Seborrheic Dermatitis
Anemia in Pregnancy & Misc
Hyperthyroidism
Heart Failure REF 1
Heart Failure REF 2
100
A 72-year-old man with a prior cerebrovascular accident presents with erythematous, greasy scaling of the scalp and eyebrows. He asks why this condition is so common in patients like him.
Which of the following best explains the increased prevalence of seborrheic dermatitis in patients with neurologic disorders such as Parkinson disease and stroke?
A. Increased colonization by dermatophytes
B. Excess sebum production with impaired clearance due to reduced facial movement
C. Immune dysregulation with decreased T-cell activation
D. Secondary nutritional deficiencies
Answer: B. Excess sebum production with impaired clearance due to reduced facial movement
Explanation: In Parkinson disease and cerebrovascular disease, reduced facial movement allows accumulation of excess sebum, promoting Malassezia overgrowth. The article specifies prevalence up to 59% in Parkinson patients.
100
Which of the following risk factors would increase suspicion for asymptomatic first-trimester iron deficiency anemia in this patient?
A. Eating a diet low in iron-rich foods.
B. Using tobacco.
C. Being of Black race or Mexican American ethnicity.
D. Living at a high altitude.
E. Having a short interval between pregnancies.
The correct answers are A, C, and E. Diets low in iron-rich foods (such as a vegan diet) and short intervals between pregnancies are risk factors for iron deficiency anemia in pregnancy.1 In addition, data suggest that there is an increased prevalence of iron deficiency anemia in Black and Mexican American pregnant women. Tobacco use (carbon monoxide exposure) and living at a high altitude (lower partial pressure of oxygen) are not commonly cited risk factors, but they may cause chronic hypoxic conditions that can result in increased erythropoiesis and hemoglobin production and mask underlying iron deficiency or iron deficiency anemia
100
A 68-year-old man with a history of hypertension presents with 15-pound unintentional weight loss, new-onset atrial fibrillation, and palpitations. Exam reveals an irregularly irregular rhythm and a multinodular goiter. TSH is suppressed, free T4 is mildly elevated, and radioactive iodine uptake shows multiple areas of focal uptake.
Which of the following is the most likely diagnosis?
A. Graves disease
B. Toxic multinodular goiter
C. Subacute thyroiditis
D. Exogenous thyroid hormone use
1. Graves disease → Answer: C. Thyroid eye disease with proptosis
Thyroid eye disease is pathognomonic for Graves disease and occurs in ~25% of patients.
A single nodule (A) = toxic adenoma; low uptake + ESR (B) = thyroiditis; postpartum painless goiter (D) = lymphocytic thyroiditis.
100
A 70-year-old woman with HFrEF is started on sacubitril-valsartan. Two weeks later, her BNP is elevated compared with baseline. Which of the following is the best interpretation?
A. BNP levels are unreliable in patients on sacubitril-valsartan; NT-proBNP should be monitored instead
B. BNP elevation indicates worsening heart failure and requires hospitalization
C. This is a laboratory error; repeat the BNP
D. BNP should not rise with sacubitril-valsartan; discontinue therapy immediately
Answer : A
Explanation: Sacubitril inhibits neprilysin, which increases BNP levels, making BNP less reliable. NT-proBNP is preferred for monitoring patients on sacubitril-valsartan.
100
Which of the following is true regarding IV iron in HFrEF?
A. Improves mortality significantly
B. No proven benefit on exercise capacity
C. Reduces hospitalizations but not mortality
D. Contraindicated if ferritin <100
Answer: C
Explanation: IV iron improves symptoms and reduces hospitalizations, but not mortality.
200
A 45-year-old man with recurrent scalp seborrheic dermatitis asks why antifungal shampoos work if this is “just a skin condition.”
Which of the following best describes the underlying pathophysiology targeted by antifungal shampoos?
A. They reduce keratinocyte proliferation and normalize epidermal turnover
B. They decrease sebaceous gland secretion by altering androgen activity
C. They limit Malassezia overgrowth promoted by excess sebum
D. They suppress neutrophil chemotaxis to the affected skin
A 35-year-old man has severe seborrheic dermatitis unresponsive to topical antifungals, corticosteroids, and calcineurin inhibitors. You are considering systemic therapy.
Which of the following has been shown to reduce sebum production and inflammation in refractory cases?
A. Oral terbinafine alone
B. Low-dose oral isotretinoin
C. Long-term systemic corticosteroids
D. Oral doxycycline
Answer: C. They limit Malassezia overgrowth promoted by excess sebum
Explanation: The article emphasizes three factors in pathophysiology: (1) Malassezia yeast overcolonization (target of antifungals), (2) sebum accumulation, and (3) dysregulated inflammatory response.
Answer: B. Low-dose oral isotretinoin
Explanation: In severe refractory cases, low-dose isotretinoin can be effective by reducing sebum production and inflammation. Oral antifungals (fluconazole, itraconazole, terbinafine) are alternatives but isotretinoin is unique for targeting seborrhea itself.
200
According to the USPSTF recommendation statement on screening for iron deficiency or iron deficiency anemia, which one of the following statements about iron supplementation in pregnancy is correct?
A. It has been shown to increase maternal hematologic indices (eg, hemoglobin).
B. It has been shown to improve maternal and neonatal morbidity and mortality.
C. It has been shown to increase neonatal hematologic indices.
D. It is recommended in pregnant patients with symptomatic anemia.
The correct answer is A. Although iron supplementation has been shown to increase maternal hematologic indices, there is insufficient evidence to assess whether iron supplementation during pregnancy improves patient health outcomes, such as maternal and neonatal morbidity and mortality, according to systematic review.3Potential harms of iron supplementation include gastrointestinal symptoms such as nausea, constipation, abdominal pain, vomiting, and iron overload. In the absence of evidence, clinicians should use their judgment.
200
A 68-year-old man with a history of hypertension presents with 15-pound unintentional weight loss, new-onset atrial fibrillation, and palpitations. Exam reveals an irregularly irregular rhythm and a multinodular goiter. TSH is suppressed, free T4 is mildly elevated, and radioactive iodine uptake shows multiple areas of focal uptake.
Which of the following is the most likely diagnosis?
A. Graves disease
B. Toxic multinodular goiter
C. Subacute thyroiditis
D. Exogenous thyroid hormone use
2. Toxic multinodular goiter → Answer: B. Toxic multinodular goiter
Elderly patient with multinodular goiter, AF, and multiple focal uptake on RAI scan is classic for toxic multinodular goiter.
Graves shows diffuse uptake, thyroiditis shows low uptake, and exogenous hormone shows low uptake with no nodules.
200
A 68-year-old man with HFrEF on GDMT presents with worsening kidney function. His eGFR decreased from 65 to 36 mL/min per 1.73 m² after initiation of sacubitril-valsartan. He is otherwise stable and asymptomatic. Which of the following is the best management?
A. Discontinue sacubitril-valsartan immediately
B. Continue therapy despite up to a 30% decline in eGFR
C. Give cautious IVF/gentle hydration and resume in 2 days
D. Reduce all heart failure medications and repeat labs in 2 months
Answer: B
Explanation: A ≤30% decline in eGFR after starting renin-angiotensin system/neprilysin inhibitors is expected and not an indication to stop therapy. Long-term use provides nephroprotective benefit.
200
Which is true regarding MRAs in HFrEF?
A. Contraindicated if eGFR <60
B. Contraindicated if K+ >5.5 mEq/L
C. No mortality benefit, only symptoms
D. Can be Given with hyperkalemia, if treated with insulin
Answer: B
Explanation: MRAs reduce mortality 15–30%, but must be stopped if K+ >5.5 or eGFR <30.
300
A 29-year-old man with a history of seborrheic dermatitis presents with ill-defined hypopigmented patches and fine scaling along the hairline and nasolabial folds. He has darker skin and is worried about “losing skin color.”
Which of the following is the best long-term therapy to minimize hypopigmentation risk and maintain remission?
A. High-potency topical corticosteroid solution applied daily
B. Tacrolimus 0.1% ointment twice weekly
C. Oral fluconazole 200 mg weekly
D. Coal tar shampoo daily
Answer: B. Tacrolimus 0.1% ointment twice weekly
Explanation: In skin of color, prolonged corticosteroid use carries higher risks of hypopigmentation. Maintenance therapy with topical calcineurin inhibitors (e.g., tacrolimus) reduces relapse and avoids steroid side effects.
300
A 35-year-old woman reported feeling pressure in her lower neck and chest a few hours after meals. The symptoms had started several months prior. The sensation was worse with dry foods, such as bread. She had a history of chronic idiopathic urticaria, which was well controlled with cetirizine. She was not allergic to any medications.
Although the patient did not report weight loss, she had lost 3% of her body weight on chart review. Physical examination did not reveal oropharyngeal or abdominal abnormalities. A barium swallow test was ordered
Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis?
A. Eosinophilic esophagitis.
B. Esophageal cancer.
C. Esophageal stricture.
D. Esophageal webs.
E. Zenker diverticulum.
Answer is E: Zenker diverticulum, an outpouching of esophageal mucosa and submucosa through the posterior esophageal wall between the thyropharyngeus and cricopharyngeus muscles. The condition is thought to be caused by increased hypopharyngeal pressure secondary to incomplete opening of the upper esophageal sphincter. Zenker diverticulum is most common in men 70 to 80 years of age. It presents with dysphagia, regurgitation of undigested foods, and halitosis. When untreated, the most common complications include chronic cough, aspiration, and weight loss.
300
A 33-year-old woman presents with anxiety, heat intolerance, and palpitations. She reports that her “eyes feel dry and gritty.” On exam, she has conjunctival erythema, lid lag, and proptosis. TSH is suppressed and free T4 is elevated.
Which of the following is the most appropriate initial management for her condition?
A. Radioactive iodine ablation
B. Methimazole therapy and beta blocker
C. Corticosteroids alone
D. Immediate thyroidectomy
3. Initial management of Graves with eye disease → Answer: B. Methimazole therapy and beta blocker
First-line therapy for Graves is thionamides (methimazole preferred) plus beta blockers for symptom control.
RAI can worsen eye disease (contraindicated here), steroids are adjuncts, and thyroidectomy is for compressive goiter or refractory disease.
300
A 58-year-old Black patient with HFrEF (EF 25%) remains symptomatic despite maximally tolerated ARNI, beta blocker, MRA, and SGLT2 inhibitor. Which of the following additional therapies is most appropriate?
A. Ivabradine
B. Isosorbide dinitrate + hydralazine
C. Vericiguat
D. Digoxin
Answer: B
Explanation: Hydralazine + isosorbide dinitrate is specifically recommended for Black patients with persistent symptoms on optimized GDMT. Other agents (ivabradine, vericiguat, digoxin) have more selective use cases.
300
Which of the following is the best timing to initiate a beta blocker in HFrEF?
A. Immediately in all patients
B. After adequate diuresis in new-onset HF
C. Withhold indefinitely if NYHA IV
D. Only after device therapy
Answer: B
Explanation: Start beta blockers after diuresis in new-onset HF; continuation is safe during decompensations if previously on therapy.
400
A 40-year-old man with moderate scalp seborrheic dermatitis asks if medicated shampoos are “really any better than placebo.” You recall a Cochrane review.
Which of the following is the number needed to treat (NNT) for ketoconazole shampoo to achieve clearance compared with placebo?
A. 2
B. 4
C. 5
D. 10
Answer: C. 5
Explanation: A Cochrane meta-analysis cited in the article found an NNT of 5 for ketoconazole shampoo versus placebo for clearance of seborrheic dermatitis symptoms.
400
A 72-year-old woman with chronic venous insufficiency presents for follow-up after healing of a venous stasis ulcer on her left lower leg. She has no history of arterial disease, and her pulses are intact on examination. She asks what she can do to prevent recurrence.
According to evidence from a Cochrane systematic review, which of the following is the most evidence-based recommendation to prevent ulcer recurrence?
A. No compression therapy, because ulcers rarely recur after healing
B. Light compression stockings (15–20 mm Hg) are as effective as heavy compression (30–40 mm Hg) in preventing recurrence
C. Heavy compression stockings (≈30–40 mm Hg; EU class 3) significantly reduce recurrence compared with no compression, but adherence may be limited
D. Thigh-length compression stockings are superior to below-knee stockings in preventing recurrence
E. Intermittent pneumatic compression devices are the first-line long-term option for recurrence prevention
C. Heavy compression stockings (≈30–40 mm Hg; EU class 3)
Compression stockings can reduce the recurrence of venous leg ulcers, based on limited evidence. Higher-grade compression is more effective, but patients are more likely to be noncompliant with therapy.1 (Strength of Recommendation: B, systematic review of few fair-quality trials.)
400
A 56-year-old man with untreated hyperthyroidism is brought to the emergency department with agitation, confusion, fever (39.7°C), profuse sweating, and severe tachycardia (HR 152). Exam reveals a diffusely enlarged thyroid and mild jaundice. Labs show TSH suppression, elevated free T4, and mildly elevated bilirubin. His Burch-Wartofsky score is 60.
Which of the following is the most appropriate next step in management?
A. Admit to ICU, start propranolol, propylthiouracil, hydrocortisone, and supportive care
B. Admit to ICU, administer methimazole and radioactive iodine
C. Perform urgent thyroidectomy
D. Start atenolol and schedule outpatient endocrinology referral
4. Thyroid storm → Answer: A. Admit to ICU, start propranolol, propylthiouracil, hydrocortisone, and supportive care
Thyroid storm is a life-threatening emergency with fever, tachycardia, delirium, and multi-system involvement.
Treatment is ICU admission, beta blocker, PTU (blocks synthesis + T4→T3 conversion), and corticosteroids; RAI and surgery are contraindicated.
400
A 64-year-old patient with HFrEF and frequent hospitalizations asks about device therapy. His EF is 32% after 4 months of optimal GDMT. QRS is 160 ms. Which of the following is the best next step?
A. Implantable cardioverter-defibrillator (ICD) only
B. Cardiac resynchronization therapy (CRT)
C. Wearable cardioverter-defibrillator
D. Digoxin for arrhythmia prevention
Answer: B
Explanation: CRT is indicated in symptomatic HFrEF patients with EF ≤35%, on optimized GDMT, and QRS >150 ms. ICD is also beneficial, but CRT is preferred here due to prolonged QRS with ventricular dyssynchrony.
400
Which finding suggests referral for palliative care or advanced heart failure therapies?
A. NYHA IV symptoms controlled on GDMT
B. Unintentional 5% weight loss (cachexia) in 1 year
C. EF of 15% with Optimised GDMT
D. Isolated asymptomatic bradycardia persistently under 40
Answer: B
Explanation: Cardiac cachexia (≥5% unintentional weight loss in 12 months) is a marker of advanced HF and poor prognosis → consider advanced HF team or palliative care.
500
A 28-year-old man presents with chronic pruritus, scaling, and debris in his external ear canals. You suspect seborrheic dermatitis.
Which of the following is the most appropriate management?
A. Otic-specific antifungal drops are required
B. High-potency steroid solutions are contraindicated in the ear
C. Topical antifungals and low- to medium-potency corticosteroids in oil/solution form
D. Oral antifungals are first-line for ear involvement
Answer: C. Topical antifungals and low- to medium-potency corticosteroids in oil/solution form
Explanation: The article highlights that external ear seborrhea can be managed effectively with topical antifungals and corticosteroid oils/solutions; otic-specific preparations are generally unnecessary.
500
Which one of the following statements best describes the US Preventive Services Task Force (USPSTF) recommendation on screening for iron deficiency or iron deficiency anemia?
A. There is convincing evidence that early detection results in improved maternal and fetal outcomes.
B. Patients should not be screened because sufficient evidence exists to suggest screening could result in maternal or fetal harm.
C. Only patients with symptoms of iron deficiency should be screened, which allows for earlier treatment to reduce the risk of poor maternal or fetal outcomes.
D. Physicians should use clinical judgment when deciding to screen patients.
The correct answer is D. The USPSTF reviewed the evidence on screening and supplementation for iron deficiency and iron deficiency anemia during pregnancy to determine whether these services improved the health of pregnant women and their infants. However, not enough evidence was found regarding the effectiveness of screening.3 In the absence of evidence, clinicians should use their judgment and listen to any patient concerns when deciding whether to screen.
500
A 42-year-old woman presents with fever, severe anterior neck pain, and fatigue following an upper respiratory infection. On exam, her thyroid is firm, enlarged, and exquisitely tender to palpation. TSH is suppressed, free T4 is elevated, and ESR is 65 mm/hr. Radioactive iodine uptake is diffusely low.
Which of the following is the most appropriate treatment?
A. Methimazole
B. Propylthiouracil (PTU)
C. Beta blocker and nonsteroidal anti-inflammatory drug (NSAID)
D. Radioactive iodine ablation
5. Subacute thyroiditis → Answer: C. Beta blocker and NSAID
Subacute granulomatous (de Quervain) thyroiditis presents with painful, tender thyroid, elevated ESR, low uptake.
It is due to hormone release, not overproduction → thionamides and RAI are not effective. NSAIDs/corticosteroids control inflammation.
500
A patient with EF 30% on maximized GDMT has HR 80 bpm in sinus rhythm. Next best add-on?
A. Vericiguat
B. Ivabradine
C. Hydralazine + isosorbide dinitrate
D. Digoxin
Answer: B
Explanation: Ivabradine indicated if sinus HR ≥70 despite maximized beta blocker.
500
A 29-year-old woman develops HFrEF (EF 25%) 2 weeks after giving birth. She is stable and breastfeeding. Which of the following is the most appropriate pharmacologic management?
A. Sacubitril-valsartan + carvedilol + spironolactone
B. Lisinopril + metoprolol succinate + furosemide PRN
C. Hydralazine + isosorbide dinitrate + metoprolol succinate
D. Dapagliflozin + carvedilol + spironolactone
Answer: C
Explanation: In peripartum cardiomyopathy, ACEI/ARB/ARNI and SGLT2 inhibitors are contraindicated in breastfeeding. Safe options include beta blockers, hydralazine, nitrates, diuretics, and sometimes MRAs.