Podcast Episode 87: Ten Internal Medicine EOR Questions

The Audio PANCE and PANRE Physician Assistant Board Review Podcast

Welcome to episode 87 of the Audio PANCE and PANRE PA Board Review Podcast.

Join me as I cover ten internal medicine rotation EOR content blueprint questions from the Smarty PANCE physician assistant board and rotation review website.

Special from today’s episode:

• Check out the updated Smarty PANCE Internal Medicine Rotation (EOR) Review Course
• Download your Free Trello Smarty PANCE PAEA Internal Medicine EOR Tracking Template
• Members can take the all-new Internal Medicine Rotation Practice Exam
• View the interactive Smarty PANCE Internal Medicine Rotation (EOR) Topic List

Below you will find an interactive exam to complement the podcast.

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Podcast Episode 87: Ten Internal Medicine EOR Pulmonology Questions

The following questions are linked to PAEA Content Blueprint lessons from the Smarty PANCE and PANRE Board Review Website. If you are a member, you will be able to login and view this interactive video lesson.

1. A 67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, mid abdominal distention, and lower left quadrant tenderness. Stool guaiac is negative. An absolute neutrophilic leukocytosis and a shift to the left are noted on the CBC. Which of the following is the most accurate test for this patient’s condition?

A Barium enema
B Colonoscopy
C CT scan
D. Sigmoidoscopy

Click here to see the answer

Answer: C CT scan

Diverticulitis presents with left lower quadrant abdominal pain, systemic symptoms (such as fever), nausea, vomiting, and leukocytosis on lab values. It typically occurs in a patient with a history of diverticulosis. The most accurate test for diverticulitis is a CT scan. Colonoscopy is contraindicated as it could cause rupture. Further management is keeping the patient NPO and administering ciprofloxacin, metronidazole, and IV fluids. Patients who can not tolerate oral antibiotics should be started on IV antibiotics. (Review topic: Diverticular disease)

• Barium enema is contraindicated in diverticulitis as it could cause irritation. A barium enema is the most accurate test in diverticulosis.
• Colonoscopy and sigmoidoscopy are contraindicated in diverticulitis as they could cause rupture. Colonoscopy is an accurate test for diverticulosis.

2. A 42-year-old homeless man presents to the emergency department with fever, painful muscle spasms in his arms and legs, and difficulty eating because of painful spasms in his jaw muscles. Until a week ago, he was wandering around the city looking for food and work and taking shelter in a commercial construction site. He reports not having seen a medical professional in more than 15 years. Examination of his feet reveals shoes with holes in the soles and a small, puncture-type wound on the bottom of the right foot. It is surrounded by erythema and somewhat tender to touch. The patient is uncertain what he may have stepped on. X-ray is negative for any radiopaque foreign body. In addition to hospital admission, which of the following is the first-line therapy for this patient?

A Tetanus immune globulin and tetanus toxoid
B Tetanus immune globulin and metronidazole
C Tetanus toxoid and penicillin
D Tetanus immune globulin, tetanus toxoid, and metronidazole

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The answer is D Tetanus immune globulin, tetanus toxoid, and metronidazole

Clostridium tetani infection is a vaccine-preventable disease that results in approximately 50 cases per year in the United States. Even with modern medical resources, 20% to 25% of patients with generalized tetanus die. Treatment includes airway protection, benzodiazepines for muscle spasm, tetanus immune globulin immediately, and three doses of tetanus toxoid given by the standard schedule. Metronidazole or penicillin is also administered to destroy the organism and prevent toxin production. (Review topic: Tetanus)

3. A 21-year-old male presents to the ED with increasing dyspnea and pleuritic chest pain of sudden onset after getting hit in the left side of the chest during a bar fight. Examination reveals moderate respiratory distress with an absence of breath sounds and hyperresonance to percussion on the left, with tracheal deviation to the right. Which of the following is the most appropriate next step?

A Order a V/Q scan
B Order a chest x-ray
C Administer a sclerosing agent
D Insert a large-bore needle into the left 2nd ICS stat

Click here to see the answer

The answer is D Insert a large-bore needle into the left 2nd ICS stat

Simple aspiration by insertion of a needle into the involved side will decompress the tension pneumothorax until a chest tube can be inserted. (Review topic: Pneumothorax)

• A V/Q scan is indicated in suspected cases of pulmonary embolism.
• Patients in respiratory distress and evidence of a tension pneumothorax, such as tracheal deviation, should have treatment initiated without waiting on a chest x-ray to be taken.
• Pleurodesis by the administration of a sclerosing agent is indicated in the treatment of recurrent, not traumatic, pneumothorax.

4. A 55-year-old woman with a history of ulcerative colitis presents to the emergency department with a severe flare. The patient reports numerous bloody loose stools and has been febrile for two days. Vital signs are T 102.0 HR 98 BP 131/86 RR 17 Sat 100%. The abdominal exam is notable for markedly distended abdomen with tympani and tenderness to palpation without guarding or rebound. A CT scan shows a markedly dilated descending and sigmoid colon with no perforations. What is the next best step in management for this patient?

A Oral prednisone
B IV hydrocortisone
C Rectal 5-ASA
D IV Metoclopramide
E IV Ondansetron

Click here to see the answer

The answer is B IV hydrocortisone

This patient is presenting with toxic megacolon secondary to ulcerative colitis (UC). The first-line treatment for patients with toxic megacolon from UC is IV glucocorticoids to reduce inflammation and the need for surgical intervention. (Review topic: Ulcerative colitis)

• Oral prednisone is not appropriate, as patients with toxic megacolon require NGT suction and NPO.
• While rectal 5-ASA is a treatment option for moderate colitis, but this patient has severe colitis.
• Metoclopramide is a Dopamine-2 receptor antagonist used as a prokinetic agent in individuals with a variety of gastric motility diseases. It is also an antiemetic (via 5-HT3 antagonist activity) and has further prokinetic activity by acting as an agonist on 5-HT4 receptors.
• Ondansetron is a Serotonin-3 receptor antagonist used as an antiemetic in patients with postoperative nausea or nausea due to chemotherapy.

5. A 21-year-old male with hematemesis. He is brought by his girlfriend who reports that he and his buddies have been out drinking every night last week in celebration of his 21st birthday. He reports having vomited each night, but tonight when he started vomiting, he noticed that there was streaking of blood. Concerned, he decided to come to the emergency department. Which of the following best describes the most likely diagnosis?

A Dilated submucosal esophageal veins
B Gastric mucosal erosion
C Mucosal tear at the gastroesophageal junction
D Transmural distal esophagus tear
E Transmural erosion of the gastric wall

Click here to see the answer

The answer is C Mucosal tear at the gastroesophageal junction

This patient is presenting with blood in his vomitus after forceful vomiting suggesting a diagnosis of a Mallory-Weiss tear. A Mallory-Weiss tear occurs secondary to a mucosal laceration at the gastroesophageal junction. (Review topic: Mallory-Weiss tear)

• Dilated submucosal esophageal veins describes esophageal varices. Though variceal bleeds could lead to bloody vomitus, this is a less likely diagnosis given this patient’s young age and lack of a past medical history of cirrhosis. There is no mention of ascites in the case and the normal PT/PTT suggests against a diagnosis of cirrhosis.
• Gastric mucosal erosion can occur due to decreased prostaglandin production which occurs in gastritis and peptic ulcer disease and presents with gnawing/burning epigastric pain, and can be associated with nausea and vomiting. This can occur with NSAID use or with alcohol abuse.
• Transmural distal esophagus tear describes Boerhaave syndrome which presents after violent retching with similar symptoms to a Mallory-Weiss tear but with the additional findings of subcutaneous emphysema and odynophagia. This is a surgical emergency and is a progression from a simple Mallory-Weiss tear which presents with only bleeding.
• Transmural erosion of the gastric wall describes a perforated gastric ulcer which can cause bleeding from the left gastric artery, epigastric pain, and unstable vitals. It is less likely to present after violent vomiting. A perforated peptic ulcer could present with severe abdominal pain and free air under the diaphragm.

6. A 25-year old female presents to the clinic with an 8-month history of intermittent crampy lower abdominal pain, with the passage of loose stools 4 times a day. Pain is usually worse during her menstrual period and is relieved by defecation. She also feels bloated. She says she has been undergoing work-related stress for months. There are no ALARM symptoms and there are no significant findings on physical examination. Which of the following is associated with this patient’s condition?

A Alvarado score
B Ranson criteria
C Rome criteria
D Revised Jones criteria

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The answer is C Rome criteria

The diagnosis of IBS can be made using the Rome criteria if patients have no red flag findings, such as rectal bleeding, weight loss, and fever, or other findings that might suggest another etiology. Patients with one of these red flag findings require further imaging studies and/or colonoscopy. (Review topic: Irritable bowel syndrome)

• The Alvarado score is used in making a diagnosis of acute appendicitis
• Ranson criteria Are used in assessing the severity of acute pancreatitis
• Revised Jones criteria are used in diagnosing rheumatic fever

7. A 56-year-old woman came to the clinic complaining of a lump protruding from her anal opening. It was initially reducible, but it now irreducible. There is associated pain and itching. She also noticed bright red blood on her stool when she defecates. There is an associated history of chronic constipation. Examination of the perianal area revealed skin tags and a tender perianal mass covered with mucosa. Inspection of the anal mucosa showed no fissure. What is the grade of the condition?

A Grade I
B Grade II
C Grade III
D Grade IV

Click here to see the answer

Answer: D Grade IV

This is a Grade IV permanently prolapsed hemorrhoid. (Review topic: Hemorrhoids)

Incorrect Answers:

• Grade I is bleed only no prolapse
• Grade II is prolapsed but reduces spontaneously
• Grade III is prolapsed and has to be manually reduced

8. A 45-year-old male presents with complaints of heartburn, belching, and epigastric pain for the past six months. He reports that symptoms occur within an hour of eating a meal and are aggravated by drinking coffee, eating fatty foods, and lying down. He has tried eating smaller meals and avoiding spicy food to no avail. He denies vomiting, difficulty swallowing, recent weight loss, or changes in stool color. His temperature is 98.9 °F, blood pressure is 147/82 mmHg, pulse is 86/min, respirations are 18/min, and BMI is 32 kg/m^2. His abdomen is soft, non-tender, and bowel sounds are auscultated in all quadrants. His laboratories are unremarkable and his fecal occult blood test (FOBT) is negative. What is the next best step in this patient’s management?

A 24-hour pH monitoring
B Endoscopy
C Metoclopramide
D Ranitidine
E. Omeprazole

Click here to see the answer

The answer is E. Omeprazole

GERD is a common complaint at primary care offices. It classically presents with heartburn, epigastric pain, and a sour taste that occurs within an hour of consuming a meal. PPIs are the initial medical management, except in the case of alarm symptoms. Any patient with symptoms of GERD accompanied by dysphagia, recurrent vomiting, weight loss, hematemesis, anemia, melena, or age > 50 should undergo endoscopy as these are considered high risk for the presence of an upper gastrointestinal malignancy. (Review topic: Gastroesophageal reflux disease)

Incorrect answers

• 24-hour pH monitoring is considered the gold standard in the diagnosis of GERD. However GERD can usually be diagnosed clinically, and 24-hour pH monitoring should only be employed in order to confirm the diagnosis in atypical presentations or in patients refractory to PPI therapy
• Endoscopy for GERD is indicated if patients have alarm symptoms. This patient is under the age of 50 and lacks alarm symptoms; therefore, endoscopy is not indicated.
• Metoclopramide is a prokinetic agent that is often used to treat gastroparesis. While it has utility in managing GERD, it is not a first-line medical agent.
• Ranitidine is a histamine-2 receptor antagonist that is indicated if patients have failed PPI therapy. Ranitidine products were found to be contaminated with NDMA, a probable human carcinogen that may be linked to many types of cancer, including bladder cancer, colon cancer, and prostate cancer.

9. A 65-year old man who is being managed for lung cancer on the ward makes a complaint of a 2-day history of the passage of nonbloody watery stool up to 4 times per day, anorexia, cramping abdominal pain, and fever. Meanwhile, he had a 10-day course of antibiotics 4 weeks ago on account of a lung infection. Which of the following is the most likely cause of his diarrhea:

A Salmonella
B Rotavirus
C Clostridium difficile
D E. coli

Click here to see the answer

The answer is C Clostridium difficile

Clostridium difficile colitis results from a disturbance of the normal bacterial flora of the colon, colonization by C. difficile, and the release of toxins that cause mucosal inflammation. Antibiotic therapy is the key factor that alters the colonic flora. (Review topic: Gastroenteritis)

Incorrect answers

• Salmonella is a cause of diarrhea following food poisoning.
• Rotavirus is a common cause of diarrhea in children. Less common in adults. Doesn’t occur as a result of recent use of antibiotics.
• E. coli is a cause of diarrhea following food poisoning.

10. A 37-year-old male with a history of daily NSAID use complains of epigastric pain, nausea, and vomiting, all worsened by eating. On physical examination, he is tender to palpation in the epigastrium. He admits to drinking approximately two beers per day. He was prescribed a course of ranitidine followed by omeprazole after his symptoms did not resolve. He was referred for endoscopy, with findings consistent with a gastric ulcer. Biopsy with silver staining is positive for H-Pylori. Which of the following is the most effective regimen for the treatment of this condition?

A Omeprazole, metronidazole, tetracycline, bismuth
B Omeprazole, penicillin, famotidine
C Amoxicillin, clarithromycin
D Pantoprazole and levofloxacin
E Pantoprazole

Click here to see the answer

The answer is C. Omeprazole, metronidazole, tetracycline, bismuth

This patient presents with H. pylori gastritis complicated by a peptic ulcer. Treatment for H. pylori is with triple or quadruple therapy. Omeprazole, metronidazole, tetracycline, and bismuth are appropriate quadruple therapy. (Review topic: Esophagitis)

Incorrect answers

• Omeprazole, penicillin, famotidine is not a treatment regimen for H. pylori infection
• Although amoxicillin and clarithromycin is an appropriate antibiotic regimen, this combination requires a PPI such as omeprazole
• Pantoprazole and levofloxacin are not a treatment regimen for H. pylori; the combination requires the addition of amoxicillin for effective triple therapy.

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