1. Dermatology and Orthopedics Ami DeWaters
GIM Board review
Dermatology and Orthopedics
Ami DeWaters

2. ABIM Exam UT Southwestern current board pass rate – 94%
If percentage stays steady, in a class of 60, 4 would fail
If intern or second year, recommend Mayo Clinic Internal Medicine Board Review
If third year, do MKSAP (at least twice)
Not a specific GIM section on the exam however…
“Reflecting the overall predominance of office based internal medicine practice, most questions describe patient encounters that take place in outpatient settings;”
Dermatology 3% of the exam
Orthopedics combined with Rheumatology 9% of the exam

3. Dermatology – Question 1
An 18 year old man presents to your clinic with a two day history of cough, clear rhinorrhea and itchy, red eyes. He states he was brushing his teeth this morning and noticed whites spots on his cheeks so he decided to present for further evaluation. He has a history of well-controlled asthma with albuterol and fluticasone inhalers. On exam temperature is 38.1, heart rate 80, blood pressure 110/76. He is no distress, he has inflamed conjunctiva, inflamed nasal turbinates, and clusters of white papules on an erythematous base on his buccal mucosa. The rest of the physical exam is unremarkable. Which is the most likely diagnosis?
A. Hairy Leukoplakia
B. Herpes Simplex Virus Infection
C. HIV
D. Measles
E. Oral Thrush

4. Dermatology – Answer
MEASLES – these are koplik spots – they are pathognomonic for measles
With increasing rates of unvaccinated individuals in the population this will be a hot topic for the boards
If you were writing a question that fit the other answer choices…
Hairy Leukoplakia = white plaques on lateral aspect of the tongue, EBV, can’t be scraped off
HIV = ulcerations with a longer prodrome
HSV = if primary infection ulcerations, if secondary infection highly unlikely to be on buccal mucosa
Oral Thrush = white PLAQUES, not papules

5. Dermatology – Question 2
30 year old woman presents with concern over a rash for the last 2 weeks. She states that at first she noticed a red, scaly rash between her toes on both feet, but over the last week, she has also developed a red rash on her axillae and groin area. She states it is mildly itchy. She has had no other symptoms. She has no medical history and is on no medications. She likes to garden and recently started a rose garden. On physical exam, she is afebrile, blood pressure 120/70, heart rate 75. She has a well-demarcated, erythematous and scaly rash present on bilateral axillae and groins. A picture is shown here. Physical exam is otherwise unremarkable. A wood’s lamp exam reveals coral red fluorescence. What is the most likely diagnosis?
A. Erysipelas
B. Erythrasma
C. Hidradenitis Suppurativa
D. Seborrheic Dermatitis
E. Sporotrichosis

6. Dermatology – Answer Erythrasma – coral red fluorescence is classic
Caused by corynebacterium
Treat with topical clindamycin
If you were writing a question that fit the other answer choices…
Erysipelas – similar to cellulitis but only involves upper dermis, treat with PO antibiotics (MRSA coverage if purulent, MSSA/Strep coverage if non-purulent)
Hidradenitis Suppurative – same anatomic distribution but with vesicles that drain, treat with doxycycline
Seborrheic Dermatitis – virtually identical to erythrasma except for coral red fluorescence, if severe next step in management is check HIV
Sporotrichosis – related to exposure to roses, get single papule at site of inoculation that then ulcerates, treat with itraconazole

7. Dermatology – Question 3
A 60 year old woman presents for an annual examination. She has no concerns. Her medical history includes diabetes, hypertension, hyperlipidemia and end-stage renal disease s/p renal transplant. Her medications include metformin, glipizide, lisinopril, amlodipine, atorvastatin, tacrolimus and prednisone. On physical exam, she is in no distress. She has an unremarkable heart and lung exam. She has a pink plaque on the right cheek about 2 mm in diameter, shown below. Which is your next step in management?
A. Counsel patient to monitor the plaque and contact you if she notes changes
B. Counsel patient to return in 6 months for general follow-up
C. Cryotherapy the plaque in your office
D. Refer to dermatology for annual skin exams
E. Refer to dermatology immediately for biopsy of the plaque

8. Dermatology – Answer
Refer to Derm ASAP – this is likely Squamous Cell Carcinoma in a patient on Tacrolimus
These patients have very poor outcomes with a 3 year survival of 29% - EARLY DIAGNOSIS KEY
The other answer choices…
Cryotherapy can be used for actinic keratosis which usually have significant white scaling present
When patients are placed on tacrolimus you should schedule annual skin exams with Derm

9. Dermatology – Question 4
A 45 year old man presents for his annual physical exam. He is bothered by his right great toe nail which he states has become yellow over the last few months. Initially, only the distal part of the nail was yellow, but it has now extended to cover his whole nail. It is not painful, but is visibly thickened. He has no other symptoms. He has no medical history and is not on any medications. On physical exam, his vital signs are within normal limits. His right great toenail is thick and entirely yellow, and nontender to palpation. The rest of his physical exam is normal. What is the next best step in management?
A. Nail scraping and KOH preparation
B. Prescribe Oral Terbinafine
C. Prescribe Topical Efinaconazole
D. Prescribe Topical Corticosteroid treatment

10. Dermatology – Answer
Obtain Nail Scraping and KOH prep to confirm diagnosis of fungal infection
Many conditions masquerade as onychomycosis, like nail psoriasis, trauma, onychogryphosis
Due to length of treatment want to be sure of correct diagnosis
The other answer choices…
Oral Terbinafine for 12 weeks 1st line for toenails with severe infection (>50% of surface involved)
Topical Efinaconazole for 48 weeks 1st line with mild to moderate infection
Topical Corticosteroid 1st line for nail psoriasis (description should include PITTING)

11. Dermatology – Question 5
A 30 year old woman presents to you with a one week history of an intensely pruritic rash on her back. She states that the rash starts out with vesicles and bullae but are so itchy that she breaks them open. She states she has also had mild abdominal bloating, but no diarrhea, constipation or pain. She has no medical history and is on no medications. She has vital signs within normal limits. On physical exam, she is in no distress. She has a normal heart and lung exam. Her abdomen is soft and nontender, with slight distension. Her skin exam reveals two grouped lesions of vesicles and bullae on the right side of her back. She has excoriations present and general erythema. What is your next step in management?
A. Start Dapsone and recommend she adhere to a gluten-free diet
B. Start topical clobetasol cream
C. Start oral Prednisone at a dose of 1 mg/kg
D. Start phlebotomy and hydroxychloroquine

12. Dermatology – Answer
Start dapsone and gluten-free diet, this is dermatitis herpetiformis
GI symptoms often are NOT present despite skin lesions
If you were writing a question that fit the other answer choices…
Topical clobetasol for bullous pemphigoid: patients >60 years old, bullae do NOT rupture easily
Oral Prednisone for pemphigus vulgaris: patients >60 years old, bullae do rupture easily, not pruritic, comes with oral ulcers frequently
Hydroxychloroquine/phlebotomy for porphyria cutanea tarda: bullae do NOT rupture easily, not pruritic, in sun-exposed areas, highly associated with hepatitis C/alcoholism

18. Orthopedics – Question 1
A 45 year old woman presents with a two month history of numbness and tingling in her bilateral hands. She states that the tingling is worse at night, and sometimes she wakes up from sleep due to the tingling. She has had no other symptoms. She has hypertension and is on hydrochlorothiazide. She works as an insurance claims adjuster. On physical exam, heart rate is 85, blood pressure 135/85, and BMI is 33. She has a normal heart and lung exam. She has normal bilateral wrists with no erythema, swelling, or restriction in range of motion. There is no discoloration of the fingers. Tinel’s and phalen’s signs are negative. What is your next step in management?
A. Advise wrist splinting at night
B. Order a complete blood count and basic metabolic panel
C. Order a hemoglobin A1c
D. Start NSAID therapy

19. Orthopedics – Answer
Carpal Tunnel Syndrome – classic descriptor awakens patients at night from sleep
Tinel and Phalen have horrible sensitivity (50% and 60%)
Conservative management is an appropriate management strategy – could also order EMG
If you were writing a question that fit the other answer choices…
For CBC: classic anemia picture – similar demographics but will certainly mention FATIGUE, tingling should not wake up from sleep
For A1c: similar demographics but with polyuria or polydipsia also present, with tingling in feet as well
For NSAIDs: similar demographics but with swelling, erythema or warmth of bilateral wrists that would suggest more psoriatic arthritis or even RA – NEVER use NSAIDs for carpal tunnel

20. Orthopedics – Question 2
A 48 year old man presents to you with a two week history of left shoulder pain. He states that when he wakes up in the morning he has noticed pain and stiffness in his left shoulder that lasts for about 20 minutes. He has difficulty washing his hair in the shower because of the pain. He has also noticed the pain at night and cannot lay down on his left side. He has no significant medical history and takes no medications. He is employed as a commercial painter. On physical exam, he is afebrile, with a blood pressure of 125/80, and a heart rate of 80. He has tenderness to palpation from the left paraspinal muscle along the scapular spine to the subacromion. He has pain with abduction over 90 degrees of the left arm, and with internal rotation of the left arm. His drop arm test is negative and he has 5/5 strength with external rotation. Which is the most likely diagnosis?
A. Brachial Plexus Syndrome
B. Cervical Radiculopathy
C. Rotator Cuff Tear
D. Rotator Cuff Tendinopathy
E. Polymyalgia Rheumatica

21. Orthopedics – Answer Rotator Cuff Tendinopathy
You will have to know your physical exam – a tear would classically have a positive drop arm test and weakness with external rotation
If you were writing a question that fit the other answer choices…
Cervical Radiculopathy: similar patient description but with numbness, tingling, perhaps weakness
Brachial Plexus Syndrome: usually results from trauma, tingling, numbness present
Tear: usually a trauma history instead of overuse with above differences in physical exam
PMR: bilateral with more weakness than pain

22. Orthopedics – Question 3
A 70 year old woman presents to your office with a one month history of right hip pain. She states that at first the pain was minimal. The pain has progressed now and is present for most of the day. She states it is the worst in the morning, and is associated with stiffness that lasts about 20 minutes. She has also noticed that she struggles to put on her pants in the morning because moving her leg is painful. She has a medical history of hypertension, type II diabetes, osteoporosis and hypothyroidism. Her medications include lisinopril, hydrochlorothiazide, zoledronic acid, metformin and levothyroxine. On physical exam, she is afebrile with a blood pressure of 130/85, heart rate of She ambulates with a slight limp without an assistive device. She has no tenderness to palpation along the lumbar spine or lateral aspect of the hip. She has pain with internal and external rotation of the right hip and range of motion is restricted to 30 degrees. She has a negative FABER test. Which of the following is the next best step in management?
A. Obtain a hip radiograph and schedule for intraarticular steroid injection
B. Obtain a hip radiograph and start acetaminophen
C. Obtain a hip radiograph and start ibuprofen
D. Refer to orthopedic surgery for evaluation
E. Refer to physical therapy

23. Orthopedics – Answer Obtain a hip radiograph and start acetaminophen –
NSAIDS ARE NOT FIRST LINE FOR OA, unless you are sure it is inflammatory OA
Hip radiograph is appropriate in acute hip pain to rule out fracture
If you were writing a question that fit the other answer choices…
NSAIDs: middle-aged woman with acute swelling of DIP, PIP joints and pain, negative anti-CCP, classic inflammatory OA OR same patient who failed trial of Tylenol
Intraarticular steroid injection: same patient who has either failed trial of Tylenol and/or NSAIDs or has clear contraindications to Tylenol and NSAIDs
Refer to Orthopedics: same patient but with severe impairment of gait (wheelchair- bound) or complete failure of nonoperative therapies
Refer to PT: can refer in conjunction with pain control options but do not refer without addressing pain control

24. Orthopedics – Question 4
A 54 year old man presents to your office with a one week history of low back pain. He states he was helping his daughter move last week and the next morning he woke up with pain across the lower back. The pain has limited his motion. He has not had any numbness or tingling. He has a medical history of coronary artery disease and peptic ulcer disease and takes metoprolol, lisinopril, atorvastatin and pantoprazole daily. He is employed as a construction supervisor, but does not do any heavy lifting on his job. On physical exam he is afebrile with a blood pressure of 115/65 and heart rate of 65. He has tenderness to palpation along the paraspinal muscles but not along the vertebrae. He has restricted flexion and extension of his back due to pain. His straight leg test was negative. His gait is normal. What is the next best step in management?
A. Obtain lumbar plain films and start acetaminophen
B. Obtain lumbar plain films and start ibuprofen
C. Start acetaminophen and recommend absence from work for one week
D. Start acetaminophen and recommend return to work
E. Start ibuprofen and recommend return to work

25. Orthopedics – Answer Start acetaminophen and recommend return to work
DO NOT limit physical activity unless absolutely necessary – it prolongs recovery
DO NOT order imaging for acute low back pain
ALWAYS keep on eye out for contraindications to NSAIDs
NSAIDs are first line therapy for back pain

26. Orthopedics – Question 5
A 60 year old man presents to your office with left hip pain. He states it started about three days ago and the pain is intense and sharp. He has not been able to lay on his left side at all because of the pain. He has not noticed any groin pain. He has a history of hypertension and is on hydrochlorothiazide. On physical exam, he is afebrile with a blood pressure of 135/90, heart rate of 70. He has no tenderness to palpation along the lumbar spine. He has pain with palpation laterally along the left hip with maximal pain over the superoposterior facet of the trochanter. He has no pain with external or internal rotation of the hips. His FABER test is negative. His gait has a slight limp. What is your next step in management?
A. Obtain hip radiograph and start acetaminophen
B. Obtain hip radiograph and start ibuprofen
C. Obtain hip radiograph and plan bursa steroid injection
D. Perform bursa steroid injection
E. Start acetaminophen therapy

27. Orthopedics – Answer
Start acetaminophen therapy – this is classic trochanteric bursitis for which you do not need a radiograph first – EXCEPTION to the rule
Triad: pain when lying on affected side, maximal tenderness over greater trochanter, lateral pain without radiation to the groin
Treat with acetaminophen first, then NSAIDs and if fail conservative therapy then perform injection