ROSH: Internal Med ALL Questions And Answers Rated A+

A 10-year-old boy presents to the pediatrics clinic for evaluation of his asthma. He is currently only taking a rescue inhaler as needed. He has daytime symptoms four days per week, nighttime symptoms once per month, and uses a rescue inhaler four days per week. Which of the following medication regimens is most appropriate for this patient? Albuterol Albuterol and fluticasone Albuterol, fluticasone, and salmeterol Albuterol, fluticasone, salmeterol, and a short course of oral prednisone - Albuterol and fluticasone Asthma is classified according to severity to help guide treatment and monitor symptoms. The classifications include intermittent asthma and mild, moderate, or severe persistent asthma. Albuterol (A) is a short-acting beta-agonist bronchodilator. Albuterol is used as needed to treat intermittent asthma. The patient in this vignette has mild persistent asthma because he has symptoms four days per week. Albuterol, fluticasone, and salmeterol (C) is incorrect. This regimen includes a shortacting beta-agonist, inhaled corticosteroid, and long-acting beta-agonist. This regimen would be appropriate if the patient had moderate persistent asthma. Albuterol, fluticasone, salmeterol, and a short course of oral prednisone (D) is incorrect. Prednisone is sometimes indicated in severe persistent asthma and is often used in the treatment of acute asthma exacerbations. Question: What are the measurement criteria used to define reversible obstruction on spirometry? Answer: FEV1 that increases 12% and 200 cc after bronchodilation. A 12-year-old boy presents to your office for a routine sports physical exam. Family history reveals the patient had an uncle who died of a sudden unexplained cardiac event. You obtain a screening ECG, which is shown above. Which of the following best describes the pathophysiology of the suspected diagnosis? Accessory conduction pathway Atrioventricular nodal reentrant pathwayDecreased atrioventricular node transmission Multiple atrial electrical foci - Accessory conduction pathway Wolff-Parkinson-White syndrome is caused by an accessory conduction pathway formed between the ventricles and atria of the heart. In Wolff-Parkinson-White syndrome, an accessory conduction pathway (also known as the bundle of Kent) allows the electrical impulse to bypass the AV node and, thus, cause preexcitation of the ventricular myocardium. The accessory pathway in Wolff-Parkinson-White syndrome can cause reentrant or supraventricular tachycardia (AFib or atrial flutter). Many patients with WolffParkinson-White syndrome are asymptomatic. However, symptoms may include intermittent chest pain, palpitations, shortness of breath, or syncope. The diagnosis is usually made with an ECG. Characteristic ECG findings in Wolff-Parkinson-White syndrome include narrow complex tachycardia, a short PR interval, and a delta wave (slurred upstroke of QRS complex). AV nodal reentrant pathways (B) are the cause of paroxysmal supraventricular tachycardia. Paroxysmal supraventricular tachycardia occurs when an additional electrical conduction pathway is formed within the AV node. This new pathway causes a reentrant tachycardia. Decreased AV node transmission (C) is the cause of AV node block. AV nodal block occurs when the electrical impulse originating from the SA node is slowed or not transmitted through the AV node. AV nodal block results in mild to severe bradycardia, depending on the extent of the block. Multiple atrial electrical foci (D) cause atrial fibrillation. Atrial fibrillation causes tachycardia due to excitable atrial foci that emit electrical impulses at varying rates. Question: What antidysrhythmic medication classes are preferred when providing medical prophylaxis for reentrant tachycardia in Wolff-Parkinson-White syndrome? Answer: IA or IC. A 14-year-old girl presents to her primary care provider for an annual sports physical. Her past medical history is unremarkable. On physical exam, a left-sided rib hump is present on the Adam forward bend test. Examination of the chest wall reveals pectus excavatum. A midsystolic click is heard on cardiac auscultation. A Cobb angle of 15° is calculated from spine radiography. Her ECG rhythm strip is shown above. A transthoracic echocardiogram reveals a left ventricular ejection fraction of 70%, bowing of the mitral leaflets into the left atrium during systole, and trace to mild tricuspid regurgitation. Which of the following is the most appropriate next step in management? Reassurance and clearance for sports participation Referral to a cardiologist for further evaluationRepeat echocardiography annually for three years Surgical consult for valve repair - Reassurance and clearance for sports participation Mitral valve prolapse (MVP) is a valvular condition that occurs when the mitral leaflets bulge upward (prolapse) into the left atrium during systole. These "floppy" valves are most commonly a result of degenerative processes, but they can also be a normal anatomic variant most often seen in healthy, thin, young women. MVP can be associated with systemic collagen disorders (e.g., Marfan or Ehler-Danlos syndrome) and skeletal changes such as scoliosis and pectus excavatum. MVP is a common cause of mitral regurgitation. Isolated MVP and MVP with mild mitral regurgitation are commonly asymptomatic, though some patients may have mild symptoms such as nonspecific angina, dyspnea, and fatigue. Chronic MVP that results in moderate to severe mitral valve regurgitation can lead to an increased left atrial pressure, pulmonary edema, and progressive exertional dyspnea with fatigue. A midsystolic click on cardiac auscultation is heard when the mitral valve leaflets prolapse into the left atrium. A holosystolic murmur best heard at the apex is consistent with mitral regurgitation. A transthoracic echocardiogram is the best initial diagnostic tool to evaluate valvular conditions. CT or MRI angiography is indicated in patients with MVP who may have aortic root disease or aortic dilation. In patients with isolated MVP, such as the patient in this case, no treatment or follow-up is needed unless they become symptomatic. Referral to a cardiologist for further evaluation (B) is indicated in patients with MVP and audible mitral regurgitation. Only a midsystolic click consistent with MVP was heard on auscultation in this patient, and echocardiography showed no evidence of mitral regurgitation. Repeat echocardiography annually for three years (C) is not necessary for this patient since she A 17-year-old boy presents to your office after experiencing a head injury while playing football 3 weeks ago. He lost consciousness for less than 5 seconds after hitting his head during a tackle. Upon regaining consciousness, he was taken to the hospital for evaluation due to experiencing symptoms of headache, nausea, and mild confusion. Computed tomography of the head was negative for any acute findings. The patient and his parents now have questions about return to activity and ongoing health maintenance after a concussion. Which of the following is the most appropriate guidance? A Annual brain imaging B Cognitive rehabilitation C Immediate return to activity D Stepwise return to activity - Stepwise return to activityConcussion is also referred to as mild traumatic brain injury and occurs as a result of head injury. It is often seen in adolescents and young adults in the context of playing sports, such as American football, soccer, and ice hockey. It is most often defined by a Glasgow Coma Scale score of 13 to 15 assessed at 30 minutes postinjury. A stepwise return to activity once the athlete is asymptomatic and under close supervision of medical providers, coaches, family, and athletic trainers will help to prevent any complications of the injury. Postconcussive syndrome is a sequelae of concussion, with symptoms including headache, dizziness, cognitive impairment, and neuropsychiatric symptoms. Most cases occur within the first 10 days after the injury with the majority being completely resolved within 3 months. Follow-up imaging of the head is dependent on the patient's ongoing symptoms and if there was imaging done at the time of injury. Most patients will have computed tomography or magnetic resonance imaging done initially as part of their acute workup. For those with ongoing severe symptoms, magnetic resonance imaging should be done to rule out any serious pathology. Annual brain imaging (A) is not recommended. Cognitive rehabilitation (B) is a controversial treatment option due to its cost and lack of research support in nonmilitary populations. More studies are needed before recommending this modality as treatment of sports-related concussions. Immediate return to activity (C) is not recommended in athletes who are suspected of having a concussion, as there is a greater risk of injury in these individuals. Players should be asymptomatic and off all medications before returning to play. Question: True or false: concussion risk is greater for female athletes participating in basketball or socc A 2-week-old boy presents to the emergency department with his mother. The child was born at 37 weeks gestation, and his mother had sporadic prenatal care. The child presents with fever, lethargy, and vomiting. Vital signs are 101.5°F, pulse 155 beats per minute, respirations 30/min, blood pressure 95/60 mm Hg, and oxygen saturation of 98% on room air. Physical exam reveals a lethargic baby with dry mucous membranes. What cerebrospinal fluid analysis confirms the most likely diagnosis? A20 cm opening pressure, clear appearance, 30 mg/L protein, 75 g/dL glucose, and 15 cells/HPF white blood cells B25 cm opening pressure, fibrin webs visible, 100 mg/L protein, 45 mg/dL glucose, and 100 cells/HPF white blood cells C35 cm opening pressure, turbid appearance, 200 mg/L protein, 35 mg/dL glucose, and 80,000 cells/HPF white blood cells D40 cm opening pressure, clear appearance, 150 mg/L protein, 80 g/dL glucose, and 2,000 c - 35 cm opening pressure, turbid appearance, 200 mg/L protein, 35 mg/dL glucose, and 80,000 cells/HPF white blood cellsThis patient has bacterial meningitis. The most common pathogens of bacterial meningitis depend on the age of the patient. Group B Streptococcus and Listeria monocytogenes are the most common pathogens in infants less than 1 month old. Neisseria meningitidis and Streptococcus pneumoniae are the most common pathogens from 1 month to 50 years of age. Streptococcus pneumoniae and Listeria monocytogenes are the most common pathogens in patients greater than 50 years old. Patients will present with the classic triad of fever, headache, and altered mental status. They may also report nausea, vomiting, and symptoms of meningeal irritation. The physical exam will reveal fever, altered mental status, Kernig sign (the inability to straighten the knee with hip flexion), and Brudzinski sign (flexion of the neck produces hip and knee flexion). A lumbar puncture is the gold standard for definitive diagnosis. Evaluation of cerebrospinal fluid will reveal elevated polymorphic neutrophils, decreased glucose, increased protein, and elevated cerebrospinal fluid opening pressure. If the patient has focal neurologic findings, papilledema, or a history of other central nervous system diseases, then a CT scan should be considered prior to lumbar puncture to assess for midline shift, which increases the risk of herniation when lumbar puncture is performed.