Internal-Medicine

Answers and Explanations
1. (A) This patient has gonorrhea, and since 1986,
increasing penicillin resistance has meant that
penicillin/ampicillin are no longer drugs of
choice. Alternatives to ceftriaxone include
ciprofloxacin, ofloxacin, or cefixime given
orally, with 7 days of doxycycline, or a single
1 g dose of azithromycin in case of coinfection
with Chlamydia. In Asia and the Pacific (as well
as in California), quinolones are not considered
first-line therapy because of the high rate
of resistant organisms. In these locations, ceftriaxone
is the drug of choice. In pregnant
women, erythromycin replaces doxycycline.
Disseminated gonococcal infection should be
treated in a hospital with IV antibiotics. (Kasper,
pp. 860–862)
2. (C) The impaired physiologic reserve of every
organ system is characteristic of aging. The
term homeostenosis has been used to describe
this phenomenon. Decline in most systems
starts in the third decade and is gradual and
progressive. Decrements in each organ system
seem independent of other systems and are
influenced by diet, environment, personal
habits (e.g., exercise), and genetic factors, as
well as just chronologic age. At times, it can be
difficult to differentiate between age-related
physiologic change and age-related diseases.
(Kasper, pp. 44–45)
3. (C) Other tests to rule out reversible disease
might include serum electrolytes, B 12
levels,
CBC, Venereal Disease Research Laboratory
(VDRL), and CT or MRI. Diagnosis of
Alzheimer’s disease remains a diagnosis of
exclusion. However, the insidious and subtle
onset, with few focal signs (except for higher
mental functioning) and a slowly progressive
course are characteristic. Careful attention to
the pattern of cognitive defects also improves
diagnostic accuracy. The intensity of investigation
will depend on numerous factors, including
age, presence of atypical findings, and the
timing of presentation. There is as yet no definite
consensus on the most appropriate plan of
investigation. (Kasper, pp. 2397–2398)
4. (D) This patient has hyperthyroidism. Cardiac
complications are more common in the elderly
patient and may dominate the clinical presentation.
There is often a wide pulse pressure,
systolic murmurs, increased intensity of the
first heart sound, and cardiomegaly. Sinus
tachycardia and atrial fibrillation are the most
common arrhythmias. A to-and-fro highpitched
sound in the pulmonic area (Means-
Lerman scratch) can mimic a pericardial
friction rub. (Kasper, p. 1423)
5. (B) A whole host of locally produced hormones
and cytokines, as well as ectopically produced
hormones, are implicated in local osteoclastic
hypercalcemia. Parathormone-related protein
is often elevated in malignant hypercalcemia
(with or without bony metastases), but ectopic
PTH production in malignancy is quite rare.
(Kasper, pp. 561–562)
6. (C) Sarcoidosis presents as an asymptomatic
CXR in at least 10–20% of cases in the United
States, but more frequently in countries where
pre-employment CXRs are mandatory. At least
40% of patients present with acute symptoms
and hilar lymphadenopathy. Approximately
90% will have an abnormal CXR at some point
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