©THEBRIGHT EXAM STUDY SOLUTIONS 8/22/2024 12:54 PM
Primary Care Practice Cases Exam
Questions With Correct Answers.
George is a 15-year-old Caucasian male who presents with rough, scaly, cauliflower-like, flesh-
colored lesions on his third and fourth fingers of his left hand. He says they don't hurt much, but
"they've grown a little over the past month" and he hates the way they look and wants to get rid
of them. What is George's diagnosis and how do you treat him? What microbe causes George's
condition? What second line treatment is also an option? - answer✔✔George has veruccae
vulgaris or "warts," caused by HPV. You treat George with cryotherapy; debriding the excess
skin, freezing the wart with LN2 for a few seconds, letting it thaw completely, then repeating for
a couple cycles. You tell George to cover the lesions with Compound W after it has heals from
the cryo and occlude it with duct tape, and return to see you for another round of cryo in two
weeks. You advise him that the warts will not disappear immediately and that he will have to
make multiple visits for additional therapy. If cry fails, you could also try injecting the lesions
with candida.
Ben is an 8 year old male who presents with an itchy scalp. His mother says he takes baths every
other day so she doesn't know how he could have an infection. What do you expect to find on
your PE. How do you dx and tx Ben? - answer✔✔Ben has head lice, or pediculosis. On his PE
you find nits and lice on the hair follicles in his scalp. You tell his mother that the infestation is
not associated with poor hygiene, and you suspect that Ben got infected at school. You tell them
that everyone should be treated for lice. Use a lice comb to remove nits from wet hair, then
suffocate the remaining lice by covering the scalp in mayo under a shower cap for 2 hours before
rinsing. Repeat the treatments one week later to kill any remaining/ newly hatched lice. Wash all
clothes in hot water and dry on high heat. Put all nonwashables in plastic bags for 2 weeks to kill
any lice on them. Vacuum pillows and throw away the bag. Ben can return to school but should
not touch heads or share clothes with other kids.
Chris is a 32-year-old male who presents with malaise, wart-like lesions on his genitals, and
erythematous, 2-3mm, round lesions on his palms. He reports that he has had multiple male
sexual partners in the past 3 months. What test do you run? How do you dx and treat Chris? Pt
education? - answer✔✔Chris has secondary syphilis, caused by T. pallidum. You would test
serum to confirm dx. Tx is a single shot of penicillin IM. You advise Chris to make sure all his
partners are screened treated, and to use protection. He should not be sexually active until his
symptoms have resolved entirely.
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Marian is a 30-year-old female who presents with clusters of erythematous papules in the webs
of her fingers. Mary says the rash isn't painful, but she doesn't know where it came from. She
regularly frequents used-clothing and vintage stores. This is the first time she's had a rash like
this? What is Mary's dx and how do you treat her? Pt education? - answer✔✔Marian has scabies,
and infestation of the Sarcoptes scabiei mite that burrows under the skin. Mary's rash is from her
first infestation, likely caused by wearing unwashed clothes from a vintage-store a few weeks
ago. You prescribe permethrin cream and tell her to apply it from the neck down, then wash off
8-14 hours later. Repeat in 2 weeks. Make sure everyone in her household follows this tx plan.
She should wash all her clothes in hot water and dry on high heat and bag everything that can't
be washed for 3 days. She should always wash secondhand clothes before wearing them from
now on.
Cory is a 70-year-old Caucasian male who presents with a vesicular, red, rash on his right lower
back that has spread slightly down and around to his right abdomen over the past day. He says
the pain began before the rash, but the rash is incredibly painful to the touch and he can't sleep at
night because "the sheets touching the blisters is too painful." What disease do you think Cory
has? What disease do you think he had sometime in his past? How do you treat Cory? How
might Cory have prevented the infection? - answer✔✔Cory has Herpes Zoster, or "shingles," a
reactivation of the varicella virus, so you suspect that Cory had chicken pox sometime in his
past. Because he's come in to see you so soon after the rash began, you can prescribe Acyclovir
with confidence it will help heal the rash. You suggest ibuprofen to help with his pain. You
inform Cory that there are two available vaccines, and the newer one, Shingrix, has been shows
to be more effective. You tell him that anyone over 50 who has had chicken pox should come get
vaccinated to reduce the possibility of developing shingles later.
Milly is a 22-year-old female who presents with a rash that looks like a bulls eye on her left calf.
She complains of fatigue and malaise. She was camping in Northern Minnesota a couple weeks
ago and thinks she might have an "infected bug bite" and thinks she needs abx. What does Milly
have? What is her rash called? What is it caused by? How do you tx her? - answer✔✔Milly has
Lyme disease, caused by a tick bite (Ixodes scapularis), causing a Borrelia burgdorferi infection.
The rash is very characteristic and is called erythema migrans. You tell her that she does need
abx and you prescribe doxycycline 14-21.
Laura is a 16-year-old Caucasian female who presents with a vegetation of hypopigmented
macules with fine scale on her back that vary in size. She started a summer job taking care of her
city's public garden areas and spends her whole day outside during the hottest hours. What is
Laura's diagnosis? How do you confirm it? How do you tx her? - answer✔✔Laura has pityriasis
versicolor caused by Malassezia yeast. This infection is most commonly seen in adolescents, and
often occurs during the summer months, exacerbated by sweat. You can confirm your diagnosis
using a KOH test or a Wood's lamp test (her skin will fluoresce yellow/green). You tell Laura
she can buy selenium sulfide shampoo to wash her skin and that she isn't contagious. You
suggest she wears plenty of sunscreen and breathable clothes when she works.
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Dave is a 32-year-old Caucasian male who presents with pearly, pink, umbilicated papules on
and around his genitals that emit a thick material when squeezed. He says they don't hurt but he's
worried he's contracted genital warts. He's had unprotected sex with 2 partners in the past three
months. What is your diagnosis for Dave? Do you run any tests? What other population do you
commonly find this infection in? What is the microbial cause of this infection? If Dave presented
with these types of lesions on other parts of his body outside his genitals, what comorbidity
would you suspect? - answer✔✔Dave has Molluscum contagiosum, caused by a virus in the
poxviridae family. You tell him he does not have warts, but he did likely contract this highly
contagious virus from one of his sexual partners. Because Dave has had unprotected sex, you
advise and he agrees to run an STD panel, all of which come back negative. You tell him that the
infection will resolve spontaneously, normally in months, but possibly in years, and he shouldn't
have sexual contact until the lesions are gone. He should inform his partners that they should
also seek treatment. You offer curettage or cryotherapy or cantharone as an alternative, more
immediate treatment. This condition is also very commonly seen in children. When seen in
adults with lesions outside of the genital region, the pt often has HIV.
Billy is a 12-year-old Asian-American male who presents with a pruritic, scaly, erythematous
patch on his inner left elbow. His mother says his arm looked fine at first but he wouldn't stop
itching it and he developed the lesion, then the scaling described above. He recently started
attending an all-day outdoor summer camp with his friends. How do you diagnose and treat him?
Pt. education? - answer✔✔Billy has atopic dermatitis (eczema), aggravated by the heat and
sweat of playing outdoors all day at summer camp. You prescribe Billy a topical corticosteroid
like hydrocortisone cream and suggest Benadryl and cold, wet compresses to address the itching.
You advise his mother to make sure Billy stays cool and in the shade while he's at camp.
John is a 14-year-old Asian-American boy who presents with pustules, papules, inflammation,
and nodules on his cheeks and forehead. You notice some scarring around the existing lesions.
John says he "can't get rid of these zits" and that he's been "washing his face like crazy" a couple
times a day. How do you help John? What medication would you suggest if initial treatment
doesn't work? - answer✔✔John is right! He has severe cystic acne with scarring. You explain to
John that he should be more gentle when washing his face, as he may be encourage his skin to
produce even more oil, exacerbating the problem. You right him a prescription for tretinoin (a
topical retinoid), clindamycin (a topical abx) to be alternated with benzoyl peroxide topically.
You also write him an rx for doxycycline (oral abx). You refer him to a dermatologist for a
second opinion and so that s/he can write John an rx for Isotretinoin if initial treatment is
unsuccessful.
Ming is a 23-year-old Asian-American male who presents with a completely hyperkeratotic
toenail w/ subungual debris. He has a hx of tinea pedis. He says the nail is painless except when
he is wearing shoes, and he doesn't like the way it looks and wants to resolve it. What lab do you
order? How do you diagnose and treat Ming? Would your treatment differ if the nail were only
affected near the tip? How so? - answer✔✔Ming has onychomycosis, a fungal toenail, likely
infected a long time ago when he had tinea pedis. You run a fungal culture to confirm your dx.
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Because the whole nail is infected you rx Terbinafine oral (Lamisil) for 12 weeks. You run liver
tests prior to beginning the drug, and tell Ming you will monitor throughout. You advise him that
the tx is 50-76% effective, and if he is cured, he should put terbinafine cream on his nail
prophylactically daily to prevent recurrence. If a small portion of the nail were infected, you
would tx topically w/ vicks vapor rub, urea compound (to thin the nail), or funginail
Colin is a 58-year-old Caucasian male who was recently laid off from work and who presents
with a well-defined, salmon-colored plaque on his neck and reaching into his hairline. The
plaque has silvery scaling. Colin says he hasn't noticed any hair loss since the patch started to
appear - he believes its grown a bit over time. When asked, he says his mother experiences
something similar at times, but her "patch" shows up on her elbows. How do you diagnose and
treat Colin and what is one sign that could help to confirm your diagnosis? What complication do
5-8% of those with Colin's disease also suffer from? - answer✔✔Colin has chronic plaque
psoriasis. You could gently scrape a few of the scales off to examine for pinpoint bleeding
(Auspitz' sign) to help confirm. You advise him to remove the scales gently after soaking in
water. You advise that he can use tar shampoo topically, and because the plaque is small you
could also give him a steroid injection (triamcinolone) if he would prefer or if the shampoo is
inadequate. 5-8% of those with psoriasis also suffer psoriatic arthritis - red, swollen, tender joints
in the hands and feet and sometime smaller joints.
Eric is a 29-year-old male who presents with a headache, malaise, and a "rash" on his genitalia.
Physical exam shows a crop of painful, pruritic, white ulcers on his genitals. Social history
reveals 9 sexual partners in the past year. His symptoms started 5 days ago and he says the ulcers
started as "red bumps." What test do you run, what is your diagnosis, and how do you treat Eric?
Pt education? - answer✔✔Eric has Herpes Simplex virus. You run a viral culture to confirm.
You explain that his first outbreak will be the most severe, and further outbreaks will be
preceded by itching and tingling, with fewer lesions. You explain that the infection will remain
in his body indefinitely and he will always be contagious. He needs to inform his sexual partners,
and abstain from sex when lesions and prodrome are present. Condom use could help reduce
transmission. Reducing stress will help reduce outbreaks. You tell him you can also prescribe
him an oral antiviral (acyclovir) to control the symptoms and reduce transmission if he has
frequent outbreaks.
Megan is a 20-year-old female who present with an erythematous, edematous, painful, fluctuant
index finger on her left hand. She has a hx of biting her nails and her cuticles. PE shows the signs
are localized and Megan has no other symptoms. What are the possible microbial causes of this
infection? How do you diagnose and tx Megan? In chronic cases what causes the secondary
infxn? - answer✔✔Megan has paronychia, an infection of the nail bed generally caused by S.
aureus or strep. You treat her with I&D and instruct her to use topical bacitracin and hot soaks w/
antibacterial soap to hep resolve the infection. Chronic cases of paronychia are due to secondary
infection with Candida yeast.
Rachel is a 27-year-old female who presents with a crop of cauliflower-like lesions on her
genitals. She has a history of smoking and has had 4 sexual partners in the last 6 months. What
