TOPNOTCH MEDICAL BOARD PREP INTERNAL MEDICINE PHASE 3 DIGITAL HANDOUT BY RICHARD L.

VILLALUNA, RMT, MD
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• The Anion Gap (AG) is calculated as follows: AG = Na – (Cl +
HCO3)
DISCLOSURE • The normal AG values is between 6-12 mmol/L
The handouts/review materials must be treated with utmost confidentiality. It shall be the
responsibility of the person, whose name appears therein, that the handouts/review • There are 4 principal causes of high AG acidosis:
materials are not photocopied or in any way reproduced, shared or lent to any person or o Lactic acidosis
disposed in any manner. Any handout/review material found in the possession of another
person whose name does not appear therein shall be prima facie evidence of violation of RA
o Ketoacidosis
8293. Topnotch review materials are updated every six (6) months based on the current o Toxins
trends and feedback. Please buy all recommended review books and other materials listed o Renal failure
below.
THIS HANDOUT IS NOT FOR SALE!
A 40-year-old woman has been found unresponsive and
REMINDERS barely breathing by her husband. There is an empty bottle
1. Phase 3 serves as the final coaching. It is expected that you have finished Phase 0, of narcotic analgesic near the patient in the bathroom.
1, and 2 prior to watching the Phase 3 videos Which of the following arterial blood gases are most
2. The guided content of the video lectures are seen within the handout. Answers to
consistent with her clinical presentation?
questions / blanks will be seen in the Phase 3 video.
A. pH 7.02, PaCO2 60, HCO3 15, Anion gap 12
B. pH 7.1, PaCO2 20, HCO3 6, Anion gap 30
This handout is only valid for the March 2021 PLE batch. This will C. pH 7.27, PaCO2 60, HCO3 26, Anion gap 12
be rendered obsolete for the next batch since we update our D. pH 7.51, PaCO2 49, HCO3
handouts regularly. • Respiratory acidosis can be due to severe pulmonary disease,
respiratory muscle fatigue, or abnormalities in ventilatory


control and is recognized by an increase in PaCO2.
INTERNAL MEDICINE - PHASE 3 • Narcotics may depress the medullary respiratory center causing
alveolar hypoventilation, as evidenced by elevation in arterial
By Richard L. Villaluna, RMT, MD, FPCP, DPCCP paCO2. Thus, the scenario is most consistent with acute
respiratory acidosis.
CONTENTS • Renal compensation for respiratory acidosis takes hours to start
and days to be completed
• Part I
o Basic Skills in Clinical Medicine
o High-Yield General Principles in Clinical Medicine
o Cardinal Manifestations and Presentation of Diseases
• Part II
o System-specific Disorders

A 57-year-old man who has been intoxicated with alcohol
presents at the ER with vomiting and altered mental status.
Emergent laboratory values are shown below:

Arterial pH 7.36 (N 7.35-7.45), PaCO2 40 (N 35-45), HCO3- 23 (N

22-26)
Sodium 140, Chloride 80, Potassium 3.8

What acid-base disorder does this patient have?

A. Normal acid base
B. High anion gap metabolic acidosis
C. Compensated respiratory acidosis
D. Combined metabolic and respiratory acidosis

• The high anion gap (AG) is significant clinically even if the HCO3
or pH is normal.
• Similarly, normal values for HCO3, PaCO2 and pH does not ensure
the absence of an acid-base disturbance. A classic example is an
alcoholic man who has been vomiting may develop metabolic
alkalosis and has develop a superimposed alcoholic
ketoacidosis. A 70-year-old man with history of hypertension and
diabetes presents to your clinic for complaints of syncope.
ALCOHOLIC POTENTIAL He states that twice in the past month, he has
VOMITING spontaneously passed out with no warning symptoms. You
KETOACIDOSIS NET EFFECT
HCO3- request an ECG as shown below.
40 à 25 Normal
(22-26)
pCO2
47 à 40 Normal
(35-45)
pH
(7.35- 7.55 à 7.4 Normal
7.45) What type of atrioventricular block is present?
A. First-degree AV block
Metabolic Metabolic
Normal B. Second-degree Mobitz type I AV block
Alkalosis Acidosis
C. Second-degree Mobitz type II AV block

D. Third-degree AV block

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 TOPNOTCH MEDICAL BOARD PREP INTERNAL MEDICINE PHASE 3 DIGITAL HANDOUT BY RICHARD L. VILLALUNA, RMT, MD
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• First-degree AV block
o PR interval is > 0.20 sec

A 48-year-old man who has been previously healthy is
• Second-degree AV block (Mobitz type I) admitted to the hospital with a 2-day history of cough,
o Progressive lengthening of PR interval until a beat is “dropped” dyspnea, fever and right-sided pleuritic chest pain. Chest x-
ray shows pleural effusion. Thoracentesis is performed.
The following laboratory results are shown below:

Serum: Protein 7 g/dl, LDH 200 U/L (N 100-200 U/L)
Pleural fluid: Glucose 75mg/dl, Protein 4 g/dl, LDH 400 U/L

What is the pathogenesis of the pleural effusion?
• Second-degree AV block (Mobitz type II)
A. Increase in hydrostatic pressure
o Drop beat is not preceded by a change in the length of PR
B. Decrease in oncotic pressure
interval
C. Bacterial infection in the pleural space
D. Increase permeability of visceral pleural membrane
capillaries
• Pleural fluid accumulates when pleural fluid formation exceeds
pleural fluid reabsorption; or when there is decreased fluid
removal by the lymphatics.
• Normally, fluid enters the pleural space from the capillaries in
• Third-degree AV block the parietal pleural and is removed via the lymphatics in the
o P waves and QRS are dissociated (a marching of P waves parietal pleural.
without relation to R waves • Fluid can also enter the pleural space from the interstitial spaces
of the lung via the visceral pleura or from peritoneal cavity via
small holes in the diaphragm

• Cirrhosis accounts for 84% of cases of ascites.
• Cardiac ascites, peritoneal carcinomatosis, and “mixed ascites”
resulting from cirrhosis and a second disease account for 10-
15% of cases.
• Less common causes of ascites include massive hepatic
metastasis, infection (tuberculosis), pancreatitis, and renal
disease (nephrotic syndrome).
• The serum-ascites albumin gradient (SAAG) is useful in
distinguishing ascites caused by portal hypertension from non-
portal hypertension ascites.

A 60-year-old man presents with increasing abdominal
girth and cachexia. He had history of blood transfusion 20
years ago. Physical examination suggests ascites. You
performed paracentesis removing 4 liters of serous fluid.
The following laboratory results were obtained:

Serum: Na 128 meq/dl, Creatinine 1.2 mg/dl, Albumin 3.6 g/dl
Ascites: Albumin 1.1 g/dl, Protein 0.9 g/dl • The SAAG is calculated by subtracting the ascitic albumin
concentration from the serum albumin level.
Which of the following is the most likely cause of this o SAAG > 1.1 g/dl reflects the presence of portal hypertension.
patient’s ascites? o SAAG < 1.1 g/dl indicates that the ascites is not related to
A. Cirrhosis portal hypertension.
B. Heart failure
C. Tuberculosis
D. Nephrotic syndrome
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 TOPNOTCH MEDICAL BOARD PREP INTERNAL MEDICINE PHASE 3 DIGITAL HANDOUT BY RICHARD L. VILLALUNA, RMT, MD
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A 32-year-old woman consults you at the clinic for jaundice Which of the following is the correct interpretation of the
and elevated AST and ALT. She has history of unprotected above panel?
sexual activity with several different male partners for A. Acute hepatitis B
past 5 years. You requested for hepatitis serology panel B. Chronic active hepatitis B
which shows: C. Chronic hepatitis B carrier
(+) HBsAg; (+) anti-HBc lgG; (+) HBeAg; (-) anti-HBs; (-) anti- D. Vaccinated
HBc IgM
Time Period HBsAg Anti-HBs Anti-HBc HBeAg Anti-HBe
Incubation Period (+) Negative Negative (+) Negative
Acute Infection (+) Negative (+) IgM (+) Negative
Chronic Active (+) Negative (+) IgG (+) Negative
Chronic Carrier (+) Negative (+) IgG Negative (+/-)
Vaccinated Negative (+) Negative Negative Negative
Complete Recovery Negative (+) (+) IgG Negative (+/-)
Window Period Negative Negative (+) IgM (+/-) (+/-)

A 30-year-old man begins coughing up large volumes of

bright red blood. He was rushed to the emergency room
after expectorating around 100ml amount of blood. You
requested chest imaging as shown below.

Which is the recommended first step in evaluating
hemoptysis?
A. Determine the amount or severity of bleeding
B. Description of the sputum
• HBsAg later disappears when the antibody (anti-HBs) is C. Inquire for risk factors for malignancy
produced D. Protect airway
• There is an interval between the disappearance of HBsAg and the • Most hemoptysis is due to vessels in the bronchial circulation
appearance of anti-HBsAb. This period is referred to as the and is, therefore, under systemic pressure, making it more
“window period.” During this interval, anti–hepatitis B core challenging to arrest the bleeding.
antigen (anti–HBc) is the only detectable serology • The bronchial arteries supply the airways and have the ability to
• Persistence of HBsAg or HBeAg is a marker for chronic hepatitis neovascularize tumors, dilate airways of bronchiectasis, and
• Patients who have been vaccinated will have a positive Anti-HBs cavitary lesions.
• Tuberculosis had long been the most common cause of
A 19-year-old male presents to your clinic with painless hemoptysis worldwide, but it is now surpassed in industrialized
watery diarrhea with some flecks of mucus. He appears countries by bronchitis and bronchiectasis.
dehydrated. He recalls consuming shellfish 2 days prior to
onset of symptoms. What is the mechanism of diarrhea in
this case?
A. Osmotic
B. Secretory
C. Exudative disorder
D. Motility disturbance
• There are four basic mechanisms that result in diarrhea:
o osmotic (lactose intolerance)
o exudative disorders (inflammatory bowel disease)
o secretory (V. cholerae)
o motility disturbance (hyperthyroidism)
• V. cholerae and diarrhea: Toxin binds to receptors on apical
Tree-in-bud pattern seen on CT represents radiologic sequelae of an
membrane of crypt cells and activates adenylate cyclase, which infectious or inflammatory process.
increases intracellular cyclic adenosine monophosphate (cAMP)
and secretion of chloride. Both sodium and water follow the • The first step in evaluating hemoptysis is to determine the
chloride into the lumen and result in the secretory diarrhea. amount or severity of bleeding. It is crucial to determine whether
• Sudden-onset of painless watery diarrhea “rice watery stool” the amount of blood expectorated is massive.
after 24-48 hours incubation. • Blood loss of 400 mL in 24 hours or 100–150 mL expectorated
at one time are considered massive hemoptysis.

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 TOPNOTCH MEDICAL BOARD PREP INTERNAL MEDICINE PHASE 3 DIGITAL HANDOUT BY RICHARD L. VILLALUNA, RMT, MD
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This handout is only valid for the March 2021 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.

A 42-year-old woman with presents to your clinic for the • In a patient with chronic productive cough, examination of
second time today because of cough. She is complaining of expectorated sputum is warranted, because determining the
productive cough for over 2 months. Physical examination, cause of mucus hypersecretion is critically important.
chest radiograph and laboratory examination were all See diagram on chronic cough below
unrevealing. Which of the following is true regarding chronic
cough? A 32-year-old man presents with cough and fever. On
A. ACE-induced cough is believed to be due to low levels auscultation, there is decreased breath sound on the right
of bradykinin lower lung field. Which step of the physical examination
B. Examination of expectorated cough is warranted can be used as adjunctive assessment to determine
C. In combination, GERD, ACE inhibitor use, asthma and whether an area of decreased breath sound is due to
postnasal drainage accounts for 90% of cases consolidation or pleural effusion?
D. Chest CT scan should be pursued A. Inspection
• Chronic cough (>8 weeks) may be caused by a wide variety of B. Percussion
cardiopulmonary diseases. C. Palpation
• When initial assessment with chest examination and D. Auscultation
radiography is normal, cough-variant asthma, gastroesophageal • Palpation can demonstrate subcutaneous air in the setting of
reflux, nasopharyngeal drainage, and medications (angiotensin- barotrauma. It can also be used as an adjunctive assessment to
converting enzyme [ACE] inhibitors) are the most common determine whether an area of decreased breath sounds is due to
identifiable causes of chronic cough. consolidation (increased tactile fremitus) or a pleural effusion
(decreased tactile fremitus)
See table on lung physical examination at next page

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 TOPNOTCH MEDICAL BOARD PREP INTERNAL MEDICINE PHASE 3 DIGITAL HANDOUT BY RICHARD L. VILLALUNA, RMT, MD
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A 52-year-old man, who is a heavy smoker, presents with
chest pain at the ER. Physical examination is • Myocardial ischemia causing chest discomfort, termed angina
unremarkable. ECG shows ST segment depression on leads pectoris, is a primary clinical concern in patients presenting with
V1-V4. Which of the following is characteristic of ischemic chest symptoms. The clinical characteristics are highly similar
chest discomfort? whether the ischemic discomfort is a manifestation of stable IHD,
A. Radiating to right arm unstable angina or MI.
B. Radiating to trapezius ridge
C. Pain reaches peak intensity immediately
D. Worse in the supine position

A 20-year-old man who plays basketball in a college varsity
team presents to the ER due to syncope. There is mid
crescendo-decrescendo systolic murmur on auscultation.
ECG shows regular sinus rhythm. Point of care
echocardiogram shows thickened ventricular septum with
systolic anterior motion of the mitral valve. Which
maneuver will decrease the intensity of murmur?
A. Squatting
B. Valsalva
C. Standing up
D. Straining

• Hypertrophic cardiomyopathy is defined as left ventricular
hypertrophy that develops in the absence of causative
hemodynamic factors. It is the leading cause of sudden death in
the young and is an important cause of heart failure.
• Patients presents with abnormal physical findings (murmur) or
symptoms of exertional dyspnea, angina, or syncope.
• Cardiac imaging is central to diagnosis due to the insensitivity of
examination and ECG and the need to exclude other causes for
hypertrophy.

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• In hyperpyretic patients with CNS disease or trauma (CNS
bleeding), reducing core temperature mitigates the detrimental
effects of high temperature on the brain.
• Fever increases the demand for oxygen (i.e., for every increase
of 1°C over 37°C, there is a 13% increase in oxygen
consumption) and can aggravate the condition of patients with
preexisting impairment of cardiac, pulmonary, or CNS function.

Effect of Change in Venous Return
CARDIAC
Increase Decrease
LESION
(squat, leg raise) (Stand, Valsalva)
Aortic stenosis
Aortic
regurgitation
Mitral stenosis
Increased murmur Decreased murmur
Mitral
regurgitation
Ventricular
Remember: “R” Right-ward shift = RISE (except in pH) = RELEASE oxygen
septal defect

Hypertrophic A 42-year-old man presents with a 2-day history of the rash
obstructive
(as pictured). Which of the following signs or symptoms is
cariomyopathy Decreased murmur Increased murmur also likely to develop in this patient?
Mitral valve
prolapse

A 40-year-old woman presents to the ER with severe
headache which she considers as the worse headache of
her life associated with nausea and vomiting. What is the
recommended step to do?
A. Rule out stroke mimickers
B. Obtain brain imaging
C. Consider thrombolysis
D. Consider BP lowering

A. White macular spots with an erythematous halo on
the oral buccal mucosa
B. A fissured lip, strawberry tongue, and coronary
aneurysms
C. Bradycardia with an ECG finding of complete
atrioventricular dissociation
D. Diffuse exanthematous rash with desquamation of the
hands and feet
• This is a classic picture of erythema migrans due to Borellia
burgdorferi, or Lyme disease.
• The rash is characterized as papule expanding to erythematous
annular lesion with central clearing
• Classic cardiac complications is the possibility of progression to
• When worrisome symptoms and signs are present, rapid complete heart block.
diagnosis and management are critical. A careful neurologic • For early Lyme disease, doxycycline is effective and can be
examination is an essential first step in the evaluation. administered to men and non-pregnant women.

Which of the following is true concerning regimens for the
treatment of fever?
A. Ibuprofen effectively reduce fever and the most
preferred antipyretics
B. Fever increases the demand for oxygen
C. Cooling blankets can be used even without oral
antipyretics
D. Reducing core temperature is not beneficial for
patient with CNS bleeding
• Oral aspirin and NSAIDs effectively reduce fever but can
adversely affect platelets and the gastrointestinal tract.
Therefore, acetaminophen is preferred as an antipyretic.
• In hyperpyrexia, the use of cooling blankets facilitates the
reduction of temperature; however, cooling blankets should not
be used without oral antipyretics.

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Erythema marginatum Erythema migrans Erythema multiforme
• Evanescent macular rash • Annular patch • Erythematous plaque
• Central clearing • Central erythema • Central vesicle
• Serpigineous edge • “Bull’s eye appearance” • Target or iris morphology
• Migrates • Expands (not migrate) • Pruritic
• Non-pruritic

A 37-year-old woman presents to your clinic with jaw

weakness and difficulty chewing. The patient is diagnosed
with myasthenia gravis. What would be the effect at the
neuromuscular junction if the patient is started with
neostigmine?
A. Suppress antibody production and improve muscle
strength
B. Prevent metabolism of acetylcholine
C. Blocks acetylcholine release
D. Blocks the release of glycine and GABA
• The underlying pathophysiology in myasthenia gravis is the
development of antibodies to peripheral ACh receptors. The
release of ACh remains normal, but because of the reduction in
the number of receptors, the endplate potential is reduced and
may fail to reach threshold for muscle action potentials.
• In the synaptic junction, ACh is readily metabolized by the
enzyme acetylcholinesterase.
• Muscle weakness due to myasthenia gravis improves after a
period of rest or after administration of an acetylcholinesterase
inhibitor such as neostigmine or pyridostigmine.

A 24-year-old man presents to your clinic with intense
pruritic rash involving the volar wrist, digital web spaces,
penis and scrotum. His brother who lives with him also
complains of the same problem.
Which of the following is an appropriate first-line
treatment?
A. Permethrin cream
1.
B. Topical steroids
C. Topical antifungal
D. Oral antiviral
What is the classic description of lesions in this case?
A. Classic lesions involving the circle of Hebra
B. “Dew drop” on a rose petal with lesions at
A 60-year-old woman with pituitary tumor presents with 2. various stages of evolution
bitemporal hemianopia. Where is the location of lesion in C. Herald patch with lesions appearing in
the visual pathway? “Christmas tree” pattern
A. Optic nerve D. Red advancing border that are dry and vesicular
B. Optic chiasm
C. Optic tract • This is a case of Scabies. The human itch mite, Sarcoptes scabiei
D. Geniculocalcarine tract var. hominis is a common cause of itchy dermatosis. It should be
• Bitemporal hemianopia is caused by a lesion at the optic chiasm. considered in patients with pruritus and symmetric superficial,
This finding is usually caused by symmetric compression in the excoriated, papulovesicular skin lesions in characteristic
sellar region by a pituitary adenoma, meningioma, locations most common on the volar wrists and along the digital
craniopharyngioma, glioma, or aneurysm. web spaces.
• Lesions anterior to the chiasm (retinal injury, optic nerve injury) • Other sites: penis, scrotum, intertriginous areas, navel and belt
will cause unilateral impairment. line, axilla, buttocks and upper thigh. The face, scalp, neck, palms
• Post chiasmic lesions (temporal, parietal, occipital cortex) will and soles are usually spared.
cause homonymous lesions.

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• This is a case of irritant contact dermatitis. The most common
irritants encountered are chronic wet work, soaps and
detergent. The most common area of involvement is the hands.

• If contact dermatitis is suspected and an offending agent is
identified and removed, the eruption will resolve.
• Usually, treatment with high-potency topical glucocorticoids is
enough to relieve symptoms.
• For those patients who require 331 systemic therapy, daily oral
prednisone—beginning at 1 mg/kg, but usually ≤60 mg/d—is
sufficient. The dose should be tapered over 2–3 weeks, and each
daily dose should be taken in the morning with food.
• Patch testing is helpful in identifying these agents but should not
be attempted when patients have widespread active dermatitis
or are taking systemic glucocorticoids.

A 25-year-old woman presents with silvery micaceous
scaling on the scalp and extensor surfaces of the arm.
What is the sign characterized by the removal of the
scale causing pinpoint bleeding in this case?
A. Koebner sign
1.
B. Isomorphic phenomenon
C. Auspitz sign
D. Oncholysis
Which treatment is appropriate for widespread
lesions?
A. Mid potency topical steroid
2.
B. Topical vitamin D or retinoid
C. PUVA
D. Methotrexate
• Scabies burrow under the skin must be scraped out to establish
a diagnosis. • This is a case of psoriasis. It is an immune-mediated disease,
• Permethrin cream are applied thinly from the jawline down, characterized by erythematous, sharply demarcated papules
umbilicus and interdigital spaces n after bathing and removed and plaques covered by silvery micaceous scale.
after 8-14 hours later. • Koebner phenomenon – traumatized area often develops lesions
• Single oral dose of Ivermectin is effective. of psoriasis. Auspitz sign—Removal of the scale causes pinpoint
• Antihistamines, salicylates, and calamine lotion relieve itching bleeding.
during treatment. Topical glucocorticoids are useful for pruritus • Topical glucocorticoids for most cases of localized, plaque-type
that lingers after effective treatment. psoriasis. Alternatives are topical vitamin D analogue
• Bedding and clothing should be washed and dried on high heat (calcipotriene) and a retinoid (tazarotene).
or heat-pressed • Ultraviolet (UV) light is an effective therapy for many patients
• Close contacts even if asymptomatic should be treated. with widespread psoriasis.
• Methotrexate is an effective agent, especially in patients with
A 34-year-old woman who recently works as a dishwasher psoriatic arthritis.
in a restaurant complains painful erythematous rashes on
her hands few hours after washing the dishes. A 25-year-old male bus driver is being screened for
What is the most likely diagnosis? pulmonary tuberculosis due to 2 weeks cough and fever.
A. Peripheral vasodilation What is the best initial test?
1. B. Inhibition of sympathetic tone A. Chest x-ray
C. Temperature rise to 39°C 1. B. Sputum AFB
D. Lactic acidosis C. TB LAMP
Which of the following is true in the management of D. Xpert MTB Rif
this condition? You learned that the patient has HIV, what is the best
A. Removal of offending agent will resolve the initial test?
eruption A. Chest x-ray
2.
B. Low-potency topical glucocorticoids is enough B. Sputum AFB
2. C. TB LAMP
to relieve symptoms
C. Systemic steroid should be taken in the morning D. Xpert MTB Rif
before meal
D. Patch testing can be done even while the patient
is on steroid

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A 22-year-old man has taken anti-TB drugs for 3 weeks • New – has never had treatment for TB or has taken anti-TB drugs
only 3 months ago. He presents to your clinic with 1-week for less than one month
cough and hemoptysis. Sputum Xpert MTB-Rif shows MTB • Retreatment – has been treated before with anti-TB drugs for
detected; rifampicin resistance not detected. at least one month. This includes the following:
What is the treatment category of this patient? o Relapse – previously treated for TB and declared cured or
A. New treatment completed, but is presently diagnosed with active
1. B. Relapse TB disease
C. Treatment after failure o Treatment after failure – previously treated for TB but failed
D. Treatment after lost to follow-up most recent course based on a positive SM follow-up at five
What is the recommended treatment regimen? months or later, or a clinically diagnosed TB patient who does
A. 2 HRZE / 4 HR not show clinical improvement anytime during treatment
2. B. 2 HRZE / 10 HR o Treatment after lost to follow-up – previously treated for TB
C. 3 SE / 6 HR but did not complete treatment and lost to follow-up for at
D. 2 SHE / 10 HE least two months in the most recent course
• TB Disease Registration Group – refers to the classification of o Previous treatment outcome unknown – previously treated
TB cases based on history of previous treatment. for TB but whose outcome in the most recent course is
unknown

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A 62-year-old woman with type 2 diabetes presents with If the duplex scan shows acute DVT and the patient
fever, cough and tachypnea with RR of 32/min. Chest x-ray presents with moderate-to-severe vaginal bleeding.
shows right basal pneumonia. A SARS-COV 2 rt-PCR swab What is the most appropriate treatment?
shows a positive result. 2. A. Vena cava filter
What is the disease severity classification based on the B. Oral warfarin
WHO 2021 update? C. Enoxaparin
A. Mild D. Short acting IV unfractionated heparin
1.
B. Moderate • Hampton’s hump is peripheral wedged-shaped density above
C. Severe the diaphragm.
D. Critical • Westermark’s sign is a focal oligemia (this is the side with little
After 3 days in isolation, the patient was intubated blood flow or hypovolemia; distal to the site of PE).
progressive hypoxemic failure due to ARDS. Which • Palla’s sign is enlarged right descending pulmonary artery.
intervention has shown mortality benefit and has class • McConnell’s sign is hypokinesis of the RV free wall with normal
A recommendation? or hyperkinetic motion of the RV apex.
A. Low tidal volume with target plateau pressure
2.
<30
B. Conventional tidal volume with target plateau
pressure < 30
C. Prone positioning
D. High PEEP

Disease Severity Classification of Adult Patients with COVID-
19 (WHO 2021)
Fever, cough, dyspnea or other symptoms of
MILD influenza-like illness without signs of pneumonia
or hypoxia
With signs of non-severe pneumonia
Moderate
RR 21-30/minute, Sp02 > 92% on room air
Sever acute respiratory infection
Severe RR > 30/minute, severe respiratory distress, or
SpO2 < 92% on room air
Critical ARDS, Sepsis, Septic shock

A 46-year old man, non-smoker, presents to your clinic for
executive checkup. Routine chest x-ray shows a 4-mm
calcified solitary pulmonary nodule in the left upper lobe.
What is the next best step?
A. No further work-up since it is more likely benign
1. B. Obtain old chest x-ray films
C. Initial plain chest CT scan
D. Tuberculin skin test
If this patient shows a 2.5 cm calcified nodule on chest
x-ray, asymptomatic and has >20-pack-year smoking
history. What should you do?
2. A. Sputum cytology
B. PET scan
C. Biopsy
D. Resection
• A solitary pulmonary nodule is defined as an x-ray density that
is completely surrounded by normal aerated lung with
circumscribed margins, of any shape, usually 1-6 cm in greatest
diameter.
• Prior CXRs and CT scans should be obtained if available for
comparison.
• Radiologic criteria thought to predict the benign nature of SPN:
o Lack of growth over 2 years
o Calcification patterns: “bull’s eye” (granuloma) and “popcorn
ball” (hamartoma) are highly suggestive of benign lesions

A 45/F with cervical cancer presents with acute
breathlessness and tachypnea. Chest x-ray shows
peripheral wedged-shaped density above the diaphragm.
What is the above radiographic finding?
A. McConnell’s sign
1. B. Hampton’s hump
C. Westermark’s sign
D. Palla’s sign

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• Factors indicating the likely need for a procedure more invasive
than a thoracentesis (in increasing order of importance) include
the following:
o Loculated pleural fluid
o Pleural fluid pH <7.20
o Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
o Positive Gram stain or culture of the pleural fluid
o Presence of gross pus in the pleural space

A 50-year old male, smoker, presents to the ER with
worsening cough, fever and dyspnea at rest. The illness
started a week ago with fever, abdominal pain and
diarrhea.
Which of the following is the most appropriate initial
antibiotics of choice?
A. Oral amoxicillin
1.
B. Intravenous co-amoxiclav
C. Intravenous ceftriaxone
D. Oral azithromycin
Which of the following is the best initial test to
determine the etiology?
A. Chest x-ray
2.
B. Sputum culture on BCYE agar
C. Blood culture
D. Urine antigen test
• Legionella typically presents with myalgias, abdominal pain,
diarrhea, and severe pneumonia. This patient is also more
susceptible to Legionella given his smoking status.
• Given the nonspecific clinical manifestations of Legionnaires’
disease and the high mortality rates for untreated Legionnaires’
disease, the use of Legionella testing—especially the Legionella
urinary antigen test— is recommended for all patients with
A 40-year old man, presents with fever, shortness of breath community-acquired pneumonia
and pleuritic chest pain. These is decreased breath sounds
on the left base. Chest x-ray revealed left-sided pleural
effusion.
What is the next best step?
A. Start empiric antibiotics immediately
1. B. Initiate treatment with furosemide
C. Perform ultrasound guided thoracentesis
D. Perform tube thoracostomy
If thoracentesis is performed and the pleural fluid
shows thick purulent material with pH 7.12, glucose
40, WBC 59,000 and gram stain negative. What is the
next best step?
2.
A. Continue antibiotics and observe response
B. Continue furosemide treatment
C. Repeat ultrasound guided thoracentesis
D. Perform tube thoracostomy

A 26-year-old man with HIV comes to the ER with fever, dry
cough and dyspnea. His CD4 count is < 200. The LDH is
elevated and the chest x-ray shows bilateral interstitial
infiltrates.
Which of the following is the most accurate test?
A. Silver stain of bronchoalveolar lavage
1. B. Acid fast smear of the sputum
C. Serum cryptococcal antigen test
D. Sputum gram stain showing G+ diplococci
Which of the following is the treatment of choice?
A. Trimethoprim-sulfamethoxazole
2. B. Amphotericin + 5-flucytosine
C. Sulfadiazine + pyrimethamine
D. Clarithromycin + ethambutol
• Pneumocystis is an opportunistic pathogen that is an important
cause of pneumonia in immunocompromised hosts, particularly
those with HIV infection.
• PCP presents as acute or subacute pneumonia that may initially
be characterized by a vague sense of dyspnea alone but that
subsequently manifests as fever and nonproductive cough with
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progressive shortness of breath, ultimately resulting in What is the most likely diagnosis?
respiratory failure and death. A. Chronic obstructive pulmonary disease
• The results of routine laboratory tests are nonspecific in PCP. 1. B. Bronchial asthma
Serum levels of lactate dehydrogenase (LDH) are often elevated C. Pulmonary tuberculosis
as a result of pulmonary damage. D. Heart failure
• Although the initial chest radiograph may be normal when If this is a case of stable COPD, actively smoking, with
patients have mild symptoms, the classic radiographic resting hypoxemia, which intervention will provide
appearance of symptomatic PCP consists of diffuse bilateral the greatest benefit?
interstitial infiltrates that are perihilar and symmetric. 2. A. Supplemental oxygen
• The demonstration of organisms in bronchoalveolar lavage B. Smoking cessation
(BAL) fluid is almost 100% sensitive and specific for PCP. C. Inhaled Tiotropium daily
• The diagnosis is typically established in lung tissue or D. Inhaled salbutamol as needed
pulmonary secretions by highly specific staining of the cyst— • For patients with chronic hypoxemia, supplemental oxygen has
e.g., with methenamine silver, toluidine blue O, or Giemsa; or by a significant impact on mortality, with a greater benefit with
staining with a specific immunofluorescent antibody. continuous usage, rather than intermittent or nocturnal-only
usage.
• Bronchodilators such as tiotropium and salbutamol improve
symptoms and FEV1, but offer no mortality benefit.
• For patients with resting hypoxemia (resting O2 saturation
≤88% in any patient or ≤89% with signs of pulmonary
hypertension or right heart failure), the use of O2 has been
demonstrated to have a significant impact on mortality.
A 26-year-old, female, medical intern reports a 1-week history
of cough, coryza, and a low-grade fever. Today at the ER, she
complains of escalating chest discomfort. She notes that the
pain becomes more intense when he takes a deep breath. On
examination, a rasping extracardiac sound is heard on
auscultation. Troponin levels are undetectable 6 hours later.
Which is the most appropriate next step?
A. Refer for treadmill stress test.
B. Prescribe ibuprofen and colchicine.
1. C. Administer Aspirin, Clopidogrel, sublingual
Nitroglycerin, and Enoxaparin.
D. Emergently obtain transthoracic
echocardiogram
Which of the treatment should be avoided?
A. Aspirin
2. B. Enoxaparin
C. Colchicine
D. Prednisone
• This is a classic case of acute pericarditis from viral illness.
A 24-year-old, male, non-smoker, non-hypertensive, with • The four principal diagnostic features are:
history of atopic dermatitis, presents to your clinic o Chest pain (pleuritic, positional)
complaining of intermittent cough for 3 months associated o Pericardial friction rub
with nighttime awakening. Chest examination is o Diffuse ST segment elevation in limb leads and V2-V6 with PR
unremarkable. depression
Which of the following would be consistent for o Pericardial effusion
asthma? o Treatment includes Aspirin plus gastric protection, NSAIDs
A. Slip knot (Ibuprofen, Indomethacin), Colchicine and Glucocorticoid
1.
B. Surgeon’s knot (Prednisone).
C. Square knot • Anticoagulant should be avoided in acute pericarditis because
D. Double square knot their use could cause bleeding into the pericardial cavity and
If diagnosis is in doubt in the setting of normal precipitate tamponade.
spirometry, what is the next best step? • The clinical picture suggests the patient has developed
A. Peak expiratory flow pericardial tamponade, which may be life threatening and often
2.
B. Fractional exhaled nitric oxide requires urgent pericardiocentesis. Intravenous saline may be
C. Histamine challenge test administered as the patient is being readied for the procedure,
D. Radioallergosorbent test (RAST) but the pericardiocentesis must not be delayed.
• Spirometry can confirm airflow obstruction with reduced forced A 65-year-old female, diabetic, presents to the ER with severe
expiratory volume in 1 second (FEV1) and FEV1/ forced vital substernal squeezing chest pain radiating to the right arm.
capacity (FVC). Which of the following is the most appropriate next
• Positive bronchodilator responsiveness is defined as reversible step?
obstruction with an increase in FEV1 or FVC of more than 12% A. Perform ECG
1.
and increase of 200 cc of volume after short acting B. Check troponin I
bronchodilator treatment or 4-week trial of anti-inflammatory C. Give aspirin
treatment. D. Emergency percutaneous coronary intervention
• If the diagnosis is in doubt, bronchial hyperresponsiveness (the If this is a case of STEMI, when should fibrinolytic
fundamental pathophysiologic abnormality in asthma) can be therapy be initiated?
confirmed by a reduction in FEV1 after challenge with a A. Within 30 minutes
2.
provocative agent such as methacholine or histamine. If B. Within 90 minutes
methacholine is used, a positive test is defined as a 20% fall in C. Within 120 minutes
FEV1 D. Within 6 hours
• The most likely diagnosis is acute coronary syndrome. The first
A 60-year-old male presents to your clinic due to on and off and foremost priority should be to “save the myocardium”.
cough, dyspnea and sputum production. He is a Initial ECG and cardiac markers may be normal in early stages of
nonsmoker. He works as a jeepney driver for 30 years. ACS, serial studies are necessary. Aspirin is the first agent to be
Chest auscultation reveals a quiet lung but no wheezes. used as it decreases mortality in the face of an acute coronary
Chest x-ray shows hyperaerated lung. event.

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A 70-year-old woman with history of heart failure has been DUKES CRITERIA FOR DIAGNOSIS OF ENDOCARDITIS
non-compliant with her medications for the past 2 weeks. • Major Criteria
She comes to the emergency department with acute
• Isolation of typical organisms (viridans Streptococci, S.
shortness of breath, crackles mid to base and jugular
sureus, Enterococci, Streptococcus bovis or one of the HACEK
venous distention. Her BP is 100/70 mmHg and oxygen
organisms) from to separate blood cultures, or persistently
saturation is 97% on room air. What is the best initial step
positive blood cultures with other organisms
in management?
• Evidence of endocardial involvement: either
A. Intravenous Furosemide
echocardiographic evidence of endocarditis, e.g. oscillating
B. Oxygen supplementation
intracardiac mass, or new valvular regurgitation
C. Echocardiography
D. Dobutamine • Minor Criteria
• What is the manifestation of the acute decompensated heart • Predisposing valvular lesions or intravenous drug use
failure? • Fever > 100.4°F (38°C)
o 1. “Pulmonary edema” • Vascular phenomena; arterial or septic pulmonary emboli,
§ Vasodilators mycotic aneurysm, Janeway lesions
§ Diuretics
• Immunologic phenomena: glomerulonephritis, Osler nodes,
§ Oxygen
Roth spots, positive rheumatoid factor
o 2. “Low output”
• Positive blood cultures not meeting major criteria
§ Inotropic + vasodilators
o 3. “Cardiogenic shock”
§ Inotropes A 23-year-old male from Mindoro complains of
§ Mechanical circulatory support (IABP) progressively enlarging abdomen. He underwent
A 24-year-old man complains of shaking chills and fever. ultrasonography which shows typical periportal or pipe
He is febrile with blood pressure of 110/60 mmHg, heart stem fibrosis. He travelled to Manila for further consult. At
rate 109/min and a new holosystolic murmur at the apex. the ER of PGH, the patient had hematemesis.
He has linear streaks of induration on both forearms. What is the best next step in assessing the patient?
Which of the following is a major criterion for A. Measure the heart rate and blood pressure
diagnosis? 1. B. Emergent upper endoscopy
A. Intravenous drug use C. Determine hemoglobin and hematocrit
1. D. Abdominal CT scan with triphasic contrast
B. Predisposing valvular lesion
C. 1-set of positive blood culture Which of the following is most likely pathogen
D. Oscillating intracardiac mass responsible?
Which is critical for diagnosis and planning of A. Paragonimus wetermani
2.
treatment? B. Schistosoma japonicum
A. Blood culture C. Schistosoma hematobium
2.
B. Transesophageal Echocardiography D. Clonorchis sinensis
C. Empiric IV antibiotic • Humans acquire the infection when they contact water infested
D. Drug test with the infectious cercariae.
• Within 30 minutes, the cercariae have penetrated the epidermis
and transformed into schistosomules, which enter the
peripheral circulation, where they eventually become adults in
the hepatoportal system or venous plexus surrounding the
bladder.

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• A granulomatous reaction surrounds the eggs and leads to
fibrosis of the liver (periportal “pipestem” fibrosis) with S.
mansoni and S. japonicum.
• In chronic cases, blood flow to the liver is impeded, which leads
to portal hypertension, accumulation of ascites in the abdominal
cavity, hepatosplenomegaly, and esophageal varices.
• Measurement of the heart rate and blood pressure is the best
way to initially assess patient with GI bleeding. Postural change
in BP and tachycardia may point to clinically significant bleeding
and warrant emergent endoscopy.

A 33/M presents with epigastric pain and heartburn for the
past year which was temporarily relieved by omeprazole. • Gallstone: Still the leading cause of acute pancreatitis (30-60%)
He is an 8 pack-year smoker and he drinks alcohol (1-2) • Alcohol: second most common cause (15-30%)
daily. He denies weight loss, vomiting, dysphagia. PE • Acute pancreatitis may also complicate 5-10% of cases
showed mild epigastric tenderness, no palpable mass. undergoing ERCP
• Hypertriglyceridemia (TG >1000 mg/dL): 1.3-3.8% of cases
CBC: o Fenofibrates also induces cholesterol supersaturation in bile
Hemoglobin 10 g/dL (and decreases bile salt concentrations)
WBC 13,000/mm3 o Statins: prevents gallstone disease
Platelet count 185,000/uL • Aggressive intravenous fluid resuscitation: most important
treatment modality
What is the best next step? o Guided by BUN and hematocrit
A. Trial of proton pump inhibitor (PPI) o Most common cause of early death: hypovolemic shock
B. Non-invasive H. pylori testing o NPO: “rest the pancreas”
C. Ambulatory pH study
• IV narcotic analgesics: control abdominal pain
D. Endoscopy
• ERCP: those with evidence of ascending cholangitis
• Always check for alarm symptoms IN GERD.
• Cholecystectomy: gallstone pancreatitis; same admission or
o Dysphagia
within 4-6 weeks of discharge
o Odynophagia

o Anemia
A 32/M was admitted for dark-colored urine, oliguria,
o Weight loss
muscle pain and malaise. He reports having undergone
o Vomiting
whole-body cupping therapy (Ventosa) a night prior. Labs
• Testing for H. pylori indicated in patients with dyspepsia showed:
• Ambulatory pH study indicated in GERD patients who do not
respond to empiric therapy Serum creatine 2.8 mg/dL (normal 0.6-1.2)
K at 7 mmol/L; hemoglobinuria and myoglobinuria on
A 47/F who is a smoker, alcoholic, on fenofibrate for past 3 urinalysis
months for elevated lipids is admitted for severe epigastric 12L-ECG shows widened QRS
pain radiating to the back and shoulders with nausea and
vomiting. PE shows direct epigastric tenderness, distended What is the most urgent step in management of this
abdomen with hypoactive bowel sounds and a discrete patient?
discoloration on both flanks. A. Hydration with intravenous saline
What is the best next step? B. Intravenous bolus of diuretics
A. Serum lipase C. Urine alkalinization
B. Whole abdominal ultrasound D. Intravenous calcium gluconate
1.
C. Endoscopic retrograde • Rhabdomyolysis: severe muscle necrosis leads to hyperkalemia
cholangiopancreatography (ERCP)
• Classic ECG changes: tall, peaked T waves; loss of P waves;
D. Abdominal CT scan with intravenous contrast widened QRS
Which of the following conditions most likely led to • Treatment pillars
the patient’s acute pancreatitis?
o Immediate antagonism of cardiac effects
A. Gallstones
2. o Rapid reduction of plasma K concentration (compartment
B. Alcohol shifts)
C. Hypertriglyceridemia o Removal of potassium
D. Smoking
• Damaged muscle also binds calcium
Which of the following is the most important
• Treatment
treatment intervention?
o Bolus of normal saline
A. Intravenous fluid resuscitation
3. o Mannitol and diuresis (to decrease contact time of myoglobin
B. Analgesia (IV narcotics)
with tubules)
C. NPO
o Alkalinization of urine (to decrease chance of myoglobin
D. Cholecystectomy
precipitation)
• Any severe acute pain in the abdomen or back should make you
suspect acute pancreatitis. A 60/M with CKD from diabetes was brought to the ER for
• Diagnosis typically established by two of the following: nausea, lethargy, confusion, epigastric pain and anuria of
o Typical abdominal (epigastric) pain that may radiate to the few days. PE shows pallor, distended neck veins, decreased
back breath sounds bilaterally, distinct heart sounds systolic
o 3x or greater elevation in serum lipase and/or amylase murmur at right upper sternal border. Labs showed:
o Imaging findings compatible with acute pancreatitis
o In uncomplicated cases, the best step would be to confirm the K 6.5 mmol/L, serum creatinine 9.5 mg/dL
diagnosis by testing for serum lipase/amylase Serum calcium 2.0 mmol/L (normal 2.2-2.7),
• Ecchymoses in abdomen: extravasation of hemorrhagic Hemoglobin 8 g/dL, 12L ECG shows peaked T waves
pancreatic exudate
• Complicated acute pancreatitis: do imaging! What is the most appropriate therapy for this patient?
o Clinches diagnosis A. Intravenous insulin and glucose
o Checks of other complications B. Intravenous sodium bicarbonate
C. Urgent pericardiocentesis
D. Urgent hemodialysis

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• CKD: hyperkalemia + hypocalcemia + anemia A 28/F consults you for tea-colored urine. BP noted to be
• Usual criteria for initiating dialysis elevated. CBC shows mild anemia while urinalysis shows
o Uremic symptoms mild proteinuria and presence of RBC casts.
o Intractable hyperkalemia What is the most likely diagnosis?
o Persistent ECV expansion A. Acute renal failure
o Refractory acidosis 1. B. Acute nephritis
o Bleeding diathesis C. Chronic renal failure
o eGFR 10 mL/min and lower D. Nephrotic syndrome
Further probing revealed that the patient also had
episodes of hair thinning and increased hair loss,
episodic oral ulcers and a rash behind her ears. What
is the most likely diagnosis?
2.
A. Post-streptococcal GN
B. Endocarditis-associated GN
C. Lupus nephritis
D. IgA nephropathy

What is the treatment of choice for this patient?
A. Ciprofloxacin 500 mg BID for 3 days
2. B. Cotrimoxazole 800/160 mg BID for 3 days
C. Co-amoxiclav 625 mg BID for 7 days
D. Fosfomycin 3 g single dose
• Acute uncomplicated cystitis: dysuria, urinary frequency,
urgency
o Urinalysis typically not a pre-requisite
o Acute uncomplicated pyelonephritis: also with fever +/-
lower-back or costovertebral-angle pain
o Fever: main distinguishing feature; high-spiking “picket-fence”
pattern (resolves over 72 hours of treatment)
o Urinalysis and urine culture is recommended

DOSE, FREQUENCY,
ANTIBIOTICS
DURATION
Nitrofurantoin
100 mg QID for 5 days
Primary macrocrystals
Fosfomycin 3g single dose
Ciprofloxacin 250 mg BID for 3 days
Ciprofloxacin XR 500 mg OD for 3 days
Ofloxacin 200 mg BID for 3 days
Levofloxacin 250 mg OD for 3 days
Alternative
Norfloxacin 400mg BID for 3 days
Co-amoxiclav 625 mg BID for 7 days
Cefuroxime 250 mg BID for 7 days
Cefixime 200 mg BID for 7 days


A patient sustained a superficial abrasion on the leg
A 27/F presents with few days' history of dysuria, without bleeding from a dog bite. What is the
frequency, urgency and occasional episodes of gross recommended post exposure prophylaxis?
hematuria. She denies fever, flank pain, vaginal discharge A. None
and other systemic complaints. B. Administer vaccine
What is the most likely diagnosis? C. Administer vaccine and immune-globulin
A. Pelvic inflammatory disease D. Administer antitetanus and antibiotics
1. B. Pyelonephritis
C. Cystitis
D. Chorioamnionitis
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EXPOSURE MANAGEMENT
• Feeding/touching animal • Wash exposed skin A 45/M admitted in the wards for moderate-risk CAP. He
• Licking of intact skin immediately with presented with non-severe non-bloody diarrhea after a few days.
• Exposure to patient with soap and water C. difficile antigen testing was positive.
signs of rabies by sharing • NO vaccine or RIg What is the next best plan for this patient?
I A. Treat with oral metronidazole
utensils needed
• Casual contact of patient • Pre-exposure B. Treat with oral vancomycin
with rabies vaccination may be C. Treat with oral fidaxomicin
considered D. Do not treat with antibiotics
• Nibbling/nipping of • Treatment of choice for C. difficile diarrhea
uncovered skin with o Mild-to-moderate disease: metronidazole
bruising o Severe disease: vancomycin
• Minor scratches, abrasions, • Start vaccine • ~25% will eventually relapse
II o Mild-to-moderate disease may be treated again with
abrasions without bleeding immediately
(includes wounds induced to metronidazole
bleed) • Fidaxomicin: reduced failure rates
• Licks on broken skin o May be considered in those with frequent relapses
• Transdermal bites or
scratches A 42/F presents with raised nodular hypesthetic skin
• Contamination of mucous lesions on her elbow. Scrapings from these lesions shows
membranes with saliva numerous acid-fast bacilli. Lepromin skin test was
• Exposure to a patient negative.
through bites, What is the most likely diagnosis?
contamination of mucous A. Tuberculoid leprosy
membranes or open skin 1. B. Borderline leprosy
lesion with body fluids, licks C. Lepromatous leprosy
• Start vaccine and RIg D. Bartonella henselae
III of eyes, lips, vulva, sexual
immediately What is the mainstay of treatment for this condition?
activity, kisses
• Handling of infected carcass A. Clofazimine
or ingestion of raw infected 2. B. Dapsone
meat C. Rifampin
• All category II exposures on D. Ethionamide/prothionamide
head and neck areas
• Does not include sharing of
food/drink/utensils and
casual contact

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 TOPNOTCH MEDICAL BOARD PREP INTERNAL MEDICINE PHASE 3 DIGITAL HANDOUT BY RICHARD L. VILLALUNA, RMT, MD
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• Acute schistosomiasis (aka Katayama fever; snail fever): 4-8
weeks after skin invasion
o Fever + generalized LAD + hepatosplenomegaly + marked
peripheral eosinophilia
• Chronic schistosomiasis
o Clinical manifestations are species-dependent
o Granulomatous reaction surrounds eggs and leads to fibrosis
of the liver (periportal “pipestem” fibrosis) with S. mansoni and
S. japonicum

A 30/M from presents to the ER with fever, periorbital
edema, elevated blood eosinophilia and elevated CPK. He
reports having a history of intake of raw pork.
A 30/M from Samar presents to the ER with fever,
lymphadenopathy and peripheral eosinophilia. He recalls What is the most likely diagnosis?
having pruritic maculopapular rash on his legs about a A. Cercarial dermatitis
month prior to this admission. B. Katayama syndrome
C. Trichinellosis
What is the most likely diagnosis? D. Strongyloidiasis
A. Cercarial dermatitis • Trichinellosis is acquired from consumption of pork or wild
B. Katayama syndrome animal meat
C. Trichinellosis • Migrating Trichinella larvae provoke local and systemic
D. Strongyloidiasis reactions
• Swimmer’s itch (cercarial dermatitis): 2-3 days after cercarial • Presumptive diagnosis: fever, eosinophilia, periorbital edema
skin penetration and myalgia after a suspect meal
• Confirmatory diagnosis: rise in parasite-specific antibody titers
• Definitive diagnosis: surgical biopsy

A 40/M complains of intermittent headache and focal • If human ingest “measly beef” or “measly pork” containing
seizures. MRI shows cystic lesions with ring-enhancement bladder-like larvae called cysticerci, they acquire infections of T.
and characteristic scolex. saginata and T. solium, respectively
What is the most likely diagnosis? • An important difference between the two: humans can be the
A. Cysticercosis intermediate host for T. solium, similar to pigs
1. B. Katayama syndrome • Infections that cause human cysticercosis follow the ingestion of
C. Trichinellosis T. solium eggs, usually from close contact with a tapeworm
D. Strongyloidiasis carrier or from his/her own feces (autoinfection)
What is the manner of transmission that leads to this
case? A 20/M presents with multiple tender grouped vesicles on
A. Ingestion of undercooked pork containing his penis.
cysticerci What is the next step in the patient’s management?
2.
B. Ingestion of undercooked beef containing A. Viral culture
cysticerci 1. B. Dark-field microscopy
C. Ingestion of Taenia solium eggs C. Single shot of Penicillin G
D. Ingestion of Taenia saginata eggs D. Valacyclovir

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 TOPNOTCH MEDICAL BOARD PREP INTERNAL MEDICINE PHASE 3 DIGITAL HANDOUT BY RICHARD L. VILLALUNA, RMT, MD
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If this patient instead presented with a painless penile If the lesion was consistent with a chancre but the
lesion with firm induration, what is the most likely results of dark-field microscopy and rapid serologic
diagnosis? tests for syphilis are negative, what is the next best
2. A. Chancroid step?
3.
B. Primary syphilis A. Biopsy
C. Genital herpes B. PCR testing
D. Lymphogranuloma venereum C. Culture
D. Presumptive treatment

A 31/F consults for worsening fatigue over the past half If testing reveals a normal serum uric acid, what will
year. She has a history of menorrhagia. She denies PND, be your diagnosis?
orthopnea, or other signs of heart failure. PE showed pale A. Gouty arthritis
2.
palpebral conjunctiva and a grade 2-3 systolic murmur at B. Osteoarthritis
the apex. C. Rheumatoid arthritis
What is the best initial test for this patient? D. Septic arthritis
A. Transvaginal ultrasound • This is a case of gouty arthritis.
1. B. 12-L ECG • Podagra: involvement of the first MTP
C. STAT 2D-echo with Doppler studies • Tarsal joints, ankles, and knees also affected commonly
D. CBC with peripheral smear • Usual precipitating factors
She then hands you over copies of her previous o Binge drinking of alcohol
complete blood counts showing her hemoglobin falling o Use of thiazide diuretics
from 11 g/dL to 8 g/dL in 3 months. Her latest CBC o Use of nicotinic acid
showed low MCV and MCH. Which of the following is • Serum uric acid levels can be normal or low at the time of an
2. the most likely etiology for her anemia? acute attack
A. Folate deficiency o Inflammatory cytokines are uricosuric
B. Vitamin B12 deficiency o This limits value of serum uric acid determination in the
C. Iron deficiency anemia diagnosis of gout
D. Inflammation • Nonetheless, serum urate levels are almost always elevated at
• Anemia is a clinical finding and not a diagnosis some point in time and are important to use to follow the course
• The CBC and differential count with its RBC indices are helpful in of hypouricemic therapy
narrowing the differential diagnosis • Initiation of hypouricemic agents at time of flare can trigger
• Reticulocyte count: indicates bone marrow erythroid activity inflammatory reaction and precipitate gouty attacks
• Iron studies: ferritin, serum iron, TIBC A 40/F presents with an 8-week history of hand joint pain
with morning stiffness lasting for more than one hour.
MICROCYTIC NORMOCYTIC MACROCYTIC What is the most likely diagnosis?
ANEMIA ANEMIA ANEMIA A. Gouty arthritis
MCV <80 fL MCV 80-100 fL MCV >100 1. B. Osteoarthritis
• Thalassemia • Anemia of • Folate deficiency C. Rheumatoid arthritis
• Anemia of chronic disease • Vitamin B12 D. Systemic lupus erythematosus
chronic disease • Anemia of kidney deficiency Which of the following joints is most frequently
• Iron deficiency disease • Hemolysis involved in this condition?
anemia • Others • Acute blood loss A. Wrist
2.
• Lead poisoning • Drug toxicity B. Distal interphalangeal joint
• Sideroblastic C. Knee
anemia D. Hip

Rheumatoid
A 35/M, obese, presents to your clinic with a 3-day history Osteoarthritis
arthritis
of swollen and painful left big toe. He is dyslipidemic and Morning stiffness <30 minutes >1 hour
hypertensive and was recently started on simvastatin and DIP Yes No
hydrochlorothiazide. PIP Yes Yes
What is the most likely diagnosis? MCP No Yes
A. Gouty arthritis RF, anti-CCP No Yes
1. B. Osteoarthritis Joint fluid
C. Rheumatoid arthritis <2,000 5,000-50,000
leukocytes count
D. Septic arthritis *Most common affected joints in RA= wrists, metacarpophalangeal joints
and proximal interphalangeal joints
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 TOPNOTCH MEDICAL BOARD PREP INTERNAL MEDICINE PHASE 3 DIGITAL HANDOUT BY RICHARD L. VILLALUNA, RMT, MD
For inquiries visit [Link] or [Link]
This handout is only valid for the March 2021 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.
Synovitis • Arthralgia/myalgia, Intermittent polyarthritis
• Hemolytic anemia, Leukopenia or lymphopenia,
Blood thrombocytopenia (any blood involvement
counts as 1 criterion)
Renal • Hematuria, proteinuria, RBC cast, ESRD, Biopsy
Alopecia • Seen in 40% of cutaneous lupus
• ANA, anti-dsDNA, Anti-Sm, Antiphospholipid,
Serology Low serum complement, positive direct
Coombs test

Which of the following cases has T2DM?
A. 39/F with fasting blood sugar of 160 mg/dL 3 months
ago and 110 mg/dL on repeat testing
B. 45/M with single HbA1c result of 6.8%
C. 21/F admitted at the ER for vomiting with initial CBG
of 420 mg/dL and metabolic acidosis on ABG
D. 54/F with weight loss and 2H-OGTT of 199 mg/dl

ANY OF THE FOLLOWING:
HbA1ca ≥6.5%
Fasting Plasma
≥126mg/dL (7.0 mmol/L)
Glucose (FPG)b
2-hour plasma
glucose during 75-g ≥200mg/dL (11.1 mmol/L)
A 33/F presents with worsening fatigue, joint pains,
OGTT
photosensitive rash on the cheeks, hair thinning and
occasional episodes of frothy urine. Random Blood ≥200mg/dL (11.1 mmol/L) with
Sugarc classic symptoms of hyperglycemia
What is the most likely diagnosis?
a Perform HbA1C with an assay-standardized method
A. Gouty arthritis b Fasting: defined as no caloric intake for at least 8 hours
1. B. Osteoarthritis c Random: defined as without regard to time since last meal
C. Rheumatoid arthritis For FPG, 2-gour PG, or A1C criteria: in the absence of unequivocal
D. Systemic lupus erythematosus hyperglycemia, these criteria should be confirmed by repeat testing on a
Which of the following autoantibodies is least likely to different day.
IM Platinum. 3rd ed. 2018. p. 379
be present in this patient?

A. Antinuclear antibodies
2. A 50-year-old female, newly diagnosed with diabetes,
B. Antiphospholipid
presents with +4 glucosuria and complaining of vaginal
C. Anti-dsDNA
irritation. Which of the following drug was most likely
D. Anti-La (SS-B)
instituted?
A. Metformin
B. Sitagliptin
C. Pioglitazone
D. Canagliflozin
• Sodium-glucose co-transporter 2 inhibitors (canagliflozin,
dapagliflozin, empagliflozin) lower blood glucose by selectively
inhibiting this co-transporter, expressed almost exclusively in
the PCT in the kidney
• This leads to increased urinary glucose excretion
• Due to increased urinary glucose, urinary or vaginal infections
are more common
• Diuretic effect can also lead to reduced intravascular volume



Continuously Test Yourself and Absorb the Feedback
Recalling information from memory has been shown to actually
improve memory and is better than studying without testing. Even
answering questions incorrectly is more effective than passive
reading, especially if incorrect answers are followed by feedback.
One theory is that testing prompts us to forge more connections and
therefore create a more enduring network for knowledge. Another
view is that answering questions trains the brain to retrieve the
information when asked. Whether you call it “retrieval practice,”
“test-enhanced learning,” or “the testing effect,” evidence shows that
answering questions strengthens your knowledge.
(NEJM, 2020)


• Cognitive dysfunction (loss of memory,

Brain reasoning), excruciating headache, seizures,
psychosis, acute confusion states, myelopathy
END OF INTERNAL MEDICINE PHASE 3
Oral • Small oral or nasal ulcerations; resembles

ulcers aphthous ulcers
• Acute: Photosensitive, “butterfly rash” (nose/
cheeks), neck, chest
• Subacute: Scaly red patches (similar to
Skin
psoriasis); rimmed lesions
• Chronic: Discoid rash, roughly circular, raised,
hyperpigmented
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This handout is only valid for the March 2021 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.