FRONTRUNNERS® 2019 INTERNAL MEDICINE QUESTIONS & ANSWERS PREP FOR THE 2019 ABIM EXAMS►►sample only by FRONTRUNNERS®

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FiFloN,rr:U 'NNEiFlS® ~ IN7CERNBL MEDICINE Q&a REVIEW:

SYLLRBUS COMPRNION FOR BORRD R€VI€W / Practice Questions & Rnswers for the RBIM €ram

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BRADLEY MITTMAN, M.D.

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16th Edition

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~ ~ ~ ~ ~ ~ ~ Fi=\.ON'ri=\.UNNe~ aoai=\.Ll INTERNAL MEDICINE BOARD REVIEW

TOLL-FREE 866-MDBOARD or 866-IMREVIEW (866-632-6273 or 866-467 -3843)

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www.gofrontrunners.com

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TABLE OF CONTENTS: HOT OFF THE PRESS: THIS JUST IN!

NEPHROLOGY & CLINICAL TOXICOLOGY BLOOD GASES RHEUMATOLOGY GASTROENTEROLOGY INFECTIOUS DISEASES DERMATOLOGY NEUROLOGY, GERIATRICS ALLERGY & IMMUNOLOGY CARDIOLOGY I & II PULMONARY MEDICINE & CRITICAL CARE ENDOCRINOLOGY HEMATOLOGY ONCOLOGY STATISTICS ANSWER KEY EXPLANA TIONS

REFERENCES INDEX

PREFACE Welcome to FRONTRUNNERS INTERNAL MEDICINE Q&A REVIEW, designed to prepare you for the MEDICINE BOARDS as well as the medicine and subspecialty components of the USMLE STEPS 2 & 3. Students who are preparing for the USMLE and are thinking about a residency in medicine as well as current medicine residents will ALSO be way ahead of the game when it comes time to sit for their medicine boards (yes, there's actually one more exam after step 3 (!) and it's the all-important one that makes you "board-certified"). This book is an excellent companion to the Frontrunners Internal Medicine Board Review Syllabus, which remains the syllabus for the Frontrunners Board Review courses that are held throughout the year. While designed with the boards in mind, these resources are nonetheless outstanding study aids for medical students. residents. and practicing internists who simply want the best no-nonsense and most realistic Q&A review of internal medicine in all of its subspecialties. And for those who are simply looking to expand their fund of knowledge in medicine, this back is without compare, and is ideal for health care professionals at all levels, including nursing practitioners and physician assistants. If you're a mnemonics fan (and who isn't?) and you're prepping for the board~ then you'll definitely want to check out TURBO MNEMONICS FOR THE BOARDS. See the "Uuu:k Oute1-- rCU1~' at the end of this book. With over 400 memory aids to the most commonly asked material, it can only turbo-boost your performance on the boards! This critical board review resource is chock-full of over 1,300 internal medicine boardoriented questions for you to review before you physically sit for your exam, because, just as important as knowing your "stuff" is being psychologically prepared. Equally important, this review will prepare you for the "all except", "next best step", and multiple choice-type questions and answers that are now customary on the exams. While this Q&A review is an excellent companion to the Frontrunners syllabus, the two need not be used together. These Frontrunners "warm-up exercises" will prepare you well for the essential material that you can expect to find on your boards. In our efforts to incorporate as much of this key material as possible into your review in as succinct a manner as possible, you will find explanations to questions where explanations are due, and not simply to "just fill space". The explanations will not serve to simply reiterate the entire core of the syllabus, but rather to shed light as needed. The length of the questions has been abbreviated to allow you to maximize your content exposure in as little time as possible. This book has also been popular in helping physicians make "connections" or concept links, so that "if you see this in the question, look for this in the answer." The matching style questions are especially great for this building these links in your mind. The tighter those links in your mind, the better you'll performance will be on the exam. Having said all this, we also realize that there are individuals who have, over the years, grown weary of tedious self-study and who want to take advantage of a sit-down, "feed-me" style of board review, even if the Frontrunners' AUDIO SYLLABUS. SLIDE SHOWS & book packages can just be ordered. For this reason in early August each year we continue to offer our formal WEEKEND MARATHON REVIEW board review course which covers 20 hours of high-yield-onlv review for the boards over one Saturday-Sunday weekend. For details/registration on any of our internal medicine board review courses or if you simply want to get the Audio ~lIabus or Slide Shows, call us toll-free 866-MDBOARDS or 866-IMREVIEW. See the "Ouu:k O~ rc~' at the end of this book. HMOs are requiring that their PCPs be board-certified, or, at the very least, board-eligible to come on-board and stay on-board In fact, the terms "board-certified" and "board-eligible" are increasingly becoming an integral part of HMO contracts and renewal criteria. Being boardcertified, therefore, is no longer a luxury. To some physicians, it's more than just placating the HMOs or even maintaining one's practice. It's about personal challenge; it's about being able to call oneself a "board-certified internist"; but even more simply, it's about winning! We want you to win. However you plan to use this book, our greatest hope is that we help you achieve your goals and make your life, dare we say, a little easier?

With greatest wishes for you,

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FRONTRUNNERS BOARD REVIEW

I-Io,r OFF ,rl-lE ?MESS! ",rl-lIS JUs,r IN": Q&a =019 1. A new drug recently underwent a controlled study showing that out of 1833 patients receiving the drug, 1063 showed improvement to target, while of 1340 controls, only 335 showed improvement. What was the Number Needed to Treat (NNT)?

A. 1.5 B. 3.0 C.5.0 0.7.5

Answer/Explanation: Answer is B. 3.0. Here's how to do NNT on the exam: NUMBER NEEDED TO TREAT (NNT) The Absolute Risk Reduction (ARR) is the difference between the event rate in the experimental group and the event rate in the control group. It is the denominator in the NNT calculation. Many reviews and trials provide this information, so if you have it and convert it into a proportion, then you can get the NNT by dividing 1 by the ARR, or ~ NNT = 1/ARR

1 =

NNT= ARR

(IMPrxl TOTrx) - (IMPcon 1 TOTcon)

(1063/1833) - (335/1340)

IMPrx

= # patients receiving treatment (rx) where there was an IMPact (i.e. reached treatment goals or target) TOTrx = Total # of patients receiving the treatment IMPcon = # patients who achieved target on control TOTcon= Total # of patients in control group

I=I 2.

.58 - .25

.33

NNT = 3.0

A 28 yo after-school teacher presents with complaints of 2 weeks of bilateral . arthralgias involving her hands, knees, wrists and ankles. She also complains of weakness and fatigue. She has a history of menorrhagia and iron deficiency anemia, is currently half-way thru her menstrual period, but describes that while the joint pains seem to be slowly resolving over the last few days, her weakness and fatigue are worse than usual for her period. Which of the following would be the most likely cause of her complaints?

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 A. B. C. D.

Sickle cell disease Still's disease Parvovirus Serum sickness

Answer: C. This is a classic Parvovirus B19 presentation in an adult. You have to know it. Although parvovirus infections in adults are most commonly asymptomatic, an estimated 60 percent of women with symptomatic disease manifest arthropathy. The symptoms usually subside within one to three weeks. Approximately half of adults will not have a rash at all. one half of patients have an associated generalized rash, and about 15 percent have the typical facial exanthema or "slapped cheek" rash. The distribution and symmetry of arthralgias also makes this classic, along with her past medical history of iron deficiency anemia. Because parvovirus B 19 infects erythroid progenitor cells in the bone marrow and causes temporary cessation of red blood cell production, patients who have underlying hematologic abnormalities (and thus depend on a high rate of erythropoiesis) are prone to cessation of red blood cell production if they become infected. This can result in a transient aplastic crisis, which may occur in persons with chronic hemolytic anemia and conditions of bone marrow stress. Thus, patients with sickle cell anemia, thalassemia, acute hemorrhage and iron deficiency anemia are at risk. When adults get the rash, it's typical a generalized exanthema, whereas in kids, the exanthem most commonly involves the malar eminences and spares the nasal bridge and perioral areas, giving the characteristic "slapped-cheek" appearance. See pp 103, 304 & 336 of Frontrunners Syllabus and pp 2, 85, 107, 213 & 222 of this book for additional related questions.

3. One year ago 75 yo male smoker with hypertension was diagnosed with a 4.1 cm abdominal aortic aneurysm on ultrasound. The patient is asymptomatic and his BP has been stable at 140/85. He represents for follow-up measurement which has increased to 4.5 cm. He is referred by his primary care physician for surgical consultation. The surgical fellow discusses the risks and benefits of surgery and the patient is schedule for. In addition to the informed consent, which of the following should be discussed:

A. B. C. D.

Increasing the dose of his blood pressure medication Patient's resuscitation wishes in the event of an emergency Health care proxy Likelihood of rupture

Answer: D. Likelihood of rupture. This patient is not yet a surgical candidate. Remember, aneurysms less than 5 cm do not pose a great risk of rupture and are usually followed up regularly with ultrasound and other non-invasive investigations. The general recommendation is to consider elective aneurysmorrhaphy for aneurysms with a diameter of 5 cm or greater or for small aneurysms that have an average growth rate of more than 0.5 cm/y.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 4. 22yo male athlete in excellent condition on no medicines, except 2 different types of multivitamin to make sure he gets all his daily requirements of magnesium, as well as his shark cartilage and his daily protein powder milkshake, presents for routine exam. His physical is unremarkable and his serum calcium is 10.8. His family history is unremarkable other than diabetes in his maternal aunt. Which of the following is most likely going on in this patient? A. B. C. D.

Hypervitaminosis 0 Hyperalbuminemia due to increase protein intake Hyperparathyroidism MEN I Answer: A. Hypervitaminosis D. See Frontrunners Syllabus p. 282 & 285 if you even thought it might have been c) or d).

5. 35 yo woman presents referred by her obstetrician following a spontaneous abortion and swelling in her right leg. Patient has given birth to a healthy boy 5 years ago, but experienced a transient ischemic attack during that child birth. She has no other symptoms. Aside from obvious swelling in her lower right leg, exam is benign. Ultrasound reveals a venous thromboembolism in her right posterior tibial artery. Which of the following do you suspect? A. B. C. D.

Hyperfibrinogenemia Factor V Leiden Prothrombin 20210 mutation Antiphospholipid antibody Answer: D. Antiphospholipid antibody. This is a typical Antiphospholipid antibody syndrome question. Additional clinical manifestations include: recurrent spontaneous abortion, thrombocytopenia, neurologic events, venous thromboses; arterial thromboses. See pp 331 & 334 of Frontrunners Syllabus and pp 3, 58 & 173 of this book for additional related questions.

6. A 28-year-old female presents with high fever and dry cough. Serum sodium is 127, glucose 102, and calcium 9.2. Which is the treatment of choice? A. B. C. D.

Cefotaxime Erythromycin Amino glycoside Isoniazide Answer: B. The scenario is typical for Legionnaires disease. Note the typical hyponatremia. See page 233 of Frontrunners Syllabus or Pulmonary Q&A #8 p. 149 for more.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 7. A 59-year-old lady presents for evaluation of a mole on her chest. She states that, though it has been present for years, she recently noticed changes in its size and border irregularity. You recommend a biopsy. If cutaneous melanoma is confirmed, which is most important with regards to outcome?

A. B. C. D.

Evolution of the lesion from a dysplastic nevus Tumor diameter Tumor thickness Tumor location Answer: C. For primary tumors, the most consistent factor predictive of outcome is tumor thickness, as described by the Breslow depth. See page 156 of Frontrunners Syllabus and memorize those boxed-in margins!

8. A 16-year-old boy presents with fever and joint pain. Rheumatoid factor is negative, WBC are elevated and the spleen tip is palpable. What do you suspect?

A. B. C. D.

Infection Rheumatoid arthritis Still's diseases Infectious mononucleosis Answer: C. See pp 34 of the Syllabus for more key info you'll need to know re Still's disease and pp. 4, 50 & 203 of this book for additional related questions.

9. A 14 year old boy has unprovoked edema of the dorsal aspect of his right hand. Family history is significant for a sudden parent death at the age of 31. Which further testing would you order?

A. B. C. D.

C 1 and C4 level C5 ... C8 complement components Wheal and flare test MRI of the affected hand Answer: A. The history leads to suspicion of hereditary angioedema (HANE) due to C1 deficiency. Careful not to confuse with choice B indicated for recurrent neisseria gonorrhea infections. See p.181 of Frontrunners Syllabus or this book Q&A pp. 104 & 221 for more.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 10. The mechanism of action of ACE inhibitors involves which of the following?

A. B. C. D.

Efferent arteriole Leakage of protein Pressure reduction Glomerular filtration regulation Answer: A The efferent arteriole of the kidney. ACE inhibitors reduce efferent arteriole resistance and relieve glomerular hypertension, improve renal hemodynamics and interrupt the progression of glomerulosclerosis. In fact, ACE inhibitors and angiotensin-receptor antagonists reduce intraglomerular pressure by inhibiting angiotensin-Ii-mediated efferent arteriolar vasoconstriction.

11. A 64 male patient presents with ascites and portal hypertension. Serum albumin is 3.9 while the level of albumin in the ascitic fluid was 3.0. Which of the following would be a potential cause of this patient's ascites?

A. B. C. D.

Portal vein thrombosis Congestive heart failure Massive liver mets Peritoneal carcinomatosis Ans. D SAAG = 0.9. Of these 4 choices only peritoneal carcinomatosis fits a SAAG (serum ascites albumin gradient ) less than 1.1. See p. 57 of Frontrunners Syllabus for section on SAAG.

12. Of the following, which is the most common side effect of Infliximab (RemicadeÂŽ ) ?

A. B. C. D.

Myelosuppression Hepatic toxicity Proteinuria Upper respiratory tract infections Answer: D The most common side effects of infliximab are upper respiratory tract infections, urinary tract infections, cough, rash, back pain, nausea, vomiting, abdominal pain, headache, weakness and fever. See page 30, 85 of Frontrunners Syllabus for more.

13. A 45-year-old alcoholic lady presents with confusion, pruritis. On exam she's found to be jaundiced and mentally obtunded. AL T and AST show marked transaminitis. Bilirubin is 9.0. Direct bilirubin is 7.3.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 Alkaline phosphatase is elevated. Antimitochondrial antibodies (AMA) are positive. Which of the following is the treatment of choice?

A. B. C. D.

Alpha interferon Liver transplant Ursodeoxycholic acid Portocaval shunt Answer C. Ursodeoxycholic acid. Patient has a classic Primary Biliary Cirrhosis (PBC). Remember, at least 6 months of sobriety is required for liver transplant. Portocaval shunt would make any encephalopathy worse. See page 69 of Frontrunners Syllabus and p. 66 & 207 of this book for more.

14. A patient who presents with acute SOB and JVD undergoes right heart cath. Right heart cath later reveals tall V-waves. Which of the following conditions is consistent with these findings?

A. B. C. D.

Aortic stenosis Mitral regurgitation Tricuspid stenosis Pulmonary insufficiency Answer: B. Mitral regurgitation. When seen, tall v-waves are usually indicative of acute and/or severe mitral regurgitation, as seen in papillary muscle dysfunction or rupture with mitral regurgitation. Tall vwaves can also be seen in tricuspid regurgitation, as blood is regurgitated into the RA during ventricular systole. Watch for this in Inferior Wall MI and right ventricular infarctions. For patients with large anterior wall Mis, remember too Ventricular Septal Defect (VSD) can also give these tall v-waves. See p. 207 Frontrunners Syllabus for more on wave forms and classic findings on right heart cath.

15. A 44 year old male presents with headache, fever, sore throat, and dry cough. Cold agglutinins are positive. Chest X-Ray reveals patchy bilateral interstitial infiltrates. Which of the following is the most likely etiological agent?

A. B. C. D.

Streptococcal pneumonia Mycoplasma pneumonia Legionnaires' disease Streptococcal pyogenes Answer: B. Mycoplasma pneumonia. Syllabus for more.

See p. 113 Frontrunners

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 16. A 68-year-old patient with a history remarkable for colon cancer stage C by Duke's staging comes to your clinic with right supraclavicular node, which after biopsy proved to be adenocolonic cancer. Currently, patient presents with a lytic lesion in the femor head. Which is the treatment of choice?

A. B. C. D.

Surgically remove Chemotherapy Needle biopsy Do not treat Answer: B. The current accepted practice for colonic tumors with positive lymph nodes (stage C) is adjuvant chemo. See page 346 of Frontrunners Syllabus for Duke's staging and more key info on this topic.

17. A 57 year old male presents with symptomatic arrhythmia. EKG reveals delta waves. Which is the treatment of choice?

A. B. C. D.

Beta blockers Radiofrequency catheter ablation Digitalis Calcium blockers Answer B Catheter ablation is the treatment of choice for WPW patients with symptomatic arrhythmias. See pp. 203, 204, 215 of Frontrunners Syllabus for critical info on this topic.

18. A pregnant woman notes a red, circular, expanding rash with a central clear zone on her right anterior thigh. She claims it erupted a few days after she returned from a trip to Wisconsin. From the following choices, which is the best option?

A. B. C. D.

There is not enough evidence to pursue treatment Doxycycline 100 mg po bid for 10 days Amoxicillin 500 mg po tid for 28 days Ceftin (cefuroxime axetil) 500 mg po bid for 21 days Answer D. The patient presents with a classic ECM (Erythema Chronicum Migrans) of early Lyme disease. No doxycycline (or tetracycline) in pregnancy. One trick here is the Amoxicillen. Yes, Amoxicillen is a treatment option, but in early localized Iyme disease, treatment is Amoxicillen 500 tid x 10-21 days or Ceftin (cefuroxime axetil) 500 mg po bid for 21 days. The 28 day treatment shown in answer C is for Lyme arthritis in pregnancy. See pp. 41, 42, 150, 159 of Frontrunners Syllabus and p. 106 of this book for related material on ECM.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019

19. A 55-year-old nonalcoholic, male runner on no meds and with an unremarkable past medical history presents with complaints of left hip pain that seems to radiate down the lateral aspect of his thigh. He does not recall any trauma. His symptoms are made worse when he lies on his left side and the pain often awakens him at night. He also notes that weight bearing can often exacerbate the pain and he feels that the pain limits his strength in that leg. On exam, you find point tenderness over the left hip. Lateral hip pain is reproduced with flexion of the hip and followed by resisted hip abduction. Straight leg raising test is negative and neurologic exam is unremarkable. Strength testing reveals 5/5 throughout. There's no crepitus and plain films are unremarkable. Which is the testing modality of choice?

A. B. C. D.

Osteoarthritis Avascular necrosis Trochanteric bursitis Lumbosacral radiculopathy Answer: C Trochanteric bursitis is characterized by painful inflammation of the bursa located just superficial to the greater trochanter of the femur. Patients typically complain of lateral hip pain, although the hip joint itself is not involved. The pain may radiate down the lateral aspect of the thigh. The most classic finding is point tenderness over the greater trochanter, which reproduces the presenting symptoms. Exacerbation of his symptoms by lying on that side is also typical in trochanteric bursitis. Most commonly, repetitive (cumulative) trauma is involved. All the other signs are also classic. Be able to recognize this on your exam.

20. Which of the following is the best indication of virologic failure following Highly Active Anti Retroviral Therapy (HAART)?

A. CD4 count <350 B. Failure to increase 100 cells/mm 3 above the baseline CD4 cell count over the first year of therapy C. >400 HIV RNA copies/ml after 24 weeks of treatment D. >300 HIV RNA copies/ml after 24 weeks of treatment Answer C . For convenience, the following explanation is reproduced from Frontrunners HIV Primer™: ~

CRITERIA FOR TREA TMENT FAILURE

Virologic Failure (H IV RNA) • >400 viral copies/mL after 24 wks of treatment • >50 viral copies/mL after 48 wks of treatment • >400 viral copies/mL after suppression of viremia © 2019 FRONTRUNNERS BOARD REVIEW. ALL RIGHTS RESERVED.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 o

Immunologic Failure: • Failure to increase 25-50 cells/mm 3 above the baseline CD4 cell count over the first year of therapy

Clinical Failure • Occurrences of HIV-related events (after >3 months on therapy; excludes immune reconstitution syndromes)

Instituting Changes In HAART: • Ideally, all agents should be changed in cases of treatment failure. However, at least 2 of the 3/4 drug regimens should be changed to new drug classes, one of which should be an NNRTI if not already part of the regimen being changed. • Consider resistance testing • It is acceptable to change a single agent if patients are unable to tolerate a specific agent of course.

21. A 31 yo pregnant woman presents with a maculopapular rash over her palms and soles several months after the sudden onset of a painless chancre that disappeared without treatment. Patient is currently VDRL negative and is known to be allergic to penicillin. Which is the treatment of choice?

A. B. C. D.

No treatment is indicated since VDRL negative Abort fetus and initiate doxycycline Desensitize and initiate penicillin Give penicillin despite current allergy Answer: C. Penicillin is the only medication for syphilis in a pregnant woman as it crosses the placenta and treats the fetus as well. See p. 35, 119, 120, 129,130,152,212 of Frontrunners Syllabus and pp 50,101,214,228 of this book for more key information on syphilis.

22. A 26-year-old athlete complains of recent onset of wheezing and chest tightness since he began adding to his daily exercise regime an early morning run. Which of the following is the first line of drug therapy?

A. B. C. D.

Steroids Short acting beta agonist Leukotriene inhibitors Cromolyn Answer: B. See page 240 of Frontrunners Syllabus and p. 157 of this boook for more key information on exercise-induced asthma.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019

23. A 50-year-old postmenopausal lady presents for an annual physical exam. A thyroid nodule is found. Patient does not describe any symptoms nor show any signs consistent with hyper- or hypothyroidism. Which would be your next step?

A. B. C. D.

No further testing as patient is asymptomatic Thyroid scan Fine needle aspiration Ultrasound Answer: C. Fine needle aspiration is the initial step in the workup for any thyroid nodule. See page 279 of Frontrunners Syllabus for the workup of a thyroid nodule and more.

24. A 28 pregnant lady comes in for her first trimester ultrasound. Incidentally, patient asks you if the hot flashes she is feeling are a consequence of the pregnancy. Upon further questioning patient admits she sweats all the time and had several episodes of palpitations. A quick look at her recent blood exam documents hyperthyroidism. Which is the treatment of choice?

A. B. C. D.

Do not treat during pregnancy due to teratogenicity of medications Methimazole Propylthiouracil (PTU) Surgery Answer: C. PTU is considered a safe option for treatment of Graves' during pregnancy. See page 279 of Frontrunners Syllabus.

25. A 18-year-old lady on no meds and in otherwise excellent health presents with amenorrhea. Beta-HCG and prolactin levels are both normal. Which do you order next?

A. B. C. D.

DHEAS LH: FSH ratio Estrogen levels Progesterone challenge Answer: D. A progesterone challenge should always be done at this stage to check for withdrawal bleeding, which indicates that patient's estrogen levels are sufficient to prime the uterus for bleeding. If there is withdrawal bleeding, rule out pcas. See Frontrunners Syllabus p. 261 for more.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 26. Your very next patient is a 27 yo woman presents with amenorrhea and hirsutism. Beta-HCG is negative. Which of the following is the next best step?

A. B. C. D.

DHEAS LH: FSH ratio Estrogen levels Progesterone challenge Answer: B. This time the answer is B because of the additional hirsutism and you should suspect pcas. An i LH/FSH ratio (>3/1) is what you expect to find. See Frontrunners Syllabus p. 261 for amenorrhea workup. Now, if this patient had simply had hirsutism without the amenorrhea, then DHEAS would have been your answer, checking for congenital adrenal hyperplasia and adrenal tumor, since DHEAS is an adrenal androgen. See pp. 259-260 for more on hirsutism workup and CAH (know the link between 21-hydroxylase deficiency, hirsutism, and virilization!)

27. A 32-year-old man presents with hypertension, headaches, weight loss and palpitations. A 24-hour urine specimen was significant for vanillylmandelic acid (VMA). Which is the treatment of choice?

A. B. C. D.

Propranolol Phentolamine ACE inhibitors Verapamil Answer: B. Alpha-blockers are most important in the treatment of pheochromocytoma. See p. 223 of Frontrunners Syllabus for more on pheochromocytoma.

28. A 23-year-old type 1 diabetic presents with abdominal pain, change of vision, and nausea. Blood test reveals a pH of 7.18, a measured serum sodium of 131 and glucose level of 500mg/dl. Anion gap is 10. Which of the following should be included in the treatment?

A. NS, insulin, bicarbonate B. ~ NS, insulin, bicarbonate C. NS, insulin D. ~ NS, insulin Answer. B. The corrected sodium level is 137 therefore ~ NS is indicated. Bicarbonate is given when pH level is <7.2. Definitely see page 288 of Frontrunners Syllabus if you don't know how to calculate corrected sodium.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 29. 78-year-old man presents with lower back pain and generalized weakness. Plain film of the lumbosacral area reveals a fracture of the L4 vertebral body. Serum protein electrophoresis (SPEP) shows an M protein spike with M-protein = 2.3 g/dL. Mild anemia is detected on CBC. Plasma cells in the bone marrow are 7%. Which is the recommended management?

A. B. C. D.

Melphalan Melphalan and prednisone No treatment Methotrexate Answer C. Patient has monoclonal gammopathy of undetermined significance (MGUS) and should be left alone. Remember that, in differentiating MGUS from Multiple Myeloma, 3.0g/dL and 10% are the cutoffs, respectively, for M-protein and plasma cells in the marrow. See pp. 317 & 358 of Frontrunners Syllabus for more on MGUS and pp 3,11,23,301, 317-318 for more on Multiple Myeloma.

30. A 74 yo female with chronic bronchitis presents in acute pulmonary distress. She is vented, stabilized and shows improvement during the first 24 hours. On the second hospital day, the nurse calls you saying the patient's peak pressures alarm has been going off all day and if you could take a look at her vent settings and reevaluate the patient. Plateau pressures and compliance are normal. Which of the following could be setting off the alarm?

A. B. C. D.

Mucus plugging Cuff leak or cuff rupture Pneumothorax ARDS Answer: A. Mucus plugging. Cuff leak/rupture gives low peak pressure. Pneumothorax yields high peak and plateau pressures. ARDS can simply give low compliance. Other scenarios that can yield high peak pressures include: ETT down the right mainstem bronchus, kinked tubing, bronchospasm, and patient bucking the vent. See Frontrunners Syllabus p. 255 and pp 46 & 161 of this book for related questions.

31. 30yo male suffered a crush injury with a broken femur after being hit by a car while jogging. EKG showed tall T-waves. What's the next best step in management?

A. B. C. D.

Insulin and D5W Lasix and Kayexalate Calcium gluconate Sodium bicarbonate Answer: C. Calcium gluconate (K+>6.5 mEq/L or any K+ level with EKG changes consistent with hyperkalemia). See p. 202 of Frontrunners Syllabus for more.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 32. According to the American Heart Association's recently revised recommendations on endocarditis prophylaxis, prophylaxis for dental procedures is still recommended for each of the following cardiac conditions except:

A. B. C. D.

Prosthetic cardiac valve Previous infective endocarditis Mitral Valve Prolapse Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure Answer: C. See p. 205 of Frontrunners Syllabus for more on the latest recommendations. However, you should know that Endocarditis Prophylaxis is NO LONGER RECOMMENDED for any of the following: ./ Mitral Valve Prolapse ./ Rheumatic Heart Disease ./ Bicuspid Valve Disease ./ Calcified Aortic Stenosis ./ Congenital heart conditions, like VSD, ASD, and HCM

33.

19 yo sexually active woman presents with low-grade fever, multiple arthralgias and left knee effusion. Joint cultures and cervical smears are taken. Gram stain of joint fluid is negative. Cervical gram stain showed gram negative diplococci. Which of the following is the best treatment option?

A. B. C. D.

Arthroscopy and debridement Ceftriaxone 125mg 1M & azithromycin 1.0 g PO Benzathine PCN G 2.4 million units 1M x 1 Doxycycline 100mg BID x 3 weeks Answer: B. The patient should be assumed to have disseminated neisseria gonorrhea. Gram stain of synovial fluid is not sensitive ÂŤ60%) for the presence of bacteria. She should also be treated for presumed Chlamydia as well (azithromycin) See p. 110 of Frontrunners Syllabus.

34. A 46 yo woman comes to your office for a routine visit. Her mother died last month at age 74yo of intraductal breast carcinoma, which had been diagnosed 7 years ago. Her father died of colon ca last year, and her 57yo sister developed breast ca five years ago. Patient's last physician breast exam and mammogram were negative 6 month's ago. Which is the next best step in management?

A. B. C. D.

Repeat mammogram now Bilateral breast ultrasound Nothing now; repeat provider exam and mammogram in 6 months. BRCA testing

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 Answer: C. See Frontrunners Syllabus p. 361 section that starts with "Genetic testing is indicated ... ". 35. A 44 yo woman presents with diarrhea and weight loss for 2 months. Studies reveal a quantitative 72 hour fecal fat of 20 grams, and a 5-hour urine d-xylose excretion of 2.5 grams following ingestion of 25g of d-xylose. What is the next best step in management?

A. B. C. D.

Secretin testing Small bowel biopsy Hydrogen breath testing for lactose intolerance Gluten-free diet Answer B. A 5-hour urine d-xylose excretion of 2.5 grams following ingestion of 25g of d-xylose is under the 4.5 and is therefore considered abnormal, pointing to either the pancreas or the small intestine as the culprit. Of the options listed, small bowel biopsy is the next best step in management. See Frontrunners Syllabus pp. 84-85 for more on the workup of malabsorption.

36.

In June a patient is brought into your office by his hunting partner after a recent hunting trip in Indiana and Illinois. The partner noticed his friend was not his usual self and seemed confused at times, more forgetful, and 'just not himself'. That patient had also complained to his partner about some neck pains 2 days ago and admitted, that they were literally "covered in ticks" during their expedition. Which of the following is the patient most likely to have?

A. B. C. D.

Lyme disease Rocky Mountain Spotted Fever Tularemia Borreliosis Answer A. Be able to recognize a classic Lyme meningitis (confusion, neck pain, etc following a tick bite) in classic/endemic areas, like Indiana following common activities associated with those areas and with the disease itself, like hunting. See Frontrunners Syllabus p. 41,42.

37. 45 yo male complains of left hip pain when he sits in the car after 15 minutes and when he lays on his left side. He does not drink alcohol, nor has he had any trauma to his hip that he can recall. His only medication is 15mg prednisone qd for Polymyalgia Rheumatica that was diagnosed 3 years ago, at which time he began the treatment. Which of the following studies is appropriate at his time?

A. B. C. D. 14

Plain film of the left hip with coned views MRI of the lumbosacral spine MRI of the left hip Computerized tomography

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 Answer: C. Chronic steroids and hip pain ~ Rule out avascular necrosis always with an MRI. It's always there and an easy point on the exam. See Frontrunners 36, 43, 162. 38.

Patient status post cardiac cath 4 days ago, now with blue 2nd/3rd/4th left toes. What is the most likely pathology?

A. B. C. D.

Nephrotic syndrome with AT III deficiency Berger's disease Cryoglobulinemia Abdominal aortic atherosclerosis Answer: D. Cholesterol emboli. See Frontrunners Syllabus, p 55, 150, 203, 222 and p.58 of this book for more.

39. A 45yo white female patient of yours for the past five years, known for her bubbly, sunny disposition, comes in feeling down and states she just lost her brother, who was just a year or two older than her, two days ago. She's been having crying spells and not been eating or sleeping well. No suicidal ideation. She is close with the rest of her family who have always been there for her. Of the following, which is the initial management of choice?

A. B. C. D.

Do nothing. She'll get better on her own. Counseling with a psychiatrist SSRI Diazepam Answer: B. Professional counseling.

40. A 26 yo woman presents with complaints of an intensely pruritic rash on her 'backside', a 7.5 Ib (3.4kg) weight loss and loose BMs for 1 month. On exam her weight is a 117 Ib (53kg), and derm exam reveals flesh-colored-to-erythematous vesicles in a herpetiform pattern, symmetrically distributed over her buttocks. Which of the following is the most likely diagnosis?

A. B. C. D.

Ulcerative Colitis Collagen Colitis Crohn's Disease Celiac Disease Answer: D. This is celiac disease with the classic "intensely pruritic" rash of dermatitis herpetiformis usually found on extensor surfaces. See Frontrunners Syllabus p. 83, 150 and 157 for more on Celiac disease and dermatitis herpetiformis. See also pp. 22, 101, 105, 111, 220, 223 of this book.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 41. A 48 yo asthmatic woman with exercise-induced asthma times 3 years now complains of her usual symptoms but occurring more frequently and even at rest. She recounts that her albuterol MOl treatments have become much more frequent. What is the next best step in management? A. Nedocromil B. Montelukast (Singulair® ) c. Steroid inhaler D. Oral steroids Answer: A. See Frontrunners Syllabus p. 240 for answer.

42. Young woman presents with a classic history of occupational asthma at her office job. What's the best way to confirm your suspicions? A. B. C. D.

RAST testing Skin prick testing Peak flows testing at specific times Advise her to change jobs and see if it gets better. Answer: C. Peak flows, i.e. peak expiratory flow rates, should be done to confirm the diagnosis at the end of the work period and during the period away from work. A four-fold decrease in nonspecific bronchial hyperresponsiveness at the end of the work period confirms an association of disease with the work environment. See Frontrunners Syllabus p. 239 on this.

43.

Man with a history of severe depression and a good response to fluoxetine (Prozac®) complains of ED (erectile dysfunction). Testosterone level is normal. What is the next best step in management? A. Stop the fluoxetine altogether B. Switch to sertraline (Zoloft®) C. PSA testing o. Testosterone patch Answer. C. Don't be too quick to jump on the SSRI. He may just have stage C (or worse) prostate ca invading the neurovascular bundle.

44.

On returning from vacation in Europe, a 67yo male with a history of longstanding hypertension presents to the E.R. with complaints of severe headache. He had run out of his blood pressure medications just prior to leaving on vacation but was not able to make it to the pharmacy in time for his flight.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 He didn't think a week would make much of a difference. In the ER, his BP is found to be 240/130. His blood pressure is treated in the ER, but his admission chest x-ray comes back revealing "probable thoracic aneurysm". Follow-up studies confirm this finding and reveal this to be a syphilitic aortic aneurysm. He is informed but does not tell his wife. What should you do?

A. B. C. D.

Personally inform his wife of his diagnosis Do not tell his wife, but strongly encourage him to do so Consult the hospital ethics committee Report the case to your state's department of health Answer: D. Syphilis is a reportable communicable disease. They, in turn, will take the necesary steps to adequately inform those who may be at risk.

45. Which of the following is a known complication of infliximab? A. Optic neuropathy B. Autoantibodies C. Myelosuppression D. Photosensitivity Answer: B.

46. A 34 year old female presents with complaints of dry mouth, and a pustular rash on her hands, arms and face, accompanied by swelling of the joints of her hands, elbows, and knees. Labs: BUN 30, creatinine 1.7, Rheumatoid Factor 1:20, AntiRNP 1:64. Anti-ds DNA, anti-Sm, anti-Ro, and anti-La antibodies are negative. What is the most likely diagnosis?

A. B. C. D. E.

Scleroderma Dermatomyositis Mixed Connective Tissue Disease Rheumatoid Arthritis SLE Answer: C. For the boards, if you see an elevated titre on RNP, look for MCTD in the answer. Negative anti-ds DNA and anti-Sm (Smith) antibodies rule out SLE per se. Negative anti-Ro and anti-La autoantibodies rule out Sjogren's per se. It is essential to know your autoantibodies for these exams. Another easy one is anti-histone antibodies which point to drug-induced SLE, as classically seen with hydralazine or procainamide. See Frontrunners Syllabus p. 45 for an excellent important summary of these.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 47.

Ingestion of which of the following fruits / fruit juices interferes with the absorption of amiodarone? A. B. C. D.

Orange Grape Cranberry Grapefruit Answer: D. Grapefruit juice dramatically increases blood levels of amiodarone. Grapefruit juice is a potent inhibitor of the intestinal cytochrome P-450 3A4 system (specifically: CYP3A4 - mediated drug metabolism) which is responsible for the first-pass metabolism of many medications. This interaction can lead to increases in bioavailability and corresponding increases in serum drug levels. Amiodarone is not the only one to remember. Other important examples include:(1) excessive sedation with benzodiazepines. (2) increased risk of rhabdomyolysis with many HMG-CoA reductase inhibitors (statins); (3) symptomatic hypotension with many dihydropyridine calcium antagonists.

48. An asymptomatic 47 yo woman presents for her annual routine exam and mammogram. Her physical exam, including a complete breast exam, is unremarkable. Except for new microcalcifications noted in the left upper outer quadrant, her mammogram is completely normal. What is the next best step in management? A. B. C. D. E.

Ultrasound Fine needle biopsy Stereotactic core needle biopsy Open biopsy Nothing for now; repeat mammogram in 1 month. Answer: C. There are two general types of calcifications: microcalcifications and course calcifications. Most often, microcalcifications have nothing to do with cancer. However, in about 30% of cases they can be related to an early breast cancer. Course calcifications are almost always benign. In addition to magnification and compression views of the area in question and a follow-up mammogram in 3 to 6 months, a stereotactic core needle biopsy (SCNB) is generally recommended for microcalcifications. In the last several years, a number of "non-surgical" methods for the evaluation of clinically occult breast lesions have been developed. These include stereotactically-guided and ultrasound-guided biopsies using either the fine needle aspiration (FNA) or core biopsy techniques. Of these, SCNB has been method of choice. Experience to date has indicated that there is excellent correlation between the findings on SCNB with those on open biopsy.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019

SCNB utilizes computer assisted stereotactic mammography for localization of the lesion and an automated spring loaded biopsy gun equipped with a large core (preferably 14-gauge) cutting needle. This procedure was initially used to evaluate non-palpable soft tissue densities but has more recently been used to study microcalcifications as well. Dedicated stereotactic mammography units and units which can be added on to existing mammography units are both commercially available, with the former the units of choice for most radiologists. SCNB was developed with two goals in mind: 1) to eliminate the need for open biopsy in patients with benign lesions and 2) to provide a non-surgical means to definitively diagnose breast cancer, given the limitations of FNA in this regard. In particular, in contrast to FNA, the core needle biopsy procedure rarely results in insufficient material for evaluation, generates the type of specimen most pathologists feel comfortable interpreting, and more often results in a definitive diagnosis than FNA. In addition, SCNB specimens are suitable for immunohistochemical studies of markers of potential therapeutic or prognostic importance including estrogen and progesterone receptors, proliferation markers, oncoproteins, and others.

49. Which of the following disorders is generally treated with a regimen of chlorambucil and prednisone? A. B. C. D.

Multiple myeloma AMl Cll CMl

Answer: C. See Frontrunners Syllabus, p. 316, 349. it's important to know the Rai stages for ell since treatment does not prolong survival in stages I or II, and is generally reserved for Stage 3 and 4 only! Management of Rai 3 (+ anemia) and Rai 4 (+ thrombocytopenia) includes chlorambucil + prednisone. For patients who relapse, fludarabine is often used. For multiple myleoma (and amyloidosis), management is generally with melphalan + prednisone. For Acute Myelogenous leukemia (AMl) the usual course of treatment involves one or two rounds of "induction" therapy followed by "post-remission" therapy. Typical induction regimens consist of cytarabine + (daunarubicin or idarubicin) Âą etoposide. The goal of remission induction is to rid the blood and marrow of visible leukemic blast cells, allowing normal blood cell production to resume. If blast cells are still evident, a second course of chemotherapy may be required to rid the marrow of blasts. The goal of post-remission therapy is to eliminate undetected leukemic cells that linger after the patient has achieved a complete remission. It is generally assumed that a substantial burden of leukemia cells persists undetected (ie, "minimal residual disease"), leading to relapse within a few weeks or months if no further therapy were administered.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 Therefore, following successful induction, "postinduction" (aka "postremission" or "remission consolidation") therapy usually comprises one or more courses of chemotherapy or bone marrow transplantation. It is designed to eradicate residual leukemia, allowing the possibility of cure. There are three basic treatment choices for postremission therapy: consolidation chemotherapy, typically using regimens of cytarabine + (daunarubicin or 6-thioguanine), or allogeneic or autologous bone marrow transplantation (BMT). Allogeneic BMT appears to significantly reduce the rate of relapse but is associated with a higher morbidity and mortality. Autologous HCT allows the use of myeloablative therapy in patients who lack an allogeneic marrow donor and also in older patients. The appropriate role for this treatment modality is controversial. Treatment-related morbidity and mortality are relatively low (:S 5 percent), thereby allowing its use in patients up to 70 years old. However, relapse rates are high, and overall outcomes are not clearly better than those in patients who receive intensive but nonablative chemotherapy.

50. Which of the following is a known complication of hydroxychloroquine?

A. B. C. D.

Optic neuropathy Thrombocytosis Hypertrichosis Pulmonary infiltrates

Answer: A. Bul/'s eye maculopathy (heavy macular pigmentation surrounding by depigmented area surrounded by pigmented area) is classic . . A more complete list of ocular complications includes: disturbance in accommodation, keratopathy, corneal changes/deposits (visual disturbances, blurred vision, photophobia reversible on discontinuation), macular edema, atrophy, abnormal pigmentation, retinopathy (early changes reversible - may progress despite discontinuation if advanced), optic disc pallor/atrophy, attenuation of retinal arterioles, pigmentary retinopathy, scotoma, decreased visual acuity, and nystagmus. Among the hematologic adverse reactions, you can see aplastic anemia, agranulocytosis, leukopenia, hemolysis (in patients with glucose-6-phosphate deficiency), and thrombocytopenia; not thrombocytosis. Also, hydroxychloroquine can cause alopecia, not hypertrichosis. 51. A patient with terminal cancer under your care is on an intermediate pain medication, but continues to complain of pain. What is the next best step in management?

A. B. C. D.

Ask the patient what medicine he would like Consult the daughter who has power of attorney Give higher dose of long-acting pain medication Consider alternative medicine

Answer: C. 20

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 52. You have a new 23 yo asthmatic patient, previously well-controlled on her MDls, but now with increased asthmatic epidsodes and coughing up brown mucus plugs. To confirm your suspicions, what test do your order next? A. B. C. D.

Fiberoptic bronchoscopy Sputum culture Ig A levels Ig E to aspergillus Answer: D. Brown mucus plus and breakthrough asthma are the clues here, pointing to Allergic Bronchopulmonary Aspergillosis (ABPA). Sputum cultures can simply yield unrelated, aspergillus colonizers. Check for total IgE ~1 000 and Aspergillus-specific Ab as well as peripheral blood t eos ~ 8 %. Remember, in ABPA, treatment is steroids, not antifungals. See page 132, 232, 235, 237 & 244 of Frontrunners Syllabus and pp 21, 152, 156, 217 & 249 of this book for additional related questions.

53. A 58 yo diabetic man presents with, hypertension, worsening renal function, creatinine of 3.0, proteinuria and a urine pH of 6.5. Serum potassium is pending. Which of the following do you suspect? A. B. C. D.

Type Type Type Type

I RTA II RTA III RTA IV RTA

Answer: A. Type I is the only RTA with an t urinary pH. Serum K+ distinguishes Type II (-I..) from Type IV (t). See Frontrunners Syllabus p. 1 for the table you should memorize, along with the urinary pH and K trick. 54. A 65 yo NYHA Class IV heart failure with an ejection fraction fo 20% on coumadin, metoprolol, ramipril, and digoxin. Which of the following medications needs to be added? A. B. C. D.

Hydrochlorothiazide He is already maximized. Just titrate his current meds as appropriate Spironolactone ACE receptor blocker Answer C. See Frontrunners Syllabus p. 216, 219 for a convenient summary.

55. This summer, your patient who's been taking prednisone for some time suddenly develops a chronic, asymptomatic scaling dermatosis on his chest, characterized by well-demarcated scaling macules with variable pigmentation. Gently abrasion of the surface accentuates the scaling. No 'herald patch' is seen. Of the following choices, what is the most likely diagnosis? COPYRIGHT

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 A. B. C. D.

Pityriasis Versicolor Pityriasis Rosea Sweet's Syndrome Pemphigus Vulgaris Answer A. High levels of cortisol (e.g. Cushing's or exogenous steroids) increase susceptibility to pityriasis versicolor (tinea versicolor).

56.

A 38 year old woman presents with diarrhea, excessive flatulence, and a rash behind her thighs. She sees you and is placed on a lactose-free diet, but after one month, she shows no signs of improvement. What do you do next? A. B. C. D.

72-hour fecal fat Sudan stain D-xylose test Gluten-free diet Answer: D. The rash on her extensor surfaces is likely dermatitis herpetiformis, the rash often associated with celiac disease, or glutensensitive enteropathy. A gluten-free diet is always the first step when you suspect this entity. In fact, the most definitive diagnosis is had by noting symptomatic resolution on a gluten-free diet. Specifically, one should avoid foods containing barley, rye, oats, and wheat (these should raise your "BROW"); foods containing rice, corn, and soybean are, however, permissable. Diagnosis should certainly be confirmed checking for the presence of the specific culprit autoantibodies, namely anti-endomysial antibody, anti-gliadin antibody, & antireticulin antibody. Small bowel biopsy may follow. See Frontrunners Syllabus p. 83-86, 150 and 157 for more on celiac disease and dermatitis herpetiformis. See also pp. 22, 101, 105, 111, 220, 223 of this book.

57. A 30 year-old woman in her third trimester of pregnancy presents with numbness and tingling of the hands. Her exam reveals positive Tinel's and Phalen's signs. Her exam is otherwise completely normal. Her labs are entirely unremarkable. What is the most appropriate management? A. B. C. D.

Surgical release EMG Splints Tendon injections Answer: C. Alterations in fluid balance may predispose some pregnant women to develop carpal tunnel syndrome.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 Symptoms are typically bilateral and first noted during the third trimester. Conservative measures are appropriate, because symptoms resolve after delivery in most women with pregnancy-related carpal tunnel syndrome. To date, rest and night splinting serves as the cornerstone of treatment for pregnancy-induced carpal tunnel syndrome.

58.

A 74 year old woman with a long-standing history of osteoarthritis states she recently started a walking regimen for her cardiovascular fitness and overall health, walking 30 minutes every other day. She denies any overt trauma or sudden pains However, yesterday she noticed sensing a sensation of a "strain" in her right calf, followed by bruising that extended into the thigh. You suspect what?

A. B. C. D.

Deep Venous Thrombosis Torn Achilles ligament Proximal soleus muscle tear Ruptured Baker cyst

Answer: D. An extension of inflamed synovium into the popliteal space; also known as a 'Baker cyst'. Also termed a 'popliteal cyst', it's the most common mass in the popliteal fossa and results from fluid distension of the gastrocnemiosemimembranosus bursa. A ruptured Baker cyst may resemble acute DVT, and has therefore also been referred to as 'pseudophlebitis'. Ultrasound is typically the initial imaging modality of choice. The differential diagnosis is primarily DVT; popliteal artery aneurysm; lymphadenopathy; and tumor. Osteoarthritis is a significant risk factor. In fact, Baker cysts have been noted in some studies in as many as 42% of OA cases. Baker cysts have been noted in 5-18% of MRI studies, 37% of arthroscopy cases, and 30% of cadaveric dissections. Medical conditions associated with Baker cyst, listed in descending order, include: osteoarthritis RA, Juvenile RA, Gout, Reiter syndrome, Psoriasis, & SLE. But Osteoarthritis is by far the most common cause of Baker cyst. MRI, is the best diagnostic tool as it yields far more detail than ultrasound. The advantages of MRI are derived from the superior soft tissue contrast resolution and multiplanar capability, which help determine the extent of the popliteal cyst and its composition and much more easily distinguish Baker cyst from other differentials, like myxoid liposarcoma (which you don't have to know about per se).

59. A 57 year-old male presents with chest pain and shortness of breath and is found to have an acute inferior wall myocardial infarction. Which of the following is an indication for a pacemaker?

A. B. C. D. E.

Mobitz II, symptomatic Sinus bradycardia, HR of 40, asymptomatic 2nd degree block, Type I, asymptomatic Sinoatrial block or sinus arrest, asymptomatic Right bundle branch block with left axis deviation without syncope or other symptoms of intermittent AV block.

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 Answer: A. Not only is the Mobitz II symptomatic, but particularly in this setting of an inferior wall MI, it can progress to third degree heart block. Pacing is not indicated for any of the following conditions: sinus bradycardia without significant symptoms; Sinoatrial block or sinus arrest without significant symptoms; asymptomatic prolonged RR intervals with atrial fibrillation or other causes of transient ventricular pause; Asymptomatic bradycardia during sleep; asymptomatic second-degree Mobitz I (Wenckebach) AV block; a hyperactive cardioinhibitory response to carotid sinus stimulation in the absence of symptoms or in the presence of vague symptoms such as dizziness, lightheadedness, or both; right bundle branch block with left axis deviation without syncope or other symptoms of intermittent AV block.

60. Which of the following cell types is seen in myelofibrosis?

A. B. C. D.

Target cell Teardrop cell Sideroblast Spherocyte

Answer: B. Teardrop cells are commonly seen in myelofibrosis, one of the 4 main myeloproliferative diseases. Teardrop cells (and target cells!) are also commonly seen in thalassemia. In addition to thalassemia, target cells may also be seen in hepatitis, post-splenectomy; G6PD deficiency (Heinz bodies too); and HbC and HbSC disease. Additional important features of myelofibrosis include a hypocellular marrow secondary to replacement of marrow by hyperproliferation of fibroblasts leads to pancytopenia; splenomegaly always; a characteristic "Leukoerythroblastic" peripheral blood smear (nucleated RBCs, early myeloid forms, including blasts) in 96%; large, abnormal platelets. There is no specific therapy for idiopathic myelofibrosis. Treatment includes supportive care with transfusions, growth factors, and antibiotics as needed. Hydroxyurea, splenectomy, and radiation therapy can palliate symptomatic splenomegaly. See p. 321,323 of Syllabus for the key items to know for myelofibrosis, and also p. 309 of Frontrunners Syllabus for a great summary of the key cell types you'll need to know for your exam! 61. All of the following are recommendations and concepts in newly detected AFib except:

A. Rhythm control has not been shown to be superior to rate control (with chronic anticoagulation) in reducing morbidity and mortality. Therefore rate control with chronic anticoagulation is the recommended strategy for the majority of patients with AFib. B. Most patients converted to sinus rhythm from AFib should not be placed on rhythm maintenance therapy since the risks outweigh the benefits. C. Antiarrhythmics like amiodarone, disopyramide, propafenone, and sotalol. are now considered routine management for most patients with newly detected AFib. D. Digoxin controls heart rate at rest but not during exercise. 24

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 Answer: C. Antiarrhythmics are still an option ... but mostly for patients who are highly symptomatic when they aren't in normal sinus rhythm. For these patients, consider amiodarone, disopyramide, propafenone, or sotalol. See p. 192 of Frontrunners Syllabus for an excellent summary of the updated guidelines re rate and rhythm control in newly diagnosed Afib. 62.

How do you treat a teenager with comedones?

A B C D

Benzoyl Peroxide +

Topical Tretinoin

+ + -

Oral Tretinoin

Topical antibiotic

+ -

Oral antibiotic + + -

Answer: B. See p. 159 of Frontrunners Syllabus for an excellent summary of the modern approach to treatment of acne. 63. Your AIDS patient comes back from the ophthalmologist with a print-out of the consultation letter and findings, and reads only "endophthalmitis". Which of the following is the most likely cause?

A. B. C. D.

Cryptococcus Cytomegalovirus Sepsis MAl Answer: B. CMV retinitis is the only one you should think about for the exam in an H IV patient. The retinitis yields a so-called "ketchup-and-mustard" or "pizza pie" fundoscopic appearance. Most importantly, on the exam, look for the patient with AIDS who complains of "floaters"! Treatment with Gancyclovir (re: bone marrow suppression) or Foscarnet (re: nephrotoxicity) or Cidofovir. See p.143 of Frontrunners Syllabus.

64. A 42 yo woman becomes ill with fever and cough after traveling from Florida to St. Louis, where she visited her favorite zoo. Of the following choices, which is the most likely diagnosis?

A. B. C. D.

Actinomyces Cryptococcus Histoplasmosis Aspergillosis Answer: C. Histoplasmosis is a common infection which is usually asymptomatic but occasionally results in severe illness. Histoplasmosis and its causative agent, Histoplasma capsulatum, are found worldwide; within the United States, infection is most common in the midwestern states located in the Ohio and Mississippi River valleys. The central river valleys in the midwestern and south central United States are endemic for histoplasmosis. COPYRIGHT

I-Io,r OFF ,rl-lE i=lMESS! ",rl-lIS JUs,r IN": Q&a =019 Approximately 250,000 individuals are infected annually. Clinical manifestations occur in <5% of the population. Major forms include chronic pulmonary, progressive disseminated, and acute pulmonary histo, as in this case. In acute pulmonary histo, approximately 90% of patients are asymptomatic. If symptoms develop, onset occurs 3-14 days after exposure. Fever, headache, malaise, myalgia, abdominal pain, and chills are the most common symptoms. Remember, histo can present just like sarcoidosis: pulmonary manifestations with arthritis or arthralgia plus erythema nodosum. It's critical to make the right diagnosis as a mistake in diagnosis may be disastrous if the histo patient is treated with steroid or other immunosuppressive for sarcoidosis. Although the patient may appear to improve near-term, s/he'li eventually experience progressive disseminated disease and even death. Diagnostically, while antigen detection in urine and blood is more sensitive for acute pulmonary forms, fungal stains, culture, and serology studies are more sensitive in chronic forms. Ketoconazole is the drug of choice for treating prolonged mildly symptomatic acute pulmonary histo. It is administered for 3-6 weeks. It's also an alternative to ampho B in chronic pulmonary histo and chronic/subacute disseminated progressive pulmonary histo. Duration of treatment is 6-12 months. Ampho B is the drug of choice for treating overwhelming acute pulmonary histo, chronic pulmonary histo, and all forms of progressive disseminated pulmonary histo. 65. A retired 70 yo woman presents with bilateral knee pain when she walks or plays golf, and frequent lower back pain. Her X-rays show joint space narrowing and lines of calcium in the joint space. Of the following choices, which is the most likely diagnosis? A. B. C. D.

Osteoarthritis Gout Pseudogout Rheumatoid arthritis

Answer: C. See Frontrunners Syllabus p. 27 for a nice summary of the key radiologic features of RA and Osteoarthritis. Joint space narrowing can be seen in either RA or OA. The location favors OA. However, the lines of calcium point to the characteristic radiographic finding of chondrocalcinosis seen in pseudogout. Chondrocalcinosis is caused by the penetration of calcium pyrophosphate dihydrate (CPPD) microcrystals into the structures of the joint, including hyaline cartilages and fibrocartilages; hense the name. It occurs most often in women older than age 50. In CPPD, chondrocalcinosis commonly affects the menisci of the knees, the triangular fibrocartilage of the wrists, and the pubic symphysis. See pp. 33-34 & 282 of Frontrunners Syllabus. You've got to know the major clinical associations with pseudogout (hyperparathyroidism, hemochromatosis, hemosiderosis, hypothyroidism, gout, 1 Mg, 1 Phos, Wilson's disease, aging, and amyloidosis), should know that it can both mimic and coexist with gout, and that, similar to gout, surgery, trauma, and alcohol can "precipitate" events.

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1. Know that for the delta-delta equation, it's <1 for non-anion gap metabolic acidosis and >1 for metabolic alkalosis. See p. 22 of Frontrunners Internral Medicine Board Review Syllabus: Core Review. 2. Know that digitalis and IV verapamil are contraindicated in a patient with WPW and A Fib. See pp. 203 & 214 of Frontrunners Syllabus. 3. Know that disseminated gonorrhea commonly occurs in two phases. See p. 110 of Frontrunners Syllabus. 4. Know the presentations of Vibrio Vulnificus. See pp for more.

& 152 of Frontrunners Syllabus

5. Be able to recognize a slide of rouleaux formation. Know that Waldenstrom's Macroglobulinemia, and not just Multiple Myeloma, can also yield rouleaux. Be able to differentiate WM from MM (see table in Hematology). See p. 301 of Frontrunners Syllabus for more, and see SLiDESHOWS CD-Rom for all the key Heme/Onc images in full color, succinctly annotated for your I.M. board review (and, of course, all the Derm/Radiology/EKGs/Ophtho slides). 6. Back pain worse when walking downhill better with sitting; what to order to confirm suspicions ~ MRI R/O spinal stenosis. See pp 162 & 171 Frontrunners Syllabus for more. 7. Know exactly how calcium chloride or calcium gluconate. See p. 202 of Frontrunners Syllabus for more on the role of these in management of hyperkalemia, and the EKG changes in hyperkalemia. 8. Know the presentations and management of MGUS (Monoclonal Gammopathy of Undetermined Significance). See pp. 317 & 358 of Frontrunners Syllabus for more. 9. Know the presentations of myasthenia gravis. See page 149, 162 & 166-167 of Syllabus and Neurology #2 Q&A for more. 10. Know that pseudogout involves a positive bifringence rhomboid crystal. See pp. 33-34 & 282 of Frontrunners Syllabus. 11. Know the treatment for early erythema chronicum migrans. Antibiotics without serologic testing are recommended for patients with rash resembling ECM and a high probability of having Lyme disease. Doxy 100mg PO bid x 10 days (alternative: amox 500 tid x 203 wk). See pp 41-42 & 159 of Frontrunners Syllabus and 30, 106 & 223 of this book for additional related practice questions. 12. Know that active lupus nephritis will yield elevated ESR and anti ds DNA, as well as low C3, C4 and CH50. See page 6, 44-45 & 110 of Frontrunners Syllabus and pp 33, 57, 90 & COPYRIGHT

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204-205 of this book for additional related of this book for additional related practice questions. 13. Know the presentations of anti phospholipid antibody syndrome. See pp 331 & 334 of Frontrunners Syllabus and pp 3, 58 & 173 of this book for additional related questions. 14. Know that treatment for autoimmune hepatitis is steroids and azathioprine. See page 63 & 69 of Frontrunners Syllabus and 30, 65, 82 & 212 of this book for additional related questions. 15. Know that diagnosis of hepatitis C involves ELISA and supplemental assay, and that treatment depends on the patients' characteristics. See pp. 53 & 62-67 of Frontrunners Syllabus for all the key concept links you'll have to know re Hep C for the boards and pp 64, 65 & 107 of this book for additional related questions. 16. Know that when T score is osteoporotic and spine is normal, osteomalacia is more likely than Pagets. See pp 49-50 of Frontrunners Syllabus and pp 60, 167 & 205 of this book for additional related questions on osteomalacia; and see pp 50 of Frontrunners Syllabus and p. 60 of this book for related questions on Pagets. 17. Know that the definitive test in a fat young female with virilization is LH/FSH ratio at least 2 or 3: 1 (normal 1: 1). See Frontrunners Syllabus pp 259 & 261 for more key info on PC as and pp 163 & 254 of this book for additional related questions. 18. Know that calcium oxalate is the most common type of renal stone. See pp 4, 14, 85-86 & 93 of Frontrunners Syllabus and pp 32, 36, 70, 77 & 195 of this book for additional related questions. 19. Know that the postulated mechanism of ACE inhibitors is related to dilatory effects on glomerular efferent arterioles, the reduction of intraglomerular pressure and decreased damage from hyperfiltration. See pp 156, 200, 204, 213, 218, 286 & 293 of Frontrunners Syllabus and pp 5, 36, 145 & 246 of this book for additional related questions. 20.

Know that infiximab can cause a reactivation of TB. See also p. 85 of Frontrunners Syllabus and pp 5 & 17 of this book for related questions on infliximab.

21.

Know that paradoxical split 52 is indicative of LBBB. See page 209 of Frontrunners Syllabus for more.

22.

Know that Bordetella Pertusis can manifest with vomiting after coughing. Remember too erythromycin. See p. 232 of Frontrunners Syllabus and pp 149 & 248 of this book for additional related questions.

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23.

Know that neomycin can cause contact dermatitis (delayed hypersensitivity, Type IV). See pp 154, 180 & 366 of Frontrunners Syllabus and pp 128 & 234 of this book for additional related questions.

24.

Know that viral load check is used to monitor HIV therapy. See pp 139, 142 of Frontrunners Syllabus.

25.

Know that exposure to infected squirrels or rabbits thru cuts acquired before or during hunting and skinning of infected animals, and garbage handling in endemic areas are widely recognized risk factors in acquiring tularemia. The bacteria may also be transmitted via blood sucking anthropods or ticks.

26.

Know that there is no role for antifungal therapy in ABPA (allergic bronchopulmonary aspergillosis). Treatment involves steroids. See page ~232, 235, 237 & 244 of Frontrunners Syllabus and pp 21, 152, 156, 217 & 249 of this book for additional related questions.

27. Watch for fat embolus after femoral neck fracture. Will look just like pulmonary embolus of course, but in the setting of trauma. 28.

Know that steroids are indicated as treatment for PCP when Pa02<70 and A-a gradient >35. See pp. 142, 143,235 of Frontrunners Syllabus and pp 87,213, 251 of this book for additional related questions.

29.

Know that Parvovirus B19 can manifest as arthritis in adults. See pp 103, 304 & 336 of Frontrunners Syllabus and pp 2, 85, 107, 213 & 222 of this book for additional related questions.

30.

Know that in a 28-year-old male who has a first-degree relative with colorectal ca at >60yo, screening may be considered. See page 99 of Frontrunners Syllabus and pp 80, 183 & 265 of this book for additional related questions.

31.

Know that for acute mesenteric ischemia, unlike ischemic colitis, angiography is indicated. See pp 96-97 of Frontrunners Syllabus.

32.

Know that IgM anti- HBc is indicative of acute Hep B infection. See page 63-65 of Frontrunners Syllabus; see index of this book for additional Hepatitis B questions.

33.

Know that diagnosis of restless legs syndrome can be made via an overnight polysomnogram, which records sleep and the bioelectrical processes which govern it. See p. 125 of this book for other related questions.

34.

Know that CMV is suspected in a patient with sore throat and nonexudative pharynx when monospot and strep tests are negative. See pp 101, 142, 143, 146, 151, 155,307 & 323 of Frontrunners Syllabus and pp 25 & 29 of this book for additional related questions. COPYRIGHT

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35.

Know that H Pylori is responsible for chronic type B antral gastritis. See p. 89 of Frontrunners Syllabus.

36.

Know that ultrasound is the initial test of choice for a 28 yo healthy son who's father has a polycystic kidney. See p. 4 of Frontrunners Syllabus for more.

37.

Know your d-xylose! See pp 84-85 of Frontrunners Syllabus and pp 14, 22, 72-73 & 209 of this book for additional related questions.

38.

Know the association between anti-smooth muscle antibody & autoimmune hepatitis. See pp 63, 69 of Frontrunners Syllabus and p. 65 of this book for additional related question(s).

39. As with any exam on internal medicine, you should always be able to recognize Erythema Chronicum Migrans (rash of Lyme). See SLiDESHOWS CO-Rom. 40.

Be able to recognize a classic Lyme meningitis (confusion, neck pain, etc following a tick bite) in classic/endemic areas, like Indiana following common activities associated with those areas and with the disease itself, like hunting.

41.

Know that viral load (>500 copies) is a better marker than increasing CD4 count (> 350) to show that HAART has failed. See Frontrunners HIV PRIMER for the Boards.

42.

Know that probenicid is given for chronic gout management. See the Rheumatology section of Frontrunners Syllabus for more.

43.

Know that, in a chronic renal failure patient on dialysis who develops t JVD, Kussmaul sign, pericardial knock, and hypotension with chest x-ray reveals "cardiomegaly" and a needle pericardiocentesis that returns no fluid, your treatment is isotonic saline. The needle pericardiocentesis is a false negative and the cardiomegaly interpreted in CXR is pericardial fluid yielding an enlarged silhouette. Intravenous saline solution should be given to patients with cardiac tamponade awaiting pericardial drainage in an effort to expand the intravascular volume. See pp 192, 200, 202-203, 206-208 of the Syllabus for more key re cardiac tamponade and see pp. 131, 136, 138, 143, 144,238,240,245 of this book for additional related questions.

44.

Know to consider Still's disease in a patient with a history of rheumatoid arthritis, who presents with fever, swelling of his joints, and macular rash. See pp 34 of the Syllabus for more key info you'll need to know re Still's disease and pp. 4, 50 & 203 of this book for additional related questions.

45.

Be able to identify any of the following findings in a given photo: cotton wool spots; dot and blot hemorrhages; copper wiring; microaneurysms. See the extremely helpful SLIDE SHOWS CO-Rom, which features important images you should learn before sitting for the boards.

REFERENCES 1. FRONTRUNNERS® 2019 VISUALS I SLIDE SHOWS for the INTERNAL MEDICINE BOARDS, FEATURING ALL THE KEY IMAGES YOU'LL NEED TO KNOW FOR THE ABIM I INTERNAL MEDICINE BOARDS, Frontrunners Board Review, Aliso Viejo, CA, © 2019. 2. FRONTRUNNERS® 2019 INTERNAL MEDICINE BOARD REVIEW SYLLABUS : Core Review for the ABIM Certification and Recertification Exams, Frontrunners Board Review, Aliso Viejo, CA, © 2019. 3. TURBO MNEMONICS FOR THE BOARDS: Over 400 Memory Aids, Tips & Tricks To ... Help You SPEED D'A~ The Most Commonly Asked Clinical Material For The ABIM Internal Medicine Boards, 7th edition, Frontrunners Board Review, Aliso Viejo, CA.

4. FRONTRUNNERS® 2019 AUDIO SYLLABUS for the INTERNAL MEDICINE BOARDS, Frontrunners Board Review, Aliso Viejo, CA, © 2019. 5. UpToDate Clinical Reference Library, UpToDate, Inc., Wellesley, MA. 6. Prescribers Letter, Stockton, CA., Therapeutic Research Center 7. The Sanford Guide to Antimicrobial Therapy, David N. Gilbert, MD, et ai, 48th ed, 2018. 8. www.gofrontrunners.com/Product-Vault.htm 9. Medical Knowledge Self-Assessment Program VII thru XVIII, American College of Physicians, Philadelphia, PA. 10. ACP Board Review Course, 1996-2018. 11. FRONTRUNNERS® WEEKEND MARATHON REVIEWS, 1996-2019, © Frontrunners Board Review, New York I California.

COPYRIGHT © 1996-2019. ALL RIGHTS RESERVED. FRONTRUNNERS BOARD REVIEW I FRONTRUNNERS PUBLISHING This publication is protected by copyright. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic or mechanical, including photocopy without the prior written permission by Bradley D. Mittman, MD.

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