Internal Medicine: 12 practice questions

The state of insufficient blood flow to the tissues of the body as a result of problems with the circulatory system. It is divided into four main types by underlying cause: hypovolemic, cardiogenic, obstructive and distributive.

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ARDS, by the Berlin criteria: acute onset within 1 week of an apparent clinical insult with progression of respiratory symptoms, bilateral opacities on chest imaging not explained by other lung pathology, and respiratory failure not explained by heart failure or volume overload. Severity is graded by PaO2/FiO2 — mild 201–300, moderate 101–200, severe 100 or below — measured on at least 5 cmH2O of PEEP.

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Atherosclerosis of the coronary arteries, producing a mismatch between myocardial oxygen supply and demand.

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A comedone. Comedones (blackheads and whiteheads) must be present to diagnose acne — their absence points instead to rosacea, folliculitis or a drug eruption, all of which produce papules and pustules without them.

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Worldwide, too little iodine in the diet is the most common cause. In countries with sufficient dietary iodine, Hashimoto's thyroiditis — an autoimmune disease in which the immune system reacts to the thyroid gland — is the most common cause. It presents with poor ability to tolerate cold, extreme fatigue, muscle aches, constipation, slow heart rate, depression and weight gain: everything slows.

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Duodenal. With a duodenal ulcer the pain occurs about 3 hours after a meal and wakes the person from sleep — food buffers acid briefly, and pain returns once the stomach empties. With a gastric ulcer the pain may worsen with eating instead. The distinction is suggestive rather than diagnostic, but it is a favourite discriminator.

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Acute onset developing over the course of hours to days, inattention — easy distraction and inability to maintain attentional focus — a fluctuating course through the day, and altered consciousness with disturbed awareness and higher-order cognition. Inattention is the cardinal feature: a patient who cannot hold the thread of a simple question is delirious until proved otherwise.

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Vitamin B12 deficiency — from achlorhydria-induced malabsorption, deficient intake such as a vegan diet, pernicious anaemia or gastrectomy — and folate deficiency from alcoholism, deficient intake, or increased needs in pregnancy, infancy and cirrhosis. The film shows a mean corpuscular volume above 100 fL, macrocytes, ovalocytes, and hypersegmented neutrophils with six or more lobes.

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Past infection, now cleared and immune. HBsAg is the first detectable viral antigen to appear during infection; if the host clears it, HBsAg becomes undetectable and is followed by IgG antibodies to surface and core antigen. Vaccination gives anti-HBs alone — the anti-HBc marks natural exposure, so the two together separate a recovered patient from a vaccinated one.

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Neck stiffness, sudden high fever, and altered mental status.

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Penicillin or amoxicillin. Antibiotics are useful both to prevent complications such as rheumatic fever and to speed recovery — the second benefit is modest, the first is the real justification. For viral infections antibiotics have no effect, which is the whole argument for testing before prescribing.

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Vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness; the breath may develop a specific fruity or acetone smell. The deep gasping breathing is respiratory compensation — blowing off carbon dioxide to offset the metabolic acidosis. Abdominal pain in DKA can mimic a surgical abdomen and has sent patients to theatre by mistake.

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