mksap

This content is excerpted from MKSAP with permission from the American College of Physicians (ACP).

MKSAP: 59-year-old man with intermittent itching

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Conditions

August 24, 2014

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A 59-year-old man is evaluated for a 3-month history of intermittent itching on the forearms. He describes the itch as deep, with a burning or tingling sensation. Scratching helps somewhat, but over-the-counter topical corticosteroids have not helped. Cooling the skin soothes the itch. He did not notice a rash until he started …

MKSAP: 21-year-old man with a heart murmur

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Conditions

August 23, 2014

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A 21-year-old man is evaluated during a medical examination for health insurance. The patient is a weight lifter. He has no medical problems and takes no medications or illicit drugs.

On physical examination, blood pressure is 128/73 mm Hg, pulse rate is 56/min, and respiration rate is 16/min; BMI is 30. Increased skeletal …

MKSAP: 19-year-old man with a sore throat

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Conditions

August 17, 2014

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A 19-year-old man is evaluated for a sore throat, daily fever, frontal headache, myalgia, and arthralgia of 5 days’ duration. He also has severe discomfort in the lower spine and a rash on his trunk and extremities. He returned from a 7-day trip to the Caribbean 8 days ago. The remainder of …

MKSAP: 57-year-old woman with decreased exercise tolerance

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Conditions

August 16, 2014

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A 57-year-old woman is evaluated for a 2-week history of decreased exercise tolerance and substernal chest pain on exertion. She also has an 8-month history of macrocytic anemia.

On physical examination, temperature is 36.7 °C (98.0 °F), blood pressure is 137/78 mm Hg, pulse rate is 104/min, and respiration rate is 17/min. BMI …

MKSAP: 25-year-old man with slowly progressive solid-food dysphagia

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Conditions

August 10, 2014

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A 25-year-old man is evaluated for a 5-year history of slowly progressive solid-food dysphagia that is accompanied by a sensation of food sticking in his lower retrosternal area. He has compensated by modifying his diet and avoiding fibrous meats. He has not lost weight, and he has not had trouble drinking liquids. …

MKSAP: 72-year-old man with community-acquired pneumonia

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Conditions

August 9, 2014

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A 72-year-old man is hospitalized for treatment of community-acquired pneumonia. Despite 4 days of treatment with intravenous fluids and antibiotics appropriate for the bacteria cultured from sputum and blood, he remains febrile with mild tachycardia. The patient subsequently develops mild hypotension and is transferred to the intensive care unit. Results of two …

MKSAP: 68-year-old woman with exertional leg discomfort

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Conditions

July 26, 2014

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A 68-year-old woman is assessed for a 6-month history of progressive exertional leg discomfort, described as a “heaviness” involving both calves. The symptoms are relieved within 5 to 10 minutes of rest. She has noted the same limiting heaviness with bicycling. Medical history is significant for hypertension, type 2 diabetes mellitus, and …

MKSAP: 65-year-old woman with prodrome of pain on the tip of the nose

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Conditions

July 19, 2014

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A 65-year-old woman is evaluated for a prodrome of pain on tip of the nose followed by a painful eruption involving the right periorbital tissue.

On physical examination, all vital signs are normal. There are grouped vesicles on an erythematous base on the tip of the nose and about the right eye.

Which of …

MKSAP: 64-year-old man with knee osteoarthritis

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Meds

July 12, 2014

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A 64-year-old man is evaluated for a 2-year history of knee osteoarthritis. He has bilateral knee pain that worsens with walking. He has tried topical therapies, physical therapy, and acetaminophen, none of which has provided relief. The patient also has peripheral vascular disease, hyperlipidemia, and hypertension. Medications are hydrochlorothiazide, pravastatin, and a …

MKSAP: 38-year-old man with a 1-year history of cough

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Conditions

July 5, 2014

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A 38-year-old man is evaluated for a 1-year history of cough with mucoid sputum and a 6-month history of mildly progressive dyspnea. He has a 12-pack-year history of smoking. He has no history of asthma, allergies, skin disease, or liver disease.

On physical examination, vital signs are normal. Pulmonary examination discloses decreased breath …

MKSAP: 35-year-old woman with new-onset thrombocytopenia

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Conditions

June 28, 2014

A 35-year-old woman is evaluated for new-onset thrombocytopenia. She is gravida 1 at 36 weeks’ gestation. Her pregnancy has been otherwise uncomplicated. She takes only a prenatal vitamin.

On physical examination, temperature is normal, blood pressure is 110/65 mm Hg, pulse rate is 110/min, and respiration rate is 22/min. There are no ecchymoses or petechiae. Abdominal examination discloses no right upper quadrant pain. She has a gravid uterus. Neurologic examination is …

MKSAP: 32-year-old woman with nonproductive cough

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Conditions

June 7, 2014

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A 32-year-old woman is evaluated for a 6-month history of nonproductive cough. She has no history of recurrent upper respiratory tract infections and has never smoked cigarettes. She has no fever, dyspnea on exertion, hemoptysis, heartburn, or wheezing. She has worked in the same office for 7 years and has lived in …

MKSAP: 51-year-old woman with diarrhea and bloating

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Conditions

May 31, 2014

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A 51-year-old woman is evaluated for a 6-month history of diarrhea and bloating. She reports four to six loose stools per day, with occasional nocturnal stools. She has had a few episodes of incontinence secondary to urgency. She has not had melena or hematochezia but notes an occasional oily appearance to the …

MKSAP: 32-year-old woman is evaluated for increased hair growth

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Conditions

May 24, 2014

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A 32-year-old woman is evaluated for increased hair growth on the face and chest and a 3-month history of irregular menses. She has a 5-year history of hypothyroidism. Her only medication is levothyroxine.

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 110/72 mm Hg, and pulse rate is 80/min; …

MKSAP: 64-year-old man with a rapidly spreading rash

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Conditions

May 17, 2014

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A 64-year-old man is evaluated in the emergency department for a rash that first developed 3 days ago and has rapidly spread to cover most of his body. His skin is painful. He has a history of mild psoriasis and asthma. His psoriasis has been well controlled with topical corticosteroids as needed. …

MKSAP: 63-year-old man with pleuritic left-sided anterior chest pain

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Conditions

May 10, 2014

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A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when …

MKSAP: 76-year-old woman with left knee pain

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Conditions

April 19, 2014

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A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. …

MKSAP: 24-year-old woman with increasing asthma symptoms

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Conditions

April 5, 2014

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A 24-year-old woman is evaluated for increasing asthma symptoms. Her symptoms now require her to use her as-needed albuterol inhaler two to three times per week, and she has been waking up at night at least once a week with asthma symptoms that require her inhaler. She is still able to perform …

MKSAP: 24-year-old woman with painful muscle spasms

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Conditions

March 30, 2014

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A 24-year-old woman is evaluated for a 3-week history of painful muscle spasms and twisting movements in the neck and trunk. She says that her neck feels as if it is being pulled backward. She also reports general restlessness and an inability to keep still. Her medical history is notable for asthma, …

MKSAP: 59-year-old woman with type 2 diabetes mellitus and hyperlipidemia

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Conditions

March 22, 2014

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A 59-year-old woman is evaluated during a routine follow-up visit. She was recently diagnosed with type 2 diabetes mellitus and hyperlipidemia. She feels well. Medications are metformin, atorvastatin, and aspirin.

Physical examination findings and vital signs are normal. BMI is 27.

Laboratory studies reveal a serum creatinine level of 0.9 mg/dL (79.6 µmol/L), an …