PRIMARY CARE PRACTICE CASES
QUESTIONS WITH THE ONLY DETAILED
VERIFIED ANSWERS
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. - answer ✔✔-
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?
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. - answer ✔✔-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?
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. - answer ✔✔-
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?
,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. - answer
✔✔-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?
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. - answer ✔✔-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?
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. - answer ✔✔-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?
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. - answer ✔✔-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?
,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. - answer ✔✔-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?
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. - answer ✔✔-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?
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. - answer ✔✔-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?
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. 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 -
, answer ✔✔-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?
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. - answer ✔✔-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?
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. - answer ✔✔-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?
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. - answer ✔✔-
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?
QUESTIONS WITH THE ONLY DETAILED
VERIFIED ANSWERS
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. - answer ✔✔-
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?
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. - answer ✔✔-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?
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. - answer ✔✔-
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?
,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. - answer
✔✔-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?
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. - answer ✔✔-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?
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. - answer ✔✔-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?
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. - answer ✔✔-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?
,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. - answer ✔✔-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?
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. - answer ✔✔-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?
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. - answer ✔✔-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?
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. 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 -
, answer ✔✔-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?
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. - answer ✔✔-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?
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. - answer ✔✔-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?
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. - answer ✔✔-
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?
