SMARTY PANCE: INTERNAL MEDICINE QUESTIONS
AND ANSWERS
acute interstitial nephritis
Acute interstitial nephritis (AIN) is a renal lesion that causes a decline in kidney function
and is characterized by an inflammatory infiltrate in the kidney interstitium. Drugs
(remembered as the 5 Ps) are the most common cause of AIN. The 5 Ps are Pee
(diuretics, especially sulfa ones), Pain-free (NSAIDs), Penicillins and cephalosporins,
Proton pump inhibitors, and rifamPin. Patients will present with elevated creatinine,
eosinophils, WBC casts, and hematuria. - Answers - A 62-year-old man presents to
your office with a sudden onset of fever and rash. His review of systems is negative. He
was recently started on omeprazole for acid reflux 14 days ago. Routine laboratory tests
reveal a serum creatinine of 3.5 mg/dL and eosinophilia. Urine studies showed white
blood cell casts. What is the most likely diagnosis?
A Acute interstitial nephritis (AIN
B Acute tubular necrosis
C IGA Nephropathy
D Postreptococcal Glomerulonephritis
Subluxations (e.g. boutonniere and swan-neck deformities), joint ankylosis, z-thumb
deformity
Rheumatoid arthritis's early signs include soft tissue swelling, osteopenia, erosions, and
joint space narrowing. Later changes include subluxation causing ulnar deviation, z-
thumb, boutonniere, and swan neck deformities, and ankylosis. - Answers - A 63-year-
old woman presents with pain in her hands for three years. She describes the pain as
progressive - coming on slowly and worsening over the course of the three years. She
says that her aunt and wheelchair-bound grandmother had problems with their hands as
well. A hand X-ray is obtained which shows soft tissue swelling and marked juxta-
articular osteopenia in her metacarpophalangeal and proximal interphalangeal joints,
and minor bony erosions. Which of the following will most likely be present on her plain
film ten years from now?
A Pencil-in-cup deformity, ankylosis, periostitis, dactylitis
B Subchondral sclerosis, subchondral cysts, osteophytes, joint space narrowing
C Subperiosteal bone resorption
D Subluxations (e.g. boutonniere and swan-neck deformities), joint ankylosis, z- thumb
deformity
Thrombotic Thrombocytopenic purpura
,This clinical presentation is consistent with thrombotic thrombocytopenic purpura (TTP),
which is associated with a pentad of signs and symptoms including fever,
microangiopathic hemolytic anemia, thrombocytopenia (with associated petechiae),
renal dysfunction, and neurological or mental status changes. Physical exam
demonstrates petechiae, a result of thrombocytopenia, and his peripheral blood smear
is positive for schistocytes (RBC fragments), which are seen in microangiopathic
hemolytic anemias such as TTP. - Answers - A 45-year-old man is brought to the
emergency room by his partner because he has been acting confused for the past day.
He is febrile, with an oral temperature of 103.6 deg F; vital signs are otherwise stable.
His physical exam is significant for the petechiae on the left foot; he has never noticed
lesions like these before. He also has subtle right-sided weakness affecting upper and
lower extremities. Labs reveal hemoglobin 7.0 g/dL, hematocrit 21%, white blood count
of 10.2 x 10^3 µL, and platelet count of 20 x 10^3 per µL. PT/INR and PTT are normal.
Schistocytes are noted on his peripheral blood smear. What is the most likely
diagnosis?
A Idiopathic thrombocytopenic purpura
B Disseminated intravascular coagulation
C Thrombotic thrombocytopenic purpura
D Hemolytic uremic syndrome
Lymph Node Biopsy
This patient presents with possible lymphoma. Diagnosis is made by lymph node
biopsy. Bone marrow biopsy and CT scan of the chest are used for staging of the
disease. - Answers - A 26-year-old male presents with a four-week history of fatigue,
night sweats, and a painless mass in his neck. Physical examination confirms the
presence of an enlarged right posterior cervical lymph node. What is the next best step
in the evaluation of this patient?
A Bone marrow biopsy and aspiration
B Lymph node biopsy
C CT scan of the chest
D Reexamine in 2-4 weeks
Venodilation
Stable angina pectoris results when myocardial oxygen demand exceeds oxygen
supply. Nitrates, the first-line therapy for acute episodes and they act principally through
smooth muscle relaxation and venodilation which causes blood pooling in the peripheral
vasculature with a concomitant reduction in preload. Decreased preload decreases
cardiac contractility and oxygen demand. - Answers - A 46-year-old man comes to the
office because of a four-month history of intermittent episodes of chest discomfort and
tightness. His symptoms typically occur only on exertion, such as when gardening or
playing with his children, and are relieved by rest. He says the episodes last less than
20 minutes. He has otherwise been healthy and his personal medical history is
,noncontributory. His father has coronary artery disease but is alive and well. Physical
exam, laboratory studies and ECG are normal. The medication most appropriate for
treating his acute episodes acts by which of the following mechanisms?
A Blocking calcium channels
B Controlling coronary artery vasospasm
C Decreasing heart rate
D Venodilation
E Arteriolodilation
Electrocardiogram
Electrocardiogram is the gold standard for diagnosing myocardial infarction within the
first 6 hours of symptom onset. Electrocardiogram changes will include ST-segment
elevation (signifying transmural infarct), ST-segment depression (signifying
subendocardial infarct), and Q waves (signifying transmural infarct). - Answers - A 48-
year-old man comes to the emergency department because of severe substernal chest
pain radiating to his left arm that began 1.5 hours prior to arrival. The pain is
accompanied by diaphoresis and shortness of breath. His blood pressure is 165/94 mm
Hg, pulse is 82/min, and respiratory rate is 18/min. An acute myocardial infarction is
suspected. Which of the following tests is the most important tool in the initial evaluation
of this patient?
A Aspartate aminotransferase
B Creatine kinase-myocardial bound
C Electrocardiogram
D Echocardiogram
E Lactate dehydrogenase
Abdominal Ultrasonography
The diagnostic procedure of choice in this patient is abdominal ultrasonography.
Gallstones will be demonstrated in approximately 95% of cases, and the specificity of
the procedure is high. Ultrasound examination should be done after 8 hours of fasting
because gallstones are visualized better in a distended, bile-filled gallbladder.
Ultrasound findings that suggest acute cholecystitis are pericholecystic fluid, gallbladder
thickening, and sonographic Murphy sign. CT scan and MRI is more sensitive in
diagnosis of choledocholithiasis; however, they are expensive and offer no more
sensitivity in the diagnosis of gallstones or acute cholecystitis. The HIDA scan is
expensive and reserved for cases in which the ultrasound study or CT scan is
nondiagnostic but there is a high suspicion of cholecystitis. - Answers - A 32-year-old
woman presents with 4-day history of sudden right upper quadrant abdominal pain that
is referred to the right shoulder tip. Pain was initially colicky, and then became constant.
Positive history of fever, nausea, and vomiting. On examination, she's acutely ill looking,
anicteric, febrile, positive murphy's sign, right upper quadrant abdominal tenderness
with muscle guarding and rebound tenderness present. CBC done showed WBC: 13 x
, 109/L; Serum amylase: 170U/L. Which of the following investigative procedures would
be the best initial test to aid in the diagnosis?
A Computed tomography (CT) scan of the abdomen
B Hydroxy iminodiacetic acid (HIDA) scan
C Abdominal ultrasonography
D Magnetic resonance imaging (MRI) of the abdomen
Fistula formation
This patient has Crohn's disease which is characterized by a transmural inflammation of
the GI tract. It may affect any part of the GI tract but is usually associated with the
terminal ileum, the colon, or both. On colonoscopy, areas of ulceration and submucosal
thickening give the bowel a cobblestone appearance, with some skipped areas of
normal bowel. In addition to the transmural inflammation, there are granulomas,
abscesses, fissures, and fistula formation. Symptoms include fever, weight loss,
abdominal pain (usually the right-lower quadrant), diarrhea (rarely with associated
blood), and growth retardation in children. Complications include intestinal obstruction;
toxic megacolon, which is usually more common in ulcerative colitis; malabsorption,
particularly associated with fat-soluble vitamins and especially vitamin B12; intestinal
perforation; fistula formation; and development of gall and - Answers - A 25-year-old
man with an 18-month history of chronic abdominal pain. The patient has seen several
physicians and has been diagnosed as having a "nervous stomach," irritable bowel
syndrome, and "depression." Associated with this abdominal pain for the past 3 months
have been nonbloody diarrhea, anorexia, and a weight loss of 20 pounds. He has
developed painful oral ulcers and a painful area around the anus. On examination, the
patient has diffuse abdominal tenderness. He looks thin and unwell. He has a tender,
erythematous area in the right perirectal area. Which of the following would be
associated with this patient's condition?
A Inflammation limited to the superficial layer of the bowel wall
B An affinity to involve the rectosigmoid junction
C Decreased risk of colon cancer
D Continuous mucosal areas of ulceration that affect the anus
E Fistula formation
Amlodipine
This patient has Raynaud phenomenon secondary to limited scleroderma. Treatment
involves stress management and cold avoidance. Calcium channel blockers (CCB),
such as oral nifedipine or amlodipine, are the first-line option. Topical nitrates and
phosphodiesterase type 5 inhibitors (e.g. sildenafil) can be used in patients with
contraindications to CCBs or who have failed prior CCB treatment. - Answers - A 39-
year-old woman is being evaluated for episodes of "hand discoloration." The patient
reports that these episodes are triggered by cold temperatures and resolve after 15-20
minutes. Past medical history is significant for hypertension, for which she has been
AND ANSWERS
acute interstitial nephritis
Acute interstitial nephritis (AIN) is a renal lesion that causes a decline in kidney function
and is characterized by an inflammatory infiltrate in the kidney interstitium. Drugs
(remembered as the 5 Ps) are the most common cause of AIN. The 5 Ps are Pee
(diuretics, especially sulfa ones), Pain-free (NSAIDs), Penicillins and cephalosporins,
Proton pump inhibitors, and rifamPin. Patients will present with elevated creatinine,
eosinophils, WBC casts, and hematuria. - Answers - A 62-year-old man presents to
your office with a sudden onset of fever and rash. His review of systems is negative. He
was recently started on omeprazole for acid reflux 14 days ago. Routine laboratory tests
reveal a serum creatinine of 3.5 mg/dL and eosinophilia. Urine studies showed white
blood cell casts. What is the most likely diagnosis?
A Acute interstitial nephritis (AIN
B Acute tubular necrosis
C IGA Nephropathy
D Postreptococcal Glomerulonephritis
Subluxations (e.g. boutonniere and swan-neck deformities), joint ankylosis, z-thumb
deformity
Rheumatoid arthritis's early signs include soft tissue swelling, osteopenia, erosions, and
joint space narrowing. Later changes include subluxation causing ulnar deviation, z-
thumb, boutonniere, and swan neck deformities, and ankylosis. - Answers - A 63-year-
old woman presents with pain in her hands for three years. She describes the pain as
progressive - coming on slowly and worsening over the course of the three years. She
says that her aunt and wheelchair-bound grandmother had problems with their hands as
well. A hand X-ray is obtained which shows soft tissue swelling and marked juxta-
articular osteopenia in her metacarpophalangeal and proximal interphalangeal joints,
and minor bony erosions. Which of the following will most likely be present on her plain
film ten years from now?
A Pencil-in-cup deformity, ankylosis, periostitis, dactylitis
B Subchondral sclerosis, subchondral cysts, osteophytes, joint space narrowing
C Subperiosteal bone resorption
D Subluxations (e.g. boutonniere and swan-neck deformities), joint ankylosis, z- thumb
deformity
Thrombotic Thrombocytopenic purpura
,This clinical presentation is consistent with thrombotic thrombocytopenic purpura (TTP),
which is associated with a pentad of signs and symptoms including fever,
microangiopathic hemolytic anemia, thrombocytopenia (with associated petechiae),
renal dysfunction, and neurological or mental status changes. Physical exam
demonstrates petechiae, a result of thrombocytopenia, and his peripheral blood smear
is positive for schistocytes (RBC fragments), which are seen in microangiopathic
hemolytic anemias such as TTP. - Answers - A 45-year-old man is brought to the
emergency room by his partner because he has been acting confused for the past day.
He is febrile, with an oral temperature of 103.6 deg F; vital signs are otherwise stable.
His physical exam is significant for the petechiae on the left foot; he has never noticed
lesions like these before. He also has subtle right-sided weakness affecting upper and
lower extremities. Labs reveal hemoglobin 7.0 g/dL, hematocrit 21%, white blood count
of 10.2 x 10^3 µL, and platelet count of 20 x 10^3 per µL. PT/INR and PTT are normal.
Schistocytes are noted on his peripheral blood smear. What is the most likely
diagnosis?
A Idiopathic thrombocytopenic purpura
B Disseminated intravascular coagulation
C Thrombotic thrombocytopenic purpura
D Hemolytic uremic syndrome
Lymph Node Biopsy
This patient presents with possible lymphoma. Diagnosis is made by lymph node
biopsy. Bone marrow biopsy and CT scan of the chest are used for staging of the
disease. - Answers - A 26-year-old male presents with a four-week history of fatigue,
night sweats, and a painless mass in his neck. Physical examination confirms the
presence of an enlarged right posterior cervical lymph node. What is the next best step
in the evaluation of this patient?
A Bone marrow biopsy and aspiration
B Lymph node biopsy
C CT scan of the chest
D Reexamine in 2-4 weeks
Venodilation
Stable angina pectoris results when myocardial oxygen demand exceeds oxygen
supply. Nitrates, the first-line therapy for acute episodes and they act principally through
smooth muscle relaxation and venodilation which causes blood pooling in the peripheral
vasculature with a concomitant reduction in preload. Decreased preload decreases
cardiac contractility and oxygen demand. - Answers - A 46-year-old man comes to the
office because of a four-month history of intermittent episodes of chest discomfort and
tightness. His symptoms typically occur only on exertion, such as when gardening or
playing with his children, and are relieved by rest. He says the episodes last less than
20 minutes. He has otherwise been healthy and his personal medical history is
,noncontributory. His father has coronary artery disease but is alive and well. Physical
exam, laboratory studies and ECG are normal. The medication most appropriate for
treating his acute episodes acts by which of the following mechanisms?
A Blocking calcium channels
B Controlling coronary artery vasospasm
C Decreasing heart rate
D Venodilation
E Arteriolodilation
Electrocardiogram
Electrocardiogram is the gold standard for diagnosing myocardial infarction within the
first 6 hours of symptom onset. Electrocardiogram changes will include ST-segment
elevation (signifying transmural infarct), ST-segment depression (signifying
subendocardial infarct), and Q waves (signifying transmural infarct). - Answers - A 48-
year-old man comes to the emergency department because of severe substernal chest
pain radiating to his left arm that began 1.5 hours prior to arrival. The pain is
accompanied by diaphoresis and shortness of breath. His blood pressure is 165/94 mm
Hg, pulse is 82/min, and respiratory rate is 18/min. An acute myocardial infarction is
suspected. Which of the following tests is the most important tool in the initial evaluation
of this patient?
A Aspartate aminotransferase
B Creatine kinase-myocardial bound
C Electrocardiogram
D Echocardiogram
E Lactate dehydrogenase
Abdominal Ultrasonography
The diagnostic procedure of choice in this patient is abdominal ultrasonography.
Gallstones will be demonstrated in approximately 95% of cases, and the specificity of
the procedure is high. Ultrasound examination should be done after 8 hours of fasting
because gallstones are visualized better in a distended, bile-filled gallbladder.
Ultrasound findings that suggest acute cholecystitis are pericholecystic fluid, gallbladder
thickening, and sonographic Murphy sign. CT scan and MRI is more sensitive in
diagnosis of choledocholithiasis; however, they are expensive and offer no more
sensitivity in the diagnosis of gallstones or acute cholecystitis. The HIDA scan is
expensive and reserved for cases in which the ultrasound study or CT scan is
nondiagnostic but there is a high suspicion of cholecystitis. - Answers - A 32-year-old
woman presents with 4-day history of sudden right upper quadrant abdominal pain that
is referred to the right shoulder tip. Pain was initially colicky, and then became constant.
Positive history of fever, nausea, and vomiting. On examination, she's acutely ill looking,
anicteric, febrile, positive murphy's sign, right upper quadrant abdominal tenderness
with muscle guarding and rebound tenderness present. CBC done showed WBC: 13 x
, 109/L; Serum amylase: 170U/L. Which of the following investigative procedures would
be the best initial test to aid in the diagnosis?
A Computed tomography (CT) scan of the abdomen
B Hydroxy iminodiacetic acid (HIDA) scan
C Abdominal ultrasonography
D Magnetic resonance imaging (MRI) of the abdomen
Fistula formation
This patient has Crohn's disease which is characterized by a transmural inflammation of
the GI tract. It may affect any part of the GI tract but is usually associated with the
terminal ileum, the colon, or both. On colonoscopy, areas of ulceration and submucosal
thickening give the bowel a cobblestone appearance, with some skipped areas of
normal bowel. In addition to the transmural inflammation, there are granulomas,
abscesses, fissures, and fistula formation. Symptoms include fever, weight loss,
abdominal pain (usually the right-lower quadrant), diarrhea (rarely with associated
blood), and growth retardation in children. Complications include intestinal obstruction;
toxic megacolon, which is usually more common in ulcerative colitis; malabsorption,
particularly associated with fat-soluble vitamins and especially vitamin B12; intestinal
perforation; fistula formation; and development of gall and - Answers - A 25-year-old
man with an 18-month history of chronic abdominal pain. The patient has seen several
physicians and has been diagnosed as having a "nervous stomach," irritable bowel
syndrome, and "depression." Associated with this abdominal pain for the past 3 months
have been nonbloody diarrhea, anorexia, and a weight loss of 20 pounds. He has
developed painful oral ulcers and a painful area around the anus. On examination, the
patient has diffuse abdominal tenderness. He looks thin and unwell. He has a tender,
erythematous area in the right perirectal area. Which of the following would be
associated with this patient's condition?
A Inflammation limited to the superficial layer of the bowel wall
B An affinity to involve the rectosigmoid junction
C Decreased risk of colon cancer
D Continuous mucosal areas of ulceration that affect the anus
E Fistula formation
Amlodipine
This patient has Raynaud phenomenon secondary to limited scleroderma. Treatment
involves stress management and cold avoidance. Calcium channel blockers (CCB),
such as oral nifedipine or amlodipine, are the first-line option. Topical nitrates and
phosphodiesterase type 5 inhibitors (e.g. sildenafil) can be used in patients with
contraindications to CCBs or who have failed prior CCB treatment. - Answers - A 39-
year-old woman is being evaluated for episodes of "hand discoloration." The patient
reports that these episodes are triggered by cold temperatures and resolve after 15-20
minutes. Past medical history is significant for hypertension, for which she has been
