Dr's Dilemma Study #1

Gastroenterology & Hepatology

100

A 45-year-old man presents with a chronic nonproductive cough that worsens after heavy meals and is associated with occasional heartburn. A chest radiograph is normal. What is the most appropriate management?

Empiric trial of a PPI

200

A patient with chronic liver disease and a history of heavy alcohol use is hospitalized for pneumonia and becomes restless and agitated. What is the treatment of choice for these symptoms?

Benzodiazepines (Lorazepam)

300

This diagnosis requires recurrent abdominal pain at least 1 day a week for 3 months associated with a change in stool frequency or form.

Irritable Bowel Syndrome (IBS)

400

This clinical entity is an autoimmune condition of the pancreas often associated with IgG4-related diseases, such as retroperitoneal fibrosis and sclerosing cholangitis.

Autoimmune Pancreatitis

500

In candidates for kidney transplantation with this specific viral infection, treatment can be safely timed either before or after the transplant.

 

Hepatitis C (HCV)

Cardiology

100

A 49-year-old asymptomatic man with low calculated cardiovascular risk requests cardiac screening. According to High Value Care, what is the most appropriate next step?

No further testing

200

A sedentary 67-year-old man with type 2 diabetes and a family history of early MI requires this intensity of statin therapy for primary prevention.

High-intensity statin

300

To reduce the risk of future stroke, this intensity of statin therapy is recommended for patients who have recently experienced a transient ischemic attack (TIA).

High-intensity statin

400

A 62-year-old man experiences syncope while playing basketball. Examination reveals a late-peaking grade 4/6 systolic murmur at the right upper sternal border. What is the most likely diagnosis?

Aortic Stenosis

500

According to MKSAP 19, this intensity of statin therapy should be initiated in adults aged 40 to 75 years with diabetes mellitus and a 10-year ASCVD risk of less than 7.5%

Moderate-intensity statin

Neurology

100

• A 52-year-old man presents with weakness in dorsiflexion and eversion of the left foot. EMG shows slow velocity of nerve conduction around the fibular neck. What is the most likely diagnosis?

Peroneal mononeuropathy

200

• 200: A 79-year-old man presents with abrupt vertigo and vomiting. HINTS examination is positive only for the presence of vertical skew. What is the most appropriate next diagnostic step?

MRI of the brain

300

• 300: This prion-related disorder presents with rapidly progressive dementia and myoclonus, and the real-time quaking-induced conversion assay (RT-QuIC) is the most sensitive diagnostic test.

Creutzfeldt-Jakob disease

400

• 400: An 82-year-old woman with an 18-month history of progressive memory loss has an MRI showing significant hippocampal atrophy bilaterally. What is the most likely diagnosis?

Alzheimer disease

500

• 500: In patients with multiple sclerosis and labored gait, this potassium channel antagonist is most likely to improve their walking ability.

Dalfampridine

Nephrology

100

• 100: A 54-year-old man taking metformin and amlodipine for diabetes and hypertension presents with new bilateral lower extremity pitting edema. What is the most likely cause of the edema?

Amlodipine

200

• 200: To prevent contrast-associated nephropathy in a high-risk patient with an eGFR of 25 mL/min/1.73 m², what is the most appropriate periprocedure intravenous measure?

Intravenous 0.9% saline

300

• 300: This specific type of renal tubular acidosis (RTA) is characterized by a normal anion gap metabolic acidosis, hypokalemia, glycosuria, and renal phosphate wasting.

Type 2 (proximal) RTA

400

• 400: Recommending discontinuation of routine breast cancer screening is appropriate for a 75-year-old woman on dialysis due to this specific clinical factor.

Limited life expectancy

500

• 500: This clinical syndrome, identified by new-onset hypertension during pregnancy with a BP >160/110 mm Hg and end-organ damage, requires magnesium sulfate and immediate delivery.

Severe Preeclampsia

Dermatology

100

• 100 Points: A 78-year-old woman presents with a shallow, exudative, and nonhealing ulcer located above the right medial malleolus, surrounded by hyperpigmentation and varicosities. What is the most appropriate next step in management?

Compression therapy (or compression stockings)

200

• 200 Points: An 81-year-old woman with a history of extensive sun exposure presents with dark red, painless patches on her forearms that appear after minor trauma and resolve without treatment. What is the most likely diagnosis?

Actinic purpura (or Senile purpura)

300

• 300 Points: A 67-year-old woman with end-stage kidney disease on hemodialysis presents with severely painful, progressive, and necrotic ulcers on her abdomen and thighs. A skin biopsy shows calcification in the media of small-to-medium-sized dermal arterioles. What is the most likely diagnosis?

Calciphylaxis (or Calcific uremic arteriolopathy)

400

• 400 Points: A 28-year-old woman is hospitalized with fever and widespread skin sloughing involving more than 30% of her body surface area, occurring two weeks after starting trimethoprim-sulfamethoxazole. What is the most likely diagnosis?

Toxic epidermal necrolysis (TEN)

500

• 500 Points: In patients who have received a kidney transplant and are on chronic immunosuppressive therapy, this is the recommended frequency for clinical skin cancer screening examinations.

Annual (or every year)