Dermatology Questions

Dermatology - Item 1
A 45-year-old man is referred to you by his dermatologist for therapy. He was seen several
weeks ago by the dermatologist for evaluation of recurrent purpuric lesions on his legs. He has
noted the lesions for the past 3 months, and other than some mild burning, the eruption is
asymptomatic. he patient denies other complaints, including arthralgias, myalgias, chest
pain, and headaches. His medical history includes a motorcycle accident in !"#" that
necessitated several operations. He believes that he was given several transfusions at that
time. He denies the use of illicit drugs, e$cept for e$perimentation with mari%uana during
college. &hysical e$amination is normal, e$cept for multiple small, palpable, purpuric lesions
on his legs. 'o ulceration is present. (kin biopsy specimen shows a leukocytoclastic vasculitis.
)esults of laboratory tests include a positive hepatitis * antibody, a positive rheumatoid factor
titer of !+!,, and a hepatitis * viral )'A load of ,--,--- copies.m/. )esults of cryoglobulin
testing are negative. A liver biopsy reveals periportal fibrosis with some bridging.
he most appropriate therapy for this patient is+
0A1 2nterferon and ribavirin
031 4ethotre$ate and folic acid
0*1 &rednisone and a5athioprine
061 *yclophosphamide
071 2ntravenous immune globulin
A 89-year-old woman is evaluated in your office for the recent onset of a pruritic vesicular
eruption, which is locali5ed to her thighs and lower legs 0:igure1. (he is otherwise healthy, has
no systemic symptoms, and is taking no medications regularly. 7$cept for her skin, the results
of the physical e$amination are normal.
(ee the figure
;hat is the most likely diagnosis<
0A1 Allergic contact dermatitis
031 3ullous pemphigoid
0*1 6ermatitis herpetiformis
061 Herpesvirus infection
071 3ullous impetigo
A !"-year-old man comes to your office for evaluation of acne that is almost e$clusively
comedonal.
;hich of the following treatments is most appropriate for this patient<
0A1 opical erythromycin
031 opical ben5oyl pero$ide
0*1 opical tretinoin
061 (ystemic tetracycline
071 (ystemic isotretinoin
A 33-year-old man comes to your office with his two sons because he recently had a =thin>
melanoma removed from his back. His physician told him that the =odd-looking> moles
scattered on his trunk, arms, and legs predispose him to develop melanoma. he patient
would like to know if anyone else in his family has this type of mole. His older son, who is !3
years old, has numerous moles, but the younger son, who is # years old, has a few moles
0:igure1.
(ee the figure
;hat advice would you give the patient about his younger son<
0A1 he moles should be surgically removed over the ne$t year.
031 3iopsy of one of the lesions should be done to make sure it is normal.
0*1 His son should be referred to a dermatologist for monitoring with yearly skin
e$aminations.
061 he moles should be fro5en with li?uid nitrogen to prevent them from progressing.
071 'o further management is necessary.
A 58-year-old man comes to your office for evaluation of a several-year history of intermittent
abdominal pain and fatty, foul-smelling stools. He has no nausea or melena, but he has lost
appro$imately 8.3 kg 05 lb1 in the last several months. he patient has otherwise been well,
but he indicates that he has had a long history of pruritic lesions on the elbows, knees, and
buttocks.
&hysical e$amination reveals several grouped, crusted lesions on his elbows and knees.
7$amination of the oral mucosa is normal. here is some right abdominal fullness on
palpation. he remainder of the physical e$amination is normal. ;hat is the most likely
diagnosis<
0A1 &orphyria cutanea tarda
031 6ermatitis herpetiformis
0*1 &araneoplastic pemphigus
061 /inear 2gA bullous dermatosis
071 )ecurrent herpes simple$
A ,#-year-old woman comes to your office for evaluation of a 3-week history of generali5ed
pruritus that wakes her at night. &hysical e$amination shows widespread e$coriations and a
linear burrow between her thumb and inde$ finger. (he mentions that her 3-year-old
grandchild, whom she cares for on a daily basis, has similar symptoms. (he would like you to
write a prescription for both of them.
;hat is the topical treatment of choice for this condition in patients of all ages<
0A1 3en5yl ben5oate
031 *rotamiton
0*1 /indane !@
061 &ermethrin 5@
071 !-@ sulfur in petrolatum
A 34-year-old man is evaluated in your office for a 4-month history of fragility of the skin on
the dorsal surface of his hands. He is otherwise healthy. He denies smoking and the use of
illicit drugs but admits that he drinks alcoholic beverages daily. He notes that he was abused
as a child and remembers having to be cared for in a hospital on multiple occasions, but he
does not remember if he received a blood transfusion. He is married and has been
monogamous, and he believes that his wife has also been monogamous. &hysical e$amination
reveals blisters, erosions, and milia on the dorsum of his hands. here is no hypertrichosis or
hyperpigmentation. )esults of laboratory tests reveal a normal complete blood count and
chemistry panel. Arinary uroporphyrin levels are elevated about !- times normal. (erum iron
level is elevated about !.5 times normal, as is the total iron-binding capacity. A hepatitis
profile reveals a positive hepatitis * antibody, but negative hepatitis A and 3 antibodies. /iver
biopsy reveals fibrosis and bridging of the portal triads, but cirrhosis is not evident.
2n addition to advising that he stop drinking alcohol, the most appropriate initial therapy for
this patient is+
0A1 2nterferon
031 &hlebotomy
0*1 )ibavirin
061 (odium bicarbonate
A 3!-year-old man comes to your office for evaluation of a vesicular eruption on the instep of
his left foot. &otassium hydro$ide preparation of the lesion shows septate hyphae.
0A1 *andidiasis
031 inea versicolor
0*1 6ermatophytosis
061 Herpesvirus infection
071 2mpetigo
A !"-year-old woman with severe, therapy-resistant acne with early scarring is evaluated in
your office because her acne has not improved with oral antibiotic therapy. Bou are considering
treatment with oral isotretinoin.
;hich of the following laboratory assessments is the most crucial to monitor regularly if oral
isotretinoin therapy is initiated in this patient<
0A1 *omplete blood count
031 /iver function tests
0*1 *holesterol level
061 Arinalysis
071 &regnancy test
A !"-year-old cross-country runner comes to your office because she needs a physical
e$amination for clearance to participate on the varsity track and field team. 6uring the course
of the e$amination, you note that she has brown hair, brown eyes, a medium comple$ion, and
more than !-- small 08- to 4-mm1, relatively flat to slightly elevated, well-demarcated, evenly
pigmented, dark moles scattered over her trunk and e$tremities 0:igure1. (he says that she
tans easily and deeply. (he can recollect having a sunburn only one time, the first day of a
vacation in Hawaii with her parents when she was !8 years old. here is no family history of
melanoma.
(ee the figure
;hat should you tell this patient about her moles<
0A1 Her moles are normal and of no significance.
031 (he is in grave danger of developing a melanoma before age 3- years.
0*1 Although the moles present no danger to her, her children will be at increased risk of
melanoma.
061 Her children will be at increased risk for congenital nevi.
071 Her moles increase her chances of developing a melanoma.
;hich one of the following helps distinguish herpes simple$ virus infection from herpes 5oster
virus infection<
0A1 &ruritus
031 &eriodic recurrence in the same area
0*1 &rodromal neuralgia
061 4ultiple vesicles
A 3#-year-old man comes to your office for a physical e$amination. Cn e$amination, he has
light-brown hair, brown eyes, and only a few scattered moles, none of which is atypical.
However, he has a melanoma on his upper back. 7$cept for some freckle-like lesions across his
shoulders and upper back, his skin does not seem to be photodamaged or weathered. he
patient reports that he does not have many outdoor pursuits, other than coaching the boysD
soccer team after school. He says he tans if he spends enough time outdoors.
;hat history would best e$plain the development of this patientDs melanoma<
0A1 A series of five tanning booth sessions
031 &eriodic weekend hiking trips
0*1 4ultiple childhood sunburns
061 *hronic e$posure to radiation from indoor fluorescent lighting
071 A 8-week scuba diving trip last summer
A ,5-year-old woman comes to your office for evaluation of severe central facial
telangiectasias. he differential diagnoses include rosacea, systemic lupus erythematosus, and
dermatomyositis.
;hich of the following is the best test to determine the diagnosis<
0A1 6irect immunofluorescence microscopy
031 (kin biopsy for routine processing
0*1 Antinuclear antibody test
061 *omplete blood count
071 (erum creatine kinase level
A ,9-year-old man is evaluated in your office for a 3-week history of pruritic and slightly
painful bullae on his back, chest, abdomen, and thighs. He was initially treated by his primary
care physician with oral diclo$acillin for possible bullous impetigo. He subse?uently developed
additional blisters and urticarial papules.
Cn physical e$amination, multiple tense blisters and some flaccid blisters are noted on the
trunk and pro$imal lower e$tremities, along with several edematous, red papules 0:igure1.
here are no oral lesions or lesions on his scalp or arms.
(ee the figure
;hat should be done to immediately determine the level of the pathologic process in the skin<
0A1 )efer the patient to a dermatologist, and re?uest a skin biopsy for routine processing and
direct immunofluorescence.
031 &erform a 5anck test.
0*1 &ush on an intact blister to see if it can be e$tended.
061 )ub an edematous papule to see if it urticates.
071 Anroof a blister, and culture the area for atypical mycobacteria.
A ,4-year-old man comes to your office for evaluation of lesions on his hands 0:igure1.
(ee the figure
0A1 Eout
031 &soriasis
0*1 6ermatophytosis.onychomycosis
061 )heumatoid arthritis
071 (arcoidosis
A 3--year-old man presents to your office because of central facial flushing in association with
his rosacea.
;hich of the following is the most important for this patient to avoid<
0A1 Alcohol
031 *affeine
0*1 (picy foods
061 (unlight
071 Hot beverages
A 89-year-old woman with a history of atopic dermatitis is hospitali5ed because of a tender,
red, swollen left hand. Cn physical e$amination, she has a temperature of 39.3 F* 0!-! F:1
and enlarged, tender left a$illary lymph nodes. 2ntravenous vancomycin therapy is initiated.
:ive days after initiation of therapy, she develops several tense, sausage-shaped blisters,
some in an annular configuration, on the trunk, which cannot be e$tended with application of
pressure.
0A1 3ullous impetigo
031 6rug-induced linear 2gA bullous dermatosis
0*1 Acute contact dermatitis
061 Acute flare of atopic dermatitis
071 &emphigus
A 3--year-old homose$ual man comes to your office for evaluation of numerous asymptomatic
skin lesions on his face and neck. He had a partner who died several years ago of
&neumocystis carinii pneumonia. He knew that his partner was H2G-positive, but he has
refused to be tested for H2G infection until now. &hysical e$amination reveals multiple facial
lesions, as well as some lesions on his neck. He also has a scaly rash involving the nasolabial
folds, eyebrows, and scalp. )esults of laboratory tests include a positive H2G antibody and a
*64 count of 5-.H/. (everal months following the initiation of highly active antiretroviral
therapy 0HAA)1, the *64 count increases to 5--.H/, and the viral load is undetectable.
he patientDs skin lesions are likely to+
0A1 )emain stable
031 (lowly progress
0*1 )esolve
061 3ecome secondarily infected
071 ransform into a malignancy
A 84-year-old man is evaluated in your office for a ,-month history of painful oral ulcers and
crusted skin lesions. He believes that the process began following a tick bite, but he was never
able to find the tick. He is a cement worker and had been off work recently because of an
in%ury to his hand. (ince returning to work, he is fatigued and has lost 8.# kg 0, lb1 without
trying to lose weight. He denies other health problems. He is taking no medications and does
not smoke or chew tobacco. He denies intravenous drug use but has smoked mari%uana on
occasion and drinks four to si$ beers daily after work. Cn physical e$amination, vital signs are
normal. here are ulcerations bilaterally on his buccal mucosa 0:igure1 and crusted verrucous
lesions on his face and upper back. 3iopsy of the lesions in the mouth and on the back is done
and reveals suprabasilar clefting with acantholysis. 2mmunofluorescence microscopy of
specimens from the mouth and ad%acent normal skin reveals 2gE deposition within the
epidermis. 2ndirect immunofluorescence of serum using monkey esophagus and rat bladder as
substrate reveals intercellular antibodies.
(ee the figure
he most likely diagnosis is+
0A1 2mpetigo
031 *utaneous lupus erythematosus
0*1 (weetDs syndrome
061 &araneoplastic pemphigus
071 Elucagonoma syndrome
An 9--year-old man with a history of type ! diabetes mellitus, hypertension, and coronary
artery disease comes to your office for evaluation of several -.5- to !.--cm bullae on the
abdomen and thighs. A skin biopsy is done for routine processing and direct
immunofluorescence, and results show a subepidermal blister with numerous eosinophils and
the linear deposition of *3a and 2gE at the basement membrane 5one, respectively.
;hat is the most appropriate treatment for this patient<
0A1 etracycline and niacinamide
031 &rednisone
0*1 6iclo$acillin and topical clobetasol
061 A5athioprine and prednisone
071 4ethotre$ate
A ,4-year-old man comes to your office for evaluation of bruises on his face that have
appeared over the past !8 months. He has been thought to be in good health but recently has
noted fatigue and mild dyspnea with e$ercise. He has noticed that the bruising is worse after
episodes of constipation, when he has had to strain to defecate. Cn physical e$amination, vital
signs are normal. (everal macular, purpuric areas are noted on the patientDs face 0:igure1. he
tongue may be slightly enlarged. *ardiac e$amination reveals a mid to late systolic murmur,
but no e$tra sounds are heard. A skin biopsy reveals eosinophilic, amorphous material around
the dermal blood vessels. (erum protein electrophoresis reveals a monoclonal paraprotein.
(ee the figure
he most likely diagnosis is+
0A1 Actinic purpura
031 &rimary systemic amyloidosis
0*1 2diopathic thrombocytopenic purpura
061 (mall-vessel vasculitis
071 IaposiDs sarcoma
A 84-year-old woman is evaluated in your office because she has had urinary fre?uency and
burning for the past 3 days. Arinalysis shows numerous leukocytes and erythrocytes, and a
urine sample is sent for culture. herapy with double-strength trimethoprim-sulfametho$a5ole,
twice daily, is started. hree days after initiation of therapy, the patient develops generali5ed
malaise and a diffuse redness and tenderness to her skin.
Cn physical e$amination, she has a generali5ed erythema on her face, upper chest, back,
abdomen, arms, and pro$imal lower e$tremities. (everal bullae are noted on the abdomen,
and two erosions are visible on the buccal mucosa.
;hat is the most appropriate treatment for this patient<
0A1 *ontinue trimethoprim-sulfametho$a5ole, and begin prednisone, 4- mg.d.
031 6iscontinue trimethoprim-sulfametho$a5ole, and start topical triamcinolone cream, -.!@
twice daily, to the affected areas.
0*1 6iscontinue trimethoprim-sulfametho$a5ole, and begin prednisone, 85 mg.d.
061 6iscontinue trimethoprim-sulfametho$a5ole, and hospitali5e the patient for intravenous
immunoglobulin therapy.
071 6iscontinue trimethoprim-sulfametho$a5ole, and hospitali5e the patient for treatment
with intravenous gentamicin and ampicillin.
A healthy 4--year-old nurse comes to your office for evaluation of a !-month history of
vesicular eruptions on the dorsum and the distal portion of her hands.
;hat is the best initial topical therapy for this patient<
0A1 *alcipotriene
031 'eosporin
0*1 *lotrima5ole-betamethasone dipropionate
061 riamcinolone acetonide
071 retinoin
A 59-year-old woman who recently underwent wide local e$cision for a melanoma of the right
thigh comes to your office for a follow-up visit. (he also had sentinel node e$amination of the
ipsilateral groin nodal basin. he sentinel node was negative for tumor. he melanoma
measured !." mm in thickness and was classified as a *lark level 2G lesion. As her primary
care physician, you plan to see the patient at 3-month intervals.
;hat is the most useful test for detecting early metastases during this patientDs follow-up
visits<
0A1 (erial serum lactate dehydrogenase levels
031 3iannual chest radiography
0*1 History and physical e$amination
061 4)2 of the brain
071 * of the thora$, abdomen, and pelvis
A variant of scabies, =crusted scabies,> is fre?uently associated with which of the following
underlying conditions<
0A1 Acute myelogenous leukemia
031 *ystic fibrosis
0*1 7pstein-3arr virus infection
061 H2G infection
071 &soriasis
A 39-year-old woman comes to your office for evaluation of a 4-month history of a slowly
progressive papular and pustular erythematous eruption on both cheeks 0:igure1. here is no
history of skin disease. he application of fluorinated glucocorticoid cream produced transient
improvement, followed by pronounced worsening.
(ee the figure
0A1 6ermatophytosis
031 *ontact dermatitis
0*1 (ystemic lupus erythematosus
061 )osacea
071 (eborrheic dermatitis
A 48-year-old woman comes to your office for a follow-up visit after removal of a melanoma
from her upper thigh ! month ago. (he has spent a great deal of time suntanning all her life,
and she has suffered sunburns at the beginning of each summer since her teens. Her skin is
weathered, with numerous freckle-like lesions on her shoulders and upper back. he tumor
she had removed ! month ago had clear margins and a -.9-mm 3reslow thickness and was
classified as a *lark level 222 lesion. Bou plan to see her for follow-up e$aminations every 3
months for the ne$t year and twice a year after that.
2n addition to supplying her with sun-protection program literature, what else should be done
in managing this patient<
0A1 each her how to do monthly skin self-e$aminations.
031 (tart her on a course of monthly intramuscular interferon in%ections.
0*1 6o immediate lymphoscintigraphy and sentinel node biopsy.
061 )efer her for psychologic counseling for high-risk behavior modification.
071 6o biannual * scans of the skull, chest, and abdomen.
A 58-year-old woman is evaluated in your office for a 4-year history of a recurrent rash that
occurs three to four times a year on her buttocks. (he often notes a slight =tingling> feeling
before the eruption occurs. (he describes the acute eruption as a flat, red, slightly tender
area. 'o blisters ever develop on the site. Although she has no acute eruption at present,
there is a well-defined, nonscaling, brown-gray macule 0measuring 3.- cm J 5.8 cm1 on the
left lateral gluteal area. he patient does not apply topical agents on the area. Her only
medications are an occasional aspirin and la$ative as needed.
0A1 )ecurrent herpes simple$ virus infection
031 )ecurrent contact dermatitis
0*1 )ecurrent urticaria
061 A fungal infection
071 A fi$ed-drug eruption
A 8--year-old man comes to your office for evaluation of acute contact dermatitis from poison
ivy 0rhus dermatitis1 on his left and right forearms. He also has chronic psoriasis with pla?ues
on the knees, elbows, scalp, and trunk.
;hich of the following is the best treatment for this patient<
0A1 opical clobetasol
031 Cral prednisone in a 8-week taper
0*1 Cral methylprednisolone dose pack
061 2ntramuscular triamcinolone acetonide
071 /oratadine
A ,5-year-old man presents with a lesion on his cheek 0:igure1. he patient says it has been
slowly enlarging for about !- years and has never bothered him in any way.
(ee the figure
;hat is the appropriate management for this patient<
0A1 )efer him to a dermatologist for a biopsy of the lesion.
031 )emove the lesion with li?uid nitrogen.
0*1 )emove the lesion with laser treatment.
061 &erform appropriate laboratory tests.
071 'o management is necessary.
A ,#-year-old man with hypertension, mild heart failure, bipolar disorder, rosacea, and
psoriasis comes to your office for evaluation. he psoriasis was previously stable and confined
to his elbows and knees, but it has suddenly become widespread.
;hich one of the following drugs being taken by the patient is likely to have e$acerbated his
psoriasis<
0A1 Hydrala5ine
031 /ithium
0*1 Hydrochlorothia5ide
061 6igo$in
071 etracycline
A 45-year-old woman comes to your office for evaluation of a rash that has been present for
the past month. )ecently, she has noted a marked amount of fatigue and has had difficulty
maintaining her normal activities, including a regular tennis game. (he states that her legs
feel heavy after climbing one flight of stairs in her house and that she has had difficulty drying
her hair with a hair dryer. (he denies other problems, including weight loss, and a review of
systems is unrevealing. &hysical e$amination shows erythematous, scaly pla?ues on the dorsal
surface of the handsK a poikiloderma on the upper chest 0:igure1K an edematous, violaceous
eruption around the eyesK and weakness in the shoulder and pelvic girdle muscles, but normal
grip strength. he remainder of the physical e$amination is normal.
(ee the figure
he test most likely to detect a malignancy in this patient is+
0A1 3arium enema
031 3rain scan
0*1 *arcinoembryonic antigen 0*7A1 level
061 &elvic ultrasonography
071 hyroid scan
A 88-year-old woman is started on empiric phenytoin therapy after undergoing a craniotomy
for a subdural hematoma resulting from an automobile accident. welve days later, she
develops a temperature of 39.3 F* 0!-! F:1, and therapy with intravenous cefta5idime is
started after the results of blood cultures are received. wo days later, the patient develops a
generali5ed, erythematous, papular eruption. A complete blood count shows a leukocyte count
of !8,9--.H/, with ,9@ neutrophils, 8@ bands, "@ eosinophils, 3@ basophils, and !#@
lymphocytes. /iver function tests reveal a serum bilirubin level of !.8 mg.d/, aspartate
aminotransferase level of ,, A./, and an alanine aminotransferase level of #8 A./. Her serum
electrolyte, blood urea nitrogen, and serum creatinine levels are normal.
;hat should be done ne$t for this patient<
0A1 6iscontinue both medications, and treat with intravenous methylprednisolone sodium
succinate.
031 6iscontinue phenytoin, and continue cefta5idime.
0*1 (ubstitute carbama5epine for phenytoin.
061 *ontinue phenytoin and cefta5idime.
071 *ontinue phenytoin, and discontinue cefta5idime.
A 5"-year-old man is referred to your office for evaluation of a pigmented lesion on his chest
0:igure1, which he has had for several months. he lesion occasionally becomes inflamed and
tender.
(ee the figure
0A1 *ongenital nevus
031 4alignant melanoma
0*1 &igmented basal cell carcinoma
061 (eborrheic keratosis
071 (olar lentigo
A 49-year-old woman comes to your office for evaluation of an eruption on her face, arms, and
upper chest. (he first noticed the eruption about a month ago while she was on vacation in
Hawaii. (he has a history of having rashes following intense sun e$posure, but in the past,
they have always faded within several days to ! week. his time, her rash not only has
persisted but also has spread. (he also complains of fatigue and stiffness in the morning.
&hysical e$amination reveals a papular eruption on her cheeks and annular erythematous
lesions on the upper e$tremities 0:igure1. here are no lesions on her ears or scalp. he
remainder of the physical e$amination is normal.
(ee the figure
he test most likely to confirm the diagnosis of this patientDs condition is+
0A1 (kin biopsy for routine processing
031 2mmunofluorescence microscopy
0*1 Antinuclear antibody
061 Anti-)o 0antiL((-A1 antibody
071 (chirmerDs test
A ,5-year-old woman is referred to your office because of sudden pancytopenia, nausea, and
elevated liver en5yme levels. (he has been taking weekly low-dose pulse methotre$ate
therapy for severe psoriasis for 3 years and has had stable hematologic and liver function
parameters.
;hich medication recently added to this patientDs regimen most likely accounts for her
methotre$ate to$icity<
0A1 2tracona5ole
031 &rednisone
0*1 &ropranolol
061 rimethoprim-sulfametho$a5ole
071 4inocycline
A #3-year-old man has recently moved to your city and is consulting you for the first time
about his skin. He has lived in the southwestern Anited (tates his entire life and plays golf
regularly since retiring !! years ago. Cn physical e$amination, the patientDs skin is heavily
sun-damaged. He has many actinic keratoses on his face, ears, forearms, and the dorsum of
his hands. 'o lesions of skin cancer are apparent.
;hich of the following would be the best management strategy for this patient<
0A1 reat the thicker actinic keratoses with cryotherapy 0li?uid nitrogen1.
031 Apply topical 5-fluorouracil 05-:A1 cream, twice daily for 8 weeks.
0*1 )efer the patient for photodynamic therapy.
061 reat individual lesions with li?uid nitrogen, followed by a course of topical 5-:A cream.
071 )eassure the patient, and re-e$amine him in , months.
A ,--year-old woman is evaluated in your office for a rash on her upper chest and arms. he
rash has been present for about 8 months. (he notices that it worsens following her weekend
golf game. (he has a history of hypertension and is postmenopausal. (he has had problems
with intermittent =acne> on her face since early adulthood. Her medications include
hydrala5ine and hydrochlorothia5ide for her hypertension, minocycline for her acne, and
con%ugated estrogens and etidronate to prevent osteoporosis. Her medical history includes a
blood transfusion following childbirth. (he has had four pregnancies that resulted in three
healthy children. Her one pregnancy loss occurred as a first-trimester spontaneous abortion.
(he smokes ! pack of cigarettes daily and drinks an occasional mi$ed drink on the weekends
when she is out with friends at a restaurant. (he states that she has never used illicit drugs.
here is no significant family history, e$cept for allergic rhinitis in several of her siblings.
&hysical e$amination reveals an annular erythematous eruption on the chest and arms
0:igure1. (he has mild peripheral edema. Her blood pressure is normal. he remainder of her
physical e$amination is normal. )esults of laboratory tests include a normal complete blood
count, urinalysis, and chemistry panel. A skin biopsy reveals an interface dermatitis
compatible with a diagnosis of cutaneous lupus erythematosus. (he has a positive antinuclear
antibody M !+,4-, speckledK positive anti-)o 0anti-((-A1 and anti-/a 0anti-((-31 antibodiesK
and a negative anti-n6'A antibody.
(ee the figure
he most likely cause of this patientDs eruption is+
0A1 *on%ugated estrogens
031 Hydrala5ine
0*1 Hydrochlorothia5ide
061 4inocycline
071 7tidronate
Bou advise the patient in 2tem 39 to stop smoking, but her condition continues to be
unaffected by treatment.
;hich of the following therapies should now be prescribed<
0A1 2ntravenous immunoglobulin
031 *arbama5epine
0*1 4ycophenolate mofetil
061 halidomide
071 &rednisone
A #8-year-old man comes to your office because of a !-week history of severe oral sores and a
rash on his trunk and upper arms. He notes that he has been more tired in the last 8 months
and has lost appro$imately 8.3 kg 05 lb1, which he attributes to his age. His only medication is
a thia5ide diuretic, which he has been taking for the last 9 years for mild hypertension.
Cn physical e$amination, multiple oral erosions are present on the buccal mucosa and tongue.
here are numerous edematous papules and bullae 0!.- to !.5 cm in diameter1 on the trunk.
&ressure applied to the edge of one of the blisters results in its e$tension.
0A1 &araneoplastic pemphigus with autoantibodies against type G22 collagen
031 (evere, erosive lichen planus with no autoantibodies
0*1 &emphigus vulgaris or paraneoplastic pemphigus with antibodies against desmoglein 3 or
desmoglein ! and 3 and the plakin proteins, respectively
061 3ullous pemphigoid with antibodies against bullous pemphigoid antigen ! 03&AE!1 and
3&AE8
071 A thia5ide-induced blistering reaction with detectable 2g7 antibodies against desmoglein !
and the plakin proteins
A 5#-year-old man comes to your office for evaluation of a hairy mole on his left sideburn. He
reports that he was born with this mole and that it has undergone some changes since he saw
you last year. he hairs in it, which have always been dark, have turned gray, and a small
bump has appeared. 2t has not bled, itched, or hurt. he lesion measures appro$imately 4 J 8
cm 0:igure1.
(ee the figure
;hat is the ne$t step in the management of this patient<
0A1 )eassure the patient that these are normal aging changes of a congenital nevus.
031 &erform a shave 0tangential1 biopsy of the nodule to rule out melanoma.
0*1 Arrange for e$cision of the entire lesion.
061 6efer biopsy until lymphoscintigraphy can be done.
071 7$amine the lesion at 3-month intervals for further changes.
A 8#-year-old man has developed a generali5ed pruritic eruption 0:igure1 ! year after
receiving an allogeneic bone marrow transplantation.
(ee the figure
;hich of the following dermatologic conditions most closely resembles this characteristic
eruption of chronic graft-versus-host disease<
0A1 /ichen planus
031 &ityriasis rosea
0*1 &soriasis
061 Atopic dermatitis
071 inea corporis
A 8!-year-old woman received a prescription for a medication from her primary care physician
who warned her about avoiding sun e$posure while taking the medication. However, she did
not reduce her time of e$posure in her tanning bed, and she suffered a severe burn.
;hich drug is the most likely offending agent<
0A1 *olchicine
031 Hydro$ychloro?uine
0*1 b-*arotene
061 6o$ycycline
071 A5athioprine
A 8--year-old man comes to your office for evaluation of a !-week history of pruritic papules.
he lesions last from 3 to 5 hours and then resolve. He says that the eruptions are associated
with playing basketball or lifting weights, and the lesions often occur at the sites of trauma. He
has a history of atopic dermatitis and allergic rhinitis, but these conditions have been inactive
for the last 8 years. He is not taking any medications and does not have recurrent fever sores.
Cn physical e$amination, there are no visible cutaneous lesionsK however, when the skin is
stroked, an immediate wheal and flare reaction develops. ;hat is the most likely diagnosis<
0A1 &ressure-induced urticaria
031 Articarial vasculitis
0*1 *holinergic urticaria
061 he urticarial form of erythema multiforme
071 (ymptomatic dermographism
A 83-year-old professional golfer comes to see you because he would like to know what he can
do to prevent skin cancer. he patient has a light comple$ion and red hair.
;hat advice would you give this patient<
0A1 Avoid the sun when possible.
031 )ely primarily on high-(&: sunscreens.
0*1 )ely primarily on protective clothing and hats.
061 Ieep a =protective> tan all year by going to a tanning salon.
071 /imit tournaments to locations in northern latitudes.
A 49-year-old avid fisherman comes to your office to ask your advice about appropriate sun-
protective hats. Antil now he has worn a small thin-brimmed fishing cap. His ears have
become burned on occasion, and his neck shows the effects of chronic sun e$posure.
;hat recommendation would you give to this patient<
0A1 Avoid hats altogether, and use sunscreen on the face, neck, and ears.
031 ;ear a broad-brimmed, fenestrated straw hat to keep cool.
0*1 ;ear a 4-inch broad-brimmed cloth hat.
061 ;ear a baseball cap with a 4-inch brim.
071 ;ear a baseball cap with removable earflaps and neck flaps.
;hich of the following clinical features is most characteristic of chronic ec5ematous eruptions
regardless of the underlying disease 0for e$ample, contact dermatitis, stasis dermatitis, or
atopic dermatitis1<
0A1 Gesicles
031 /ichenification
0*1 Ioebner phenomenon
061 6ermal edema
071 Annular configuration
A ,3-year-old man, who is a retired forest ranger, comes to your office for evaluation of
numerous rough, scaly spots on the dorsum of his hands and on his forearms 0:igure1. 3efore
you outline a management plan, you would like him to disrobe for a total skin e$amination in
order to check for more serious skin cancer.
(ee the figure
;hat malignancy would most likely be found in this patient<
0A1 Ieratoacanthoma
031 3asal cell carcinoma
0*1 4elanoma
061 (?uamous cell carcinoma
A 45-year-woman whom you have been seeing intermittently over the years for asthma is
planning a mid-winter 4editerranean cruise and wants to know about the wisdom of obtaining
a =base tan> at a tanning salon. (he plans to soak up as much sun as she can on this once-in-
a-lifetime vacation and wants to be prepared the minute the ship sails. (he claims she can get
a tan if she works at it but will often burn during her first outing at the beach each summer.
Bou note she has light brown hair and eyes and a light comple$ion. here is some fine
wrinkling of her face, but no characteristics associated with photoaging.
;hat recommendation would you give to this patient<
0A1 3y all means get the =base tan.>
031 Avoid going to the tanning salon entirely.
0*1 Eo for a few tanning salon sessions, but plan to use sunscreen on board the ship.
061 *ontinue tanning salon sessions on her return to sustain her tan.
071 *ombine tanning salon sessions with as much outdoor activity as possible.
A 3!-year-old nurse comes to your office for evaluation of a hand rash that she has had for
the last 8 years. (he suspects that her hand cream is causing the rash, so she recently has
changed brands. (he wears late$ gloves intermittently while caring for her patients. (he
denies symptoms of allergic rhinitis or asthma. Cn physical e$amination, there is a slightly
red, scaling, macular eruption on the dorsum of both hands, with a distinctive line at the wrist,
but her palms are normal.
;hat is the best method for evaluating this patientDs disorder<
0A1 (end a serum sample for radioallergosorbent test 0)A(1 to late$ antigen.
031 Cbtain a skin biopsy to rule out late$ allergy.
0*1 )efer to an allergist for skin-prick testing to a number of common antigens, including
late$.
061 )efer her to a dermatologist for patch testing to a number of common antigens, including
rubber additives.
071 &erform an inhalation challenge with late$ antigen and pulmonary function tests.
A !"-year-old woman who works as a lifeguard asks your advice about the sunscreen she has
been using. (he says that on occasion, the (&:-!5 sunscreen she has used in the past has not
protected her from getting sunburned after a day at the pool. (he admits that she applies it
only after arriving at the community swimming pool and has never reapplied it after the initial
application.
;hat advice should you give this patient about sunscreens<
0A1 A sunscreen with an (&: greater than !5 is unnecessary.
031 (unscreens should be applied about a half hour before going into the sun.
0*1 )eapplication of sunscreen is re?uired only after swimming.
061 Her redness is a reaction to the sunscreen and not a sunburn.
A 58-year-old woman who recently moved to Ari5ona from 'ew Bork comes to your office for
advice on sun-protective clothing. (he would like to know if there are any differences in the
properties of clothing in hiking shirts. (he cannot recall ever having a sunburn, and she tans
easily. (he is unfamiliar with the type of clothing that would be best suited for e$tended
periods of sun e$posure under conditions that may result in heavy sweating, such as hiking.
;hich of the following characteristics of clothing is most effective in protecting the skin from
the sun<
0A1 *olor
031 ightness of the weave of the fabric
0*1 ;hether or not the garment is wet or dry
061 hickness of the fabric
071 ;hether the garment fits snugly or drapes loosely
All of the following skin changes seen in older white patients are attributable to photodamage
7N*7&+
0A1 :ine wrinkling
031 /entigines
0*1 /a$ity
061 )ed, scaly keratoses
071 elangiectasias

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