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A 41-year-old woman presented to the emergency department with leg ulcers and ecchymosis on her ears that began to develop one month prior. The leg ulcers began as painful, fluid-filled blisters and evolved into ulcers with a black crust. The lesions had appeared and resolved several times over the previous three years, but she did not seek medical attention. She took prednisone intermittently for psoriasis and had a long history of cocaine abuse

The answer is A: levamisole-induced vasculitis. A skin biopsy showed a leukocytoclastic vasculitis consistent with levamisole-induced vasculitis. Levamisole is an antihelminth drug that was used as an antineoplastic agent, but adverse effects such as agranulocytosis and an ulcer-causing vasculopathy have now limited its use to veterinary medicine. It is commonly used to lace cocaine because of its psychoactive effects. It is estimated that 70% of cocaine in the United States contains levamisole.

A 14-year-old boy presented with a tender red papule on his finger. He first noticed it two months earlier. It bled several times, especially when rubbed by his baseball mitt. He had no medical problems or allergies, and he was not taking any medications. He had no other similar skin lesions, and the review of systems was negative for bleeding problems, easy bruising, and frequent infections. Physical examination revealed a solitary bright-red papule on the distal lateral portion of his left fifth finger (Figure 1). On dermoscopy, the lesion was homogeneously red and surrounded by a white collarette of scale (Figure 2). There was no evidence of a pigment network, pigment globules, or dotted vessels.

The answer is C: pyogenic granuloma. Pyogenic granulomas are more accurately described as lobular capillary hemangiomas because the lesions are not purulent or granulomatous. They are benign vascular tumors that typically evolve over weeks to months, rarely growing larger than 1 cm. They can occur at any age but are most common in children and young adults. Most are solitary, and they are often attributed to trauma. They are also associated with several medications, including isotretinoin, capecitabine (Xeloda), and indinavir (Crixivan).1 On dermoscopy, 92% of pyogenic granulomas have a homogeneous reddish area and 85% have a white collarette2; the combination of these two findings was found to be 100% specific for pyogenic granulomas

A 28-year-old woman presented with a fleshy, erythematous eruption with an annular configuration on her elbow that began 10 months earlier. The lesion was asymptomatic and had slowly increased in size. Her medical history was unremarkable, and she had no history of trauma. Physical examination revealed erythematous, annular, nonscaly plaques with elevated and indurated borders (Figure 1). The plaques were composed of small fleshcolored papules and were localized to the right elbow.

The answer is A: granuloma annulare. Granuloma annulare is an idiopathic papular dermatosis. There are several subtypes of granuloma annulare, including localized, generalized, subcutaneous, arcuate, and perforating. This patient had the typical characteristics of localized granuloma annulare, with asymptomatic, firm, erythematous, violaceous, brown or flesh-colored, nonscaly papules. These plaques occur in an annular configuration and usually involve the extensor surfaces of distal extremities.1 As the condition progresses, some central involution occurs.

A 50-year-old man presented with swelling in his right elbow that began 10 days earlier. He had no history of injury to the arm, but he often rested his elbows on his desk at work. The elbow was not painful, and there was no arthralgia. He did not have a fever. His medical history was significant for chronic glomerulonephritis. He had been on hemodialysis for one year. Physical examination revealed a spherical, fluctuant swelling over the posterior portion of the right elbow (Figure 1). There was no redness or tenderness to palpation, and range of motion was normal

The answer is B: olecranon bursitis. This is a relatively common condition that most often affects men between 30 and 60 years of age.1 The classic finding is posterior elbow swelling that is fluctuant and clearly demarcated. It is often described as a “goose egg” over the olecranon process. The patient may report pain in the area of fluctuance, but the swelling is often painless, especially in no inflammatory, aseptic bursitis. The onset of olecranon bursitis may be sudden if it is secondary to infection or acute trauma. Range of motion in the elbow is usually normal, but there may be a slight limitation of the end range of flexion because of pain or bursal thickening.

A 16-year-old boy presented with swelling and erythema on the scalp that had worsened over the previous four weeks. Three to four months prior to the development of the swelling, he noted a red circular rash on the same area of his scalp. The rash resolved with application of an over-the-counter antifungal cream. After resolution of the rash, the swelling and erythema began, and the area became painful. He did not have a fever or chills, and there was no discharge from the site. The patient was otherwise healthy and active, and was a member of his school’s wrestling team. Examination of the scalp revealed an area of erythema and induration (Figure 1). The scalp was tender to palpation but not fluctuant. There was no cervical or occipital lymphadenopathy. Ultrasonography showed no fluid collection in the lesion

The answer is B: kerion. Kerions are the result of an inflammatory response to an invasive fungal infection of the hair follicles and scalp. The fungus is usually a dermatophyte such as Trichophyton verrucosum or Trichophyton mentagrophytes.1 Presentation ranges from a raised, spongy lesion to an extremely painful indurated lesion.1 Kerions are commonly mistaken for a staphylococcal abscess, but the absence of fever and fluctuance can help to distinguish them from a bacterial infection. The initial rash is red and circular, which is typical of tinea capitis, a Trichophyton infection that often occurs in wrestlers.

A 43-year-old man presented with a one week history of multiple weeping papules on his penis and scrotum. The lesions were not painful, and he had no other symptoms. He had no relevant medical history, including human immunodeficiency virus infection, but he had had unprotected sexual encounters with multiple women over the previous three months. Physical examination revealed more than 50 firm, moist, pink papules on the scrotum and penile shaft (Figure 1). The lesions were non tender, smooth, and flat-topped. The patient had bilateral inguinal lymphadenopathy. The remainder of the examination was normal. A rapid human immunodeficiency virus infection test was negative. A biopsy was performed for further evaluation.

The answer is C: condyloma latum. Condyloma latum is a highly contagious cutaneous form of secondary syphilis caused by the spirochete Treponema pallidum. The hypopigmented lesions are painless, firm, moist, flat-topped, smooth, pink-to-reddish papules. They generally appear on mucocutaneous sites but may also occur in moist intertriginous regions.

A 31-year-old man presented with a lesion on his tongue that he first noticed six months earlier as small red dots. His dentist thought it was caused by irritation from his dental bridge. It was painless, but he had some bleeding after brushing his teeth and tongue. He had not received any medical care for the lesion. His medical history was significant for hypertension treated with hydrochlorothiazide, and a recent clavicle fracture after a motorcycle accident. He never smoked, but he used one can per week of chewing tobacco for one year. He quit five years before presentation. He drank less than three alcoholic beverages per week. A review of systems was negative. He was not using any new toothpastes or mouthwashes. On physical examination, he was well appearing and afebrile, but overweight. His tongue had a large lateral fungating, whitish, exophytic lesion with anterior fissuring of the entire left side of the tongue (Figure 1). There was no tenderness or ulceration. He had a slight speech impediment secondary to mouth fullness but no difficulty swallowing. There were no palpable cervical lymph nodes.

The answer is D: squamous cell carcinoma, which required urgent biopsy and surgical excision. The characteristic features of oral squamous cell carcinoma include lateral location, fungating appearance, whitish color, and central ulceration. The history of tobacco use lasting for one year also makes cancer more likely. The history suggests that the lesion began as erythroplakia, which was thought to be related to his dental work. He never received follow-up because of an overseas deployment.

50-year-old woman presented for a routine catheter change. The patient was wheelchairbound because of a history of transverse myelitis. She had urinary incontinence and was dependent on chronic urinary catheterization. The patient had no symptoms beyond discolored urine. There was no dysuria or blood around the catheter. She had no history of trauma to the catheter. On examination, she was afebrile and well appearing, but the urine in her catheter bag looked purple (Figure 1). She did not know how long her urine had been discolored. Urinalysis showed leukocytes and microscopic hematuria. The urine was sent for culture.

Based on the patient’s history and physical examination findings, which one of the following is the most likely diagnosis? A. Excessive blackberry or beet consumption B. Familial benign hypercalcemia. C. Isoniazid use. D. Nitrofurantoin use. E. Purple urine bag syndrome

The answer is E: purple urine bag syndrome. The urine’s purple shade (which leads to staining of the catheter’s bag and collecting tube) is caused by the accumulation of tryptophan metabolites. Dietary tryptophan is metabolized by gastrointestinal bacteria, which results in indole production. Indole is converted to indole sulfate in the liver. Indole sulfate in turn is acted on by bacterial enzymes, resulting in the production of indirubin (which is red) and indigo (which is blue). These metabolites concentrate in the urine, and the combination of red and blue pigments produces the purple discoloration.1

. While performing a digital rectal examination of the prostate on a 67-year-old patient with diabetes mellitus, you note the finding sshown below. The patient confirms that the area has been itchy for some time but he has been reluctant to seek care. He has tried a variety of over-the-counter moisturizing lotions with limited success. Of the following topical treatments, which one is most likely to provide significant improvement? A) Antibacterial ointment B) Antifungal cream C) Antiviral ointment D) Corticosteroid cream E) Rubbing alcohol

ANSWER: D Plaque psoriasis is characterized by silvery-white scales adhered to well demarcated erythematous papules and/or plaques, typically on the scalp, extensor surfaces of the elbows and knees, or buttocks, and often extending to other exposed areas of the body. When limited to skin folds or the genital region, psoriasis can easily be confused with other conditions such as bacterial or fungal intertrigo. The lesions in this variant, known asflexural or inverse psoriasis, usually appear smooth and moist to the point of maceration, often with minimal to no scaling. Affected patients may report significant pruritus and an unpleasant odor in the involved area. Evidence-based data for treatment options is limited but supports topical application of mild corticosteroid creams, vitamin D preparations, or coal tar products. Medium- or higher-potency corticosteroid creams are best avoided, as the affected areas are either delicate, occlusive, or both, and susceptible to corticosteroid-induced atrophy.

A 58-year-old female sees you 3 days after she was clearing her sinuses with steam and burned her face. She developed small patches of dry, painful erythema without blisters on her chin, the left side of her mouth, and her left cheek. She had no difficulty breathing. She applied cold water to the burn and decided to self-treat initially but came in because she was experiencing some pain. Her injury is shown below. She received Td vaccine last year. In addition to analgesics for pain control, which one of the following would be appropriate? A) Cleaning the wound with povidone iodine (Betadine) B) Covering the wound with an occlusive dressing C) Applying aloe D) Applying hydrocortisone 1% cream E) Starting broad-spectrum antibiotics

ANSWER: C Burns can be classified based on the depth and area of the burn. Only superficial and deepthickness burns are included in the calculation of the burn area. Minor burns cover less than 10% of the body for patients 10–50 years old and 50 years old. Any burn involving the face, hands, or a major joint may be more complicated and should be promptly evaluated. 57 Superficial burns involve the epidermis and appear as painful patches of erythema and dry skin. Superficial partial-thickness burns involve part of the dermis and all of the epidermis. They cause painful blanching erythema with small blisters and weeping skin. This patient has a superficial burn but in a high-risk area. Immediate management of a minor burn may include cooling with water but should not involve ice water as this may lead to further injury (SOR C). All wounds should be cleaned with sterile water but not a cleansing agent such as povidone iodine (SOR C). The skin should remain intact if possible and small blisters should not be debrided. Topical corticosteroids should be avoided, as they do not reduce inflammation. Superficial burns do not require antibiotics or wound dressings. They can be treated with aloe vera, lotion, antibiotic ointment, or honey (SOR B). There is evidence that these treatments promote skin repair and prevent drying. Aloe vera may also decrease pain. There is also evidence that honey heals partial thickness wounds more quickly than conventional dressings.

. A 44-year-old male is being evaluated for a 3month history of cough. His chest radiograph is shown below. Which one of the following abnormalities is seen on the radiograph?

A) Bronchiectasis B) A pulmonary cavitary lesion C) A hiatal hernia D) A thoracic aortic aneurysm E) Pericardial effusion

ANSWER: D Most thoracic aortic aneurysms are asymptomatic, but symptoms can be produced by distortion, compression, or erosion of adjacent structures by the aneurysm. Resulting symptoms include cough, hemoptysis, chest pain, hoarseness, and dysphagia. A chest radiograph showing widening of the mediastinum and prominence of the aortic arch and thoracic aorta suggests a thoracic aortic aneurysm. Contrast-enhanced CT, MRI, and aortography are sensitive and specific tests for assessment of thoracic aneurysms and involvement of branch vessels. Echocardiography (especially transesophageal) helps in further evaluating the proximal ascending and descending thoracic aorta. A pulmonary cavitary lesion, seen in pulmonary tuberculosis, is typically located in the upper lung lobe and is often associated with mediastinal lymphadenopathy. The presence of a retrocardiac gas-filled structure suggests the presence of a hiatal hernia. The chest radiograph may show a “water bottle” configuration of the cardiac silhouette in a patient with pericardial effusion (SOR C).

229. A 58-year-old male sees you for a physical examination so he can receive a commercial driver’s license. On examination you note a 2cm hard, nodular protuberance on his hard palate, shown below. He believes that this has been there for some time, but says it seems to be enlarging. The most likely diagnosis is

A) osteoid osteoma B) torus palatinus C) mucocele D) osteosarcoma E) calcinosis cutis

ANSWER: B Torus palatinus is an exostosis, or benign bony overgrowth. It is usually located on the midline of the hard palate, and occurs in 12%–27% of the population. Since these are usually not symptomatic many people are not even aware of their presence. Torus palatinus is easily diagnosed from the history and physical examination. Imaging studies are usually unnecessary. These growths typically enlarge gradually throughout life but have no potential for malignant transformation.

. A 31-year-old male has experienced multiple outbreaks of the rash shown below. He was initially told that the rash was due to an allergy to an antibiotic prescribed for a suspected dental abscess, but avoiding all medications has not prevented the recurrences. Which one of the following oral medications has been shown to reduce the severity, duration, and recurrences of this type of rash? A) Acyclovir B) Cetirizine (Zyrtec) C) Prednisone D) Ranitidine (Zantac) E) Terbinafine (Lamisil)

ANSWER: A Sharply demarcated lesions with raised borders surrounding a paler region containing a darker center (target or iris lesions) are characteristic of erythema multiforme. The lesions of erythema multiforme usually appear on the distal extremities, are often accompanied by burning and pruritus, and may progress centrally. Usually the rash resolves spontaneously within 4–6 weeks but some patients experience frequent recurrences. Erythema multiforme results from a hypersensitivity reaction to any number of medications, vaccine preparations, or infections, the most commonly identified being herpes simplex virus (HSV) infection. In a minority of those harboring HSV infection, recurrent outbreaks of erythema multiforme are often associated with HSV reactivations, even those that may occur unnoticed. Continuous antiviral treatment using acyclovir, valacyclovir, or famciclovir has been shown to be effective in reducing or eliminating the frequency of recurrent outbreaks in these patients (SOR A). In patients not helped by daily antiviral suppressive therapy, treatment with dapsone, azathioprine, cyclosporine, and thalidomide have been used with some success, but evidence-based data supporting the use of these drugs is limited

. American Urological Association guidelines define asymptomatic microscopic hematuria as which one of the following in the absence of an obvious benign cause? A) ³1 RBCs/hpf B) ³3 RBCs/hpf C) ³10 RBCs/hpf D) A positive dipstick reading for blood

ANSWER: B The American Urological Association guidelines define asymptomatic microscopic hematuria (AMH) as ³3 RBCs/hpf on a properly collected urine specimen in the absence of an obvious benign cause (SOR C). A positive dipstick does not define AMH, and evaluation should be based solely on findings from microscopic examination of urinary sediment and not on a dipstick reading. A positive dipstick reading merits microscopic examination to confirm or refute the diagnosis of AMH.

In a patient with sepsis, which one of the following would confirm a diagnosis of septic shock? A) A 1.0 mg/dL increase in the creatinine level B) A platelet count of 20,000/mm3 (N 150,000– 350,000) C) A WBC count of 25,000/mm3 (N 4300–10,800) D) A serum bilirubin level of 7.0 mg/dL (N E) A serum lactate level of 2.0 mmol/L (N 0.5–1.0)

ANSWER: E Diagnostic criteria for sepsis include leukocytosis. Diagnostic criteria for severe sepsis (sepsis plus organ dysfunction) include an increase in the serum creatinine level 0.5 mg/dL, thrombocytopenia, and hyperbilirubinemia. A diagnosis of septic shock requires either hyperlactatemia or hypotension refractory to intravenous fluids.

Case (1): A 72 year old woman presents to the respiratory outpatient clinic with reducing exercise tolerance over the course of a year. She has a 60 pack year history of smoking. Her chest radiograph is shown below.

What is the most likely underlying chest disease on the basis of the chest radiograph? A-Lung neoplasm B-Interstitial fibrosis C-Chronic obstructive pulmonary disease D-Bronchiectasis E-pneumonia

Case (1):Answer is C : Chronic obstructive pulmonary disease This woman has hyperinflation on the chest radiograph, which could be in keeping with chronic obstructive pulmonary disease or asthma. The diagnosis of emphysema cannot be made from the chest radiograph alone. You should familiarise yourself with the GOLD guidelines for chronic obstructive pulmonary disease. These are available at: http://www.goldcopd.com

Case(2):A 68-year-old white female with a several-year history of well-controlled essential hypertension and a history of acute myocardial infarction 2 years ago is brought to the emergency department complaining of sudden, painless, complete loss of vision in her left eye that began 1 hour ago. Her vital signs are stable, and her blood pressure is 148/90 mm Hg. Her corrected visual acuity is: left—absent, with no light perception; right—20/30. The external eye examination is entirely unremarkable. A retinal examination reveals the findings shown in the following figure

The most likely diagnosis is A) acute narrow-angle glaucoma B) optic neuritis C) retinal hemorrhage D) central retinal artery occlusion E) central retinal vein occlusion

Case (2):ANSWER: D The retinal findings shown are consistent with central retinal artery occlusion. The painless, unilateral,sudden loss of vision over a period of seconds may be caused by thrombosis, embolism, or vasculitis.Acute narrow-angle glaucoma is an abrupt, painful, monocular loss of vision often associated with a red eye, which will lead to blindness if not treated. In persons with optic neuritis, funduscopy reveals a blurred disc and no cherry-red spot. Occlusion of the central retinal vein causes unilateral, painless loss of vision, but the retina will show engorged vessels and hemorrhages. Ref: Yanoff M, Duker JS (eds): Ophthalmology, ed 3. Mosby, 2008, pp 589592. 2) Pokhrel PK, Loftus SA: Ocular emergencies. Am Fam Physician 2007;76(6):829-836.

Case (3):A 56 year old woman is admitted with a three hour history of central chest tightness and breathlessness. She smokes 20 cigarettes a day. Her symptoms resolved on arrival in the emergency department without treatment. Her blood pressure is 140/86, pulse 75/regular. Cardiovascular examination is normal.

What is the most likely diagnosis? A-Acute inferior myocardial infarction B-Hyperkalaemia C-Myopericarditis Non-ST elevation D-acute coronary syndrome E-Pulmonary embolism

Case (3):Answer is D: Non-ST elevation acute coronary syndrome This woman's history is in keeping with an acute coronary event. Her ECG appearance, with deep, arrowhead T wave inversion in the precordial leads (V1-V4), is suggestive of a lesion in the proximal part of the left anterior descending artery. This may have already caused infarction. There are also ST and T wave changes in the inferior leads. Other suggestive findings would be ST depression, especially where it is dynamic (coming and going with pain) or ventricular arrhythmias associated with ST or T wave changes

Case(4): A 27 year old woman presents to the emergency department with a history of one hour of sudden onset chest tightness and breathlessness. She was aware of her heart racing during the episode but this has now completely resolved. She says she is tired. She drinks little alcohol and does not smoke. She is otherwise well, but has had occasional brief episodes similar to this, unrelated to exertion. On examination she is anxious, clinically euthyroid, with a blood pressure of 110/60 mm Hg and pulse of 60/minute .

What is the most likely diagnosis? A-Wolff-Parkinson-White syndrome B-Cocaine abuse C-Generalised anxiety disorder with hyperventilation D-Non-ST elevation acute coronary syndrome E-Brugada syndrome

Case (4):Answer is A :Wolff-Parkinson-White syndrome has a typical combination of ECG changes including a shortened PR interval, a widened QRS complex, delta waves (especially in V4) in the upslope of the QRS complex. The symptoms she describes are likely to be due to an intermittent supraventricular tachycardia that has resolved spontaneously. The underlying abnormality is an accessory pathway leading to pre-excitation of the ventricles.

Case (5):A 30-year-old woman presented with a nonpruritic vesicular eruption on the palms that began one week earlier. One day before the rash developed, the patient had a burning,tingling sensation in the same area. She did not have a fever or other systemic symptoms.The review of systems was unremarkable,and she was not pregnant. The patient had zoster on her trunk 10 years earlier,but no known recent contact with anyone who had a similar rash. Physical examination revealed multiple vesicles on the palms in various stages of healing with faint surrounding erythema (see accompanying figure). There was no fluctuance, induration,warmth, scaling, or exudate.

Based on the patient’s history and physical examination findings, which one of the following is the most likely diagnosis? A. Dyshidrotic eczema. B. Herpetic whitlow. C. Id reaction. D. Palmoplantar pustulosis. E. Secondary syphilis

Case(5):The answer is A: dyshidrotic eczema. Dyshidrotic eczema, also known as dyshidrosis and pompholyx, is a vesicular eruption that primarily affects the palmar aspect of the hands and lateral aspects of the fingers. It also may occur on the plantar aspect of the feet. The most common presentation is a symmetrical eruption of pruritic vesicles that resolves in three to four weeks with residual scaling. The etiology is unknown, but associated factors include stress, allergic reaction (particularly exposure to nickel and other metals),fungal infections, and genetic predisposition www.aafp.org/afp. Volume 85, Number 8 - April 15, 2012

Case(6): A 55-year-old white male comes to your office with weakness and a headache. He also describes an annoying pruritus that occurs frequently after he takes a hot shower. The physical examination is remarkable for the presence of an enlarged spleen. He has a hemoglobin level of 21 g/dL (N 12–16) and a hematocrit of 63% (N 36–48). To confirm your clinical diagnosis, you obtain additional studies.

Which one of the following would be most consistent with the most likely diagnosis in this patient? A) A low serum erythropoietin level B) A low platelet count C) A low arterial oxygen concentration D) An elevated carboxyhemoglobin level E) A low white blood cell count

Case(6):ANSWER: A The patient described in this case has polycythemia vera. Pruritus after a hot shower (aquagenic pruritus)and the presence of splenomegaly helps to clinically distinguish polycythemia vera from other causes of erythrocytosis (hematocrit 55%). Specific criteria for the diagnosis of polycythemia vera include an elevated red cell mass, a normal arterial oxygen saturation ( 92%), and the presence of splenomegaly.In addition, patients usually exhibit thrombocytosis (platelet count 400,000/mm ), leukocytosis (WBC 12,000/mm ), a low serum erythropoietin level, and an elevated leukocyte alkaline phosphatase score. High carboxyhemoglobin levels are associated with secondary polycythemia. Ref: Fauci AS, Braunwald E, Kasper DL, et al (eds): Harrison’s Principles of Internal Medicine, ed 17. McGraw-Hill, 2008,pp 672-673. 2) Goldman L, Ausiello D (eds): Cecil Medicine, ed 23. unders, 2008, pp 1250-1252.73

Case (7): You are reading a medical journal and come across an article about diabetes. The study followed 10,000 patients over 3 years. At the start of the study, 2000 people had diabetes. At the end of the study, 1000 additional people developed diabetes. What was the incidence of diabetes during the study? a. 10% b. 12.5% c. 20% d. 30% e. 50%

Case(7): The answer is b. (Rosner, pp 51-55.) The incidence of a disease is the probability that a person with no prior disease will develop a new case of the disease over a specific time period. In this case, 1000 people developed diabetes. In the study, only 8000 people began with no prior disease. Therefore,the incidence is 1000/8000 or 12.5%. The prevalence is the probability of having a disease at a specific point in time, and is obtained by dividing the number of people with the disease by the number of people in the study.

Case (8): Annie 70 years old always found conversations with her younger grandchildren particularly difficult - especially when in a noisy situation. She also found telephone conversations difficult. the following is her audiogram

What is your interpretation for this audiogram? What is the type and degree of hearing loss? What do you base your conclusions on? What is the pathophysiology of this condition?

Answer case (8): Audiogram: Air conduction and bone conduction show comparable hearing loss with no airbone gap. Audiogram slopes steeply toward high frequencies. Type of hearing loss: Sensorineural.moderate loss.presbycusis. What do you base your conclusions on? History (age of patient, no recent history of trauma,general good health), audiogram (sensorineural hearing loss mainly in high frequency region). Pathophysiology: Age related degeneration of hair cells, maximally in high frequency range (sensorineural).


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