QUESTION: 149

An 18-year-old female presents for follow-up of a rash. She states that she has been using OTC antifungal preparations without success. She used OTC cortisone cream with mild improvement, but the lesions never disappeared. Her condition also recurred with full severity once the cortisone cream was discontinued. Her family history reveals a first degree relative with similar rash. The rash is over the elbows, trunk, and scalp .

Which of the following tests is most likely to confirm your clinical suspicion?

ESR and ANA
KOH prep and microscopic analysis of scraping from rash
biopsy of the involved area
capillary microscopy
Lyme titers

Answer(s): C

Explanation:

Psoriasis is a benign chronic, inflammatory skin disorder with a genetic basis that affects approximately 2% of the population in the United States. The condition varies in its presentation from person to person, with some having only local involvement and others having a severe generalized involvement. The incidence occurs in a bimodal distribution, with peaks persons in their 20s and 50s. Those with earlier onset generally will have a more severe disease over the course of their lifetime. Psoriasis has several variants, or subtypes, including plaque type (most common), eruptive (guttate), generalized pustular, and erythrodermic psoriasis. Some patients may be asymptomatic or may have only minor itching. Others may have involvement of most of their body, with severe disfigurement and poor quality of life. Psoriasis may involve any skin area; however, areas such as the scalp, extensor surfaces, palms, soles, and nails should always be examined. The typical lesions are described as erythematous, well-demarcated plaques with overlying scales. Fine stippling (pitting) of the nails is highly suggestive of psoriasis. In addition to the skin findings, patients may also have arthritis. The lesions can be reactivated with local injury or irritation of normal skin (Koebner phenomenon). The diagnosis is predominantly clinical, based on the history and examination. There are no laboratory measures that will diagnose psoriasis. Skin biopsy, although not pathognomonic, would show features consistent with psoriasis and would help to rule out other similar appearing conditions.

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QUESTION: 150

An 18-year-old female presents for follow-up of a rash. She states that she has been using OTC antifungal preparations without success. She used OTC cortisone cream with mild improvement, but the lesions never disappeared. Her condition also recurred with full severity once the cortisone cream was discontinued. Her family history reveals a first degree relative with similar rash. The rash is over the elbows, trunk, and scalp.

Which of the following would be the appropriate initial treatment?

methotrexate
systemic steroids
phototherapy
topical steroids
systemic biologicals

Answer(s): D

Explanation:

Psoriasis is a benign chronic, inflammatory skin disorder with a genetic basis that affects approximately 2% of the population in the United States. The condition varies in its presentation from person to person, with some having only local involvement and others having a severe generalized involvement. The incidence occurs in a bimodal distribution, with peaks persons in their 20s and 50s. Those with earlier onset generally will have a more severe disease over the course of their lifetime. Psoriasis has several variants, or subtypes, including plaque type (most common), eruptive (guttate), generalized pustular, and erythrodermic psoriasis. Some patients may be asymptomatic or may have only minor itching. Others may have involvement of most of their body, with severe disfigurement and poor quality of life. Psoriasis may involve any skin area; however, areas such as the scalp, extensor surfaces, palms, soles, and nails should always be examined. The typical lesions are described as erythematous, well-demarcated plaques with overlying scales. Fine stippling (pitting) of the nails is highly suggestive of psoriasis. In addition to the skin findings, patients may also have arthritis. The lesions can be reactivated with local injury or irritation of normal skin (Koebner phenomenon). The diagnosis is predominantly clinical, based on the history and examination. There are no laboratory measures that will diagnose psoriasis. Skin biopsy, although not pathognomonic, would show features consistent with psoriasis and would help to rule out other similar appearing conditions.

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QUESTION: 151

A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees.
There does not appear to be an arrhythmia present.

Which test would be most sensitive for diagnosis of this condition?

troponin I
LDH
creatine kinase-MB isoenzyme (CK-MB)
brain natriuretic peptide (BNP)
CXR

Answer(s): D

Explanation:

This patient's presentation is most consistent with pulmonary edema from decompensated CHF. The BNP test has been found to be both sensitive and specific for the diagnosis of CHF. It can be a very useful test to order when a patient is dyspneic to help to determine if CHF is the cause. Troponin, CK- MB, and LDH are markers of damage to cardiac muscle and can be diagnostic in a MI. While MI can be a cause of CHF, and most patients presenting with CHF will have cardiac enzymes drawn as part of their evaluation, cardiac enzymes are neither sensitive nor specific for CHF. Similarly, a CXR can determine the presence of pulmonary edema but not its cause.

Acute pulmonary edema secondary to CHF will require management with diuresis for acute symptomatic relief. ACE inhibitors and beta-blockers do decrease mortality and morbidity in CHF; however their use in acute decompensated heart failure is suspected as they may induce hypotension and further cardiogenic shock. Digoxin is used for symptomatic relief either when other modalities fail or when rate control from atrial fibrillation is an issue. In patients with CHF and atrial fibrillation, beta- blockers have shown better effect and reduced morbidity than digoxin. Nevertheless, in the acute setting of decompensated heart failure with pulmonary edema, diuresis is the optimal initial treatment, not digoxin. In chronic heart failure, digoxin is reserved for patients with systolic failure that are symptomatic despite adequate ACE inhibitor and beta-blocker use. Furosemide is effective in treating the acute pulmonary edema associated with CHF by virtue of its potent diuretic action, which rapidly eliminates excess body fluid volume.

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QUESTION: 152

A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees. There does not appear to be an arrhythmia present. Which of the following medications should be given initially?

metoprolol
diltiazem
furosemide
carvedilol
lisinopril

Answer(s): C

Explanation:

This patient's presentation is most consistent with pulmonary edema from decompensated CHF. The BNP test has been found to be both sensitive and specific for the diagnosis of CHF. It can be a very useful test to order when a patient is dyspneic to help to determine if CHF is the cause. Troponin, CK- MB, and LDH are markers of damage to cardiac muscle and can be diagnostic in a MI. While MI can be a cause of CHF, and most patients presenting with CHF will have cardiac enzymes drawn as part of their evaluation, cardiac enzymes are neither sensitive nor specific for CHF. Similarly, a CXR can determine the presence of pulmonary edema but not its cause.

Acute pulmonary edema secondary to CHF will require management with diuresis for acute symptomatic relief. ACE inhibitors and beta-blockers do decrease mortality and morbidity in CHF; however their use in acute decompensated heart failure is suspected as they may induce hypotension and further cardiogenic shock. Digoxin is used for symptomatic relief either when other modalities fail or when rate control from atrial fibrillation is an issue. In patients with CHF and atrial fibrillation, beta- blockers have shown better effect and reduced morbidity than digoxin. Nevertheless, in the acute setting of decompensated heart failure with pulmonary edema, diuresis is the optimal initial treatment, not digoxin. In chronic heart failure, digoxin is reserved for patients with systolic failure that are symptomatic despite adequate ACE inhibitor and beta-blocker use. Furosemide is effective in treating the acute pulmonary edema associated with CHF by virtue of its potent diuretic action, which rapidly eliminates excess body fluid volume.

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QUESTION: 149

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QUESTION: 151

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