Preparing for Global Health: USMLE-Style Cases for the ILAC Summer Health Program

Questions

1. A 45-year-old female presents to your rural clinic in the Dominican Republic with heartburn and regurgitation three times a week, especially after meals and when lying down. She has been taking over-the-counter antacids with partial relief. She denies weight loss, dysphagia, or hematemesis. 

 

Which treatment would be most effective?

 

A) Switch to a histamine-2 receptor antagonist (H2 blocker)

B) Initiate a proton pump inhibitor (PPI)

C) Recommend lifestyle modifications

D) Perform esophageal manometry

E) Recommend anti-reflux surgery

 

2. A 50-year-old man with a history of hypertension and type 2 diabetes mellitus comes to your rural clinic in the Dominican Republic. You check his blood pressure, and the gauge reads 138/88 mmHg. The patient has been taking 10 mg of lisinopril daily. Because the patient is diabetic, you use a point-of-care HbA1c fingerstick that reads 7.4%. 

 

According to current guidelines, what is the recommended blood pressure goal for this patient?

 

A) <140/90 mmHg

B) <110/70 mmHg 

C) <120/80 mmHg

D) <130/80 mmHg

E) <150/90 mmHg

 

3. A 62-year-old woman with a history of type 2 diabetes and hypertension presents to your rural clinic. Her blood pressure is 145/90 mmHg. She tells you how she has been going on morning and evening walks and eating healthier. Her fingerstick HbA1c is 7.5% A urine dipstick test shows 1+ proteinuria.

 

Which of the following is the most appropriate antihypertensive for this patient?

 

A) Amlodipine

B) Lisinopril

C) Hydrochlorothiazide

D) Atenolol

E) Clonidine

 

4. A 25-year-old man presents to your rural clinic complaining of unusual discoloration on his chest and back. Upon examination, you noticed multiple hypopigmented patches on his upper chest and back, which were fine-scaled. He reports that the patches become more noticeable after working shirtless all day outside. He denies itching. Wood’s lamp reveals a yellow fluorescence.

 

Which of the following is the most likely causative organism?

 

A) Trichophyton rubrum

B) Microsporum canis

C) Malassezia species

D) Candida albicans

E) Sporothrix schenckii

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Answers 

Question 1

Answer B. The Patient is showing signs of GERD with no alarming symptoms. The American Gastroenterological Association (AGA) recommends a 4-to-8-week trial of single-dose PPI therapy (e.g., omeprazole, pantoprazole) for patients with troublesome heartburn and no alarming symptoms. 

Choice A. PPIs are more effective than histamine-2 receptor antagonists (H2 blockers) in relieving symptoms of GERD. 

Choice C. Although lifestyle modifications are recommended with all patients presenting with GERD, they are often not enough for frequent symptoms (two or more moderate-to-severe episodes per week) 

Choice D and E. Esophageal manometry and anti-reflux surgery are reserved for patients with refractory symptoms or specific indications after failure of medical therapy and are not first-line treatments.

 

Question 2

Answer D. The American College of Cardiology and the American Heart Association recommend a target blood pressure of <130/80 mmHg for patients with diabetes mellitus and hypertension to reduce cardiovascular and kidney complications. 

All other choices are incorrect. 

 

Question 3 

Answer B.  The American College of Cardiology and the American Heart Association recommend ACE inhibitors (e.g. Lisinopril) or ARBs as the preferred antihypertensive agents in patients with diabetes and proteinuria due to their superior efficacy in reducing urinary albumin excretion and slowing the progression of diabetic nephropathy. 

Choice A and D. ACE inhibitors like lisinopril have been shown to reduce proteinuria more effectively than other antihypertensive classes, such as calcium channel blockers or beta-blockers.

Choice C. Thiazides are used for hypertension, but they do not provide renal protection which is needed in this case because the patient is diabetic and has proteinuria (urine dipstick test showing 1+ proteinuria) 

Choice E. Clonidine is a centrally acting α₂-agonist to lower blood pressure. It is not first-line for Hypertension because it does not provide kidney protection and has CNS side effects. 

 

Question 4

Answer C. Tinea Versicolor often present as multiple hypopigmented patches with fine scaling on the upper chest and back. Sun exposure can make them more noticeable. Yellow fluorescence is also noticed when using a Wood’s lamp. Tinea versicolor is caused by Malassezia species. 

Choice A and B. Trichophyton rubrum and Microsporum cause tinea corporis and do not exhibit the hypopigmented patches with fine scaling and yellow fluorescence under Wood's lamp

Choice D. Candida albicans typically causes intertrigo, oral thrush, and candidal diaper dermatitis, presenting with erythematous, moist, and often pruritic lesions. 

Choice E. Sporothrix schenckii causes nodular lesions that can ulcerate and follow patterns along lymphatic channels.

​

References 

All questions: 

1. Ferrara BJ, Townsley E, MacKay CR, Lin HC, Loh LC. Short-term global health education programs abroad: disease patterns observed in Haitian migrant worker communities around La Romana, Dominican Republic. Am J Trop Med Hyg. 2014;91(5):871-875. doi:10.4269/ajtmh.14-0012

Question 1: 

1. Gyawali CP, Fass R. Management of Gastroesophageal Reflux Disease. Gastroenterology. 2018;154(2):302-318. doi:10.1053/j.gastro.2017.07.049

2. Yadlapati R, Gyawali CP, Pandolfino JE; CGIT GERD Consensus Conference Participants. AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review [published correction appears in Clin Gastroenterol Hepatol. 2022 Sep;20(9):2156. doi: 10.1016/j.cgh.2022.05.005.]. Clin Gastroenterol Hepatol. 2022;20(5):984-994.e1. doi:10.1016/j.cgh.2022.01.025

Question 2: 

1. 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 [published correction appears in Hypertension. 2018 Jun;71(6):e140-e144. doi: 10.1161/HYP.0000000000000076.]. Hypertension. 2018;71(6):e13-e115. doi:10.1161/HYP.0000000000000065

Question 3: 

1. 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 [published correction appears in Hypertension. 2018 Jun;71(6):e140-e144. doi: 10.1161/HYP.0000000000000076.]. Hypertension. 2018;71(6):e13-e115. doi:10.1161/HYP.0000000000000065

2. Nielsen FS, Rossing P, Gall MA, Skøtt P, Smidt UM, Parving HH. Long-term effect of lisinopril and atenolol on kidney function in hypertensive NIDDM subjects with diabetic nephropathy. Diabetes. 1997;46(7):1182-1188. doi:10.2337/diab.46.7.1182

Question 4:

1. Tinea versicolor (pityriasis versicolor) - UpToDate. UpToDate. https://www.uptodate.com/contents/tinea-versicolor-pityriasis-versicolor 

2. Nenoff P, Krüger C, Ginter-Hanselmayer G, Tietz HJ. Mycology - an update. Part 1: Dermatomycoses: causative agents, epidemiology and pathogenesis. J Dtsch Dermatol Ges. 2014;12(3):188-212. doi:10.1111/ddg.12245