Internal Medicine Written Board Exam Sample Questions
Book 2 - 2004
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QUESTION

111. Patients with selective IgA deficiency are more likely to have an anaphylactic reaction after treatment with which of the following?

     A) Amoxicillin
     B) Iodinated intravenous dyes
     C) Oral sulfasalazine
     D) Blood transfusions
     E) Coumadin

ANSWER

111.    D    Blood transfusions

IgA anaphylactic transfusion reactions occur rarely, perhaps in 1 in 20,000 to 47,000 transfusions. The signs and symptoms of these reactions do not differentiate them from other causes of anaphylaxis. The diagnosis of an anaphylactic transfusion reaction is established by showing an IgA-antibody in the patient's serum. Anti-IgA antibodies are found in approximately 20% of subjects with severe IgA deficiency and antibody levels remain relatively constant in subjects with medium to high antibody levels.

Although penicillin allergies can cause anaphylaxis, they are not IgA mediated. The same is true for iodinated dyes and sulfa-containing medications. Deficiencies of protein S or C are associated with skin necrosis in subjects on Coumadin.

1. Sandler SG, Mallory D, Malamut D, Eckrich R. IgA anaphylactic transfusion reactions. Transfus Med Rev. 1995 Jan;9(1):1-8

QUESTION

243. A 40-year-old woman presents to your office for follow up of her Type 2 diabetes. She takes an oral agent and has a recent HbA1C of 7.0%. There is no history of hypertension or heart disease. She is a nonsmoker and the family history is significant for colonic cancer only.

The fasting lipid profile is:

Total cholesterol 215 mg/dL
HDL cholesterol 50 mg/dL
Triglycerides 150 mg/dL

Which of the follow should you recommend?

     A) Begin therapy with niacin
     B) Begin therapy with fluvastatin
     C) Begin therapy with gemfibrozil
     D) No pharmacologic intervention at this time
     E) Add insulin to improve her glycemic control

ANSWER

243.    B    Begin therapy with fluvastatin

To calculate the LDL cholesterol: LDL = Total cholesterol –[triglycerides/5 + HDL], in this case 135 mg/dL. In the NCEP/ATP 3 guidelines diabetes is considered a coronary artery disease equivalent and LDL cholesterol should be treated to a goal of less than 100 mg/dL. The best medication for reducing LDL cholesterol is a statin; hence fluvastatin is the correct answer. Niacin is less powerful at LDL reduction than the statins but significantly better at reducing triglycerides and raising HDL. This patient’s triglycerides and HDL do not need intervention. Niacin should be used only as a last resort in diabetics as it worsens glycemic control. Choice E, adding insulin to improve glycemic control, can lower triglycerides and raise HDL in patients with elevated hemoglobin A1C’s.

1. National Cholesterol Education Program: Expert panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Adult Treatment Panel III, Jama 2001:285, 2486-97.

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