies acute organ dysfunction (encephalopathy) secondary to the infection. The combination of infection and associated organ dysfunction defines sepsis, making it the most accurate diagnosis.
Question 7: A 50-year-old patient with a history of hypertension, hyperlipidemia, and alcoholism arrives at the emergency room with a strong cough, a fever, chills, and generalized weakness. Her family adds that she has been acting confused, and she claims that she has had those symptoms for over a week. She recently resumed drinking and is currently taking Lipitor and Atenolol. Vitals: temperature is 102.5 degrees Fahrenheit, heart rate is 105 beats per minute, blood pressure is 110/75, and respiratory rate is 22. During a physical examination, the right lower lobe (RLL) exhibits diminished breath sounds correlated with an RLL infiltrate on a chest x-ray. What is your prevailing medical opinion?
- Increasing hoarseness (Correct answer)
- The change in the pattern of cough
- Hemoptysis
- A post obstructive pneumonia
- Worsening dyspnea
Correct answer: Increasing hoarseness
While the stem describes a patient with pneumonia, the question implicitly asks for a symptom that would raise concern for a more serious underlying condition, such as lung cancer, especially in a patient with risk factors like alcoholism. Increasing hoarseness can be a critical red flag, as it may indicate recurrent laryngeal nerve involvement due to a mediastinal tumor. This symptom suggests potential advanced disease and warrants further investigation.
Free Internal Medicine Board Review Questions and Answers
A 34-year-old mother of three brings concerns of restlessness, agitation, palpitations, sweating, and a dramatic 8-pound weight loss to her primary care physician (without any dietary or exercise intervention).
She also complains of fine trembling and heat sensitivity.
She categorically denied using any form of tobacco, alcohol, or caffeine.
Her vital signs are as follows: 37 °C (98.6 °F), 120 beats per minute for her heartbeat, 140/80 mmHg for her blood pressure, and 20 beats per minute for her breathing.
During a physical examination, the doctor noted pre-tibial myxedema, lid lag, a distinctive gaze, and fine tremors.
The thyroid gland is lobular and diffusely enlarged when palpated.
On auscultation, a bruit is audible over the surface of the gland.
According to lab tests, TSH levels are deficient, and radioactive iodine uptake is boosted.
Graves disease is identified, and potential therapies are addressed.
What long-term risks are there if a patient chooses radioactive iodine therapy?