Internal Medicine Board Review Written Board Exam
Sample Questions - Book 1 2004
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QUESTION

87. A 28-year-old man with history of Mitral Valve Prolapse comes to your office complaining of chest pain that began 1 day prior to presentation. He states he has had similar episodes recently. He describes it as searing pain at the center of his chest that now radiates to his neck. He denies an exertional component, diaphoresis, nausea, emesis, abdominal pain or dyspnea.

Your nurse has recorded two blood pressures in the right and left arm that are markedly different however she tells you she thinks this is because his arms are too long.

Physical exam reveals a diastolic murmur, no S3, marked scoliosis, clear lung fields and no edema.

The MOST likely diagnosis in this patient is?

A) Marfan’s Syndrome
B) Costochondritis
C) Mitral Valve Prolapse with Mitral Regurgitation
D) C5-6 herniated disc
E) Acute Coronary Syndrome

ANSWER

87.      A      Marfan’s Syndrome

This patient is describing Aortic Dissection, which is a life threatening emergency carrying a mortality rate of 1% per hour. This patient most likely has undiagnosed Marfan’s Syndrome given his wide arm span, scoliosis and valvular disease. Patients with Marfan’s account for 5-9% of all aortic dissections and will have classic cystic medial degeneration and are therefore at high risk to dissect at a young age. This also occurs in Ehlers Danlos Syndrome. The goal of treatment is to stop the progression of dissection therefore reducing the risk of rupture.

Costochondritis would not give this history nor would it lead to unequal blood pressures. Mitral Valve Prolapse with Mitral Regurgitation would be a systolic murmur rather than diastolic. A C5-6 herniated disc typically does not cause chest pain nor would it account for his diastolic murmur or unequal blood pressures. This patient could have an acute coronary syndrome but that should not lead to unequal blood pressures therefore a dissection must be considered first.

1. Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed., 2001:1433.

2. Goldman: Cecil Textbook of Medicine, 21st ed., 2000:354-356.

QUESTION

232. A 34-year-old mother of 2 who is now 8 weeks pregnant and works in a pre-school complains of an erythematous rash on her face and limbs with fever. She remembers a child in her class had a similar rash 2 weeks ago. She also complains of joint pains in her hands and some fatigue. (See Appendix A, Image 3 on Page 269).

On physical exam she appears non-toxic with a faint salmon colored rash on her forearms, with a temperature of 38° C. She has symmetrically swollen metacarpophalangeal and interphalangeal joints. She is up to date on her polio and measles-mumps and rubella vaccines as a child.

The MOST likely cause of her illness is:

A) Parvovirus B-19
B) Enterovirus infection
C) Coxsackie virus
D) Rubella
E) Atypical measles

ANSWER

232.     A      Parvovirus B-19

Parvovirus B-19 is commonly known to infect children and in this case the exposure to one of her students is the likely source. The incubation period is from 4-16 days and the virus can also cause hematologic disturbances, most notably anemia by arresting erythropoiesis. In addition to the slapped cheek rash with perioral sparing, which is rare in adults, but can involve the palms and soles. Arthralgias with synovial swelling are common in adults, especially women involving primarily the hands.

In this woman’s case the issue of pregnancy is important but studies have shown that fetal hydrops is unlikely even in the first trimester with this disease. No congenital abnormalities or long-term sequelae have been attributed to parvovirus B19 infection. The overall risk of serious adverse outcome from occupational exposure to parvovirus B19 infection during pregnancy is low (excess early fetal loss in 2-6/1,000 pregnancies and fetal death from hydrops in 2-5/10,000 pregnancies). It is not recommended that susceptible pregnant women be excluded routinely from working with children during epidemics3.

Atypical measles develops in patients who received killed measles virus vaccine between 1963 and 1967. The rash of atypical measles may take many different forms including hemorrhagic, urticarial and vesicular. This patient’s arthropathy, exposure in the classroom to a child with slapped cheek-like illness and the lacy appearance of her rash suggest parvo B-19 virus infection and make atypical measles less likely. Rubella is also unlikely given the vaccine history. Coxsackie virus or hand foot and mouth disease often involves mucosal surfaces and would unlikely cause the synovial changes described.

1. Levy R, Weissman A, Blomberg G, Hagay ZJ. Infection by parvovirus B 19 during pregnancy: a review. Obstet Gynecol Surv. 1997 Apr;52(4):254-9.

2. Bultmann BD, Klingel K, Sotlar K, Bock CT, Kandolf R. Parvovirus B19: a pathogen responsible for more than hematologic disorders. Virchows Arch. 2003 Jan;442(1):8-17. Epub 2002 Nov 14.

3. Gilbert GL. Parvovirus B19 infection and its significance in pregnancy. Commun Dis Intell. 2000 Mar;24 Suppl:69-71.

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