NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on Thursday in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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March 28, 2023
MKSAP 19 Nephrology, Question 32
Stem:
A 46-year-old man is evaluated for confirmed primary hypertension. The patient is asymptomatic and takes no medications. He is a current smoker with a 20-pack-year history. Family history is significant for hypertension in his mother and father; his father had a stroke at age 55 years.
On physical examination, blood pressure is 154/96 mm Hg in both arms, pulse rate is 74/min, and respiration rate is 18/min. BMI is 30. The remainder of the examination is normal.
A 12-lead ECG is normal.
The patient is instructed in lifestyle modifications, including smoking cessation, exercise, and a low sodium diet. Moderate-intensity atorvastatin is initiated.
Which of the following is the most appropriate additional therapy?
Responses Received from Members (A summary will be reported in IM Connected eNews this Thursday):
A. Amlodipine
B. Amlodipine-valsartan
C. Chlorthalidone
D. Valsartan
The Correct Answer is: B. Amlodipine-valsartan
Educational Objective
Treat stage 2 hypertension with combination drug therapy.
Critique
The most appropriate additional therapy is amlodipine-valsartan (Option B). This patient has stage 2 hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg). For patients with stage 2 hypertension with or without cardiovascular risk or disease, pharmacologic management in addition to therapeutic lifestyle interventions is recommended. The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends combination therapy with two first-line antihypertensive drugs of different classes for adults with stage 2 hypertension and an average BP that is 20/10 mm Hg above their BP target. Based on the presence of hypertension, dyslipidemia, and cigarette smoking, this patient has a calculated 10-year atherosclerotic cardiovascular disease (ASCVD) event risk of 10%. The target BP for patients with established cardiovascular disease or for patients with an estimated ASCVD event risk ≥10% is 130/80 mm Hg. This patient has an elevated 10-year ASCVD event risk and his BP is >20/10 mm Hg above target; therefore, combination drug therapy is indicated. To maximize adherence, using a fixed-dose combination agent may be more effective than adding two separate antihypertensive agents.
Starting chlorthalidone, amlodipine, or valsartan (Options A, C, D) as single-agent therapy would each be appropriate as first-line therapy for patients with stage 1 hypertension (systolic BP of 130-139 mm Hg or diastolic BP of 80–89 mm Hg). Combination therapy is recommended for patients with stage 2 hypertension and an average BP that is 20/10 mm Hg above their BP target.
Key Points
A blood pressure <130/80 mm Hg is recommended for adults with hypertension and cardiovascular disease or a 10-year atherosclerotic cardiovascular disease event risk ≥10%.
Combination therapy with two first-line antihypertensive medications of different classes is recommended for adults with stage 2 hypertension and an average blood pressure (BP) of >20/10 mm Hg above BP target.
Bibliography
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127-e248. PMID: 29146535
Copyright 2019, American College of Physicians.
March 14, 2023
MKSAP 18 Dermatology, Question 51
Stem:
A 45-year-old man is evaluated for a 6-month history of pruritic rash in the inguinal and gluteal folds. He has used topical ketoconazole for 3 weeks with no improvement. Medical history is significant for type 2 diabetes mellitus. Medications are metformin and ketoconazole cream.
On physical examination, vital signs are normal. BMI is 32. Occipital scalp has erythematous plaque with scale. Skin findings are shown.
Similar findings are noted in the gluteal cleft. Elbows and knees are clear. Nail pitting is not present.
Which of the following is the most likely diagnosis?
Responses Received from Members (1,102 Responses):
The Correct Answer is: C. Inverse psoriasis
Educational Objective
Diagnose inverse psoriasis.
Critique
Based on the finding of the well-demarcated, erythematous plaques in intertriginous areas, this patient has inverse psoriasis. Psoriasis is a chronic inflammatory dermatosis that manifests with scaling, variably pruritic plaques that may be recalcitrant to topical therapy. There are many different patterns of psoriasis including classic psoriasis vulgaris (erythematous patches with a thick, adherent scale), inverse psoriasis (red, thin plaques with variable amount of scale in the axillae, under the breasts or pannus, intergluteal cleft, and perineum), sebopsoriasis (red, thin plaques in the scalp, eyebrows, nasolabial folds, central chest, and pubic area), and guttate psoriasis (0.5- to 2-cm red plaques that erupt suddenly on the trunk often after a group A streptococcal infection). Psoriasis can also involve the nails presenting as pit-like indentations and “oil spots” often involving multiple nails. Inverse psoriasis can be difficult to diagnosis because it often lacks the classic silvery scale. It also resembles other common dermatologic conditions such as tinea, intertrigo, and allergic contact dermatitis.
Allergic contact dermatitis, while possible in these locations, would be less likely without history of exposure to an allergen. Allergic contact dermatitis does not explain the patient's erythematous plaques with scale on the scalp.
Candida is frequently found in the flexures of patients with obesity, but typically presents with a bright red plaque with satellite papules and pustules. Candida would also respond to topical antifungal treatment.
Seborrheic dermatitis can be found in the scalp, face, chest, and groin. It is more prevalent in those with HIV/AIDS or neurologic diseases such as Parkinson disease. This rash usually has a greasy, sometimes yellow scale and improves with antifungal medications.
Tinea cruris is also commonly found in the inguinal folds. It typically presents as an annular plaque with an active, scaly border. The lack of scale and lack of response to antifungal therapy makes tinea cruris an unlikely diagnosis.
Key Points
Inverse psoriasis is characterized by red, thin plaques with variable amounts of scale in the axillae, intergluteal cleft, and perineum, and under the breasts and pannus.
Bibliography
Omland SH, Gniadecki R. Psoriasis inversa: A separate identity or a variant of psoriasis vulgaris? Clin Dermatol. 2015 Jul-Aug;33(4):456-61. PMID: 26051061
Copyright 2018, American College of Physicians.