Dermatology
Infectious Disease
GI
Rheumatology
100
25 yo male is evaluated for recurrent skin eruption with oval lesions on the chest and upper back, which are occasionally itchy. Lesions began in late spring and worsened over the summer. Medical history is unremarkable; takes no medications.
Vitals normal; exam benign except for skin finding below:
What is the most likely diagnosis?
What is pityriasis (tinea) versicolor?
100
20 yo with no PMH underwent TB screening for her job as a receptionist in an Internal Medicine Clinic. She developed 8 mm of induration on tuberculin skin testing. No symptoms. PE benign.
What is the most appropriate next step in management?
What is no further testing?
100
57 yo male is evaluated for dysphagia - difficulty swallowing meat initially but now having issues swallowing softer foods. Weight loss but no other B symptoms. Long history of GERD on omeprazole. Exam benign. Labs only significant for Hgb 11 with MCV 70.
What is the most appropriate diagnostic test?
What is EGD with biopsy?
100
72 yo male is evaluated for 1 year h/o progressive worsening of bilateral knee pain and stiffness. No locking, popping, or giving way in either knee. Pain in both knees at rest and at night which awakens from sleep. No h/o injury. APAP and ibuprofen improve symptoms temporarily. Exam with bilateral bony hypertrophy and valgus deformity. No warmth, erythema, swelling, or effusion. Anterior drawer sign is negative.
What is the most appropriate diagnostic imaging test to perform?
What is standing plain radiography?
200
43 yo woman is evaluated for painful wheals on upper legs and back x 2 weeks. Individual lesions resolve with bruising in 3-4 days. Associated with joint pain, particularly of the small joints in her hands. Medical history is unremarkable and takes no medications.
Exam: Vitals normal. There are polycyclic edematous plaques on the back and upper legs. Remainder of exam, including joint exam, is normal.
What is the most appropriate management?
What is skin biopsy?
200
72 yo male with COPD and 60 pack year smoking history is hospitalized for dyspnea, night sweats, and productive cough; symptoms initially began 8 months ago along with a 20 lb weight loss. Medications include Symbicort inhaler. PE - vitals normal, diminished breath sounds; remainder exam normal. Sputum gram stain showed many PMNs but no organisms. Sputum acid-fast bacilli stains are positive. An interferon-y release assay is negative. Chest x-ray:
What is the most likely causative organism?
What is Mycobacterium avium complex?
200
52 yo male is evaluated for dysphagia x 3 months with regurgitating undigested food soon after eating solid food, occasional coughing and choking after swallowing, and chronic halitosis. No weight loss or chest pain. Drinks 2 beers/week and does not smoke. Exam, including vital signs is unremarkable. BMI 25
What is the most appropriate diagnostic test to perform next?
What is Barium esophagography?
200
25 yo male undergoes new patient evaluation. PMH of Marfan syndrome and inguinal hernia s/p repair. Father also has Marfan syndrome. He takes no medications. Exam with normal vitals, BMI 22. Tall stature, pectus excavatum, high arches palate, scoliosis, and bilateral pes planus seen.
What is the most appropriate periodic imaging test for this patient?
What is echocardiography?
300
25 yo woman is evaluated for pruritic lesions on the legs and in the groin area that first appeared several months ago. The patient is otherwise in good health and takes no medications. On physical exam, vitals are normal. Skin findings are shown.
What is the most likely diagnosis?
What is molluscum contagiosum infection?
histoplasmosis
Cryptococcosis
300
29 yo male with non-Hodgkin lymphoma is evaluated for 2 day h/o diarrhea and crampy abdominal pain. he is currently undergoing chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. On exam, temp 38.0; other vitals normal. Abdomen is non-distended, bowel sounds presents, mild diffuse tenderness to palpitation. CBC and CMP are normal. Rapid molecular gastrointestinal studies of the stool identifies Campylobacter.
What is the most appropriate empiric treatment for this patient?
What is Azithromycin?
300
55 yo woman is evaluated after screening colonoscopy showed three polyps at the rectosigmoid junction. The three polyps were 3 mm, 5 mm, and 6 mm in size. All three polyps were completely excised and pathology showed them to be hyperplastic. Family history is significant for colon cancer diagnosed in her paternal grandfather at age 80 years.
Exam benign.
When should this patient have a repeat colonoscopy?
What is 10 years?
300
74 yo male is evaluated for a 2 month h/o progressive worsening bilateral shoulder and hip pain. He has difficulty rising from a chair and reaching overhead because of pain. Also having fatigue, malaise, and 10 lb weight loss. Takes APAP w/o relief. Exam with temp 37.9 but other vitals normal; markedly limited ROM of shoulders and hips d/t pain; strength cannot be adequately assessed. CBC, LFTs, BMP, TSH normal. ESR elevated at 68.
What is the most appropriate treatment?
What is low dose (~15 mg/d) prednisone?
400
58 yo woman is evaluated for dark brown pigmentation on her thumb nail. She noticed it was getting darker and wider. She is otherwise healthy and takes no medications. On physical exam, vital signs are normal. The other nails are uninvolved. Remainder of exam is normal. Nail findings are shown:
What is the most likely diagnosis?
What is melanonychia?
Hutchinson sign -->pigmented macule on nailfold
400
24 yo woman is hospitalized for worsening SOB, fatigue, productive cough, and pleuritic chest pain x 2 week. She also c/o fevers and chills x 1 month. PMH of RA on methotrexate, etanercept, and low-dose prednisone. Lives in northern Georgia. On exam, temp 39.2, BP 125/60, HR 128, RR 26. Bilateral crackles are heard in the lungs. Abdominal exam with hepatosplenomegaly. Minimal synovitis present in wrist and MCP joints bilaterally.
Labs: Hgb 7.5, WBC 4.5, platelet 50k
CXR with bilateral reticulonodular infiltrates
Blood cx negative. Peripheral smear below:
Histoplasma urinary antigen assay is positive.
What is the most appropriate treatment?
What is liposomal amphotericin B?
400
44 yo female with intermittent diarrhea and weight loss. History of osteoporosis on alendronate therapy. Sister with celiac disease.
Lab evaluation:
total IgA <500
tissue transglutaminase IgA 0
IgG level 800
Next most appropriate test?
What is Anti-deamidated gliadin peptide IgG antibody measurement?
400
26 yo woman seeks preconception counseling. She has a 3 year h/o rheumatoid arthritis. Medications are methotrexate, hydroxychloroquine, low-dose prednisone, and folic acid. Currently her disease is under excellent control. On exam, vital signs are normal; no warmth, erythema, swelling, or tenderness of the joints.
What is the most appropriate next step?
What is discontinue methotrexate?
500
27 yo male with PMH of celiac disease diagnosed 7 months ago with c/o pruritic rash on elbows and knees x 3 years. Previously had diarrhea but resolved with gluten free diet. No other symptoms. Lab work with tissue transglutaminase IgA level of 2 (normal 0-3).
Skin biopsy consistent with dermatitis herpetiformis.
What additional lab work should be done before starting this patient on appropriate treatment?
What is measurement of glucose-6-phosphate dehydrogenase activity?
500
25 yo male is being evaluated for ongoing, frequent diarrhea (up to 10x/day). Diagnosed with HIV infection and frequent diarrhea caused by Cryptosporidium. Despite adherence to medications (including antiretrovirals and loperamide), his diarrhea continues. He plans to be a swimming instructor at a local pool this summer. On exam, temp is 37.5 and other vitals signs normal. Bowel sounds are present with mild pain to palpation but no guarding. Two weeks ago, his CD4 count was 10 and HIV viral load was 250,000.
What is the most appropriate treatment?
What is Nitazoxanide?
500
24 yo male is evaluated in the ED for 2 weeks of worsening bloody diarrhea with up to 10 BMs/day. He also reports increasing lower abdominal pain and distension. He has extensive ulcerative colitis x 5 years. Medications include infliximab and azathioprine. On exam, the patient appears ill. Temp 38.3, BP 90/60, HR 110; other vitals normal. Abdomen is distended with guarding; bowel sounds hypoactive. Labs show Hgb 10, WBC 16, and BUN of 26. Abdominal x-ray is shown.
What is the most appropriate next step in management?
What is colectomy?
500
61 yo female is evaluated for 10 month h/o generalized weakness. No pain or myalgia. PMH of HPLD treated with simvastatin for 3 years. Exam with normal vitals, symmetric weakness of arm and thigh muscles with slightly reduced grip and power of finger flexors. No muscle tenderness, rash, skin thickening, or digital ulcers. Reflexes normal.
Labs notable for normal CBC, ESR 23, CK 365. CXR normal. EMG and nerve conduction studies show myopathic changes in the proximal and distal muscles of the extremities as well as some neurogenic changes.
What is the most likely diagnosis?
What is inclusion body myositis?