Derm
What is the atopic triad?
1. Atopic dermatitis
2. Asthma
3. Allergic rhinitis
Define microcytic anemia AND name 3 potential causes
MCV < 80
Causes:
1. Iron deficiency anemia
2. Thalassemia (alpha or beta)
3. Anemia of chronic disease
4. Sideroblastic anemia
5. Lead poisoning
A 4-year-old boy is brought to the clinic for evaluation of crossed eyes. The mother noticed that the patient’s left eye has been very slightly deviated toward the nose over the last few months. Physical exam is significant for asymmetric pupillary light reflection. What is the most likely diagnosis?
Dx: Strabismus
Tx:
- Patch / blur the good eye and/or glasses
- Surgical correction if refractory
This life-threatening polymorphic ventricular tachycardia is often triggered by QT prolongation. Name 2 electrolyte abnormalities that can precipitate Torsades de Pointes.
1. Hypokalemia
2. Hypomagnesemia
3. Hypocalcemia (less common)
FEV1/FVC decreased
Obstructive lung diseases: FEV1/FVC decreased
- eg, asthma, COPD, emphysema
Restrictive lung diseases: FEV1/FVC increased
- eg, IPF, pneumoconioses
Which of the following photograph(s) is/are consistent with a diagnosis of seborrheic dermatitis?
Choices B & E
Pathophysiology: inflammatory reaction to resident yeast Malassezia furfur
Treatment: zinc pyrithione, selenium sulfide, ketoconazole; topical steroid (hydrocortisone) if refractory
What is the treatment for suspected heparin induced thrombocytopenia?
A. Discontinue all heparin products and initiate warfarin once the platelet count is <100,000/mm3
B. Continue heparin at a reduced dose and add aspirin for antiplatelet coverage
C. Discontinue all heparin products and initiate argatroban
D. Discontinue heparin and provide platelet transfusions to prevent bleeding
E. Switch from unfractionated heparin to low-molecular-weight heparin and monitor platelet counts closely
F. Discontinue heparin and initiate fondaparinux only after confirmatory PF4 antibody testing
C. Discontinue all heparin products and initiate argatroban
Pathophys: antibodies against the PF4-heparin complex → platelet consumption → paradoxical hypercoagulable state
Management: stop heparin → give direct thrombin inhibitor (eg, argatrobran, bivalrudin)
What is the name of this physical exam finding and what are 2 potential causes?
Dx: Papilledema
Causes:
1. Pseudotumor cerebri
2. Intracranial mass
3. HTN
4. Intracranial hemorrhage
5. Obstructive hydrocephalus
6. Cerebral venous sinus thrombosis
Tx: weight loss, hypertonic saline, acetazolamide, optic nerve sheath fenestration
A 22-year-old athlete undergoes a routine physical. His ECG shows a consistently prolonged PR interval (247 ms), but no dropped beats, normal QRS complexes, and he is completely asymptomatic. What conduction abnormality does this pattern represent?
First degree AV Block
Atrioventricular Block
First degree: PR > 200 ms (one "big box" on ECG)
Second degree: two subtypes
- Mobitz I (Wenckebach): progressive lengthening of the PR interval until a QRS is dropped ("longer longer longer drop")
- Mobitz II: dropped QRS without lengthening of the PR interval
Third degree: complete asynchrony between the atria and ventricles; Ps on Qs, beating independently (P-P and R-R are the same)
A 34-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He complains of acute left-sided chest pain and shortness of breath. On arrival, he is tachypneic and mildly hypoxic. Examination reveals asymmetric chest wall expansion with decreased movement of the left hemithorax.
Which of the following physical examination findings is most likely present on the left side of the chest?
A. Decreased breath sounds, dullness to percussion, increased tactile fremitus
B. Decreased breath sounds, hyperresonance to percussion, decreased tactile fremitus
C. Increased breath sounds, dullness to percussion, decreased tactile fremitus
D. Increased breath sounds, hyperresonance to percussion, increased tactile fremitus
E. Bronchial breath sounds, egophony, and increased tactile fremitus
B. Decreased breath sounds, hyperresonance to percussion, decreased tactile fremitus
Dx: pneumothorax
A 14-year-old boy is brought to the physician because of a 1-week history of a mildly pruritic rash on his left arm. He has mild asthma that is well controlled with an inhaled corticosteroid. He plays several sports and currently participates on the school wrestling team. His family lives on a farm in North Dakota. They have had a pet dog for 5 years; the dog is in good health and has no skin lesions. The patient appears well. His temperature is 37°C (98.6°F). Examination shows a 3-cm lesion over the left forearm. A photograph of the lesion is shown. Which of the following is the most appropriate pharmacotherapy?
A) Topical clotrimazole
B) Topical mupirocin
C) Topical nystatin
D) Oral cephalexin
E) Oral itraconazole
A) Topical clotrimazole
Dx: Tinea corporis (ringworm)
First-line/localized: topical antifungal (eg, clotrimazole, terbinafine)
Second-line/extensive: oral antifungal (eg, terbinafine, griseofulvin)
A 15-month-old boy is brought to the emergency department for evaluation of ankle swelling. The symptoms started yesterday evening after he played at a park, and today he has refused to walk. Since he began walking at age 12 months, he has developed bruises following minor trauma. The patient has had no fever or recent illness. The child was born at term. Vital signs are normal. Examination shows an edematous and tender left ankle with decreased range of motion. Skin examination reveals large ecchymoses on both thighs from recent vaccinations. The nares and oropharynx are clear. The abdomen is soft with no organomegaly. Plain radiographs reveal no acute fracture or dislocation at the left ankle. Laboratory testing in this patient is most likely to reveal which of the following?
.
D. Normal platelets, normal PT, increased PTT, normal platelet aggregation
Dx: Hemophilia
- Factor VIII or IX deficiency = impaired intrinsic coagulation cascade
A 52-year-old man presents to the clinic with 8 months of progressive hearing difficulty in his right ear. He also reports intermittent tinnitus and a sense of imbalance when walking on uneven ground. He denies ear pain, fever, or recent infections. Physical examination reveals decreased hearing to finger rub on the right and a reduced corneal reflex on the right. Otoscopic examination is normal. Weber test lateralizes to the left ear, and Rinne testing is normal bilaterally.
Which of the following is the most appropriate next step in evaluation?
A. Audiometry followed by hearing aid fitting
B. CT scan of the temporal bones without contrast
C. MRI of the brain with contrast
D. Trial of oral corticosteroids for presumed vestibular neuritis
E. Electronystagmography to assess vestibular function
C. MRI of the brain with contrast
Dx: acoustic neuroma
Pathophys: Benign intracranial tumor of CN VIII (at the cerebellopontine angle) → sensorineural hearing loss + vertigo / tinnitus
Diagnosis? Treatment?
Dx: Afib
Tx:
ABC
1. Electronic cardioversion
2. If electronic cardioversion fails: Ibutilide
3. Anticoagulation
Rate control
Esmolol
Diltiazem
A 3-year-old girl with a history of asthma is brought to the clinic for follow-up. Five days ago, the patient had a choking episode during a meal. She subsequently developed persistent cough and wheezing and was taken to the emergency department the same day. The wheezing improved with three treatments of nebulized albuterol, and chest radiograph was unremarkable. The patient was discharged with instructions to continue the albuterol and begin oral corticosteroids. She finished her corticosteroid course this morning, but the cough has persisted despite albuterol use. The patient has had no fever, congestion, or rhinorrhea. Vital signs are normal. The oropharynx is clear. Lung examination shows symmetric chest expansion with diminished breath sounds and a faint wheeze in the right middle lobe. There are no crackles. The left lung is clear. Cardiac examination is unremarkable. Pulses are 2+ bilaterally. The abdomen is soft and nontender. Skin examination shows no rashes. Repeat chest radiograph is unchanged.
Which of the following is the best next step in management of this patient?
A. Allergy testing
B. Antibiotic therapy
C. Bronchoscopy
D. Extended corticosteroid course
E. Pulmonary function testing
F. Supportive care with antitussives
C. Bronchoscopy
Dx: foreign body aspiration
Used for definitive diagnosis and/or retrieval
Hx: choking, coughing, unexplained wheezing, hemoptysis, kid crawling on the ground
A 4-year-old girl is brought to the emergency department due to blisters on her left hand. Two days ago, the patient developed small, fluid-filled lesions, which have since increased in size and are now mildly tender and itchy. She has a history of eczema and takes no medications. Temperature is 38.1°C (100.6°F). Vital signs are otherwise normal. Examination findings of the hand are shown in the image below. Which of the following is the most likely pathogen of this patient’s condition?
A. Coxsackie virus
B. Herpes simplex virus
C. Sporothrix schenckii
D. Staphylococcus aureus
E. Streptococcus pyogenes
F. Varicella zoster virus
D. Staphylococcus aureus
Dx: bullous impetigo
*Bonus: how would you treat?
Bullous - S. aureus
Non-bullous - S. aureus or S. pyogenes
A 5-year-old boy is brought to the emergency department for decreased urine output and fatigue. Three days ago, he developed abdominal pain and profuse diarrhea that was initially watery then became bloody. On examination, he appears pale and lethargic. Vital signs show mild hypertension. Laboratory studies reveal:
Hemoglobin: 7.8 g/dL
Platelet count: 42,000/mm³
Creatinine: 2.1 mg/dL
Peripheral blood smear is shown below. Coagulation studies demonstrate normal PT and PTT. Which of the following best explains the underlying pathophysiology of this patient’s condition?
A. Autoantibody-mediated platelet destruction
B. Endothelial injury from E. coli enterotoxin leading to microangiopathic hemolytic anemia
C. Deficiency of ADAMTS13 causing accumulation of ultra-large von Willebrand factor multimers
D. Widespread activation of coagulation with consumption of clotting factors
E. Immune complex deposition in glomeruli following streptococcal infection
B. Endothelial injury from E. coli enterotoxin leading to microangiopathic hemolytic anemia
Dx: HUS
Triad of microangiopathic hemolytic anemia, thrombocytopenia, AKI
A 12-year-old boy is brought to the clinic due to 2 weeks of itchy, red eyes. The patient has had intermittent, mild, clear eye drainage without pain or photophobia and rubs his eyes frequently, often leading to a burning sensation. These symptoms have worsened; he now has difficulty focusing while at school. The patient has had some light crusting of both eyes when he wakes in the morning. He has a history of eczema for which he uses topical emollients as needed. The patient lives with his parents and a younger sister who has had fever, cough, rhinorrhea, and pharyngitis for 2 days. Vital signs are normal. Examination shows bilateral, diffuse conjunctival injection and mild eyelid edema. Visual acuity is 20/20 in both eyes, and pupils are equal and reactive. Which of the following is the best next step in management of this patient?
A. Fluorescein staining
B. Funduscopic examination
C. Topical antihistamines
D. Topical trimethoprim-polymyxin
E. Warm compresses only
C. Topical antihistamines
Dx: allergic conjunctivitis
Key points: bilateral, itchy
D & E would be for bacterial and viral conjunctivitis, respectively
This condition causes episodic chest pain at rest, often in the early morning, with transient ST-segment elevations during attacks despite angiographically normal coronary arteries. Symptoms rapidly improve with nitrates, and long-term management targets the underlying pathophysiologic mechanism rather than atherosclerosis.
Prinzmetal (variant) angina
Tx:
Acute - nitro
Chronic - CCBs
An 18-year-old girl comes to the office with 3 days of fever, nonproductive cough, dyspnea, and fatigue. The symptoms started after she returned home from a summer school trip to Europe with friends. Her roommate had similar symptoms. The patient has no prior medical issues, and her vaccinations, including COVID-19 vaccination, are up to date. She is not sexually active. She does not use tobacco, alcohol, or recreational drugs. Temperature is 38.3°C (101°F), blood pressure is 120/80 mm Hg, pulse is 88/min, and respirations are 16/min. The patient does not appear ill. Faint bilateral crackles are present. SARS-CoV-2 testing is negative. Chest x-ray reveals bilateral diffuse infiltrates.
Which of the following is the most appropriate next step in management?
A. Amoxicillin
B. Azithromycin
C. No antibiotics needed
D. Oseltamivir
E. Trimethoprim-sulfamethoxazole
B. Azithromycin
Dx: Mycoplasma (atypical) pneumonia
Key word: bilateral, diffuse infiltratesAtypicals are treated with Macrolides or less commonly Fluoroquinolone
A 62-year-old man presents with a 3-month history of progressively worsening pruritus and tense blisters on his lower abdomen and proximal thighs. The lesions are large, intact bullae on an erythematous base. He denies oral pain or difficulty swallowing. On examination, gentle lateral pressure on uninvolved skin does not cause epidermal sloughing. Skin biopsy demonstrates a subepidermal blister, and direct immunofluorescence shows linear IgG deposition along the basement membrane.
Which of the following best explains the underlying pathophysiology of this patient’s condition?
A. Autoantibodies directed against desmoglein 3 causing loss of keratinocyte adhesion
B. Immune complex deposition within dermal blood vessels with complement activation
C. IgG-mediated destruction of hemidesmosomal proteins anchoring the epidermis to the dermis
D. CD8⁺ T-cell–mediated keratinocyte apoptosis with full-thickness epidermal necrosis
E. Keratinocyte dysplasia confined to the epidermis with abnormal mitotic activity
C. IgG-mediated destruction of hemidesmosomal proteins anchoring the epidermis to the dermis
Dx: bullous pemphigoid
PE: tense, pruritic bullae on an erythematous base with no mucosal involvement; producing subepidermal blisters, negative Nikolsky sign, and linear IgG deposition on immunofluorescence
A 17-year-old girl comes to the emergency department due to a nosebleed that began an hour ago after she was hit in the face by a basketball. She pinched the nostrils for about 20 minutes in an attempt to stop the bleeding, but the hemorrhage continued after pressure was removed. The patient has a history of heavy, painful menses and takes scheduled ibuprofen for the first few days of her period. Her last period was a week ago. Temperature is 37.2°C (99°F). Examination shows clear lung fields with normal S1 and S2. The liver span measures 8 cm along the midclavicular line, and the spleen is not palpable. Scattered ecchymoses are present on both legs and arms. Laboratory results are as follows:
Hematocrit: 36%
Platelets: 9,000/mm³
Leukocytes: 5,500/mm³
Neutrophils: 60%
Eosinophils: 1%
Lymphocytes: 32%
Monocytes: 7%
Fibrinogen: 250 mg/dL (normal: 150–350 mg/dL)
PT: 13 sec
Which of the following is the most likely cause of this patient’s condition?
A. Blocked production of thromboxane A2
B. Bone marrow infiltration by malignant cells
C. Decreased circulating von Willebrand protein
D. Deficient ADAMTS13 activity
E. Hyperactivation of coagulation and fibrinolysis
F. Platelet autoantibody production
F. Platelet autoantibody production
Dx: Immune thrombocytopenia
Tx:
Mucosal symptoms only → observation
A 24-year-old woman presents to the emergency department with recurrent episodes of nonpruritic swelling of the lips, face, and extremities that have occurred intermittently since adolescence. She has required prior hospitalization for abdominal pain with nausea and vomiting during similar episodes. She denies urticaria or itching. Family history is notable for a father with similar episodic swelling. On examination, she has marked periorbital and lip edema without erythema or wheals. Vital signs are stable.
Laboratory studies during an attack are most likely to show which of the following abnormalities?
A. Elevated serum tryptase with increased histamine release from mast cells
B. Decreased C1 esterase inhibitor activity leading to increased bradykinin production
C. Increased IgE levels with basophil degranulation
D. Increased angiotensin-converting enzyme activity resulting in excessive degradation of bradykinin
E. Decreased factor VIII levels due to impaired von Willebrand factor stabilization
B. Decreased C1 esterase inhibitor activity leading to increased bradykinin production
Dx: Hereditary angioedema (autosomal dominant)
Pathophys: C1 esterase inhibitor deficiency → uninhibited kallikrein → ↑ bradykinin → ↑ vascular permeability → angioedema → swelling, SOB, GI upset, absence of urticaria
A 24-year-old woman in the 18th week of her first pregnancy comes to the clinic due to palpitations. The patient describes frequent but short-lived episodes of her heart “beating fast” or “skipping a beat.” She has no other symptoms and describes her exercise capacity as good. The patient has no known medical conditions and takes a multivitamin daily. Blood pressure is 122/75 mm Hg and pulse is 88/min and regular. Physical examination reveals a 2/6 midsystolic murmur at the left upper sternal border, and ECG shows sinus rhythm with a right bundle branch block. Echocardiogram reveals a normal-size left ventricle with left ventricular ejection fraction of 65%. The right ventricle is moderately dilated.
Which of the following best explains this patient’s findings?
A. Anomalous coronary artery
B. Aortic coarctation
C. Atrial septal defect
D. Membranous ventricular septal defect
E. Patent ductus arteriosus
C. Atrial septal defect
Dx: midsystolic murmur at LUSB (can be "fixed, wide S2 split)
A 10-minute-old neonate is evaluated in the delivery room for low oxygen saturation and difficulty breathing. The patient was born at 36 weeks gestation to a 37-year-old mother whose pregnancy was complicated by poorly controlled type 2 diabetes mellitus. Membranes were ruptured 3 hours prior to delivery, and the fluid was clear. Apgar scores were 5 and 7 at 1 and 5 minutes, respectively.
Temperature is 36.9°C (98.4°F), pulse is 166/min, and respirations are 70/min. Examination shows cyanosis of the lips and mucous membranes. The patient is grunting and has intercostal and subcostal retractions. Cardiac examination shows a 1/6 systolic ejection murmur at the left upper sternal border. Breath sounds are decreased bilaterally. The abdomen is soft with no organomegaly. Pulses are 2+ in all extremities. Pulse oximetry on room air is 64% in the right hand and foot.
An orogastric tube is placed, and the patient is started on continuous positive airway pressure with supplemental oxygen. Pulse oximetry improves to 82%. Chest radiograph is shown. Blood cultures are obtained, and intravenous antibiotics are started.
Which of the following is the most appropriate pharmacotherapy for this patient?
A. Maternal corticosteroids
B. Fetal corticosteroids
C. Indomethacin
D. Nitric oxide
E. Prostaglandin
F. Surfactant
F. Surfactant
Dx: NRDS
Tx: maternal corticosteroids in utero, surfactant after baby born