Examples of challenging Internal Medicine board review cases

📚 Quick Study Guide: Navigating Challenging Internal Medicine Cases

• 🧐 Diagnostic Dilemmas: Many challenging cases present with vague or overlapping symptoms, requiring a broad differential diagnosis and careful application of diagnostic criteria. Think about conditions like vasculitis, atypical infections, or early autoimmune diseases.
• 🤯 Complex Comorbidities: Patients rarely present with just one issue. Cases often involve multiple chronic conditions (e.g., diabetes, heart failure, CKD) that interact, complicate presentations, and influence treatment choices, increasing the risk of polypharmacy and adverse drug reactions.
• 🧪 Subtle Presentations of Severe Illness: Be vigilant for critical conditions that might manifest non-specifically, especially in elderly, immunocompromised, or post-surgical patients. Examples include sepsis without fever, silent myocardial ischemia, or atypical stroke.
• 💊 Pharmacology & Drug Interactions: Internal Medicine boards frequently test knowledge of drug mechanisms, side effects, and interactions, particularly with new medications or in patients on multiple agents. Consider scenarios involving anticoagulants, immunosuppressants, or antiarrhythmics.
• 📊 Interpreting Advanced Diagnostics: Moving beyond basic labs, challenging questions might involve interpreting specialized imaging (e.g., CT angiography, MRI spectroscopy), genetic tests, or complex physiological studies (e.g., pulmonary function tests, electrophysiology studies).
• ⚖️ Ethical & Professional Challenges: Cases sometimes include ethical considerations such as end-of-life care, capacity assessment, conflicts of interest, or patient non-adherence, requiring application of medical ethics principles.
• 🔍 Rare Diseases Mimicking Common Ones: While boards usually focus on common conditions, a truly challenging case might feature a less common presentation of a rare disease that closely mimics a more prevalent illness, testing your depth of knowledge.

🧠 Practice Quiz: Challenging Internal Medicine Scenarios

1. A 68-year-old male with a history of hypertension, type 2 diabetes, and chronic kidney disease (CKD) stage 3 presents with sudden onset of severe abdominal pain, unresponsive to typical analgesics. Physical exam reveals mild tenderness in the epigastrium without rebound or guarding. Labs show elevated lactate (4.5 mmol/L), normal amylase/lipase, and a mild leukocytosis. ECG shows no acute ischemic changes. What is the most crucial next diagnostic step?

1. Order an abdominal ultrasound to check for cholecystitis.
2. Perform an emergent CT angiography of the abdomen.
3. Administer broad-spectrum antibiotics for suspected intra-abdominal infection.
4. Proceed with an upper endoscopy to rule out peptic ulcer disease.

2. A 35-year-old female presents with persistent fatigue, myalgias, and migratory polyarthralgia for 3 months. She also notes intermittent low-grade fevers and a recent rash on her face that worsens with sun exposure. Initial lab work reveals mild anemia, slightly elevated ESR, and positive ANA (1:640, speckled pattern). Her urinalysis is bland, and complement levels (C3, C4) are normal. Which autoantibody would be most specific for diagnosing her underlying condition in this context?

1. Anti-dsDNA antibody
2. Anti-Jo-1 antibody
3. Anti-Ro/SSA antibody
4. Anti-Centromere antibody

3. A 55-year-old male with a history of poorly controlled type 2 diabetes and hypertension is admitted with acute onset dyspnea and bilateral leg swelling. His creatinine is 2.8 mg/dL (baseline 1.2 mg/dL), and he has a significant proteinuria (urine protein/creatinine ratio 3.5). ECG shows diffuse T-wave inversions. Physical exam reveals jugular venous distension and bibasilar crackles. What is the most likely primary etiology of his acute decompensation?

1. Acute kidney injury due to rhabdomyolysis.
2. Diabetic nephropathy with superimposed acute heart failure.
3. Non-ST elevation myocardial infarction (NSTEMI) leading to acute kidney injury.
4. Hypertensive emergency causing acute pulmonary edema and renal dysfunction.

4. A 72-year-old female with a prosthetic mitral valve on warfarin presents with sudden onset of expressive aphasia and right-sided weakness. Her INR is 1.8. An emergent head CT shows no evidence of hemorrhage. What is the immediate priority for her management?

1. Administer intravenous alteplase (tPA) immediately.
2. Reverse warfarin with Vitamin K and PCC.
3. Perform an emergent carotid ultrasound.
4. Consult neurosurgery for potential thrombectomy.

5. A 40-year-old male presents with recurrent episodes of palpitations, sweating, and anxiety attacks. His blood pressure is labile, often peaking at 180/110 mmHg during these episodes. His sister was recently diagnosed with a rare genetic condition. During one such episode, a blood test reveals elevated plasma metanephrines. Which of the following genetic conditions is most strongly associated with this clinical picture?

1. Von Hippel-Lindau disease
2. Neurofibromatosis type 1
3. Multiple Endocrine Neoplasia type 2 (MEN2)
4. Hereditary hemorrhagic telangiectasia

6. A 60-year-old female with known cirrhosis secondary to NASH presents with worsening confusion, asterixis, and somnolence. She denies recent GI bleeding or infection. Her ammonia level is elevated. She is currently on lactulose daily. Which additional medication is most appropriate to add to her regimen to improve her condition?

1. Spironolactone
2. Rifaximin
3. Midodrine
4. Prednisone

7. A 28-year-old female presents with recurrent episodes of unilateral facial swelling, abdominal pain, and laryngeal edema. These episodes are not associated with urticaria or pruritus, and antihistamines have been ineffective. Her C1 esterase inhibitor level is found to be low. What is the most appropriate long-term prophylactic treatment for her condition?

1. Daily oral corticosteroids.
2. Epinephrine auto-injector for acute attacks.
3. C1 esterase inhibitor concentrate.
4. Androgen derivatives like Danazol.