MKSAP Questions of the Week

Rheumatology Q 21

A 79-year-old man is evaluated for a 2-month history of progressive malaise and weakness, aching bilateral shoulders and hips, and stiffness for 2 hours in the morning and after immobility. He recently noted aching in his jaw when chewing. He also reports new left-sided headaches. Last week he had an episode of diplopia lasting 1 minute. He has hypertension, for which he takes hydrochlorothiazide. On physical examination, vital signs are normal. Tenderness and slight swelling over the left temple are present. Painful and limited range of motion of both hips and shoulders is noted. The remainder of the examination is unremarkable. Laboratory studies show an erythrocyte sedimentation rate of 85 mm/h.

Publish date: 12/23/2020

 
Pulmonary and Critical Care Medicine Q 23

A 35-year-old woman is evaluated for a 4-month history of exertional dyspnea and a 1-week history of chest pressure. She has no sputum production, cough, or wheezes. She has never smoked. On physical examination, vital signs are normal. Oxygen saturation is 91% breathing ambient air. Cardiopulmonary examination reveals a widened split S2 with a prominent pulmonic component and neck vein distention. Lungs are clear to auscultation. Laboratory studies, including complete blood count and comprehensive metabolic profile, are normal. Electrocardiogram is normal. Chest radiograph shows clear lung fields and prominent hilae.

Publish date: 12/16/2020

 
Neurology Q 23

A 71-year-old woman is evaluated for difficulty holding her head upright. She notes that her head feels heavy and reports intermittent difficulty with swallowing and speech that is worse in the evening. She has had no pain, sensory changes, weakness in the extremities, or cognitive or visual symptoms. She has no other medical problems and takes no medication. On physical examination, vital signs are normal. Speech is mildly dysarthric. Cervical extension is weak. No ptosis, ophthalmoplegia, sensory deficit, or weakness in the extremities is noted. Results of laboratory studies show a normal serum creatine kinase level; no acetylcholine receptor antibodies are detected. Findings from routine nerve conduction and needle electromyography studies of the limbs are unremarkable, but a repetitive stimulation protocol reveals a decremental response. An MRI of the brain is normal.

Publish date: 12/09/2020

 
Nephrology Q 35

A 26-year-old man is evaluated during a follow-up visit after presenting to an urgent care clinic for back pain 1 week ago. Laboratory studies at that time were significant for a serum creatinine level of 1.4 mg/dL (123.8 µmol/L); other laboratory studies, including urinalysis, were normal. A urine albumin-creatinine ratio obtained in preparation for this visit is 10 mg/g. He is a personal trainer, and his daily exercise regimen includes weightlifting. He states that his back pain has resolved. He occasionally takes ibuprofen; the last use was 1 week ago. He takes no over-the-counter supplements. On physical examination today, vital signs are normal. BMI is 29. The patient is muscular, without signs of obesity. There is no muscle tenderness.

Publish date: 12/03/2020

 
Infectious Disease Q 29

A 19-year-old man is hospitalized with a 6-day history of lightheadedness and nightly fevers. He also reports sore throat, headache, joint and muscle aches, and a dry cough. He recalls a blotchy rash on his trunk and arms, which has resolved. He returned home 12 days ago from a trip to Vietnam, for which he did not receive specific immunizations or other prophylaxis. During the second week of his trip, he experienced 2 days of diarrhea; he has had none since, but abdominal discomfort and anorexia persist.

Publish date: 11/24/2020

 
Hematology and Oncology Q 32

A 76-year-old woman is evaluated for worsening fatigue. She reports no additional symptoms. Medical history is significant for myelodysplastic syndrome diagnosed 3 years ago, which has required the transfusion of 1 to 2 units of blood every 5 to 6 weeks to maintain a hemoglobin level of approximately 8 g/dL (80 g/L); she has exertional dyspnea when the hemoglobin level drops below 7 g/dL (70 g/L).

Publish date: 11/18/2020

 
General Internal Medicine Q32

A 65-year-old man is evaluated during a visit to establish care. He is interested in colorectal cancer screening; however, he adamantly refuses to undergo colon preparation, and he does not want to modify his diet for screening. He has never undergone colorectal cancer screening. Medical and family histories are unremarkable. He takes no medications. Physical examination, including vital signs, is normal. After discussing the colon preparation process and dietary restrictions with the patient and exploring his concerns, he is steadfast in his refusal.

Publish date: 11/11/2020

 
Gastroenterology and Hepatology Q 25

A 43-year-old man is evaluated for 4 days of fever and arthralgia, as well as a raised purple rash over his lower extremities of 1 week's duration. He is a current intravenous drug user. He has no other medical problems and takes no medications. On physical examination, temperature is 37.8 °C (100 °F) and blood pressure is 132/85 mm Hg; other vital signs are normal. The large and small joints are tender to palpation without evidence of synovitis. The abdomen is not tender to palpation. The liver edge is palpable below the right costal margin.

Publish date: 11/04/2020

 
Endocrinology Q 28

A 45-year-old man is evaluated for anorexia, dizziness, and weakness. He was discharged from the hospital 5 days ago after transsphenoidal pituitary surgery for a pituitary macroadenoma abutting the optic chiasm. His postoperative course was uneventful, and his postoperative hormone evaluation was normal; he did not require any hormone replacement. He denies any polyuria or increase in thirst. He takes no medications

Publish date: 10/28/2020

 
Dermatology Q 44

A 19-year-old man is evaluated for 4 to 5 months of persistent itching, thickening of the skin, and odor of the feet. He also has hyperhidrosis of the palms and soles. Medical history is otherwise unremarkable, and he takes no medications. On physical examination, vital signs are normal. Skin findings are shown.

Publish date: 10/21/2020

 
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