Hippo Education Internal Medicine #1

A 35-year-old woman comes to the internal medicine clinic for a routine physical examination. She says she has felt run down for the past six months and has had generalized fatigue, muscle weakness, myalgia, unintentional weight loss of 10 lb, and intermittent nausea. The patient also has been craving salt and has noticed that her skin has taken on a bronze tone even though she has not been tanning in the sun. Body mass index is 19 kg/m². Basic metabolic panel shows a sodium level of 128 mg/dL and a potassium level of 5.8 mg/dL. Which of the following is the most likely diagnosis?

• Acromegaly

• Addison disease

• Cushing disease

• 
  Hyperaldosteronism

• Pheochromocytoma

Answer explanation

Addison disease is also known as primary adrenal insufficiency and causes deficiencies in adrenal androgens, glucocorticoids, and mineralocorticoids. This patient has signs and symptoms of Addison disease. Hyperpigmentation of the skin is found in >90% of these patients and is caused by increased adrenocorticotropic hormone stimulation. Hyponatremia and hyperkalemia are also common findings. 

A 24-year-old woman is brought to the emergency department by her roommate because she had acute onset of abdominal pain as well as confusion, nausea and vomiting, and weakness 12 hours ago. The roommate does not believe that the patient has any medical conditions or takes any medications. Body mass index is 22 kg/m². Pulse rate is 110/min, and respirations are 28/min. The patient appears flushed and is oriented only to person and place. Physical examination shows decreased skin turgor. Laboratory studies show the following: plasma glucose 304 mg/dL; arterial pH 7.2; serum bicarbonate 14 mEq/L; thyroid-stimulating hormone 2.5 µU/L; and free thyroxine 1.4 µg/dL. Urinalysis is positive for ketones. Intravenous fluids are initiated, and the patient is admitted to the internal medicine ward. Which of the following is the most likely diagnosis?

• Acute adrenal crisis

• Diabetic ketoacidosis

• Hyperosmolar hyperglycemia

• Myxedema coma

  
  

• Thyroid storm

Answer explanation

Diabetic ketoacidosis (DKA) more commonly occurs in individuals with type 1 diabetes mellitus and can be the first presentation of the underlying disease. This patient is presenting with an acute onset of signs and symptoms associated with DKA and likely has previously undiagnosed type 1 diabetes mellitus. Many patients present with the classic symptoms of hyperglycemia; polyphagia, polydipsia or polyuria while others will present with nausea, vomiting, abdominal pain, fatigue and even weight loss. Diagnostic criteria include a blood sugar >250 mg/dL, an arterial pH <7.3, serum bicarbonate <15 mEq/L as well as ketones present in the urine or blood.

A 61-year-old man comes to the emergency department because he has had worsening fevers, chills, cough, and shortness of breath over the past 10 days. He says his symptoms started to get better a few days ago but then acutely worsened. The patient noticed some blood in his stool this morning. Medical history includes chronic obstructive pulmonary disease and hypertension, for which he uses an albuterol inhaler and takes lisinopril, respectively. He quit smoking two years ago, occasionally drinks alcoholic beverages, and does not use illegal drugs. Temperature is 39.2°C (102.6°F), pulse rate is 123/min, respirations are 24/min, and blood pressure is 146/82 mmHg. Oxygen saturation is 92% on room air. The patient is not in distress and is protecting his airway. Physical examination shows slight bleeding around the nares and gums. Non-blanching, 1-mm red macules are noted on his body but worse on his legs. Auscultation of the lungs shows coarse lung sounds and wheezing. Chest x-ray study shows diffuse interstitial infiltrates. Laboratory studies show the following: white blood cell count 21,000/mm³; hemoglobin 9.5 g/dL; hematocrit 29%; platelet count 45,000/mm³; prothrombin time 18 sec; partial thromboplastin time 42 sec; fibrinogen 180 mg/dL; and D-dimer 1500 ng/mL. Which of the following is the most appropriate initial step?

• Administration of fresh frozen plasma

• Administration of packed red blood cells

• Administration of vitamin K

• Emergent intubation

• Endoscopy and colonoscopy

Answer explanation

This patient is exhibiting signs of disseminated intravascular coagulation (DIC). This is a life-threatening condition that is characterized by generalized hypercoagulability that causes both micro- and macrovascular clotting. As the clotting factors and platelets are consumed, the patient begins to bleed. Common causes are infection leading to sepsis, trauma, and obstetric complications. It is important to treat the underlying cause. In addition, patients should be treated with fresh frozen plasma, cryoprecipitates, and platelets if the total platelet count is below 50,000/mm³ and they are bleeding. If the patient is not bleeding, heparin or low-molecular-weight heparin should be initiated.

A 28-year-old woman with major depressive disorder and a history of suicidal ideation is admitted to the hospital after being found in the bathroom with an empty bottle of pills. The patient is tearful and admits that she wanted to end things and took a handful of pills she found in the bathroom cabinet about four hours ago. She says she has vomited several times and has generalized abdominal pain. Pulse rate is 90/min, respirations are 26/min, and blood pressure is 110/80 mmHg; the patient is afebrile. On physical examination, mild tenderness to palpation is noted in all quadrants of the abdomen. Extensive laboratory studies are obtained including salicylate, acetaminophen, and electrolyte levels, complete blood cell count, lactate level, arterial blood gas analysis, and liver and renal function tests. All results are within normal limits except for arterial blood gas analysis showing mild respiratory alkalosis and an elevated salicylate level of 50 mg/dL. Electrocardiography shows no abnormalities. Which of the following is the most appropriate next step in management?

• Administration of benzodiazepines

• Hemodialysis

• Induce vomiting

• 
  Intubation

• Supportive care while monitoring salicylate and acetaminophen levels

Answer explanation

The patient is experiencing symptoms of a mild salicylate intoxication from intentional drug overdose. This patient is hemodynamically stable and compensating well at this point. The salicylate and acetaminophen levels should continue to be monitored. If the patient becomes more symptomatic, laboratory or EKG abnormalities occur, or the salicylate level increases, then other interventions would be necessary. Patients who are volume depleted should receive D5 along with sodium bicarbonate.

A 45-year-old woman is brought to the emergency department by her partner immediately after she lost consciousness while she was getting dressed this morning. The partner witnessed the episode and did not notice any shaking or spasming; however, the patient looked very pale. She was unconscious for about 15 seconds and woke up spontaneously without any confusion or disorientation. She has no history of similar episodes, and she has not had any changes in diet or lifestyle. Medical history includes high cholesterol and diabetes mellitus. Medications include atorvastatin 40 mg and metformin 500 mg twice daily. The patient smokes about one-half pack of cigarettes per day, does not drink alcoholic beverages, and does not use illicit drugs. Pulse rate is regular and even at 102/min, and blood pressure is 110/78 mmHg. Oxygen saturation is 95% on room air. On physical examination, no carotid bruits are noted, and the lungs are clear to auscultation. No edema is noted. Laboratory studies show white blood cell count of 9000/mm³, hemoglobin level of 14 g/dL, hematocrit of 21%, creatinine level of 0.8 mg/dL, glucose level of 102 mg/dL, and prolactin level of 6 ng/mL; electrolyte levels are within normal limits. Results of a CT scan of the head are pending. Which of the following organ systems is responsible for the findings in this patient?

• Cardiac

• Endocrine

• Neurologic

• Pulmonary

• Renal

Answer explanation

This patient is suffering from syncope, which is really a symptom as opposed to an underlying disease. The most common cause of syncope is cardiovascular. A reduction in cerebral blood flow causes a momentary loss of consciousness. This is usually not accompanied by seizure activity or a postictal state. It is important to rule out other causes of syncope including seizure activity. This patient had a witnessed episode without seizure or a postictal state, and her prolactin level was within normal limits, which may be elevated after a seizure. Her other vital signs and laboratory values do not indicate other pathology.

A 72-year-old man who comes to the clinic for routine physical examination says that he has had worsening fatigue and some slight tingling in his feet over the past three months. He also has had a 10-lb unintentional weight loss during this time. The patient has not had fevers, chills, or gastrointestinal bleeding. Medical history includes no chronic disease conditions, and he takes no medications. Temperature is 37.0°C (98.6°F), pulse rate is 90/min, and blood pressure is 128/88 mmHg. Physical examination shows no abnormalities. Laboratory findings include the following: white blood cell count 8/mm³; hemoglobin 11 g/dL; hematocrit 35%; mean corpuscular volume 90 µm³; mean corpuscular hemoglobin 30 pg/cell; mean corpuscular hemoglobin concentration 33 g/dL; platelet count 250/mm³; erythrocyte sedimentation rate 20 mm/hr; albumin-globulin ratio 0.5; thyroid-stimulating hormone 3 µU/mL; and vitamin B12 250 pg/mL. Further workup with serum protein electrophoresis shows elevated M protein. Based on these findings, this patient is at increased risk of developing which of the following conditions?

• Acquired immunodeficiency syndrome

• Hepatocellular carcinoma

• Meningococcal meningitis

• Micronutrient malnutrition

• Multiple myeloma

Answer explanation

This patient has monoclonal gammopathy of undetermined significance (MGUS). This is considered a preneoplastic condition that has an annual progression of about 1% per year. Most commonly, this progresses to multiple myeloma. It is most common in elderly males. Low A/G ratio with anemia and elevated ESR should prompt further investigation with SPEP and UPEP.

A 72-year-old man comes to the emergency department because he has had vision loss in his right eye for the past 24 hours. He says he had development of a persistent mild headache two months ago, and he now has fatigue, fever, and decreased appetite. He also says that when he tried to eat a steak yesterday, he had a very hard time chewing because of pain in his jaw. The patient does not have paralysis, weakness, or changes in mentation. He has no history of similar symptoms in the past, and he does not smoke cigarettes, drink alcoholic beverages, or use illicit drugs. Temperature is 38.2°C (100.8°F), and pulse rate is 102/min. The patient is oriented to person, place, time, and situation. Physical examination of the right temple shows an area of mild erythema with thickening and tenderness to palpation. Cranial nerves are intact; however, complete vision loss in the right eye is noted. Romberg test is negative. No weakness or numbness is noted in the extremities. Biopsy of the temporal artery is planned. Which of the following biopsy results is most likely?

• Clusters of basiloid cells with palisading

• Keratinized squamous epithelium with fibroelastic connective tissue

• Multinucleated giant cells with positive Tzanck test

• Panarteritis affecting the media with CD+ and macrophages

• Spongiosis with intercellular edema

Answer explanation

This is the histologic description of a temporal artery biopsy in a patient with temporal arteritis, which is also called giant cell arteritis. This is a systemic inflammatory vasculitis that affects the medium and large vessels. It occurs in patients when they are in their 70s. It can affect any vessel, but the classic presentation is with inflammation of the temporal artery that causes monocular vision loss, jaw claudication, and systemic symptoms. It is commonly associated with polymyalgia rheumatica. Corticosteroids are the mainstay of treatment and quick initiation will help prevent permanent blindness.

A 26-year-old man comes to the internal medicine clinic because he has had redness of the eyes with associated discharge, pain with urination, and pain in his right knee and right ankle for the past five days. He says he is generally healthy and has no chronic disease conditions; however, he had Chlamydia trachomatis about five weeks ago. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Physical examination shows conjunctivitis, edema and tenderness to palpation of the right knee and ankle, and urethral discharge. Laboratory studies show elevated C-reactive protein level and erythrocyte sedimentation rate. Which of the following is the most likely diagnosis?

• Ankylosing spondylitis

• Pseudogout

• Reactive arthritis

• Rheumatoid arthritis

• Septic arthritis

Answer explanation

Reactive arthritis, formerly known as Reiter syndrome, is a systemic inflammatory disorder that occurs after an extra-articular infection, commonly a sexually transmitted infection. It is most common in men 20 to 40 years of age, and risk factors include HLA-B27 positivity. Laboratory findings often include a complete blood cell count with a neutrophilic leukocytosis and elevated C-reactive protein level and erythrocyte sedimentation rate. This patient is presenting with the classic triad of urethritis, conjunctivitis, and asymmetrical polyarthritis associated with reactive arthritis.  

A 40-year-old man comes to the clinic for a routine physical examination. During the interview, he asks if he needs to get a colonoscopy. It is most appropriate to tell this patient that he will only need a colonoscopy at this age if he has which of the following findings on history and physical examination? 

• A 20-pack-year history of cigarette smoking

• African American ethnicity

• Inflammatory bowel disease

• Irritable bowel syndrome

• Significant diverticulosis

Answer explanation

Inflammatory bowel diseases such as ulcerative colitis or Crohn disease are reasons to start colon cancer screening early. Other reasons include having a first-degree relative with colon cancer, having certain genetic diseases, or having previous abnormal polyps removed. Otherwise, the U.S. Preventive Services Task Force recommends colon cancer screening beginning at 45 years of age for all patients and typically continuing until 75 years of age.

A 63-year-old man comes to the emergency department because he has had worsening pain in the left lower quadrant of the abdomen over the past four days. He has had some diarrhea without blood and has felt feverish. Today, he says he developed urinary discomfort. Temperature is 38.3°C (101.0°F), pulse rate is 110/min, and blood pressure is 98/58 mmHg. Physical examination shows tenderness on palpation of the left lower abdomen with rigidity and guarding. A mass is palpated in the area of tenderness. White blood cell count is 18,000/mm³, and lactic acid is 3.1 mmol/L; hemoglobin and hematocrit are within normal limits. Urinalysis shows no abnormalities. Which of the following is the most likely diagnosis?

• Colon cancer

• Diverticulitis

• Large bowel obstruction

• Left-sided nephrolithiasis

• Urinary tract infection

Answer explanation

This presentation is most consistent with acute diverticulitis with abscess formation. The patient is showing signs of sepsis with fever, elevated white blood cell count, hypotension, and tachycardia. His dysuria is likely due to sympathetic cystitis. The palpable mass is likely an abscess. Treatment consists of antibiotics with or without surgical management, depending on the size and scope of any perforation or abscess.