American Board of Internal Medicine (ABIM) Certification

A 34 year old female, mother of 3 reports to her primary care physician with the complaints of restless, agitation, palpitations, sweating and significant weight loss of 8 pounds (without any dietary or exercise intervention). She also complains of fine tremors and intolerance to hot temperatures. She denies smoking, drinking or intake of caffeine at all. Her vitals are; temperature = 37 C (or 98.6 deg F), pulse of 120/ min, blood pressure of 140/ 80 mmHg and respiratory rate of 20/ min. On physical examination, doctor observed fine tremor, pre-tibial myxedema, lid lag and characteristic stare. On palpation, thyroid gland is diffusely enlarged and lobular. On auscultation, a bruit is heard over gland surface. Lab investigations reveal very low levels of TSH and an increased radioactive iodine uptake. A diagnosis of Graves disease is made and possible treatment options are discussed. If patient choose radioactive iodine therapy, what are the possible complications in long term?

A 25-year-old male is admitted in the emergency unit for the management of severe asthma attack. He is also nauseated and complains of vomiting and diarrhea. The patient has a long history of severe asthma with multiple hospitalizations and one intubation 5 years ago. He developed shortness of breath 2 days ago that is progressively worsening since then. He tried home albuterol, ipratropium nebulizers, and cromolyn therapy but nothing improved his symptoms. In the hospital, peak flow rates are decreased by nearly 50% from baseline. Which of the following agents should most likely be added to the patient�s therapy to alleviate his current symptoms?

A 50 year-old patient with a history of hypertension, hyperlipidemia and alcoholism presents to the Emergency Department with productive cough, fever, chills and generalized weakness. She states that she has had those symptoms for over a week and her family adds that she has been acting confused as well. She takes atenolol and Lipitor and recently started drinking again. Vitals: blood pressure (BP) is 110/75, heart rate (HR) is 105bpm, respiratory rate (RR) is 22 and Temp 102.5?F. Physical exam reveals decreased breath sounds in the right lower lobe (RLL) correlating with a RLL infiltrate on chest x-ray. What is your presumptive diagnosis?

A 66-year-old man with a 59-pack-year smoking history comes to emergency center with complaints of worsening chronic shortness of breath and productive cough. He has also had several episodes of blood tinged sputum over the past few weeks. His son states that over the past 3 weeks he seems more hoarse than usual. On physical examination, he has dense rhonchi in the right mid-lung field, in addition to soft scattered rhonchi in both lung fields with a prolonged expiratory phase. A chest x-ray film reveals a 6-cm, irregular mass in the right middle lobe with associated lobar consolidation. Which of the following would most suggest that the patient has surgically incurable lung cancer?

A 50-year old man with a history of hypertension, seizure and alcohol abuse presents in the Emergency Department (ED) with a few weeks of productive cough, difficulty breathing, fever and chills. On Physical exam, temperature is 102.5F, HR 110bpm, he has diminished breath sounds in the right upper lobe(RUL) . Chest XR shows cavitary infiltrate with air-fluid level in the RUL . What is your presumptive diagnosis and treatment?

A 59-year old man is brought in by EMS after collapsing on a treadmill at the gym. He was pulseless for 3 minutes, but responded to bystander CPR and 1 AED shock, as well as aspirin and morphine en route. His past medical history is unknown. VS are BP 152/84, HR 112, RR 22, SaO2 100% on 3L face mask O2. On exam, he is agitated and has a small, bleeding forehead laceration, and chest wall tenderness, but moves all extremities and follows commands. The ECG obtained en route reveals inferior ST-segment elevations in leads II, III, and aVF, and deep ST depressions in the anterior precordial leads. The nearest cardiac catheterization facility is a tertiary care center 75 minutes away by ambulance. Which of the following is the most appropriate next step in management?

A 46-year old woman presents for follow-up two weeks after hospitalization for an acute anterior myocardial infarction (MI). She underwent emergency percutaneous coronary intervention, which showed an acute 99% occlusion of the left anterior descending (LAD) coronary artery and reduced left ventricular ejection fraction of 35-40%. She received a single drug-eluting stent and had an uncomplicated course. Today, she reports feeling well. She has quit smoking and is motivated to improve her health. She is again sexually active with her husband, and uses barrier contraception occasionally. Vital signs and focused exam are unremarkable. Which of the following medications is absolutely contraindicated in women who are or might become pregnant?

A 74 year-old male presents to the emergency department with three days of increased shortness of breath and lower extremity edema. He has a past medical history of coronary artery disease, hypertension, hyperlipidemia, and diabetes mellitus. On further questioning, he states that he has been experiencing shortness of breath while laying flat and often wakes up at night coughing. He also is non-compliant with all of his medications. Physical exam: HR:102 / BP:156/84 / RR:24 / Oxygen saturation: 89% on room air / Physical exam: Notable for an S3, elevated jugular venous distension, 1+ bilateral lower extremity edema, and bibasilar crackles. Labs are significant for an elevated BNP at 988. EKG shows sinus tachycardia with left ventricular hypertrophy. Initial troponin is negative. Which neurotransmitter is most likely to be chronically elevated in this patient?

A 63 year-old male with a history of insulin-dependent diabetes mellitus and newly diagnosed congestive heart failure is brought to his physician�s office with generalized weakness, sweating, and shaking. A finger stick blood glucose is checked and found to be 48. The patient improves with glucose administration. What medication did this patient most likely recently start?

Low dose diuretics initially lower blood pressure by increasing urinary sodium excretion. Compensatory increases in aldosterone eventually will stop the excess urinary sodium excretion, yet the blood pressure will still remain lower. What is the mechanism for continued blood pressure lowering after urinary sodium returns to normal?