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A 19-year-old man presents with itching, burning, tender lesions on his left index finger that started about 12 hours ago. He says nothing changed other than he has been sleeping less as he prepares for his final exams. An over-the-counter steroid cream reduces the itching, but the area remains unchanged and the itching always returns. He averages 3 drinks on weekends, does not smoke, does not use illicit substances, and does not take any prescription medications or supplements. His medical history reveals an episode of fever, pharyngitis, and gingivostomatitis with vesicular lesions when he was 12 to the extent that it interfered with his ability to eat and drink; history is otherwise unremarkable. Family history is also unremarkable. Vitals are within normal limits. On exam, you observe clusters of raised vesicles on an erythematous base, covering the medial side of his left index fingertip. The area is not fluctuant but is tender to palpation. Considering the most likely etiology, dormant infection of what tissue enables recurrent disease?

A 72-year-old man with a history of poorly controlled HTN and previous myocardial infarction presents with a nocturnal cough, bilateral ankle swelling, and dyspnea on exertion. He denies any fever, chills, URI symptoms, chest pain, headache, N/V, diaphoresis, or syncope. He further denies smoking, alcohol, or drug use. Physical exam reveals bipedal edema and bibasilar crackles. A chest X-ray is remarkable for enlargement of the cardiac silhouette and interstitial   infiltrates, while EKG analysis indicates deep S waves in lead V1 and tall R waves in lead V5. What is the most appropriate next step in the evaluation and management of this patient?

A 56-year-old man presents with a 1-week history of palpitations and shortness of breath. He has a longstanding history of poorly controlled hypertension. Physical examination reveals an elevated blood pressure of 190/98 mm Hg, elevated jugular venous pressure, mild hepatomegaly, bilateral pedal edema, and rales at the lung bases. Echocardiogram reveals concentric left ventricular hypertrophy without significant valvular abnormalities. What drug is beneficial in the treatment of the patient’s condition by causing afterload and preload reduction?

A 70-year-old woman with a history of hypertension, hyperlipidemia, and myocardial infarction presents with a 3-day history of shortness of breath at rest. She has found it difficult to walk short distances due to shortness of breath and is experiencing orthopnea and nocturnal dyspnea. She denies cough, fever, chills, nausea, abdominal pain, vomiting, diarrhea, or rashes. Upon physical examination, the patient is short of breath, requiring numerous pauses during conversation. General assessment reveals the patient is tachycardic and diaphoretic  Cool extremities. Heart exam reveals a diminished first heart sound, S3 gallop, and laterally displaced PMI. Lung exam reveals dullness to percussion, bibasilar rales, and expiratory wheezing. 2+ pitting edema of the lower extremities to the level of the mid-calf.  There is no JVD noted. What intervention will provide the greatest symptomatic relief to this patient?

A 20-year-old male presents to the primary care office for a routine wellness visit and is without complaints.  The patient states that he feels entirely well, denies recent acute illness, and has no significant PMH.  On physical examination, heart rate is noted to be irregular.  A baseline EKG is obtained.   Based on this rhythm strip (see image below), what is your initial diagnosis?  

A 64-year-old man with a history of a remote myocardial infarction and congestive heart failure presents for his 3-month follow-up. A recent echocardiogram reveals severe left ventricular   dysfunction.What intervention has been shown to reduce the risk of sudden cardiac death in similar patients?

Bonus Question: A 70-year-old man with a history of hyperlipidemia, hypothyroidism, osteoarthritis, hypertension presents for a routine evaluation. He denies any problems today and otherwise has no significant past medical history. His physical examination is remarkable for pulse rate of 44 beats per minute and blood pressure of 150/94 mm Hg.  An EKG assessment reveals sinus bradycardia and Mobitz Type II second-degree AV block.What antihypertensive agent should be avoided in the management of this patient?

During your Internal Medicine rotation, you are asked to evaluate a 48-year-old male patient who presents complaining of fever and malaise for the past 10 days.  On examination you note palatal petechiae, subungual splinter hemorrhages, painless erythematous papules on the palms of the hands and soles of the feet bilaterally, and a grade III/VI holosystolic murmur heard best at the apex.  Based on this information, which of the following conditions is the most likely diagnosis for this patient?

Mr. Gonzales’ colonoscopy revealed several large benign polyps, which his physician removed in a _______.

Mr. Ling’s history revealed that his father died of colon cancer. Due to Mr. Ling’s age and positive family history, the physician scheduled Mr. Ling for a flexible colonoscopy. This diagnostic procedure is: