Join me as I cover ten internal medicine rotation EOR content blueprint questions from the Smarty PANCE physician assistant board and rotation review website.
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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 log in and view this interactive video lesson.
1. 55-year-old woman is admitted to the hospital because she has shortness of breath and pain on both sides of her chest with deep breathing which has worsened over the past 5 days. In recent weeks, she has been feeling fatigued and has had low-grade fevers and night sweats, and was found to have a new cardiac murmur on examination. Her temperature is 38.1°C (100.6°F), pulse is 106/min, respirations are 26/min, and blood pressure is 136/88 mm Hg. She appears diaphoretic and is in mild respiratory distress. Cardiac auscultation reveals a faint systolic murmur heard over the lower left sternal border. Her neck veins are distended and abdominal examination shows hepatomegaly. Which of the following is the most likely cause of her clinical presentation?
A. Fat embolism
B. Infective endocarditis
C. Myocardial infarction
D. Rheumatic fever
E. Small cell lung cancer
Answer: B, Infective endocarditis
Infective endocarditis (IE) is an infection of the endocardial surfaces of the heart, most commonly the heart valves. IE occurs when a microorganism begins to invade the heart valves causing an inflammatory reaction that damages the valve – sometimes leading to stenosis and sometimes leading to regurgitation. This patient developed a new cardiac murmur in recent weeks that is described as a faint systolic murmur heard over the lower left sternal border. This is most consistent with tricuspid regurgitation. She also has distended neck veins and hepatomegaly, both of which suggest right-sided heart failure which can result from tricuspid regurgitation. Small infectious emboli can break away from the primary lesion on the tricuspid valve and go into the pulmonary vasculature causing shortness of breath and pleuritic chest pain. Most cases of IE are caused by Staphylococcus aureus and Viridans streptococci, and diagnosis is confirmed by obtaining multiple blood cultures that show that there is continuous bacteremia.
Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Endocarditis
2. A 54-year-old man comes to the emergency department following a four-day history of left-sided chest pain and shortness of breath. One week ago, he experienced upper respiratory symptoms along with myalgias and general fatigue. He has no known past medical history. He has not traveled outside the US. His temperature is 38.1°C (100.6°F), pulse is 104/min, respirations are 17/min, oxygen saturation is 94% on room air, and blood pressure is 100/72 mm Hg. Physical examination shows an ill-appearing man with bibasilar rales, jugular venous distention of 11 cm with no murmurs, rubs, or gallops, and 1+ bilateral pitting edema of the lower extremities. His labs are within normal limits and his blood cultures are negative. An echocardiogram shows an ejection fraction of 35%. Which of the following is the most likely cause of this patient’s condition?
B. Coxsackie A virus
C. Staphylococcus aureus
D. Corynebacterium diphtheriae
The answer is A. Adenovirus
Myocarditis in the United States is most commonly caused by a viral infection, typically adenovirus, coxsackie B, parvovirus B19, or others. It often presents with systemic symptoms such as fatigue and chest pain, but may cause sudden death.
Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Myocarditis
3. A 42-year-old woman comes to the emergency department because of chest pain, dyspnea, and lightheadedness. She recently recovered from a presumed viral upper respiratory infection and has a 10-year history of systemic lupus erythematosus. Physical examination shows a decrease in systolic blood pressure by 20 mm Hg during inspiration. An ECG is shown here. Which of the following is the most likely diagnosis?
A. Aortic dissection
B. Tricuspid regurgitation
C. Pericardial effusion
D. Aortic stenosis
E. Mitral stenosis
The answer is C. Pericardial effusion
Pericardial effusions are associated with a variety of causes, including autoimmune disorders and infectious pericarditis. If pericardial effusion leads to cardiac tamponade, patients may have pulsus paradoxus, or a decrease in systolic blood pressure during inspiration of more than 10 mm Hg. Certain ECG findings are characteristic for pericardial effusion. In particular, electrical alternans (shown by arrows) is highly specific for pericardial effusion (usually in association with cardiac tamponade) but not particularly sensitive. This pattern, characterized by beat-to-beat changes in the QRS axis in the limb and precordial leads, is caused by swinging of the heart within the accumulated pericardial fluid. Other common findings on ECG include sinus tachycardia and low QRS voltage.
Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Pericarditis
4. A 57-year-old man comes to the emergency department because of intermittent, severe leg pain in both his calves for 2 weeks. He has a history of untreated high blood pressure, diabetes, and high cholesterol. For the past 3 years, the pain started after walking three blocks and only going away upon resting. In the past 2 weeks, he has had the same pain at rest. His temperature is 36.5°C (97.7°F), pulse is 78/min, respirations are 17/min, and blood pressure is 160/89 mm Hg. Examination shows both calves are atrophied and there is a paucity of hair, but no swelling or discoloration. Additionally, his lower calves are cool to the touch and dusky in appearance. Doppler ultrasound shows perfusion to both feet, and blood pressures of 35/20 mm Hg in the posterior tibial artery are obtained bilaterally. Which of the following is most appropriate next step in management?
A. Immediate high-dose statin therapy
B. Immediately consult vascular surgery
C. Intravenous alteplase
D. Pain control and discharge; refer to vascular surgery as an outpatient
E. Rest, elevate, and compress the affected leg
The answer is B. Immediately consult vascular surgery
Peripheral vascular disease with intermittent claudication and signs of decreased perfusion should be examined using Doppler ultrasound and the ankle-brachial index (ABI). An ABI of <0.41 is grounds for the immediate surgical consultation.
Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Peripheral vascular disease
5. A 6-year-old boy comes to the pediatric clinic because of 4 weeks of fatigue and shortness of breath. His medical history is notable for poor follow-up with yearly check-ups, but his mother notes that he has been fairly healthy for the duration of his life, except for a “bad sore throat that needed antibiotics” about 6 months ago. On examination, the boy appears fatigued, but is appropriately oriented and responsive, and is generally non-toxic appearing. He is afebrile. Cardiac examination is notable for a widely split S2, a quiet S1, and point of maximum impulse displaced to the left. Which of the following is the next best step in the management of this patient?
B. Long-term penicillin
C. Short-term course of clindamycin
D. Reassurance & routine care
E. Intramuscular ceftriaxone
The answer is B. Long-term penicillin
Rheumatic heart disease is caused by autoimmune cross-reactivity following a Streptococcal infection. Development of antibody-mediated mitral valve damage is common. Long-term penicillin is suitable for acute treatment and prophylaxis from complications.
Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Rheumatic heart disease
6. A 35-year-old woman, gravida 2, para 1, comes to the office because of her first prenatal visit at 12 weeks’ gestation. She has no current concerns, and her first child was born without complications. She has a history of long-standing untreated hypertension. Her temperature is 36.5°C (97.7°F), pulse is 78/min, respirations are 17/min, and blood pressure is 150/89 mm Hg. Which of the following medications would most likely be appropriate as initial treatment?
The answer is C. Labetalol
Chronic hypertension in pregnancy can be treated with some medications and labetalol is recommended as a first-line therapy for treatment of hypertension during pregnancy. Angiotensin-converting enzymes (ACE) inhibitors and angiotensin II receptor blockers (ARBs) should be avoided.
Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Hypertension
7. A 42-year-old man comes to the office for a routine check-up. Medical history includes diabetes mellitus and a long history of smoking. Family history includes coronary artery disease. Temperature is 36.5°C (97.7°F), pulse is 78/min, respirations are 17/min, and blood pressure is 160/89 mm Hg. A repeat blood pressure taken 2 days later shows 143/88 mm Hg. Which of the following is most likely the best initial therapy?
Answer: A. Enalapril
Hypertension in the setting of diabetes should be treated, with a goal systolic blood pressure of <130 mm Hg. The best first choice of medication is an angiotensin-converting enzyme inhibitor (ACEi).
Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Hypertension
8. A 45-year-old obese Caucasian gentleman arrives at your clinic for a routine check-up after having some blood work done during a workplace health screening. He is found to have an LDL cholesterol level of 550 mg/dL. He states that his father and brother had high cholesterol and both died at a young age from a heart attack. He has a follow-up appointment with his cardiologist because of some occasional chest pain and abnormalities seen on his EKG. Additionally, you notice that he has well-demarcated yellow deposits around his eyes. He is started on high dose statin and his LDL at 12 weeks is 350 mg/dL. What is the next best step in this patient’s management?
A. Continue high dose statin, the patient’s LDL is at goal
B. Add niacin 100 mg three times daily
C. Add ezetimibe (Zetia) 10 mg daily
D. Add a PCSK9 inhibitor
E. Refer to a lipid specialist
The answer is C: add ezetimibe 10 mg
If LDL-C is not at goal after 6-12 weeks the next best step for the treatment of familial hypercholesterolemia is to add ezetimibe 10 mg daily and check again in 6-12 weeks. If at that time the patient’s LDL is still not at goal (ideally < 150) refer to lipid specialist to consider adding a PCSK9 inhibitor.
Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Hyperlipidemia
9. A 65-year-old man comes to the emergency department because of progressive dyspnea, coughing, and orthopnea. The patient says that over the past 2 months he has been feeling fatigued with ordinary physical activity. His medical history is relevant for dyslipidemia, type II diabetes mellitus, and a posterior myocardial infarction 4 months ago. Auscultatory findings reveal a pansystolic murmur over the mitral area. His temperature is 37.5°C (99.5°F), pulse is 90/min, respirations are 17/min, blood pressure is 120/90 mm Hg, and pulse oximetry on room air shows an oxygen saturation of 95%. This patient most likely has which of the following conditions?
A. Aortic stenosis
B. Aortic valve regurgitation
C. Mitral valve regurgitation
D. Mitral valve stenosis
E. Pulmonary stenosis
The answer is C. Mitral valve regurgitation
Mitral valve regurgitation is defined as an incompetent closure of the mitral valve. Classically patients will present with a pansystolic heart murmur over the mitral area. Posterior myocardial infarction is the second most common cause of mitral valve regurgitation. Mitral valve regurgitation is characterized by an incompetent closure of the mitral valve. This condition causes retrograde blood flow into the left atrium during systole. The most common cause of mitral regurgitation is mitral valve prolapse, followed by a dysfunction of the posteromedial papillary muscle due to posterior myocardial infarction. Other causes may include, endocarditis or stretching of the mitral valve ring.
Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Valvular heart disease
10. A 43-year-old man with a history of rheumatic fever comes to the primary care clinic for a check up. Cardiac examination reveals a late systolic crescendo murmur with midsystolic click best heard over the apex and loudest just before S2. Which of the following maneuvers will cause an earlier onset of the click/murmur?
B. Rapid squatting
D. Hand grip
E. Left lateral cubital position
The answer is C. Standing
The ‘click’ of mitral valve prolapse, caused by the tightening of the chordae tendinae, moves closer to S2 with increased preload. Increased preload causes the left ventricle to stretch, as a result, the chordae tendinae are stretched as well. This makes it harder for the mitral valve to prolapse until the ventricles shrink enough to allow the chordae tendinae to let the mitral valve prolapse. Since there is more blood in the ventricles, it takes them longer to pump it out and shrink to a point at which MVP can occur, hence it occurs later in systole. Thus, the click will get closer to S2 with increased preload. Hand grip, rapid squatting, and inspiration all increase preload. Standing decreases preload and will cause an earlier onset of the click.
Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Heart murmurs
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