2014 Internal Medicine Board-Style Questions & Answers

Answer #195
The correct answer should be: A. Dissection of the ascending aorta should be treated with aggressive medical therapy and close observation.

Add the following sentence to the beginning of the explanation: The patient has Marfan syndrome and is suffering a dissection of the aorta.

The Board Testing Point should read: Recognize the clinical characteristics of a dissection of the aorta in a patient with Marfan syndrome.

Question/Answer #255
Question and Answer/Explanation #255 in Infectious Disease topic should be moved to the Nephrology topic.
The scenario, answer choices, correct answer indication, and explanation are still valid.

Answer #271
The first paragraph in the explanation currently reads:
Alkalosis is generated when H+ is lost or bicarbonate is gained by the body or contraction of the plasma volume around a fixed amout of total body bicarbonate; i.e., loss of bicarbonate-free fluid. Less common causes of alkalosis generation are H+ shifts from the extracellular to the intracellular space. The alkalosis is then maintained by the inability of the kidneys to excrete excess bicarbonate in the urine (usually driven by aldosterone and decreased distal chloride delivery). The urinary chloride concentration is the most important lab test in the workup of metabolic acidosis. Chloride-responsive alkalosis (urine chloride < 10 mEq/L) is characterized by volume depletion; examples include vomiting, nasogastric suction, and contraction alkalsois (due to remote diuretic use).

The first paragraph in the explanation should read:
Alkalosis is generated when H+ is lost or bicarbonate is gained by the body or contraction of the plasma volume around a fixed amount of total body bicarbonate; i.e., loss of bicarbonate-free fluid. Less common causes of alkalosis generation are H+ shifts from the extracellular to the intracellular space. The alkalosis is then maintained by the inability of the kidneys to excrete excess bicarbonate in the urine (usually driven by aldosterone and decreased distal chloride delivery). The urinary chloride concentration is the most important lab test in the workup of metabolic alkalosis. Chloride-responsive alkalosis (urine chloride < 10 mEq/L) is characterized by volume depletion; examples include vomiting, nasogastric suction, and contraction alkalosis (due to remote diuretic use).

Answer #291
The explanation currently reads:
Answer: Na 136, K 5.0, Cl 102, HCO3 20, Serum Creatinine 3.5, Arterial pH 7.36, Urine pH 5.0. With a moderate glomerulonephritis, metabolic acidosis is usually mild, and the anion gap is only slightly elevated, if at all.

The explanation should read:
Answer option “Na 136, K 5.0, Cl 102, HCO3 20, Serum Creatinine 3.5, Arterial pH 7.36, Urine pH 5.0” best fits the laboratory pattern of someone recovering from acute kidney injury due to glomerulonephritis. With a moderate glomerulonephritis, metabolic acidosis is usually mild, and the anion gap is only slightly elevated, if at all. The other answer options are incorrect for the following reasons: these choices portray a more severe metabolic acidosis; hypokalemia is not typically seen in acute glomerulonephritis; the presence of significant hyperkalemia would not be expected in a patient who is in renal recovery. In addition, a high urine pH with a mild metabolic acidosis signifies a tubulointerstitial process (i.e., distal RTA), whereas acute post-infectious glomerulonephritis is primarily a glomerular disease.