COMAT INTERNAL MEDICINE EXAM
QUESTIONS AND ANSWERS
Heart Failure Exacerbation - Correct Answers --Some of the common symptoms of
heart failure include dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
peripheral edema and non-specific abdominal symptoms like nausea and vomiting.
-Common physical findings in heart failure exacerbation include peripheral edema,
pulmonary crackles, elevated jugular venous pressure, hepatojugular reflex, displaced
apical impulse, and S3 gallop.
Prevention of HF exacerabtion - Correct Answers -MONITOR SODIUM
-Medication regimen typically focuses on regression or reverse modeling of the left
ventricle with beta blocker, diuretics and ACE inhibitor or Angiotension receptor blocker
therapy.
-Lifestyle changes include exercise, weight loss and a low sodium diet.
-Reduced sodium intake is a key step for prevention in non-pharmacologic management
of heart failure.
-Water always follows sodium; therefore, monitoring sodium intake is key in monitoring
plasma volume in patients.
-Increased sodium intake results in increased fluid retention which further decreases the
cardiac output.
-Sodium restriction is necessary to prevent expansion of the extracellular fluid volume
and to prevent peripheral edema to decrease the myocardial wall stress and improve
renal flow.
-Therefore, sodium intake should be reduced to less than 2 g/day to prevent heart
failure exacerbation.
Potassium in heart failure - Correct Answers --Potassium levels should be monitored
closely in patients on any potassium sparing medications like ACE inhibitors and
spironolactone.
-Also, low salt substituents for heart failure patients often contain potassium chloride,
which should be used in moderation due to risk of hyperkalemia in patients on
potassium sparing medications.
-However, low sodium intake is more important in prevention of heart failure
exacerbation than potassium.
,Warfarin Skin Necrosis - Correct Answers -*Warfarin induced skin necrosis is more
frequently seen in individuals diagnosed with protein C deficiency.*
-Warfarin therapy is one of the most commonly used regimens for anticoagulation due
to its ability to be monitored and readily reversed.
-It interferes with the gamma carboxylation of the vitamin K dependent clotting factors
such as II, VII, IX, X, protein C, and protein S.
-Other than bleeding, one of the known major complications of warfarin therapy is full
thickness skin necrosis and sloughing over fatty areas, such as the buttocks, the breast,
and the thigh.
-This phenomenon is known to occur more frequently in individuals diagnosed with
protein C deficiency.
-This can usually be avoided by using a heparin or low molecular weight heparin
(LMWH) "bridge" until the warfarin level is therapeutic.
AV Fistulas - Correct Answers -* The ideal AV fistula location is in the most distal
vessels in the non-dominant upper extremity.*
-AV fistulas are typically constructed with an end-to-side vein-to-artery anastomosis
between an artery and vein.
-In creation of dialysis access fistulas, using the most distal vessels of the upper
extremity is recommended.
-Creation of more proximal fistulas prevent potential future placement of distal AV
fistulas.
*radial artery and cephalic vein*
"Brain dead" - Correct Answers -*Spinal reflexes may be present in a patient with brain
death.*
-Brain death may be diagnosed in the absence of brainstem function.
-The patient must be free of any pharmacologic and medical conditions that could
otherwise explain their decreased brain function.
-Patients cannot be hypotensive, hypothermic, or have decreased oxygen saturation.
-*Findings consistent with brain death include: non-reactive pupils, lack of corneal
reflex, lack of oculocephalic (doll's eyes) reflex, loss of respiratory drive even with
elevated partial pressure of carbon dioxide*.
-However, movements originating from the spinal cord or peripheral nerves may persist.
-For example facial nerve twitching or fasciculations of trunk and extremities.
-Therefore, spinal reflexes may persist despite brain death making it the correct answer
choice.
Necrotizing Fasciitis - Correct Answers -* Necrotizing fasciitis is a deep infection along a
fascial plane that causes severe pain followed by rapidly progressive erythema, swelling
and subcutaneous tissue necrosis. Diabetes is a major risk factor. Early surgical
intervention is the key to management to prevent local and systemic spread of the
,infection. Treatment includes surgical debridement and broad-spectrum antibiotic
therapy.*
-Necrotizing fasciitis is a rapidly progressive infection that travels along the fascial plane
and invades local vasculature, leading to ischemia and necrosis of overlying
subcutaneous tissue.
-It can be separated into three separate types based on the causative bacteria:
polymicrobial (Type I, usually includes S. aureus, E.coli, and Clostridium perfringens),
S. pyogenes (Type II), and clostridial myonecrosis (Type III, gas gangrene).
-The infection usually begins at a site of trauma. and in diabetics
-Necrotizing fasciitis presents initially with sudden onset of intense pain at the trauma
site that is usually out of proportion of clinical findings and then gradually progresses to
anesthesia.
-Swelling and erythema then develop and quickly spread over hours to days.
-As the infection extends into the deep fascia it causes thrombosis in the blood vessels
of the dermal papillae. This causes the skin to become friable and take on a bluish,
maroon discoloration.
Necrotizing Fasciitis 2 - Correct Answers --High clinical suspicion is key to diagnosing
necrotizing fasciitis. Important signs to be aware of include tissue necrosis, putrid
discharge, bullae, severe pain, gas production, rapid burrowing through fascial planes,
and lack of classical tissue inflammatory signs.
-The infection can be definitively diagnosed by tissue biopsy and culture (performed on
deep tissue removed during debridement).
-Doppler ultrasound and/or CT can be used to determine the extent of tissue
involvement and the presence or absence of gas.
-Gas is commonly present in Type I and Type III necrotizing fasciitis, however, gas
usually is not present when the cause is S. pyogenes or MRSA.
Necrotizing Fasciitis treatment - Correct Answers --Necrotizing fasciitis is a surgical
emergency that requires prompt surgical exploration and debridement of necrotic tissue.
-Antimicrobial therapy should be started empirically and include coverage for gram-
positive, gram-negative, and anaerobic organisms.
- A common regimen used includes penicillin G, third-generation cephalosporin, and
clindamycin.
Cellulitis - Correct Answers --Cellulitis is a local infection of the connective and
subcutaneous tissue that also presents with pain, erythema, and swelling. It is also
commonly associated with fever and chills.
-Common pathogens include S. pyogenes and S. aureus.
-Early stages of necrotizing fasciitis may be mistaken for a cellulitis. Therefore,
necrotizing fasciitis must be ruled out in all patients with suspected cellulitis.
- Cellulitis is not associated with skin coloration and necrosis, as seen in this patient.
-Also, this patient's CT scan showed involvement of the deep fascial layers, which are
not involved in cellulitis.
, Compartment Syndrome - Correct Answers --Compartment syndrome is a serious
condition caused by pressure buildup within the fascial planes of an extremity, which
can lead to rapid vascular and neurological damage.
-The precipitating event is commonly a major injury to the extremity such as a fracture,
crush injury, or constricting bandage on swelling tissue.
-Patients will present with pain out of proportion of clinical findings, paresthesias, and
muscle tightness. Skin changes are not commonly present.
Erysipelas - Correct Answers --Erysipelas is a streptococcal infection (S. pyogenes) of
the upper dermis and superficial lymphatics most commonly seen in young children and
the elderly.
-It presents with abrupt onset facial swelling and well-defined, indurated lesions that
expand along the nasolabial folds and extend to involve the entire face and upper
extremities.
-The red lesions then progress to flaccid bullae during the second and third day.
-Finally, desquamation of the involved skin occurs 5-10 days later.
Pyomyositis - Correct Answers --Pyomyositis is characterized by a pus-filled abscess
that forms within the skeletal muscle.
-It is most commonly seen in children aged 2-5 who live in tropical regions.
-It is caused by S. aureus.
-The infection most commonly affects large muscle groups such as the quadriceps or
gluteal muscles and usually remains localized.
-However, if left untreated, patients may present in shock due to exotoxins (e.g., toxic
shock toxin 1) or enterotoxins produced by the organism.
Adverse effects of Niacin - Correct Answers -*Niacin adverse effects include glucose
intolerance, pruritus, and an elevation in uric acid levels.*
-Patient presents with acute gouty attack as evidenced by the erythematus, warm,
tender right great toe.
-Niacin was added to his statin therapy at his last appointment.
-Niacin is a component of two co-enzymes necessary for lipid metabolism, tissue
respiration, glycogenolysis, and inhibition of very low-density lipoprotein (VLDL)
synthesis.
-It is associated with glucose intolerance, pruritis from a transient histamine release,
and elevation in uric acid levels.
-It is not a first-line therapy for hyperlipidemia, however it is often added to statin
therapy if statins alone are not controlling the hypercholesterolemia.
-Niacin is also known to help raise HDL even more than statins, exercise, and tobacco
cessation.
Cholestyramine - Correct Answers --Cholestyramine inhibits enterohepatic re-uptake of
intestinal bile salts thus increasing fecal loss of bile salt-bound LDL and reducing serum
cholesterol.
-Adverse effects include flatus and abdominal cramping. It also has significant drug-
drug interactions due to its ability to block absorption.
QUESTIONS AND ANSWERS
Heart Failure Exacerbation - Correct Answers --Some of the common symptoms of
heart failure include dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
peripheral edema and non-specific abdominal symptoms like nausea and vomiting.
-Common physical findings in heart failure exacerbation include peripheral edema,
pulmonary crackles, elevated jugular venous pressure, hepatojugular reflex, displaced
apical impulse, and S3 gallop.
Prevention of HF exacerabtion - Correct Answers -MONITOR SODIUM
-Medication regimen typically focuses on regression or reverse modeling of the left
ventricle with beta blocker, diuretics and ACE inhibitor or Angiotension receptor blocker
therapy.
-Lifestyle changes include exercise, weight loss and a low sodium diet.
-Reduced sodium intake is a key step for prevention in non-pharmacologic management
of heart failure.
-Water always follows sodium; therefore, monitoring sodium intake is key in monitoring
plasma volume in patients.
-Increased sodium intake results in increased fluid retention which further decreases the
cardiac output.
-Sodium restriction is necessary to prevent expansion of the extracellular fluid volume
and to prevent peripheral edema to decrease the myocardial wall stress and improve
renal flow.
-Therefore, sodium intake should be reduced to less than 2 g/day to prevent heart
failure exacerbation.
Potassium in heart failure - Correct Answers --Potassium levels should be monitored
closely in patients on any potassium sparing medications like ACE inhibitors and
spironolactone.
-Also, low salt substituents for heart failure patients often contain potassium chloride,
which should be used in moderation due to risk of hyperkalemia in patients on
potassium sparing medications.
-However, low sodium intake is more important in prevention of heart failure
exacerbation than potassium.
,Warfarin Skin Necrosis - Correct Answers -*Warfarin induced skin necrosis is more
frequently seen in individuals diagnosed with protein C deficiency.*
-Warfarin therapy is one of the most commonly used regimens for anticoagulation due
to its ability to be monitored and readily reversed.
-It interferes with the gamma carboxylation of the vitamin K dependent clotting factors
such as II, VII, IX, X, protein C, and protein S.
-Other than bleeding, one of the known major complications of warfarin therapy is full
thickness skin necrosis and sloughing over fatty areas, such as the buttocks, the breast,
and the thigh.
-This phenomenon is known to occur more frequently in individuals diagnosed with
protein C deficiency.
-This can usually be avoided by using a heparin or low molecular weight heparin
(LMWH) "bridge" until the warfarin level is therapeutic.
AV Fistulas - Correct Answers -* The ideal AV fistula location is in the most distal
vessels in the non-dominant upper extremity.*
-AV fistulas are typically constructed with an end-to-side vein-to-artery anastomosis
between an artery and vein.
-In creation of dialysis access fistulas, using the most distal vessels of the upper
extremity is recommended.
-Creation of more proximal fistulas prevent potential future placement of distal AV
fistulas.
*radial artery and cephalic vein*
"Brain dead" - Correct Answers -*Spinal reflexes may be present in a patient with brain
death.*
-Brain death may be diagnosed in the absence of brainstem function.
-The patient must be free of any pharmacologic and medical conditions that could
otherwise explain their decreased brain function.
-Patients cannot be hypotensive, hypothermic, or have decreased oxygen saturation.
-*Findings consistent with brain death include: non-reactive pupils, lack of corneal
reflex, lack of oculocephalic (doll's eyes) reflex, loss of respiratory drive even with
elevated partial pressure of carbon dioxide*.
-However, movements originating from the spinal cord or peripheral nerves may persist.
-For example facial nerve twitching or fasciculations of trunk and extremities.
-Therefore, spinal reflexes may persist despite brain death making it the correct answer
choice.
Necrotizing Fasciitis - Correct Answers -* Necrotizing fasciitis is a deep infection along a
fascial plane that causes severe pain followed by rapidly progressive erythema, swelling
and subcutaneous tissue necrosis. Diabetes is a major risk factor. Early surgical
intervention is the key to management to prevent local and systemic spread of the
,infection. Treatment includes surgical debridement and broad-spectrum antibiotic
therapy.*
-Necrotizing fasciitis is a rapidly progressive infection that travels along the fascial plane
and invades local vasculature, leading to ischemia and necrosis of overlying
subcutaneous tissue.
-It can be separated into three separate types based on the causative bacteria:
polymicrobial (Type I, usually includes S. aureus, E.coli, and Clostridium perfringens),
S. pyogenes (Type II), and clostridial myonecrosis (Type III, gas gangrene).
-The infection usually begins at a site of trauma. and in diabetics
-Necrotizing fasciitis presents initially with sudden onset of intense pain at the trauma
site that is usually out of proportion of clinical findings and then gradually progresses to
anesthesia.
-Swelling and erythema then develop and quickly spread over hours to days.
-As the infection extends into the deep fascia it causes thrombosis in the blood vessels
of the dermal papillae. This causes the skin to become friable and take on a bluish,
maroon discoloration.
Necrotizing Fasciitis 2 - Correct Answers --High clinical suspicion is key to diagnosing
necrotizing fasciitis. Important signs to be aware of include tissue necrosis, putrid
discharge, bullae, severe pain, gas production, rapid burrowing through fascial planes,
and lack of classical tissue inflammatory signs.
-The infection can be definitively diagnosed by tissue biopsy and culture (performed on
deep tissue removed during debridement).
-Doppler ultrasound and/or CT can be used to determine the extent of tissue
involvement and the presence or absence of gas.
-Gas is commonly present in Type I and Type III necrotizing fasciitis, however, gas
usually is not present when the cause is S. pyogenes or MRSA.
Necrotizing Fasciitis treatment - Correct Answers --Necrotizing fasciitis is a surgical
emergency that requires prompt surgical exploration and debridement of necrotic tissue.
-Antimicrobial therapy should be started empirically and include coverage for gram-
positive, gram-negative, and anaerobic organisms.
- A common regimen used includes penicillin G, third-generation cephalosporin, and
clindamycin.
Cellulitis - Correct Answers --Cellulitis is a local infection of the connective and
subcutaneous tissue that also presents with pain, erythema, and swelling. It is also
commonly associated with fever and chills.
-Common pathogens include S. pyogenes and S. aureus.
-Early stages of necrotizing fasciitis may be mistaken for a cellulitis. Therefore,
necrotizing fasciitis must be ruled out in all patients with suspected cellulitis.
- Cellulitis is not associated with skin coloration and necrosis, as seen in this patient.
-Also, this patient's CT scan showed involvement of the deep fascial layers, which are
not involved in cellulitis.
, Compartment Syndrome - Correct Answers --Compartment syndrome is a serious
condition caused by pressure buildup within the fascial planes of an extremity, which
can lead to rapid vascular and neurological damage.
-The precipitating event is commonly a major injury to the extremity such as a fracture,
crush injury, or constricting bandage on swelling tissue.
-Patients will present with pain out of proportion of clinical findings, paresthesias, and
muscle tightness. Skin changes are not commonly present.
Erysipelas - Correct Answers --Erysipelas is a streptococcal infection (S. pyogenes) of
the upper dermis and superficial lymphatics most commonly seen in young children and
the elderly.
-It presents with abrupt onset facial swelling and well-defined, indurated lesions that
expand along the nasolabial folds and extend to involve the entire face and upper
extremities.
-The red lesions then progress to flaccid bullae during the second and third day.
-Finally, desquamation of the involved skin occurs 5-10 days later.
Pyomyositis - Correct Answers --Pyomyositis is characterized by a pus-filled abscess
that forms within the skeletal muscle.
-It is most commonly seen in children aged 2-5 who live in tropical regions.
-It is caused by S. aureus.
-The infection most commonly affects large muscle groups such as the quadriceps or
gluteal muscles and usually remains localized.
-However, if left untreated, patients may present in shock due to exotoxins (e.g., toxic
shock toxin 1) or enterotoxins produced by the organism.
Adverse effects of Niacin - Correct Answers -*Niacin adverse effects include glucose
intolerance, pruritus, and an elevation in uric acid levels.*
-Patient presents with acute gouty attack as evidenced by the erythematus, warm,
tender right great toe.
-Niacin was added to his statin therapy at his last appointment.
-Niacin is a component of two co-enzymes necessary for lipid metabolism, tissue
respiration, glycogenolysis, and inhibition of very low-density lipoprotein (VLDL)
synthesis.
-It is associated with glucose intolerance, pruritis from a transient histamine release,
and elevation in uric acid levels.
-It is not a first-line therapy for hyperlipidemia, however it is often added to statin
therapy if statins alone are not controlling the hypercholesterolemia.
-Niacin is also known to help raise HDL even more than statins, exercise, and tobacco
cessation.
Cholestyramine - Correct Answers --Cholestyramine inhibits enterohepatic re-uptake of
intestinal bile salts thus increasing fecal loss of bile salt-bound LDL and reducing serum
cholesterol.
-Adverse effects include flatus and abdominal cramping. It also has significant drug-
drug interactions due to its ability to block absorption.
