Internal Medicine Archives | The Audio PANCE and PANRE http://podcast.thepalife.com/category/podcast/end-of-rotation-exams/internal-medicine/ Physician Assistant Board Review Podcast Mon, 14 Jun 2021 03:02:25 +0000 en-US hourly 1 https://podcast.thepalife.com/wp-content/uploads/2017/04/cropped-The-Audio-PANCE-and-PANRE-512x512-32x32.jpg Internal Medicine Archives | The Audio PANCE and PANRE http://podcast.thepalife.com/category/podcast/end-of-rotation-exams/internal-medicine/ 32 32 The Audio PANCE and PANRE is an audio Board and Rotation Review Series that includes ten Multiple Choice PANCE and PANRE Board Review Questions in Each Episode. Now you can study for your PANCE, PANRE, and End or Rotation Exams in the gym, in the car, on a run, or while relaxing on the beach. This free series is limited to every other episode. To download the complete series join Smarty PANCE at https://smartypance.com/sign-up/ The Physician Assistant Life | Smarty PANCE clean The Physician Assistant Life | Smarty PANCE The PA Life, INC The PA Life, INC podcast Multiple Choice Physician Assistant Board and Rotation Review Questions on the Go - Listen and Learn Internal Medicine Archives | The Audio PANCE and PANRE http://podcast.thepalife.com/wp-content/uploads/powerpress/THE_AUDIO_PANCE_AND_PANRE_ACADEMY_PODCAST.png https://podcast.thepalife.com/category/podcast/end-of-rotation-exams/internal-medicine/ TV-G c9c7bad3-4712-514e-9ebd-d1e208fa1b76 78572745 Podcast Episode 87: Ten Internal Medicine EOR Questions https://podcast.thepalife.com/podcast-episode-87-ten-internal-medicine-eor-questions/ Mon, 14 Jun 2021 09:00:00 +0000 http://podcast.thepalife.com/?p=413 Welcome to episode 87 of the Audio PANCE and PANRE PA Board Review Podcast. Join me as I cover ten internal medicine rotation EOR content blueprint questions from the Smarty PANCE physician assistant board and rotation review website. Special from today’s episode: Check out the updated Smarty PANCE Internal Medicine Rotation (EOR) Review Course Download […]

The post Podcast Episode 87: Ten Internal Medicine EOR Questions appeared first on The Audio PANCE and PANRE.

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Podcast Episode 87 - Ten Internal Medicine EOR Questions

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

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

Special from today’s episode:

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

The Audio PANCE/PANRE and EOR PA Board Review Podcast

I hope you enjoy this free audio component to the examination portion of this site. The full board review course includes over 2,000 interactive board review questions and is available to all members of Smarty PANCE.

Listen Carefully Then Take The Practice Exam

If you can’t see the audio player click here to listen to the full episode.

Podcast Episode 87: Ten Internal Medicine EOR Pulmonology Questions

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

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

A Barium enema
B Colonoscopy
C CT scan
D. Sigmoidoscopy

Click here to see the answer

Answer: C CT scan

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

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

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

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

Click here to see the answer

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

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

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

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

Click here to see the answer

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

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

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

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

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

Click here to see the answer

The answer is B IV hydrocortisone

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

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

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

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

Click here to see the answer

The answer is C Mucosal tear at the gastroesophageal junction

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

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

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

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

Click here to see the answer

The answer is C Rome criteria

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

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

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

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

Click here to see the answer

Answer: D Grade IV

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

Incorrect Answers:

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

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

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

Click here to see the answer

The answer is E. Omeprazole

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

Incorrect answers

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

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

A Salmonella
B Rotavirus
C Clostridium difficile
D E. coli

Click here to see the answer

The answer is C Clostridium difficile

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

Incorrect answers

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

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

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

Click here to see the answer

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

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

Incorrect answers

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

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Welcome to episode 87 of the Audio PANCE and PANRE PA Board Review Podcast. Join me as I cover ten internal medicine rotation EOR content blueprint questions from the Smarty PANCE physician assistant board and rotation review website.



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



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



Special from today’s episode:



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



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



The Audio PANCE/PANRE and EOR PA Board Review Podcast



I hope you enjoy this free audio component to the examination portion of this site. The full board review course includes over 2,000 interactive board review questions and is available to all members of Smarty PANCE.



* You can download and listen to past FREE episodes here, on iTunes, Spotify, on Google Play Music or Stitcher.* You can listen to the latest episode, take an interactive quiz, and download more resources below.



Listen Carefully Then Take The Practice Exam





If you can’t see the audio player click here to listen to the full episode.



Podcast Episode 87: Ten Internal Medicine EOR Pulmonology Questions



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



1. A 67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, mid abdominal distention, and lower left quadrant tenderness.]]>
The Physician Assistant Life | Smarty PANCE full 22:25 413
Podcast Episode 81: Internal Medicine EOR Cardiology Questions https://podcast.thepalife.com/podcast-episode-81-internal-medicine-eor-cardiology-questions/ Mon, 23 Mar 2020 15:15:19 +0000 http://podcast.thepalife.com/?p=375 Welcome to episode 81 of the Audio PANCE and PANRE PA Board Review Podcast. Join me as I cover ten internal medicine rotation EOR content blueprint questions from the Smarty PANCE physician assistant board and rotation review website. Special from today’s episode: Check out the new Smarty PANCE Internal Medicine Rotation (EOR) Review Course Download […]

The post Podcast Episode 81: Internal Medicine EOR Cardiology Questions appeared first on The Audio PANCE and PANRE.

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Episode 81 episode 81 Ten PAEA Internal Medicine Rotation Exam (EOR) QuestionsWelcome to episode 81 of the Audio PANCE and PANRE PA Board Review Podcast.

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

Special from today’s episode:

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

The Audio PANCE/PANRE and EOR PA Board Review Podcast

I hope you enjoy this free audio component to the examination portion of this site. The full board review course includes over 2,000 interactive board review questions and is available to all members of the PANCE and PANRE Academy and Smarty PANCE.

Listen Carefully Then Take The Practice Exam

If you can’t see the audio player click here to listen to the full episode.

Podcast Episode 81: Ten Internal Medicine EOR Cardiology Questions

The following questions are linked to PAEA Content Blueprint lessons from the Smarty PANCE and PANRE Board Review Website. If you are a member you will be able to 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

Click here to see the answer

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.

  • Fat embolism to the pulmonary circulation almost always occurs with major trauma, including surgical procedures like intramedullary nailing of long bones. Fat emboli can occlude the microvasculature, triggering a systemic inflammatory response. The woman did not have recent trauma, and a fat embolism would not explain her cardiac murmur.
  • Clinical presentation of myocardial infarction most often includes substernal crushing chest pain, radiation of pain to the arms, left shoulder, back, neck, and jaw, as well as shortness of breath, anxiety, and fatigue. A myocardial infarction would not explain her developing a new cardiac murmur in recent weeks.
  • Rheumatic fever is an autoimmune inflammatory process that develops as a sequela of streptococcal infection. Clinical manifestations include polyarthritis, carditis, erythema marginatum, chorea, and subcutaneous nodules. Rheumatic fever can cause some of the symptoms seen in this case, but the acute onset makes this option less likely.
  • Although small cell lung cancer can present with pulmonary symptoms and low grade fevers, it wouldn’t easily explain her new cardiac murmur or the signs of right-sided heart failure.

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?

A. Adenovirus
B. Coxsackie A virus
C. Staphylococcus aureus
D. Corynebacterium diphtheriae

Click here to see the answer

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.

  • Though coxsackie B virus is one of the most common causal pathogens of acute myocarditis, Coxsackie A causes herpangina, aseptic meningitis, and hand, foot, and mouth disease.
  • Staphylococcus aureus is a common cause of bacterial endocarditis, not myocarditis. Endocarditis is more likely to present with a new murmur and signs of distant emboli such as nail-bed hemorrhage and Janeway lesions.
  • Corynebacterium diphtheriae is the causal agent of diphtheria, which may involve myocarditis. However, the patient would then most likely have other symptoms of the disease, including pseudomembranous pharyngitis, lymphadenopathy, or an arrhythmia.

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

Click here to see the answer

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.

  • Patients with aortic dissection classically present with a tearing or ripping pain in the chest or back and may have a significant variation in systolic blood pressure between arms (not across respirations).
  • The severity of tricuspid regurgitation varies widely, ranging from asymptomatic disease to symptoms of right-sided heart failure (hepatosplenomegaly, ascites, peripheral edema).
  • Patients with aortic stenosis, the most common cause of left ventricular outflow obstruction, typically present with exertional dizziness or angina. In end-stage disease, symptoms may progress to heart failure.
  • Mitral stenosis obstructs the flow of blood from the left atrium to the left ventricle and typically manifests as exertional dyspnea and decreased exercise tolerance.

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

Click here to see the answer

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.

  • Statin therapy has shown to be effective in treating intermittent claudication. However, this intervention is appropriate only when the patient is deemed to be stable, and the risk of limb ischemia has been addressed.
  • Alteplase (tPa) has been used to treat intermittent claudication, but its use is outside the scope of the emergency room. Treatments initiated in the emergency department are unfractionated heparin, aspirin, pain control, and positioning of the leg to maintain perfusion.
  • The patient has significant impairment of perfusion to his legs. Discharge and vascular surgery follow-up as an outpatient would be inappropriate and likely to result in morbidity or mortality.
  • While this leg should be rested, compression and elevation are the opposite of what is needed. These therapies will further decrease the blood flow to the leg and put the patient at increased risk of complications.

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?
Elimination tool

A. Digoxin
B. Long-term penicillin
C. Short-term course of clindamycin
D. Reassurance & routine care
E. Intramuscular ceftriaxone

Click here to see the answer

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.

  • Digoxin is a purified cardiac glycoside that is typically used in the treatment of various heart conditions, such as atrial fibrillation, atrial flutter, and heart failure that cannot be controlled by other medication. It is not recommended for use in rheumatic fever.
  • Clindamycin is an antibiotic used to treat middle ear infections, bone or joint infections, pelvic inflammatory disease, strep throat, pneumonia, and endocarditis. Clindamycin is typically used as endocarditis prophylaxis for patients that are already receiving penicillin for secondary rheumatic fever prophylaxis.
  • This patient is suffering from rheumatic fever, which can lead to rheumatic heart disease. This can cause significant carditis which manifests as congestive heart failure.
  • Ceftriaxone is an antibiotic used to treat numerous bacterial infections, such as pneumonia, ear infections, skin infections, urinary tract infection, and meningitis. It is not used in the treatment of rheumatic fever.

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?

A. Atenolol
B. Hydrochlorothiazide
C. Labetalol
D. Lisinopril
E. Losartan

Click here to see the answer

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.

  • Atenolol is a β-blocker medication, which decreases blood pressure by decreasing heart rate and stroke volume. It is contraindicated in pregnancy because it has been associated with fetal growth restriction. β-blockers considered safe in pregnancy are metoprolol and labetalol.
  • Hydrochlorothiazide is a thiazide diuretic which decreases blood pressure via volume depletion. Diuretics do not cause fetal malformations but are generally avoided in pregnancy, as they prevent the physiologic volume expansion seen in normal pregnancy. They may be used in states of volume-dependent hypertension, such as renal or cardiac disease.
  • Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor which decreases blood pressure through inhibition of the renin-angiotensin-aldosterone system. ACE inhibitors and the closely related angiotensin-receptor blockers are contraindicated in pregnancy because of the risk of birth defects including renal dysgenesis and oligohydramnios.
  • Losartan is an angiotensin II receptor blocker (ARB) which decreases blood pressure through inhibition of the renin-angiotensin-aldosterone system. ARBs and the closely related angiotensin converting enzyme (ACE) inhibitors are contraindicated in pregnancy because of the risk of birth defects including renal dysgenesis and oligohydramnios.

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?

A. Enalapril
B. Furosemide
C. Hydrochlorothiazide
D. Metoprolol
E. Nifedipine

Click here to see the answer

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).

Incorrect Answers:

  • Furosemide is a loop diuretic that can be used to treat hypertension but it is not a first line agent. Unlike ACE inhibitors, loop diuretics have no renoprotective qualities and therefore are a worse initial choice in a hypertensive diabetic patient.
  • Hydrochlorothiazide is a thiazide diuretic and a first-line agent for the treatment of hypertension in non-diabetic patients. It is relatively contraindicated in diabetes because it has the potential adverse effect of hyperglycemia. It may also precipitate attacks of gout by increasing uric acid concentrations.
  • Metoprolol is a β-blocker that is used for the treatment of hypertension but is not a first line treatment. Also, β-blocker are contraindicated in asthma, as well as in diabetic patients due to its potential to mask signs of low blood sugar.
  • Nifedipine is a calcium channel blocker that is used in the treatment of hypertension but it is not a first line therapy. It has no renoprotective effects, and commonly causes peripheral edema as an unwanted adverse effect.

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

Click here to see the answer

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.

Pearls

  • Familial hypercholesterolemia (FH) is the most common autosomal dominant genetic disease. The clinical syndrome (phenotype) is characterized by extremely elevated levels of low-density lipoprotein cholesterol (LDL-C) and a propensity to early-onset atherosclerotic cardiovascular disease. In general, homozygotes manifest the disease at a much earlier age than heterozygotes and the disease is more severe.
  • Homozygous FH patients are rare and have an estimated prevalence of approximately 1:300,000 to 1:400,000
  • Heterozygous FH is estimated to occur in 1 in 200 to 250 individuals in the United States.
  • It is estimated that about 7 percent of American adults have an untreated lipoprotein cholesterol ≥190 mg/dL but only 1.7 percent carry an FH mutation
  • Patients with undiagnosed homozygous familial hypercholesterolemia (FH) develop severe, premature, atherosclerotic cardiovascular disease and die before age 20 in many cases.
  • In patients with a negative or unknown family history, an untreated LDL-C level of ≥190 mg/dL (4.9 mmol/L) suggests FH. This value is greater than the 90th percentile for age and sex.

Diagnosis

  • The diagnosis of heterozygous familial hypercholesterolemia (FH) is made with genetic testing or clinical criteria. A causative mutation in the LDLR, APOB, or PCSK9 gene(s) secures this diagnosis
  • When genetic testing is not available or not felt to be necessary, you can use the Dutch Lipid Clinic Network criteria, which assigns points based on low-density lipoprotein cholesterol (LDL-C) levels, personal history of early atherosclerotic cardiovascular disease (ASCVD), family history of early ASCVD, or high cholesterol in a first-degree relative, and personal and physical examination finding

Treatment

  • Patients with homozygous familial hypercholesterolemia (FH) – intensive LDL-C lowering, which targets a minimal value of <150 mg/dL (3.9 mmol/L)
  • In addition to a high-dose statin (atorvastatin 80 mg daily or rosuvastatin 40 mg daily), most homozygous patients will require additional therapies such as ezetimibe, a PCSK9 inhibitor, or potentially LDL-C apheresis

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

Click here to see the answer

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.

  • Aortic stenosis is the reduction of the valvular orifice (<2 cm) with left ventricular outflow obstruction. Patients with aortic stenosis present with chest pain, syncopal episodes, and dyspnea. Here, the patient has progressive dyspnea (NYHA II), and a pansystolic murmur (mitral area), which relates to mitral valve regurgitation
  • Aortic valve regurgitation (AOR) is described as an inefficient closure of the aortic valve leading to a retrograde blood flow into the left ventricle during diastole. Patients will present with a wide pulse pressure (Corrigan hammer pulse) or an Austin-Flint murmur (severe), none of which are present in this case.
  • Mitral valve stenosis (MVS) is the reduction of the mitral valve orifice (<2.5cm). The left atrium becomes dilated and hypertrophied because of increased work of the left atrium. Patients with MVS present with dyspnea, rust-colored sputum, atrial fibrillation, and a diastolic heart murmur (diastolic rumble and opening snap).
  • Pulmonary stenosis is an uncommon valvular lesion. It is commonly associated with congenital heart disease and carcinoid heart disease. Patients present a systolic ejection murmur in the left second intercostal space.

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?

A. Inspiration
B. Rapid squatting
C. Standing
D. Hand grip
E. Left lateral cubital position

Click here to see the answer

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.

  • The click of mitral valve prolapse is heard closer to S2 in the event of increased preload. Preload is increased by hand grip, squatting and inspiration.
  • Placing the patient in the left lateral cubitus position will not affect preload and will have no effect on the timing of the click in mitral valve prolapse.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Heart murmurs

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Welcome to episode 81 of the Audio PANCE and PANRE PA Board Review Podcast. Join me as I cover ten internal medicine rotation EOR content blueprint questions from the Smarty PANCE physician assistant board and rotation review website. Welcome to episode 81 of the Audio PANCE and PANRE PA Board Review Podcast.
Join me as I cover ten internal medicine rotation EOR content blueprint questions from the Smarty PANCE physician assistant board and rotation review website.
Special from today’s episode:

* Check out the new Smarty PANCE Internal Medicine Rotation (EOR) Review Course
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* Take the FREE Internal Medicine Rotation Cardiovascular Practice Exam
* View the interactive Smarty PANCE Internal Medicine Rotation (EOR) Topic List

Below you will find an interactive exam to complement the podcast.
The Audio PANCE/PANRE and EOR PA Board Review Podcast
I hope you enjoy this free audio component to the examination portion of this site. The full board review course includes over 2,000 interactive board review questions and is available to all members of the PANCE and PANRE Academy and Smarty PANCE.

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Podcast Episode 81: Ten Internal Medicine EOR Cardiology Questions
The following questions are linked to PAEA Content Blueprint lessons from the Smarty PANCE and PANRE Board Review Website. If you are a member you will be able to 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.]]>
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