Cardiology
Dermatology
ID
100

A 67-year-old man presents to his primary care physician for increasing shortness of breath that is notable with climbing the stairs or walking two or more blocks. He reports swelling in his bilateral lower extremities. He has a medical history of hypertension, hyperlipidemia, and a recent myocardial infarction requiring percutaneous intervention. Medications include atorvastatin, aspirin, and clopidogrel. On vital signs, he has a temperature of 98.6°F, pulse of 80 bpm, blood pressure of 136/82 mm Hg, respiratory rate of 18 breaths per minute, and oxygen saturation of 98%. On physical examination, he has an audible S3 heart sound on cardiac auscultation and bibasilar crackles on pulmonary auscultation. There is 1+ pitting edema in the bilateral lower extremities and a distended jugular vein. A transthoracic echocardiogram demonstrates a left ventricular ejection fraction of 33%. Which of the following is the most appropriate pharmacotherapy for this patient? 

A Amlodipine

B Hydrochlorothiazide

C Ramipril

D Verapamil

C Ramipril

This patient’s symptoms are suggestive of heart failure, as he is experiencing exertional dyspnea, jugular venous distension, bibasilar crackles, pitting edema in the lower extremities, and an ejection fraction ≤ 35–40%. His recent myocardial infarction suggests that he has ischemic cardiomyopathy resulting in heart failure with reduced ejection fraction (HFrEF). Management of ischemic cardiomyopathy can be divided into pharmacotherapy, lifestyle modification, device therapy, and coronary revascularization. With regards to pharmacotherapy, patients should be treated with an angiotensin-converting enzyme (ACE) inhibitor (e.g., ramipril), a beta-blocker (e.g., metoprolol), statin therapy (e.g., atorvastatin) and aspirin (for secondary prevention for established coronary artery disease), and loop diuretics with salt restriction (to address the edema). A number of pharmacotherapies are associated with improved survival in patients with HFrEF, including an ACE inhibitor, angiotensin-receptor blocker, aldosterone antagonist (e.g., spironolactone), and beta-blockers (metoprolol, carvedilol, and bisoprolol). In African American patients, hydralazine plus nitrate therapy has shown a mortality benefit.

100


A 28-year-old woman presents to her primary care physician complaining of an itchy new skin lesion on her left arm. She reports no prior injury to the area. Medical history is notable for seasonal allergies, for which she takes cetirizine as needed. Vital signs are normal. On physical exam, the above lesion is present on her left arm. The rest of her skin exam is unremarkable. Examination of skin scrapings under microscopy with potassium hydroxide reveals segmented hyphae. Which of the following is the most appropriate pharmacologic therapy for this patient?

  • A Oral itraconazole
  • B Topical betamethasone-clotrimazole
  • C Topical nystatin
  • D Topical terbinafine

D Topical terbinafine

  • Patient will be complaining of a rash
  • PE will show an erythematous, scaly plaque that is annular, has raised edges, sharply marginated, with a central clearing
  • Diagnosis is confirmed by KOH preparation of skin scrapings
  • Most commonly caused by dermatophyte
  • Treatment is topical antifungal clotrimazole
100

A 48-year-old woman with no significant past medical history is in the ICU with a severe burn injury encompassing 20% of her body surface area, which is from a barbequing accident. She was admitted to the ICU 4 days ago, underwent fluid resuscitation, and briefly needed vasopressors that have since been weaned off. She is currently on vancomycin and piperacillin-tazobactam. She has been afebrile for the past 3 days, but early this morning, she developed a fever. Her vital signs include a temperature of 101.1°F, blood pressure of 119/79 mm Hg, heart rate of 80 bpm, and respiratory rate of 13 breaths per minute. She is intubated and sedated. Deep palpation in the right upper quadrant elicits wincing on abdominal exam. Blood and urine cultures are pending. Abdominal ultrasound shows a distended gallbladder with the presence of pericholecystic fluid and thickened gallbladder wall. There is a small amount of intramural gas. No gallstones are visualized. There is no dilation of intrahepatic or extrahepatic bile ducts. Laboratory results are as follows:


Hemoglobin: 12 g/dL

Leukocyte count: 4,500/mcL

Platelet count: 125,000/mcL

Sodium: 140 mEq/L

Potassium: 4.1 mEq/L

Chloride: 101 mEq/L

Bicarbonate: 12 mEq/L

Blood urea nitrogen: 12 mg/dL

Creatinine (serum): 1.1 mg/dL

Aspartate aminotransferase: 80 U/L

Alanine aminotransferase: 130 U/L

Alkaline phosphatase: 235 U/L

Bilirubin (total): 1.2 mg/dL

Bilirubin (direct): 0.9 mg/dL

Amylase: 95 U/L

Lipase: 105 U/L


Which of the following is the best next step in management?

  • A Continue broad-spectrum antibiotic coverage and supportive care
  • B Emergent laparoscopic cholecystectomy
  • C Endoscopic gallbladder drainage
  • D Percutaneous cholecystostomy



B Emergent laparoscopic cholecystectomy

  • Complaining of colicky, steadily increasing RUQ or epigastric pain after eating fatty foods
  • PE will show Murphy sign, Boas sign (hyperaesthesia (increased or altered sensitivity) below the right scapula)
  • Diagnosis is made by:

    • Initial - US
    • Gold standard - HIDA
  • Most commonly caused by obstruction by a gallstone
  • Treatment is cholecystectomy
200

A 63-year-old man who smokes and has uncontrolled hypertension presents to the emergency department with chest pain lasting 2 hours. The pain is severe, sharp, and located in the anterior chest. Physical exam is notable for a pulse of 80 bpm with a blood pressure of 160/90 mm Hg in the left arm and 135/80 mm Hg in the right arm. No cardiac murmurs are appreciated on exam. Initial ECG is without T wave or ST changes. Initial chest radiograph is notable for widening of the mediastinum. CT angiogram of the chest reveals an acute ascending aortic dissection. What is the most appropriate initial management for this patient? 

  • A Emergency surgery
  • B IV heparin drip
  • C IV labetalol
  • D Transthoracic echocardiogram


C IV labetalol

This patient is presenting with an acute ascending or type A aortic dissection. According to the Stanford classification of aortic dissection, Type A dissections involve the ascending aorta, which can extend to the thoracoabdominal aorta, whereas Type B dissections involve the descending thoracic aorta distal to the left subclavian artery. The first step in management of an aortic dissection is pain control and treatment with beta-blockers and other agents to achieve blood pressure control to prevent extension. In the absence of contraindications, IV beta-blockade by an agent such as labetalol is the most appropriate initial step in management of an aortic dissection regardless of whether it is ascending or descending. Beta-blockade with a goal heart rate < 60 bpm is recommended to decrease aortic wall stress. An immediate surgical consult should also be obtained for any suspected ascending aortic aneurysm to plan for definitive therapy with surgery.

200

A 45-year-old woman presents complaining of dyspareunia and a vulvar rash that is intensely pruritic and violaceous with erosions. This is her first presentation of these symptoms and findings. Which of the following is first-line management for the condition?

  • A Intramuscular glucocorticoids
  • B Methotrexate
  • C Minocycline
  • D Topical clobetasol
  • E Topical tacrolimus

D Topical clobetasol

This patient has vulvar lichen planus. Cutaneous lichen planus is characterized by a papulosquamous eruption that is pruritic, polygonal, and violaceous and may affect the skin, oral cavity, scalp, nails, esophagus, or genitalia. First-line therapy for vulvar lichen planus is topical corticosteroids, most commonly 0.05% clobetasol ointment. Topical calcineurin inhibitors are second-line treatment.

200

A 33-year-old pregnant woman presents to her primary care physician with fever, malaise, and rash 3 weeks after returning from a weekend camping trip. She states the rash is painless but feels hot to the touch and has been gradually expanding since it first appeared on her stomach 2 weeks prior to the onset of her current symptoms. On examination, there is circumferential periumbilical erythema measuring approximately 5 cm in diameter with central clearing that is consistent with erythema migrans. Which of the following is the most appropriate therapeutic intervention at this time?

  • A Administration of IV ceftriaxone
  • B Administration of IV penicillin G
  • C Administration of oral azithromycin
  • D Administration of oral Amoxicillin
  • E  Administration of oral Doxycycline

D Administration of oral Amoxicillin

  • Patient with a history of being in the woods, hiking or camping
  • Presents with

    • Stage 1: erythema migrans (pathognomonic), viral-like syndrome (fever, fatigue, malaise, myalgia, headache)
    • Stage 2: myocarditis, bilateral Bell palsy
    • Stage 3: chronic arthritis, chronic encephalopathy
  • PE will show slightly raised red lesion with central clearing, erythema migrans (bull's-eye) rash
  • Most commonly caused by Borrelia burgdorferi carried by Ixodes tick
  • Treatment is doxycycline; children: amoxicillin or doxycycline (if used for < 21 days); pregnant: amoxicillin
  • Bilateral facial nerve palsy is virtually pathognomonic for Lyme disease
300

A 65-year-old man is seen in the cardiac intensive care unit. He started feeling a pressure-like sensation in his chest while shopping for groceries 1 day ago. His medical history is significant for type 2 diabetes mellitus and hyperlipidemia, for which he is on metformin, glipizide, empagliflozin, and atorvastatin. He smokes a pack of cigarettes daily. An ECG shows normal sinus rhythm with no ST changes or T wave inversions. Troponin I level is 0.08 ng/mL and 0.1 ng/mL on repeat. He is diagnosed with a non-ST elevation myocardial infarction and started on aspirin, clopidogrel, metoprolol, and unfractionated heparin. He then undergoes coronary angiography, which shows normal left ventricular function, 60% occlusion of the proximal left anterior descending artery, and 70% occlusion of the left marginal artery. His vital signs have remained stable throughout the admission. What is the best next step in management? 


A Balloon angioplasty

B Coronary artery bypass graft

C Drug-eluting stent placement

D Recombinant tissue-type plasminogen activator

B Coronary artery bypass graft

On coronary angiography, he has significant (greater than 50% occlusion) two-vessel coronary artery disease. Based on the Synergy Between Percutaneous Coronary Intervention (PCI) with Taxus and Cardiac Surgery (SYNTAX) study, for patients with diabetes and multivessel disease or complex coronary disease (high grade left main or multivessel disease or determined using the SYNTAX score), CABG is preferred over PCI. Drug-eluting stent placement (C) would not be the best next step, as PCI has been shown to have higher mortality compared to CABG in patients with multivessel disease and diabetes. In patients without diabetes or those who have only left main disease with or without diabetes, either PCI or CABG can be considered. 

300

A 55-year-old woman presents to her primary care physician complaining of multiple skin lesions on her back. Over the past two years, she has noticed an increasing number of scaly lesions on her back. The lesions are neither painful nor pruritic, but, at times, they catch on clothing and get slightly irritated. Past medical history is notable for obesity and hypertension. Family history is negative for skin or other cancers. Vital signs are unremarkable. On physical exam, there are approximately fifteen well-circumscribed, hyperpigmented, and round lesions on her back, each lesion is < 0.5 cm in diameter. They have a stuck-on appearance. On dermoscopy, multiple milia-like cysts and comedo-like openings are present on each lesion. Which of the following is the most likely diagnosis for this patient?

  • A Epidermoid cyst
  • B Lentigo maligna
  • C Seborrheic keratosis
  • D Verruca vulgaris

C Seborrheic keratosis

Seborrheic keratosis is the most likely diagnosis for this patient. Seborrheic keratoses are benign epidermal tumors that develop secondary to immature keratinocyte proliferation. They are common tumors that occur most often in patients older than 50 years of age and present as a single lesion or as numerous lesions. Seborrheic keratoses develop most frequently on the trunk, face, and upper extremities. Clinical presentation typically involves a well-circumscribed, hyperpigmented, oval- or round-shaped lesion with scaling and a “stuck on” appearance 

An epidermoid cyst (A) typically presents as a skin-colored subcutaneous nodule, often with a central punctum. Lentigo maligna (B) is a melanoma in situ that develops on sun-damaged skin, most commonly on the face and neck. Clinical presentation is characterized by non-scaly and hyperpigmented macules with irregular shapes. Pigmented and asymmetrical follicular openings, rhomboidal structures, and grey dots and globules may be appreciated on dermoscopic examination. Verruca vulgaris (D), also known as the common wart, presents as a well-defined, keratotic papule that most often affects the fingers, hands, elbows, or knees. Upon dermoscopy, homogeneous red or black dots are often present, representing thrombosed capillaries.

300

A 20-year-old woman presents to the emergency room after developing weakness at home. She states that she ate breakfast early that morning as she normally does, having her usual homemade jam and toast, and otherwise felt fine during the day. She began having abdominal pain and nausea in the afternoon before noticing blurred vision, drooping eyelids, and difficulty speaking. She is an avid chef and makes much of her food from scratch using items in her garden. Her arms began to feel weak in the emergency room. Physical exam is notable for mydriasis and ptosis of both eyelids. There are no rashes or bites on her skin. Which of the following is the most likely diagnosis?

  • A Botulism
  • B Guillain-Barré syndrome
  • C Myasthenia gravis
  • D Tick paralysis
  • A Botulism

Patient with a history of eating canned food, puncture wound, or heroin injection

  • Complaining of symmetric descending paralysis
  • Most commonly caused by Clostridium botulinum
  • Treatment is antitoxin
400

A 33-year-old woman with no significant prior medical history is being evaluated for exertional dyspnea for the past 5 months. She reports no progressive change in her symptoms over that time. She has no other symptoms and is not on any medications. On exam, her vitals are unremarkable, but auscultation reveals a fixed splitting of S2. A soft systolic murmur is heard at the second left intercostal space with an associated diastolic rumble at the left sternal border. The remainder of her exam is unremarkable. Her ECG shows a right axis deviation with an incomplete right bundle branch block. Which of the following is the most likely diagnosis? 

  • A Atrial septal defect
  • B Congenital pulmonic stenosis
  • C Pulmonic regurgitation
  • D Stenotic bicuspid aortic valve

A trial septal defect

Patients with atrial septal defect (ASD) present with dyspnea on exertion, fixed splitting of the S2, and a right ventricular heave. This patient most likely has ostium secundum, which is the most common type of ASD, accounting for 75% of cases. The fixed splitting of S2 results from the prolongation of right ventricular systole and lack of respiratory change in the right ventricular stroke volume.

400

A 55-year-old Caucasian man presents to his primary care physician for evaluation of new skin growths on his scalp and the backs of his hands. He first noticed the painless growths about a month ago. He has never been diagnosed with skin cancer in the past and does not use regular sunscreen. Past medical history is notable for kidney transplant 1 year ago, and he is taking immunosuppressive therapy with cyclosporine. Vital signs are unremarkable. On physical exam, he has two 0.6 cm erythematous, scaly, and hyperkeratotic papules with underlying actinic damage located in balding areas of his scalp. He also has two similar 0.7 cm lesions on the backs of his hands. Which of the following is the most likely diagnosis?

  • A Basal cell carcinoma
  • B Cutaneous squamous cell carcinoma
  • C Kaposi sarcoma
  • D Merkel cell carcinoma

B Cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma is the most likely diagnosis. Skin cancers develop more commonly in patients who have undergone solid organ transplants, with cutaneous squamous cell carcinomas and basal cell carcinomas comprising over 90% of cases. 

  • Patient with a history of HPV, chronic sun exposure, exposure to arsenic or radiation
  • Complaining of a non-healing lesion that sometimes bleeds
  • PE will show red, scaly, hyperkeratotic nodular, papule or plaque that does not itch.
  • Most common on lips, hands, neck, head (sun-exposed areas)
  • Diagnosis is made by clinical exam, skin biopsy to confirm
  • Prevention includes sunscreen/UV light protection
  • Treatment is wide local excision, radiation therapy
  • Comments: Second most common skin cancer. Actinic Keratosis is a precursor
400

A 34-year-old man presents to the emergency department after being found profoundly disoriented by his friends. He has a past medical history of untreated AIDS and hypertension. His only medication is amlodipine. He has no known drug allergies. He smokes cigarettes but does not drink alcohol or use illicit drugs. On physical exam, he is febrile with a temperature of 38.2°C (100.8°F), pulse rate is 94 bpm, respiratory rate is 18/min, and blood pressure is 152/94 mm Hg. He is awake but drowsy and oriented to person but not to place or time. His neurologic examination is unremarkable. A lumbar puncture is performed and laboratory testing detects cryptococcal antigen in the CSF. What is the most appropriate treatment?

  • A Dexamethasone
  • B Fluconazole and amphotericin B
  • C Liposomal amphotericin B and flucytosine
  • D Micafungin and flucytosine



C Liposomal amphotericin B and flucytosine

  • Patient will be HIV (+)
  • Complaining of headache, fever, stiff neck, photophobia, vomiting
  • Labs will show CD4  < 100
  • Diagnosis is made by India ink stain of CSF (round encapsulated yeast), Cryptococcal antigen (CrAg) - CSF or serum
  • Treatment is amphotericin B (fungicidal), flucytosine (fungicidal), fluconazole (fungistatic)
500

Which of the following individuals would require endocarditis prophylaxis according to the current American Heart Association guidelines?

  • A 19-year-old man with a history of patent foramen ovale undergoing a root canal
  • B 22-year-old man with a prosthetic mitral valve undergoing tonsillectomy
  • C 45-year-old woman with a cardiac transplant undergoing cryosurgery
  • D 52-year-old woman with a history of endocarditis undergoing colonoscopy

B 22-year-old man with a prosthetic mitral valve undergoing tonsillectomy

The 2007 American Heart Association guidelines recommend endocarditis prophylaxis in patients with any of the following high-risk factors: a history of endocarditis, prosthetic cardiac valves or prosthetic material used for valve repair, cardiac transplant with valvulopathy, or congenital heart disease, including surgically unrepaired cyanotic heart defects that may have been treated using shunts or conduits, previously repaired defects with residual leaks or abnormal blood flow close to prosthetic material, and all heart defects repaired with prosthetic material or device within six months after the procedure.

A 19-year-old man with a history of patent foramen ovale undergoing a root canal (A) would not require antibiotic prophylaxis because patent foramen ovale is not a cyanotic heart defect associated with an increased risk of endocarditis. The majority of patent foramen ovale cases resolve spontaneously after birth. Persistence into adulthood primarily increases the risk for stroke from paradoxical embolism. A 45-year-old woman with a cardiac transplant undergoing cryosurgery (C) would not be considered high risk unless valvular dysfunction was simultaneously present. In addition, prophylaxis for skin procedures is only recommended for active skin, soft tissue, or musculoskeletal infections. A 52-year-old woman with a history of endocarditis undergoing colonoscopy (D) is considered high risk because of previous endocardial infection. However, prophylaxis in high-risk patients is only recommended for procedures involving the gastrointestinal tract or urogenital tract, such as esophagogastroduodenoscopy, colonoscopy, or cystoscopy, that are performed in the presence of an active infection.  

500

A 45-year-old woman presents to her primary care physician complaining of muscle weakness for the past 6 weeks. She has had particular difficulty climbing stairs and lifting up her 4-year-old daughter. Review of systems is also positive for an itchy rash on her neck and back and is negative for fevers, visual changes, muscle or joint pain, stiffness, or sensory loss. Vital signs are unremarkable. On physical exam including a detailed neurologic exam, she has 4/5 muscle strength in her bilateral hip flexors and deltoids but otherwise normal muscle strength throughout. Sensation and deep tendon reflexes are normal. She also has hyperpigmentation and telangiectasias overlying her neck and upper chest and back. Which of the following is the most likely diagnosis for this patient?

  • A Amyotrophic lateral sclerosis
  • B Dermatomyositis
  • C Inclusion body myositis
  • D Systemic lupus erythematosus



B Dermatomyositis

  • Patient will be a woman
  • Complaining of insidious, painless, proximal muscle weakness (Polymyositis) and a rash
  • PE will show:

    • Malar rash
    • Heliotrope rash
    • Gottron papules
  • Labs will show ↑ CK and aldolase
  • Diagnosis is made by EMG, muscle biopsy
  • Treatment is steroids
  • Comments: increased risk for malignancy (in adults)
500

A 36-year-old woman presents to her primary care physician for cough with mucopurulent sputum for the past 3 days. She has no recent history of travel, hospitalization, or antibiotic use. Her roommate has had respiratory symptoms for the past week. Past medical history is unremarkable, and she does not take any medications. She does not smoke, drink alcohol, or use recreational drugs. She lives with her husband and works from home as an accountant. Review of systems is also positive for low-grade fever and negative for chills, chest pain, dyspnea, or hemoptysis. On vital signs, she has a temperature of 100.4°F, pulse of 75 bpm, blood pressure of 120/74 mm Hg, respiratory rate of 18 breaths per minute, and oxygen saturation of 98%. Physical exam reveals crackles, dullness to percussion, and egophony at the right lung base. A chest radiograph shows a right lower lobe consolidation. Which of the following is the most appropriate next step in management?

  • A Amoxicillin
  • B Cefpodoxime and azithromycin
  • C Clindamycin
  • D Levofloxacin

A Amoxicillin

Amoxicillin is the most appropriate next step in management. Community-acquired pneumonia is an acute pulmonary parenchymal infection that is acquired outside the hospital setting. The most common causes are Streptococcus pneumoniae and respiratory viruses. Cefpodoxime and azithromycin (B) is incorrect. This would be a reasonable option for outpatient management of community-acquired pneumonia in a patient with a nonanaphylactic allergy to or intolerance of penicillin. Clindamycin (C) is not a recommended first-line therapy for community-acquired pneumonia. Clindamycin offers coverage of anaerobic bacteria and can be considered as a therapeutic option for the management of aspiration pneumonia in penicillin-allergic patients. Levofloxacin (D) is a fluoroquinolone antibiotic that is not a first-line community-acquired pneumonia therapy in patients without comorbidities due to concerns over antibiotic resistance and adverse effects.

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