Nokea
A young man comes to you with an extremely pruritic rash over his knees and elbows which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. On examination, you notice scabbing and crusting with some silvery scale, and you are observant enough to notice small "pits" in his nails. What would account for these findings?
- A. Eczema
- B. Pityriasis rosea
- C. Psoriasis
- D. Tinea infection
Correct Answer: C
Rationale: The correct answer is C: Psoriasis. The key clinical features described, such as pruritic rash with scabbing, crusting, silvery scale, and nail pitting, are classic signs of psoriasis. The presence of small "pits" in the nails, known as nail pitting, is a common finding in psoriasis. The worsening of symptoms in winter and improvement with sun exposure is also typical of psoriasis. Eczema (choice A) typically presents with red, inflamed, and weeping skin lesions. Pityriasis rosea (choice B) presents with a herald patch followed by smaller similar lesions. Tinea infection (choice D) presents with scaling, redness, and itching but does not typically cause nail pitting. In this case, the combination of symptoms and nail pitting point to psoriasis as the most likely diagnosis.
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On abdominal examination she has active bowel sounds, is nontender in all quadrants, and has no hepatosplenomegaly. Inspection of the anus reveals inflammation on the posterior side with erythema. Digital rectal examination is painful for the patient, but no abnormalities are palpated. Anoscopic examination reveals no inflammation or bleeding. What is the anal disorder that best describes her symptoms?
- A. Anorectal fistula
- B. External hemorrhoids
- C. Anal fissure
- D. Anorectal cancer
Correct Answer: C
Rationale: Rationale: The patient's symptoms of painful digital rectal examination and inflammation on the posterior side of the anus with erythema are consistent with an anal fissure. The absence of palpable abnormalities and bleeding on anoscopic examination further support this diagnosis. Anal fissures are common and typically present with these symptoms due to a tear in the anal lining.
Incorrect Choices:
A: Anorectal fistula typically presents with discharge, recurrent abscesses, and may have palpable tracks.
B: External hemorrhoids usually present with painless bleeding, swelling, and itching, not with the described symptoms.
D: Anorectal cancer would typically present with more severe symptoms like rectal bleeding, changes in bowel habits, and weight loss, which are not described in this case.
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?
- A. Cluster
- B. Analgesic rebound
- C. Tension
- D. Migraine
Correct Answer: C
Rationale: The correct answer is C: Tension headache. The key features in the scenario are the bilateral location of the headache, duration of 5 days, absence of nausea and photophobia, and the patient's occupation as a computer programmer. Tension headaches are typically bilateral, mild to moderate in intensity, and often related to stress, posture, and prolonged screen time. The fact that over-the-counter medication only dulled the pain supports the diagnosis of tension headache.
Summary of other choices:
A: Cluster headaches typically have a unilateral location, severe intensity, and are associated with autonomic symptoms like tearing of the eye.
B: Analgesic rebound headaches occur due to overuse of pain medications, leading to worsening of headaches when the medication wears off.
D: Migraine headaches often present with unilateral throbbing pain, nausea, and sensitivity to light and sound, which are not present in this case.
What is the most important thing to address at today’s visit for an 81-year-old male with various health concerns, including weight loss, fatigue, and a history of falls?
- A. His elevated blood pressure noted on today’s vitals.
- B. Repeating his MoCA testing to assess for cognitive change.
- C. Suggesting completion of an advance directive at visit with his goals of care in mind.
- D. Reviewing his last colonoscopy report and discussing further screening procedures.
Correct Answer: C
Rationale: Correct Answer: C - Suggesting completion of an advance directive at the visit with his goals of care in mind.
Rationale:
1. Age and health concerns: At 81 years old with weight loss, fatigue, and a history of falls, addressing end-of-life planning becomes crucial.
2. Advance Directive: Helps the patient make decisions about the care they want if they become unable to communicate their wishes.
3. Goals of care: Understanding his wishes ensures healthcare decisions align with his values, enhancing patient autonomy and quality of care.
Summary:
- A: Blood pressure is important but not the priority compared to end-of-life planning.
- B: Cognitive testing is valuable, but addressing care preferences takes precedence.
- D: Colonoscopy report is not urgent compared to ensuring the patient's wishes are known for future care.
All of the statements about Medicare are true except:
- A. All of the funding for Medicare comes from federal taxes.
- B. Durable medical equipment has no out-of-pocket cost to the patient.
- C. Part B covers outpatient services and all physician professional fees whether inpatient or outpatient.
- D. Patients are generally responsible for 20% of Part B bills.
Correct Answer: B
Rationale: The correct answer is B because durable medical equipment under Medicare typically requires the patient to pay 20% of the Medicare-approved amount.
A is incorrect because Medicare funding also comes from payroll taxes and individual premiums.
C is incorrect as Part B covers outpatient services and physician fees only in outpatient settings.
D is incorrect as patients are generally responsible for 20% of Part B bills, not no out-of-pocket cost for durable medical equipment.
Even though older adults are less likely to get counseled for smoking cessation, they have which one of the following?
- A. The same quit rates as younger individuals
- B. Approximately 50% better quit rates than younger individuals
- C. Approximately 25% better quit rates than younger individuals
- D. Much lower quit rates than younger individuals
Correct Answer: C
Rationale: The correct answer is C: Approximately 25% better quit rates than younger individuals. Older adults tend to have higher quit rates compared to younger individuals due to factors like increased motivation, life experience, and health concerns. Older adults often have more resources and support systems in place to help them quit smoking successfully. Choice A is incorrect because older adults do not necessarily have the same quit rates as younger individuals. Choice B is also incorrect as the difference in quit rates is not as high as 50%. Choice D is incorrect as older adults do not generally have much lower quit rates than younger individuals.