DERM
ID
Neurology
Cardiology
100
A 40 yo man is evaluated for a new skin rash of 10 days' duration. The rash appeared abruptly and is not tender or pruritic. The patient has poorly controlled T2DM. His current medications include metformin and glyburide. Family history is unremarkable.
On exam, vital signs are normal. BMI is 25. There are several grouped 1- to 5-mm yellow papules on extensor surfaces of extremities and buttocks. Some of the papules have surrounding erythema. The remainder of the examination is normal.
Laboratory studies show a hba1c of 12.
What lipid disorder is most likely associated?
What is hypertriglyceridemia?
100
A 45 yo man is evaluated in the ICU for continued daily fevers. He was hospitalized 6 days ago after 4 days of left-sided pleuritic chest pain, fever, and cough productive of yellow sputum with occasional blood streaks. He has a history of injection drug use and last injected heroin 7 days ago. CXR obtained at admission revealed a left lower lobe infiltrate. A sputum Gram stain showed gram-positive cocci in clusters. Empiric antibiotic therapy including vancomycin was begun. Sputum and two sets of blood cultures taken at admission grew MRSA, and antibiotic therapy was de-escalated to vancomycin monotherapy on hospital day 3. His only medication is vancomycin.
On exam, temperature is 38.5 °C (101.3 °F), blood pressure is 94/68 mm Hg, pulse rate is 118/min, and respiration rate is 28/min. Oxygen saturation is 92% breathing 6 L/min oxygen by nasal cannula. Decreased breath sounds are heard at the left lung base.
A vancomycin trough measurement is therapeutic at 15 µg/mL. Repeat blood cultures from hospital day 3 were negative at 72 hours. Repeat sputum Gram stain shows 3+ leukocytes and 1+ gram-positive cocci.
A TTE was negative for valvular vegetations. A repeat chest radiograph is shown.
Which of the following is the most appropriate management at this time?
What is thoracentesis?
100
A 51 yo woman is evaluated in the hospital after having an ischemic stroke. She has hypertension treated with candesartan and dyslipidemia treated with rosuvastatin. The patient is otherwise in good health.
On exam, blood pressure is 168/76 mm Hg. A right carotid bruit is heard. Left-sided weakness (including the face) is present.
An electrocardiogram shows sinus rhythm. A CT scan of the head shows a hypodensity in the right parietal lobe. A carotid duplex ultrasound shows greater than 80% stenosis in the right internal carotid artery. A magnetic resonance angiogram of the neck without contrast confirms greater than 80% stenosis.
Which of the following is the most appropriate next step in management?
What is carotid endarterectomy?
100
An 80-year-old man is evaluated for dizziness.
Which of the following abnormalities is demonstrated on this patient's electrocardiogram?
What is 1st degree AV block?
200
A 62 yo male was admitted to the hospital following a MVA. He underwent a craniotomy for treatment of intracranial hemorrhage following which he was started on carbamazepine. On postoperative day 19, the patient was noted to have a rash on his chest, arms, proximal legs, and buttocks, as well as redness on his face. The next day he had diffuse papules and macules on his trunk and proximal extremities, tachycardia, and hypotension. Hypotension and tachycardia responded to fluid resuscitation.
On physical examination, vital signs are normal. The patient is lethargic and confused. Skin findings are shown.
He has prominent swelling in his face. There is minimal skin erosion and no sloughing when shearing pressure is applied with the examiner's finger. There are a few erosions in the oropharynx, but no eye or genital involvement. Generalized lymphadenopathy is present.
Which of the following is the most likely cause of this patient's clinical presentation?
What is DRESS syndrome?
200
A 33 yo woman is evaluated in the emergency department in January with a 3-day history of fever, headache, stiff neck, and photophobia. She was previously well, and medical history is negative for recent travel; she takes no medications.
On physical examination, temperature is 38.5 °C (101.3 °F), blood pressure is 136/86 mm Hg, pulse rate is 100/min, and respiration rate is 18/min. The general medical examination is unremarkable. On neurologic examination, she shows photophobia, and a nondilated funduscopic examination shows no papilledema. The remainder of the examination is nonfocal.
CSF studies: WBC 324 with 60% neutrophils, protein 125, glucose 56. Gram stain negative and culture is pending.
What is the most likely cause out of the following 4 viruses: enterovirus, HSV2, mumps virus, or west nile virus?
What is HSV2?
200
A 68-year-old man is evaluated for increasing cognitive deficits, walking difficulties with occasional falls, and depression. He has become more forgetful over the past 5 years, has a 1-year history of shuffling his feet when walking, awakens three to four times each night to urinate (sometimes becoming incontinent), and generally has become more withdrawn and irritable. He also has difficulty remembering names and appointments, and his wife now manages their finances and his medications, which consist of hydrochlorothiazide for hypertension and metformin for type 2 diabetes mellitus.
On physical examination, vital signs are normal. The patient is slow to rise from a seated position. Gait examination reveals slow, short steps and difficulty turning. He scores 22/30 (normal, ≥24) on the Mini–Mental State Examination, losing four points in the orientation sections, one point in the registration section, and three points in the attention/calculation section.
An MRI of the brain shows moderate generalized atrophy and prominent cerebral ventricles.
Which of the following is most likely to be diagnostic in this patient?
What is lumbar puncture?
200
A 56-year-old man is evaluated for chest pain that occurs when he walks up the four flights of stairs leading to his apartment. Exercise stress testing is performed.
What is the most likely diagnosis?
What is ischemic CAD?
300
A 36 yo woman is evaluated for a 3-day history of pruritic rash on the arms, legs, and face. She is very symptomatic and cannot concentrate on her tasks or sleep due to the intense itching. She is a summer camp counselor. Medical history is otherwise unremarkable, and she takes no medications.
On physical examination, vital signs are normal. Representative skin findings on the leg are shown.
The remainder of the examination is normal.
Which of the following is the most appropriate treatment?
What is a 21 day taper of prednisone?
300
A 39-year yo is hospitalized for tongue pain, abdominal pain, increased weakness, and a 2-week history of malaise and fever. He reports being in good health previously. He lives in the Ohio River Valley; approximately 1 month ago, he moved his antique business from a barn to an old store in the area, after which he developed “flu-like” symptoms lasting 2 to 3 days. He says that the barn was dusty and had pigeons and bats in the rafters. He also has rheumatoid arthritis. Medications are methotrexate and prednisone.
On exam, the patient is lethargic. Temperature is 39.7 °C (103.5 °F), blood pressure is 90/50 mm Hg, pulse rate is 128/min, and respiration rate is 24/min. A shallow ulceration is visible on the right buccal mucosa and left lateral tongue. His neck is supple. Lungs are clear to percussion and auscultation. There is moderate hepatosplenomegaly.
Labs: Hgb 9, WBC 10.5, platelet 90k. CXR unremarkable.
What is the most appropriate treatment?
What is liposomal amphotericin B?
300
A 58 yo man is evaluated in the ED for abrupt onset of a right retro-orbital throbbing headache and diplopia that have been present for the past 12 hours. The patient also reports occasional chills. He had a dental procedure 6 days ago. His only medication is hydrocodone.
On exam, temperature is 38.9 °C (102.0 °F), blood pressure is 138/90 mm Hg, and pulse rate is 88/min; BMI is 28. Right proptosis with lid edema is noted. The right pupil is dilated and sluggishly reactive. Oculomotor nerve (cranial nerve III), trochlear nerve (cranial nerve IV), and abducens nerve (cranial nerve VI) palsies are present on the right. Other findings from the physical examination are unremarkable.
Labs show ESR 60, WBC 13,400 with 85% PMNs.
Which of the following is the most likely diagnosis?
What is a cavernous sinus thrombosis?
300
A 68-year-old man is evaluated during a routine examination. He is asymptomatic. Medical history is significant for hypertension and hyperlipidemia. He has a 50-pack-year smoking history but quit smoking at age 45 years. Medications are low-dose aspirin, atorvastatin, and amlodipine.
On physical examination, vital signs are normal.
An abdominal aortic duplex ultrasound shows an abdominal aortic aneurysm with a maximum diameter of 3.5 cm.
Which of the following is the most appropriate management?
What is repeat abdominal US in 2-3 years?
400
A 62 yo man is evaluated for a 4-month history of itching all over his body. He has no fatigue, weight loss, or night sweats. His appetite is good. Medical history is significant for hypertension treated with hydrochlorothiazide. He has no risk factors for HIV infection.
On exam, vital signs are normal. There are a few scattered excoriations on the arms and lower legs. There are no other significant skin findings and no lymphadenopathy.
Labs including CBC, ESR, LFTS, BMP, TSH are normal.
What is the most appropriate initial management?
What is discontinue HCTZ?
400
An 18-year-old man is evaluated for a 4-day history of frequent, large-volume diarrhea, with associated abdominal cramping, emesis, fever, and nausea. He is a lifeguard at a freshwater municipal pool, and several other swimmers who use the pool have recently developed similar symptoms.
On physical examination, temperature is 37.5 °C (99.5 °F); the vital signs are otherwise normal. On abdominal examination, bowel sounds are present, palpation elicits minimal tenderness, and no guarding or rebound is noted.
Modified acid-fast staining of the stool reveals oocysts that are about 5 microns in diameter.
Which of the following is the most likely cause of this patient's diarrhea?
What is cryptosporidium?
400
A 33-year-old man is evaluated in the emergency department for a 10-week history of worsening confusion, memory loss, and difficulty speaking. He has become progressively more disorganized at work and can no longer complete routine tasks. His medical history is otherwise unremarkable, and he takes no medication.
On physical examination, vital signs are normal. The patient exhibits decreased attention, is able to follow only simple commands, and is oriented only to person. Speech is dysarthric. Intermittent myoclonic jerking of varying limbs also is noted.
Labs: Na 128 but otherwise unremarkable including CBC, CMP, TSH, T4.
An urgent electroencephalogram shows evidence of nonconvulsive status epilepticus with focal seizures arising independently from both temporal lobes. A contrast-enhanced brain MRI is normal.
Which of the following is the most likely diagnosis?
What is autoimmune limbic encephalitis?
400
A 26-year-old woman seeks preconception counseling. She has a history of mitral stenosis and underwent mitral valve replacement with a tilting-disc mechanical prosthesis 5 years ago. She is asymptomatic. Medications are warfarin, 4 mg/d, and low-dose aspirin.
On physical examination, a normal mechanical S1 and normal S2 are appreciated. The remainder of the examination is unremarkable.
Laboratory studies reveal an INR of 3.0 (therapeutic target, 3.0).
An electrocardiogram demonstrates normal sinus rhythm.
In addition to continuing low-dose aspirin, which of the following is the most appropriate anticoagulation regimen for this patient during the first trimester?
What is continue INR adjusted warfarin?
500
A 60 yo woman is evaluated for easy bruising and bleeding after minor trauma, and a rash around her eyes. Medical history is unremarkable, and she takes no medications.
On exam, vital signs are normal. The patient has several ecchymoses located primarily on her arms and legs. Lesions around her eyes are shown.
Hepatomegaly is present. The remainder of the exam is unremarkable. Urinalysis demonstrates 4+ proteinuria but is otherwise unremarkable.
Which of the following is the most likely diagnosis?
What is amyloidosis?
500
A 25-year-old woman returns for counseling regarding results of HIV testing completed during a recent routine health maintenance visit. She reports no known exposure or risk factors for HIV infection. Medical history is unremarkable, and she takes no medications.
Laboratory studies show a reactive HIV-1/2 antigen/antibody combination immunoassay, a negative HIV-1/2 antibody differentiation immunoassay, and no RNA detected on HIV-1 RNA nucleic acid amplification testing.
Which of the following is the most appropriate management?
What is tell the patient that she does not have HIV?
500
A 35-year-old man is evaluated for a 3-year history of epilepsy. Seizures typically occur twice monthly, last 2 minutes, and are characterized by staring, lip smacking, and confusion; approximately once every 6 months, the patient experiences a whole-body convulsion marked by incontinence and prolonged confusion for several hours. Treatment with oxcarbazepine and lamotrigine, although initially reducing seizure frequency, has been largely ineffective. He no longer drives or works because of the seizures. He also has migraines, which are well controlled by sumatriptan.
On physical examination, vital signs are normal. All other physical examination findings, including those from a neurologic examination, are unremarkable.
Results of routine outpatient electroencephalography (EEG) are normal. An MRI of the brain shows right hippocampal atrophy.
Which of the following is the most appropriate next step in management?
What is a video EEG?
500
A 50-year-old man was diagnosed with hypertrophic cardiomyopathy following an episode of syncope. An implantable cardioverter-defibrillator was placed, and metoprolol was initiated. Genetic testing revealed a mutation of the β-myosin heavy-chain gene associated with hypertrophic cardiomyopathy. Medical history is otherwise unremarkable. The patient has a 16-year-old daughter who is asymptomatic.
Which of the following is the most appropriate management of this patient's daughter?
What is genetic counseling and testing?