Question 1

A 58-year-old male presents to your clinic with a two-month history of a change in voice.  He has had no stridor or respiratory difficulty, and denies hemoptysis, dysphagia, odynophagia, weight loss, or otalgia.  His past medical history is significant for 38 pack years of cigarette smoking.  His voice is slightly hoarse (raspy).  He has no palpable lymphadenopathy in the neck.  Fiberoptic laryngoscopy reveals a 4 mm diameter, exophytic, cauliflower-shaped and beige-colored mass on the mid free margin of the left true vocal cord.  A neck CT scan is negative for lymph node enlargement.  You refer the patient to an otolaryngologist, whose biopsy of the lesion reveals stage T1a (limited to one vocal cord) squamous cell carcinoma.  A metastatic survey is negative.  Regarding his treatment, you inform the patient that he will at least require which of the following?

Accepted Answer

Explanation: This patient has a T(1a)N(0)M(0) squamous cell carcinoma of the glottis. T1a designates a lesion confined to one vocal cord. Radiation is the primary nonsurgical treatment for early stage glottic tumors: T1 (confined to vocal cords) and some T2 (tumor extending to the supraglottis or subglottis with impaired vocal cord mobility) lesions. Radiotherapy may yield a more favorable voice outcome. Laser excision with a CO2 laser is also effective in curing early stage glottic cancer. (Choice B) Total laryngectomy is generally reserved as the initial treatment for more advanced glottic cancers, such as T4 lesions (tumor invading through the thyroid cartilage or with direct extralaryngeal spread). (Choice C) Since a major goal in the treatment of T1 glottic cancers is optimal voice preservation, cordectomy for such lesions is usually partial, employing endoscopy and microlaryngoscopic instruments. (Choice D) A partial or hemilaryngectomy is generally not indicated as a first-line treatment for T1 glottic cancer, unless the cancer involves the anterior comissure of the true vocal cords. It may become an option for patients with T1 lesions that failed to respond to radiotherapy or for patients with recurrent T1 lesions. (Choice E)In an attempt to preserve the larynx, induction chemotherapy followed by radiation is considered most often for T3 (tumor confined to the larynx with vocal cord fixation) lesions of the glottis. Patients whose T3 tumors respond to induction chemotherapy may be treated with further chemotherapy and radiation. Those whose T3 tumors have a limited response to chemotherapy are generally treated with partial or total laryngectomy. Educational Objective: The initial treatment of a squamous cell carcinoma of the glottis which is confined to one vocal cord and which has not metastasized [T(1a)N(0)M(0)] is radiation therapy, laser excision, or partial vocal cordectomy.

Question 2

A 49-year-old woman comes to the physician requesting treatment for "this unattractive redness of my skin."  In the past 3 months, she developed blemishes on her nose, cheeks, and chin.  She now flushes intensely in response to hot or cold temperatures, emotion, and the consumption of spicy foods or alcohol.  She has no history of dermatological problems.  Physical examination shows a reddening of the central face, erythematous papules on the nose, and sporadic telangiectasias on the nose and cheeks as shown below.  The appropriate action was taken.  Which of the following complications is most frequently associated with this condition?

Accepted Answer

Explanation: Patients with rosacea often experience ocular symptoms. Manifestations of ocular rosacea may include burning or foreign body sensations, blepharitis, keratitis, conjunctivitis, corneal ulcers, and recurrent chalazion. The chalazion is characterized by a granulomatous inflammation of a meibomian gland and presents as a painless pea-sized nodule within the eyelid. Patients with ocular rosacea should have an ophthalmology consultation to address the risk of more serious complications. chalazion (Choice A) Fistulous tracts, abscesses, sinus tracts, and fibrosis are common manifestations of cervicofacial actinomycosis. Actinomycosis is due to a filamentous, branching gram-positive bacterium. Examination of abscess fluid shows characteristic yellow "sulfur granules." (Choice B) Actinic keratoses are small scaly lesions found in sun-exposed areas and are caused by excessive ultraviolet (UV) light exposure. They are associated with up to a 20% risk of transformation to squamous cell carcinoma. Actinic keratoses (Choice D) Sinus infections can arise when mucosal edema obstructs the ostia, often subsequent to allergic rhinitis or viral upper respiratory tract infections. Sinusitis is not typically associated with rosacea. (Choice E) Cerebral venous thrombosis may be seen as a complication of invasive mucormycosis. It is also seen in patients with thrombotic disorders, advanced malignancy, or severe infections. It is not a complication of rosacea. mucormycosis Educational objective: Patients with rosacea may also experience ocular symptoms. Complications frequently include a burning or foreign body sensation, blepharitis, keratitis, conjunctivitis, episcleritis, and recurrent chalazion. References: Rosacea: a common, yet commonly overlooked, condition. (http://www.ncbi.nlm.nih.gov/pubmed/12182520)

Question 3

A 72-year-old Caucasian male comes to your office.  He is complaining of hoarseness for the past six months.  He says the hoarseness has been gradually worsening, and now he has developed difficulty in swallowing, pain in both ears, and exertional shortness of breath.  He adds that he recently had a couple of episodes of hemoptysis.  On examination, significant cervical lymphadenopathy is present.  Chest x-ray is normal.  Flexible fiberoptic endoscopy shows a laryngeal mass involving both supra glottic and infra glottic regions, as well as the vocal cords.  The biopsy report reveals squamous cell carcinoma.  The surgery and otolaryngology team, after careful review of all the findings, declare the lesion inoperable.  At this time, what is the most appropriate treatment option for your patient?

Accepted Answer

Explanation: Over 50,000 new cases of head and neck cancer (HNC) are diagnosed every year in the United States. At the time of diagnosis, about 60% of these cases are regionally advanced (stage lll and lV). Wide surgical excision is not the immediate therapeutic option for most of these locally advanced HNC. A number of studies have shown that a course of combined chemotherapy and radiotherapy, also known as chemoradiotherapy (CRT), promises superior results over chemotherapy or radiotherapy alone. It not only increases the 5-year survival rate, but also renders some inoperable HNC cases operable after treatment. (Choice A) Radiotherapy alone results in a 5-year survival rate of 10-30 percent. However, this rate still remains lower than that of CRT. (Choice B) Chemotherapy alone has produced a good response in a number of patients. This mode of management may render some laryngeal masses operable from their previously inoperable state. However, combined chemotherapy and radiotherapy promises superior results over chemotherapy alone. (Choice C) With CRT, high survival rates have been demonstrated. Unless the patient refuses to consent to chemotherapy or radiotherapy, just doing comfort measures without trying to treat the patient is inappropriate. Educational Objective: About 60% of head and neck cancers are locally advanced at the time of diagnosis and are inoperable. CRT promises superior results than chemotherapy or radiotherapy alone.

Question 4

A 23-year old Caucasian primipara gives birth to a full-term, female infant who has an isolated cleft lip. The mother says that her brother had a cleft lip and cleft palate which were surgically corrected. Her prenatal course was uncomplicated. She did not take any medications except multivitamins during the pregnancy. She does not smoke or consume alcohol. Careful inspection reveals an upper lip pit in the mother. Which of the following is the best statement concerning the infant's condition?

Accepted Answer

Explanation: Cleft lip with or without cleft palate is typically a multifactorial disorder. It has been associated with the use of teratogenic agents (commonly alcohol) during pregnancy. A careful and thorough history is important in making the correct diagnosis. Reconstruction of the cleft lip is generally performed at approximately three months of age, according to the rule of '10:' 10 lbs of weight, 10 weeks of age, and 10 g of hemoglobin. (Choices A and B) The modes of inheritance can be autosomal dominant, autosomal recessive, and X-linked. This family seems to have an autosomal dominant inheritance, called Van der Woude syndrome, with variable expressivity because the mother has a very limited expression of the disease - an upper lip pit. (Choice C)The recurrence risk in the following pregnancies is close to 50%. (Choice E)Associated cardiac and renal abnormalities are not common. Educational Objective: Cleft lip with or without cleft palate is typically a multifactorial disorder. It has been associated with the use of teratogenic agents during pregnancy, and the modes of inheritance can be autosomal dominant, autosomal recessive, and X-linked. Reconstruction of the cleft lip is generally performed at approximately three months of age, according to the rule of '10:' 10 lbs of weight, 10 weeks of age, and 10 g of hemoglobin.

Question 5

A 65-year-old woman comes to the physician with a 5-day history of rash and generalized itching.  She initially developed a rash on her hand that spread to her feet, abdomen, and groin area.  The patient also has intense pruritus that is worse at night.  Her husband started having similar symptoms approximately 3 days ago.  She works as a patient aide in a nursing home and has no other medical conditions.  The patient had chickenpox when she was 7 years old.  Her vital signs are within normal limits.  Skin examination (image below) shows multiple small erythematous papules on her palms, sides of the fingers, wrists, lateral aspect of the feet, and periumbilical area.  Her husband has similar lesions on the same body parts and also over the shaft of his penis.  The remainder of her examination is within normal limits.  
Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: This patient's presentation suggests scabies due to infestation by the Sarcoptes scabiei mite, which burrows into the skin and spreads through direct person-to-person contact. Scabies usually presents with an intensely pruritic rash (often worse at night) in the flexor surfaces of the wrist, lateral surfaces of the fingers, and the finger webs. The rash is due to a delayed type IV hypersensitivity reaction to the mite (feces and ova included). Scabies can also involve other parts of the body (eg, elbows, axillary folds, nipples and areola in women, scrotum and penis in men), but it is uncommon at the back and head (except in children). Examination usually shows excoriations with small, crusted, red papules scattered around the region, often with linear burrows. Patients can also develop small vesicles, pustules, wheals, and excoriations that can obscure the classic burrows in the skin. Diagnosis is confirmed by skin scrapings from lesions revealing mites, ova, and feces under light microscopy. (Choice A) Direct fluorescent antibody testing for varicella zoster can confirm the diagnosis of shingles, which usually presents as erythematous papules progressing to grouped vesicles in a dermatomal distribution. This patient's widespread involvement is not consistent with shingles. shingles (Choice B) Patch testing tests for various common allergens and can help differentiate between allergic and irritant contact dermatitis. Contact dermatitis usually presents as an intensely pruritic and erythematous rash with indistinct margins and is associated with a history of skin exposure to an irritant or allergic substance. allergic irritant contact dermatitis (Choice C) Potassium hydroxide staining of a skin sample can diagnose tinea infections by showing the characteristic segmented hyphae and arthrospores. Tinea infections usually present as pruritic, erythematous, circular, and scaly lesions with central clearing. tinea (Choice D) Punch biopsy is usually indicated for excluding suspected malignancy or bullous disorders, or in situations where multiple etiologies may be possible. However, this patient's presentation is more suggestive of scabies; a punch biopsy would be needed only if the skin scrapings do not confirm the diagnosis. Educational objective: Scabies is a highly contagious disease caused by mite infestation that presents with an intensely pruritic rash in the flexor surfaces of the wrist, lateral surfaces of the fingers, and the finger webs. Patients usually have excoriations with small, crusted, red papules and linear burrows. Diagnosis is confirmed by skin scrapings revealing mites, ova, and feces under light microscopy. References: Scabies (http://www.ncbi.nlm.nih.gov/pubmed/19580575)

Question 6

A 65-year-old woman comes to the office for evaluation of a rash.  The rash started nearly 3 years ago as a single lesion on her back, followed by multiple additional lesions in the same area and elsewhere on her trunk.  There is no associated pruritus.  The patient has a history of hypertension and gastroesophageal reflux disease.  Her medications include hydrochlorothiazide and omeprazole.  She has no history of tobacco or alcohol use.  Vital signs are within normal limits.  Skin examination findings are shown in the image below.  There is no warmth or tenderness around the lesions.  The remainder of her physical examination is normal.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: This patient's rash is consistent with seborrheic keratosis (SK), a benign epidermal tumor due to proliferation of immature keratinocytes. SKs typically present after age 50 and are more common in fair-skinned individuals. The pathogenesis is not well understood. Patients can develop single or multiple lesions that are well-demarcated, pigmented, round or oval, and have a dull or verrucous surface with a "stuck-on" appearance. Typical locations include the face, upper extremities, and trunk. SKs can be asymptomatic or cause pruritus, pain, or bleeding (especially with friction against clothing or jewelry). Explosive onset of multiple pruritic SKs (Leser-Trélat sign) has been associated with malignancies (especially lung and gastrointestinal tumors). Diagnosis is based on the lesions' clinical appearance but sometimes may require biopsy in uncertain cases. Because they are slow growing and benign, SKs usually do not require any treatment. However, symptomatic or cosmetically disfiguring lesions can be treated with cryotherapy or removed by curettage/shave excision or electrodessication (Choice A). (Choices B and C) Excisional or intralesional biopsy would be required if this patient had atypical-appearing lesions or if there was a concern for malignancy (eg, melanoma). However, she is asymptomatic and her rash has the characteristic appearance of SK. (Choice E) Salicylic acid is used for treating cutaneous warts, which typically present as multiple flesh-colored, hyperkeratotic papules. However, cutaneous warts are usually not as pigmented as SKs. cutaneous warts Educational objective: Seborrheic keratosis is a benign epidermal tumor that can occur on the face, upper extremities, and trunk. Lesions are well-demarcated, pigmented, round or oval, and have a dull or verrucous surface with a "stuck-on" appearance. Treatment is not necessary unless the lesions are symptomatic or cause cosmetic problems. References: Seborrheic keratosis. (http://www.ncbi.nlm.nih.gov/pubmed/18801147) Management of benign skin lesions commonly affecting the face: actinic keratosis, seborrheic keratosis, and rosacea. (http://www.ncbi.nlm.nih.gov/pubmed/19465852)

Question 7

A 48-year-old woman comes to the office due to a recurrent rash.  Six months ago, a rash developed on her legs that she describes as "red patches with raised areas."  The rash worsened that night with intense itching that disrupted her sleep.  It spontaneously resolved over the next day.  Since then, she has had repeated episodes of similar symptoms on her arms, legs, and back, each lasting 8-12 hours and occurring nearly every 2-3 weeks.  She reports no trauma, insect bites, travel history, sick contacts, or changes in weight.  Medical history is notable for hypertension treated with lisinopril.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.1 C (97 F), blood pressure is 138/77 mm Hg, and pulse is 78/min.  Physical examination is within normal limits.  The patient brings a photo of the rash, shown in the image below, from her most recent episode 2 days ago. Complete blood count, urinalysis, erythrocyte sedimentation rate, and liver function studies are within normal limits.
 The patient is concerned about her long-term prognosis.  Which of the following is the most appropriate advice for this patient?

Accepted Answer

Explanation: The symptoms of chronic urticaria are usually controllable without difficulty, with >50% of patients responding to standard therapy (Choice B). It is usually a self-limited condition that resolves spontaneously within 2-5 years, with remission rates of nearly 30%-50% at 1 year and up to 70% by 5 years. Patients with more severe episodes, angioedema, or autoimmune thyroid disease have a longer disease duration. The urticaria in those with symptoms lasting >5 years also generally improves, with up to 50% of patients achieving remission within the next 5 years (Choice C). (Choice A) Chronic urticaria without angioedema, as seen in this patient, is usually not life threatening and does not require an epinephrine injector. In contrast, acute urticaria with angioedema can sometimes be associated with life-threatening allergic reactions, requiring the patient to carry epinephrine. (Choice E) Dietary changes usually do not improve chronic urticaria because IgE-mediated food reactions are not typically associated with it. However, such reactions may cause acute urticaria and can improve with dietary modifications after the causative allergen is identified. Educational objective: Chronic spontaneous urticaria is a self-limited condition that usually responds to standard therapy and resolves within 2-5 years in most cases. References: Chronic urticaria: an overview of treatment and recent patents. (http://www.ncbi.nlm.nih.gov/pubmed/30924425)

Question 8

A 7-year-old girl is brought to the office for a routine health maintenance examination.  While in the waiting room, she develops a nosebleed.  An assistant pinches the patient's nasal alae against the nasal septum for 10 minutes while the girl is seated and leaning forward.  This slows, but does not stop, the flow of blood.  Prior to the appointment, the patient was at a summer camp playing outside in hot, dry weather.  She has had no recent facial trauma, unusual bruising, or gingival bleeding.  Blood pressure is 100/70 mm Hg and pulse is 94/min.  On examination, the patient is sitting in a chair, awake, alert, and in no distress.  A continuous trickle of blood from her left naris obscures the mucosa.  She has no oropharyngeal lesions.  Which of the following is the best next step in management of this patient's condition?

Accepted Answer

Explanation: 11ec2b69_be9e_a0e1_8f63_69720dd47e02_MD0005_00 This patient has ongoing epistaxis that is most likely due to a hot, dry climate and possible minor nasal trauma (eg, undisclosed nose-picking). The anterior nasal septal mucosa is vulnerable to bleeding as it is where the sphenopalatine, greater palatine, anterior ethmoid, and superior labial arteries anastomose (Kiesselbach plexus). Nostril pinching directly compresses the Kiesselbach plexus and usually readily controls bleeding after 5-10 minutes. However, if anterior epistaxis does not cease, as seen in this patient, topical vasoconstriction is indicated. Oxymetazoline is the preferred agent in children and should be applied with a squirt bottle or cotton pledget. Direct pressure should then be applied again to the nasal alae. Although beneficial in the acute setting, topical vasoconstrictors should not be used for >3 days due to the risk of rebound congestion. Patients should be advised to moisturize the nasal mucosa with saline sprays or a humidifier to prevent epistaxis due to dry weather. In addition, nose-picking or rubbing should be avoided. (Choice A) Intranasal corticosteroids treat allergic rhinitis but may cause thinning, dryness, and/or damage of the nasal septum, contributing to epistaxis. Patients should be instructed to spray laterally (away from the nasal septum) to avoid adverse effects and to discontinue if experiencing recurrent epistaxis. (Choice B) Chemical (silver nitrate) or electrical cautery is indicated if direct compression and topical vasoconstriction are unsuccessful. Simultaneous bilateral cauterization should be avoided due to the risk of septal ulceration and perforation. (Choice C) Anterior nasal packing (eg, bacitracin-covered sponge) is indicated if direct nostril compression, topical vasoconstriction, and cauterization fail to stop the acute episode of anterior epistaxis. (Choice D) Posterior epistaxis occurs more frequently in older adults with hypertension and arteriosclerosis and is treated with posterior nasal packing. Although uncommon in children, posterior bleeds can occur with severe nasal trauma or an underlying bleeding disorder and should be suspected if an anterior source is not identified. Educational objective: Most epistaxis originates from the Kiesselbach plexus in the anterior nasal septum. Nostril pinching is the first step in management, and a topical vasoconstrictor can be applied if direct compression alone is not effective. References: Fifteen-minute consultation: investigation and management of childhood epistaxis. (http://www.ncbi.nlm.nih.gov/pubmed/25035314) Recurrent epistaxis in children. (http://www.ncbi.nlm.nih.gov/pubmed/24172703)

Question 9

A 26-year-old woman comes to see you in the office.  She has tattoo marks on the back of her neck and anterior chest wall.  She has had these tattoos for 10 years and wants to remove them now.  Which of the following is the correct statement regarding the removal of tattoo marks?

Accepted Answer

Explanation: Tattooing is a relatively common practice. Most tattoos are seen in adolescents and young adults (age 13-25). The tattooing process involves repeated skin punctures using solid bore needles which place the tattoo pigment into the dermis. The pigment is taken up by macrophages in the dermis, which allows it to remain in the skin permanently. People who have had these marks for a long time sometimes desire tattoo removal. Some of the common techniques used to remove tattoo marks include dermabrasion, cryosurgery, thermal cautery, surgical resection, and, more recently, laser removal. These techniques can be used to remove the marks on any part of the body. Dermabrasion involves the removal of the superficial layer of the epidermis, thereby allowing the pigment to leach out of the skin. Laser removal involves the use of lasers of different wave lengths. It is thought that the laser breaks up the pigments into smaller molecules, which are taken up and cleared by the macrophages in the skin. Although it is a safe procedure, laser removal can leave scar marks and cause skin hypo- or hyper-pigmentation. (Choice A) Tattoo removal is an expensive and complicated procedure, but it is certainly possible. (Choice B)Removal of the tattoos has no relation with the age of the tattoo marks. (Choices C and D)The common techniques for tattoo removal described can be used on any part of the body. Educational objective: Dermabrasion and laser removal are the most common procedures for the removal of tattoo marks.

Question 10

A 10-year-old girl is brought to the emergency department due to right ear pain.  She was participating in a martial arts competition this afternoon when her opponent struck her on the right side of the head.  The patient has had no discharge from the ear canal and no hearing loss, rhinorrhea, or vertigo.  She has no chronic medical conditions and takes no medications.  Blood pressure is 110/70 mm Hg and pulse is 92/min.  The patient is awake, alert, and appears in moderate pain.  The face has normal contours with no point tenderness.  The pupils are equal and reactive to light; extraocular movements are intact.  There is erythema and a 2.5-cm (1-in) hematoma overlying the superior antihelix of the right pinna.  The right pinna is tender to light touch, and manipulation of the pinna is painful.  Scant dried blood is noted at the external auditory meatus.  Bilateral tympanic membranes are clear.  The mastoid process is nontender and has no bruising.  The patient's parents ask if there is anything else that needs to be done for the hematoma.  Which of the following is the most appropriate statement regarding management of this patient?

Accepted Answer

Explanation: 11ec2b69_be9c_56f0_8f63_23e6651fe2d0_MD0005_00 This patient who sustained trauma to the ear has an auricular hematoma, which is a collection of blood between the perichondrium and cartilage of the outer ear. Athletes who participate in contact sports, such as wrestling or martial arts, are at highest risk of ear injury. Physical examination is diagnostic with a swollen, erythematous, tender area of fluctuance at the site of the hematoma. hematoma The complications of an untreated auricular hematoma are significant. Infection can develop rapidly (2-3 days) and lead to an abscess. In addition, because the auricular cartilage has no direct blood supply and receives all nutrients via diffusion from the perichondrium, an auricular hematoma can cause avascular necrosis of the outer ear cartilage. Subsequent fibrocartilage overgrowth can lead to a permanent deformity known as cauliflower ear. cauliflower ear Therefore, management includes prompt aspiration or incision and drainage of the blood collection with application of a pressure dressing to prevent reaccumulation of the hematoma. Patients are treated with oral antibiotics that include coverage for skin flora and Pseudomonas aeruginosa. Daily follow-up for 3-5 days is recommended to assess healing and evaluate for signs of infection (eg, fever, purulent drainage) or blood reaccumulation. (Choice A) Failure to promptly drain an auricular hematoma can result in significant consequences (eg, infection, cauliflower ear deformity). Aspirin and other nonsteroidal anti-inflammatory drugs (eg, ibuprofen) are typically avoided to prevent rebleeding of the hematoma. (Choice C) Auricular trauma can lead to permanent ear deformity but does not affect hearing. (Choice D) Although antibiotics are prescribed to prevent secondary infection, the hematoma must first be evacuated to avoid complications such as abscess or cauliflower deformity. Educational objective: Blunt trauma to the ear can cause an auricular hematoma, which is a collection of blood between the perichondrium and cartilage of the outer ear. Prompt evacuation of the hematoma is required to avoid complications of infection, avascular necrosis, and permanent cauliflower ear deformity. References: Management of auricular hematoma and the cauliflower ear. (http://www.ncbi.nlm.nih.gov/pubmed/21086231) Sport injuries of the ear and temporal bone. (http://www.ncbi.nlm.nih.gov/pubmed/28314420)

Question 11

A 25-year-old college student comes to the office for evaluation of a rash. His symptoms began 2 months ago on his face and progressed over time to involve his upper chest, upper back, and axillary areas. The rash is associated with mild pruritus and erythema but no pain, fever, or exudate. The patient has a history of acne during adolescence and increasing "dandruff" over the last year; his medical history is otherwise unremarkable. He takes no regular medications. The patient does not use tobacco but drinks alcohol heavily on weekends and occasionally smokes marijuana. Temperature is 36.8 C (98.2 F), blood pressure is 118/70 mm Hg, and pulse is 64/min. BMI is 26 kg/m². Physical examination shows erythematous plaques on the eyebrows, nasal bridge, nasolabial folds, upper lip, upper chest, and back. The plaques have an indistinct margin and are covered by fine, greasy scales. Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_be88_32a0_8f63_1f64ce002471_MD0005_00 This patient has characteristic features of seborrheic dermatitis, including mildly pruritic, erythematous plaques with greasy scales. Seborrheic dermatitis affects areas with heavy concentrations of sebaceous glands, including the scalp (where it is often referred to as "dandruff"), central face (eg, eyebrows, nasal bridge, nasolabial folds), and ears; it may also occur on the chest, upper back, axilla, and inguinal/pubic area. Treatment commonly includes topical antifungals (eg, selenium sulfide shampoo, topical ketoconazole), topical glucocorticoids (eg, betamethasone valerate), or calcineurin inhibitors (eg, pimecrolimus cream). Seborrheic dermatitis "dandruff" Seborrheic dermatitis usually occurs as an isolated condition. However, it has an increased incidence in association with central nervous system disorders (especially Parkinson disease). It is also common in HIV infection and can be a presenting feature. Physicians should consider the possibility of HIV infection in patients with a new onset of severe or widespread seborrheic dermatitis, lesions in unusual sites (eg, extremities), or who fail to respond to appropriate treatment. severe (Choice A) The diagnosis of seborrheic dermatitis is based primarily on clinical features. Biopsy findings are nonspecific and usually not needed for diagnosis. (Choice B) Potassium hydroxide preparation of skin scrapings can identify the hyphae and yeast forms of Malassezia species in patients with tinea versicolor. Although Malassezia species are also implicated in seborrheic dermatitis, their precise role in the pathogenesis is unclear and identification is not needed for diagnosis. tinea versicolor (Choice C) Antinuclear antibody assay is used as an initial test for systemic lupus erythematosus (SLE). SLE causes a characteristic rash affecting the central face and other sun-exposed areas, but, unlike in seborrheic dermatitis, the lesions are typically not scaly and the nasolabial folds, scalp, and eyebrows are relatively spared. rash (Choice D) Sarcoidosis is associated with a variety of dermal manifestations, including lupus pernio, which presents as erythematous papules and plaques affecting the central face. This patient's involvement of the scalp, eyebrows, and nasolabial folds is more characteristic of seborrheic dermatitis. lupus pernio Educational objective: Seborrheic dermatitis is characterized by pruritic, erythematous plaques with greasy scales and typically affects the scalp, central face, and ears. It usually occurs as an isolated condition but has an increased incidence in association with Parkinson disease and HIV infection, in which it may be a presenting feature. References: Diagnosis and treatment of seborrheic dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/25822272)

Question 12

A 65-year-old woman comes to the physician with a 5-day history of rash and generalized itching.  She initially developed a rash on her hand that spread to her feet, abdomen, and groin area.  The patient also has intense pruritus that is worse at night.  Her husband started having similar symptoms approximately 3 days ago.  She works as a patient aide in a nursing home and has no other medical conditions.  The patient had chickenpox when she was 7 years old.  Her vital signs are within normal limits.  Skin examination (image below) shows multiple small erythematous papules on her palms, sides of the fingers, wrists, lateral aspect of the feet, and periumbilical area.  Her husband has similar lesions on the same body parts and also over the shaft of his penis.  The remainder of her examination is within normal limits.  The patient's test results confirm the suspected diagnosis.  Which of the following is the treatment of choice for this condition?

Accepted Answer

Explanation: Treatment of scabies includes eradicating the mites, decreasing pruritus due to the dermatitis, and prescribing oral antibiotics for any secondary bacterial skin infections. Topical application of 5% permethrin cream over the whole body (excluding the head) is preferred for eradicating the mites. The cream should be massaged thoroughly from the neck down and then removed by thorough washing after 8-14 hours. Common adverse reactions of permethrin cream include local burning and pruritus. Oral ivermectin is also a treatment option, especially for outbreaks in nursing homes and other facilities where it may be difficult to use topical therapy. Oral antihistamines can help decrease the dermatitis and associated itching, and topical steroids may be used for persistent dermatitis after mite eradication (Choice B). All family members and close contacts should be treated at the same time as the index patient to prevent re-infestation. Bedding and clothing should be cleaned or placed in a plastic bag for at least 3 days as the mite can only live away from human skin for 2-3 days. (Choices A and E) Antiviral treatment with valacyclovir is indicated for patients with herpes zoster (within 72 hours of lesion eruption) and in all patients with ophthalmic involvement. Topical acyclovir cream is indicated for herpes simplex virus infection. (Choice C) Topical application of 1% terbinafine cream is indicated in patients with localized tinea infections. Educational objective: Topical application of 5% permethrin cream over the whole body (excluding the head) is the treatment of choice for eradicating the mites of scabies. Oral ivermectin is an acceptable alternative. References: Scabies. (http://www.ncbi.nlm.nih.gov/pubmed/19580575)

Question 13

A 20-year-old college student comes to see you in the office for a physical exam before leaving for a vacation.  She plans to go to the Caribbean for a two-week summer break.  She has no medical problems.  She takes an oral contraceptive pill regularly.  She denies smoking, but admits to occasional alcohol intake on weekends.  She plans to be out in the sun a lot, and is concerned about the possible skin damage from excessive sun exposure.  You counsel her on sun protective behaviors and advise her to use a sunscreen with a SPF of 15 or more.  Which of the following measures should you recommend to help her prevent or reduce further skin damage?

Accepted Answer

Explanation: Sun exposure or UV radiation-induced skin damage (sunburn) and risk of malignancy is a common and preventable problem. Dehydration is another cause which can aggravate skin damage by causing intracellular damage and cell death. All persons, especially those at high risk of exposure, should be counseled regarding the harmful effects of prolonged sun exposure and the ways to prevent it. Such patients should be advised to use sun protective behaviors, protective barriers (e.g., clothing and sunscreens), and perform measures to maintain adequate hydration. (Choices A, B, C and E)Sea foods, corticosteroid creams, avoiding alcoholic beverages, and vitamin E have not been shown to prevent skin damage caused by excessive sun exposure. Educational objective: Sun protective behaviors, sunscreens, and maintaining adequate hydration are the key factors to prevent skin damage from sun exposure.

Question 14

A 52-year-old homeless man comes to the urgent care clinic due to itching and discomfort in both feet.  He has had these symptoms for the past year but they intensified recently.  His shoes are uncomfortable and cause irritation.  Several shelter residents also have some "swelling of the feet."  The patient was told that he has "borderline" diabetes and high blood pressure.  He has no regular medical follow-up.  Physical examination shows extensive erythema and scaling, especially between the toes, as well as multiple thickened and brittle toenails as shown in the image below.  Which of the following is the best treatment for this patient?

Accepted Answer

Explanation: This patient has typical clinical features of chronic tinea pedis (TP). TP is characterized by slowly progressive pruritus of the feet, erythema and scaling between the toes, and extension to the soles and sides of the feet with a sharp border between the involved and uninvolved skin. TP is the most common dermatophyte infection and may be accompanied by infection of the hands (tinea manuum) or groin (tinea cruris). It may also extend into the toenails as well (onychomycosis). Acute TP, presenting with rapid onset vesicular or bullous lesions and severe pruritus, is usually self-limiting. However, chronic TP is usually persistent or relapsing. The organisms causing TP are widespread, and it is most commonly seen following exposure to public places while barefoot (eg, athletic facilities, public swimming pools). (tinea manuum) (tinea cruris) Acute TP Mild TP usually responds to topical antifungals (eg, terbinafine, miconazole, clotrimazole) in 1-4 weeks. More extensive disease or failure of topical agents may require oral therapy (eg, terbinafine, itraconazole, fluconazole). Patients with onychomycosis also require oral antifungals with a prolonged 12-week treatment course. onychomycosis (Choice A) Griseofulvin is less effective than terbinafine and requires a longer treatment period. (Choice C) Topical hydrocortisone is indicated for mild inflammatory dermatoses (eg, mild contact dermatitis or atopic eczema). It may be useful as adjunctive therapy for TP in patients with unbearable itching, but it should not be used alone as it may lead to prolonged infection. (Choice D) Topical nystatin is indicated for treatment of skin infections due to Candida (eg, intertrigo) but is ineffective for TP. intertrigo (Choice E) Topical permethrin is indicated for scabies treatment. Scabies is characterized by scaly, erythematous linear papules involving the hands, wrists, and/or groin. Scabies Educational objective: Tinea pedis is a common superficial fungal infection of the foot with pruritic, erythematous, and well-demarcated lesions. Mild cases can be treated with topical antifungal agents. More severe cases or associated onychomycosis require oral antifungals. References: Oral treatments for fungal infections of the skin of the foot. (http://www.ncbi.nlm.nih.gov/pubmed/23076898)

Question 15

A 47-year-old-man comes to the physician for a lesion on his foot.  He has a 2-month history of an enlarging, painful, and thickened papule on the plantar surface of his left great toe.  The patient attempted treatment for 2 weeks with a "corn pad" without relief.  He has no prior history of similar lesions, and his past medical history is unremarkable.  
Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: This patient's presentation is consistent with plantar warts (verrucae), which are a form of cutaneous warts usually due to human papillomavirus (HPV). Plantar warts most often occur in young adults or in individuals with certain occupations (eg, meat, poultry, and fish handlers). More extensive disease occurs in patients with atopic dermatitis and conditions with decreased cellular immunity (eg, HIV, organ transplantation). Infection typically occurs via skin-to-skin contact and can have an incubation period of 2-6 months after exposure. The diagnosis of plantar warts is usually made clinically with visualization of single or multiple hyperkeratotic papules on the sole of the foot (as seen in this patient). Scrapings of hyperkeratotic debris can confirm the diagnosis by showing thrombosed capillaries (also called seeds). A shave or punch biopsy is rarely needed to confirm the diagnosis in uncertain cases (Choice B). Salicylic acid is preferred as initial treatment for plantar warts. Patients are instructed to prepare the affected area by soaking it in warm water for 10-20 minutes. The salicylic acid is then applied to the wart, taped in place with duct or athletic tape, and then kept dry for 48-72 hours. The patient should then remove the patch, pare the area down with a file or sandpaper, and then repeat the application. Liquid nitrogen cryotherapy is a reasonable alternative, but it can cause local burning and is usually avoided in dark-skinned individuals due to possible hypopigmentation. (Choice A) Daily application of duct tape alone has not been shown to effectively and consistently treat plantar warts. However, duct tape combined with salicylic acid has been effective in many patients. (Choice C) Snip or shave excision is usually preferred for filiform cutaneous warts, which usually appear as a solitary papule with finger-like keratotic projections. filiform cutaneous warts (Choice D) Topical miconazole cream is a treatment option for tinea pedis, which usually presents as chronic and progressive pruritic erosions or scales between the toes. tinea pedis Educational objective: Plantar warts usually present as single or multiple hyperkeratotic papules on the sole of the foot. Topical salicylic acid is the first-line therapy for plantar warts. Other options include liquid nitrogen cryotherapy. References: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae): a randomized controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/21652750)

Question 16

A 16-year-old boy is brought to the office due to a rash on his chin.  The boy sustained a minor cut while shaving with his father's razor 4 days ago.  The patient was also using a new shaving cream at the time.  The bleeding stopped with minimal pressure.  The surrounding skin appeared red the next day.  Since then, the affected area has increased in size, become tender, and appeared "wet."  This morning, the rash is "dry and crusty."  The patient has a history of acne vulgaris and uses a topical retinoid and benzoyl peroxide on his forehead and cheeks.  He also periodically develops "cold sores" when experiencing stress, such as before tests at school.  He takes no other medications and has no known allergies.  Temperature is 37 C (98.6 F).  Physical examination shows a well-appearing adolescent in no distress.  Skin examination reveals inflammatory acne on the cheeks and forehead.  The rash on the chin is shown in the exhibit.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Explanation: 11ec2b69_be8c_9f72_8f63_810b11d9a965_MD0005_00 Impetigo is a contagious, superficial skin infection most commonly caused by Staphylococcus aureus or Streptococcus pyogenes. Infection often develops within superficial wounds, such as in this patient with a facial cut. It can also develop from any break in the skin, such as with eczema or insect bites. Presentation includes erythematous pustules that subsequently develop a classic, thick honey-colored crusting. Lesions may be painful or pruritic. Diagnosis of impetigo is clinical. Topical antibiotics (eg, mupirocin) alone can treat isolated, small areas of infection, whereas oral antibiotics (eg, cephalexin) are warranted for extensive infection. (Choice A) Contact dermatitis presents with pruritic, painful erythema in an area exposed to an allergen or irritant. Although this patient was exposed to a new product, the slow spread of this localized rash with overlying crusting makes contact dermatitis unlikely. (Choice B) Erysipelas is also a superficial skin infection but presents with well-demarcated, bright red erythema, classically on the cheeks. This patient's rash with overlying crusting is classic for impetigo. (Choice C) Herpes simplex infection presents with clusters of painful vesicles, typically along the vermilion border of the lip. This patient's facial rash is located on the chin, is not vesicular, and has an adherent crusting characteristic of impetigo. (Choice E) Tinea barbae is a dermatophyte infection that presents in the distribution of a beard in men. Although this contagious disease can be spread via shared razors, examination reveals a scattered folliculitis with erythematous papules and pustules, not honey-colored crusting. Educational objective: Impetigo is a contagious, superficial skin infection that presents with erythematous pustules and a classic overlying honey-colored crust. References: Impetigo. (http://www.ncbi.nlm.nih.gov/pubmed/28613693)

Question 17

A 48-year-old woman comes to the office due to a recurrent rash.  Six months ago, a rash developed on her legs that she describes as "red patches with raised areas."  The rash worsened that night with intense itching that disrupted her sleep.  It spontaneously resolved over the next day.  Since then, she has had repeated episodes of similar symptoms on her arms, legs, and back, each lasting 8-12 hours and occurring nearly every 2-3 weeks.  She reports no trauma, insect bites, travel history, sick contacts, or changes in weight.  Medical history is notable for hypertension treated with lisinopril.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.1 C (97 F), blood pressure is 138/77 mm Hg, and pulse is 78/min.  Physical examination is within normal limits.  The patient brings a photo of the rash, shown in the image below, from her most recent episode 2 days ago. Complete blood count, urinalysis, erythrocyte sedimentation rate, and liver function studies are within normal limits.  
Which of the following is the best next step in management of this patient's condition?

Accepted Answer

Explanation: 11ec2b69_be93_7d48_8f63_8fc050422492_MD0005_00 This patient has chronic spontaneous urticaria, defined as episodic urticaria lasting >6 weeks that occurs without apparent triggers (eg, physical stimuli). As in this patient, lesions are intensely pruritic, presenting as confluent round or serpiginous erythematous plaques (ie, wheals). Individual lesions appear and enlarge over minutes to hours before disappearing within 24 hours. Some 40% of cases are also accompanied by angioedema. Chronic spontaneous urticaria is idiopathic 80%-90% of the time, and the diagnosis is based on clinical findings. However, because of its association with atopic and rheumatologic diseases, a limited laboratory evaluation consisting of complete blood count, inflammatory markers, liver function studies, and urinalysis is recommended, especially when other symptoms (eg, arthritis, weight loss, fever) are present. More detailed testing is not generally necessary. (Choice A) C1 esterase inhibitor levels are decreased in hereditary angioedema, which typically causes angioedema of the throat, tongue, or lips without urticaria. Patients can also have abdominal pain due to angioedema of the intestinal mucosa. (Choice C) An elevated serum antinuclear antibody level is one of the diagnostic criteria for systemic lupus erythematosus (SLE), which can be associated with chronic urticaria. However, this patient has no other clinical findings (eg, malar rash, arthritis, serositis) of SLE. (Choice D) Tryptase is a biomarker for mast cells, and elevated levels can be seen in systemic mastocytosis. However, this patient lacks the syncope, flushing, hypotension, vomiting, or abdominal pain typically seen with excessive histamine release. (Choice E) Skin biopsy is not required to diagnose chronic urticaria unless systemic symptoms (eg, abdominal pain, fever, weight loss), atypical symptoms (eg, pain instead of pruritus, petechiae/purpura, individual lesions persisting >24 hr), or elevated inflammatory markers are present to suggest urticarial vasculitis or mastocytosis. Lesions that do not respond to treatment also warrant biopsy. Educational objective: Chronic spontaneous urticaria presents with pruritic wheals that occur episodically over >6 weeks. A total of 80%-90% of cases are idiopathic, but some are associated with atopic or rheumatologic disorders. A limited laboratory workup (eg, complete blood count, inflammatory markers, liver function studies, urinalysis) is recommended to assess for potential underlying disorders. References: Chronic spontaneous urticaria: the devil's itch. (http://www.ncbi.nlm.nih.gov/pubmed/30033911)

Question 18

A 48-year-old woman comes to the office due to a recurrent rash.  Six months ago, a rash developed on her legs that she describes as "red patches with raised areas."  The rash worsened that night with intense itching that disrupted her sleep.  It spontaneously resolved over the next day.  Since then, she has had repeated episodes of similar symptoms on her arms, legs, and back, each lasting 8-12 hours and occurring nearly every 2-3 weeks.  She reports no trauma, insect bites, travel history, sick contacts, or changes in weight.  Medical history is notable for hypertension treated with lisinopril.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.1 C (97 F), blood pressure is 138/77 mm Hg, and pulse is 78/min.  Physical examination is within normal limits.  The patient brings a photo of the rash, shown in the image below, from her most recent episode 2 days ago. Complete blood count, urinalysis, erythrocyte sedimentation rate, and liver function studies are within normal limits.
 The patient currently has no rash but would like treatment recommendations for possible future episodes.  Which of the following is the most appropriate treatment for this patient?

Accepted Answer

Explanation: 11ec2b69_be95_ee4b_8f63_8b6180749f9c_MD0005_00 Chronic spontaneous urticaria is usually treated with a stepwise approach. Although the pathogenesis of the condition is not fully elucidated, H1 antihistamines provide symptom control in many patients. Therefore, initial management includes a second-generation H₁ blocker (eg, loratadine, cetirizine) along with avoidance of any apparent aggravating factors (eg, heat, cold, stress). For persistent symptoms, the following may be added: First-generation H₁ blocker (eg, hydroxyzine) at bedtime (higher risk of sedation and anticholinergic side effects) (Choice B) Leukotriene receptor antagonist (eg, montelukast) (Choice C) H₂ blocker (eg, cimetidine) (conflicting data regarding efficacy), or Brief course of oral glucocorticoids (Choice D). Patients with refractory symptoms can be considered for immune-modulating therapies (eg, hydroxychloroquine, tacrolimus, omalizumab). (Choice E) Topical corticosteroids do not effectively treat chronic urticaria and can cause dermal atrophy when used for prolonged periods. Educational objective: The initial treatment for chronic spontaneous urticaria involves a second-generation H₁ blocker (eg, loratadine, cetirizine) and avoidance of aggravating factors (eg, heat, cold, stress). In patients with refractory symptoms, a first-generation H₁ blocker at bedtime, leukotriene receptor antagonist, H₂ blocker, or brief course of oral glucocorticoids can be tried. References: Chronic urticaria: an overview of treatment and recent patents. (http://www.ncbi.nlm.nih.gov/pubmed/30924425)

Question 19

An 8-year-old girl is brought to the office by her mother due to hair loss on her scalp.  The mother first noticed a patch of hair loss a week ago, and the affected area is now slightly larger in diameter.  The area is flaking and very pruritic.  She also mentions, "My son had a similar rash on his arm but I didn't want to use his cream on her without an evaluation."  The patient has had no fever, and there is no oozing, warmth, or edema of the scalp.  She has no medical conditions and takes no medications.  Immunizations are up to date.  Physical examination shows a well-appearing girl who is scratching her scalp.  Examination of the area of hair loss is shown below.  Mildly tender posterior cervical lymphadenopathy is present.  Which of the following is the most appropriate treatment for this patient's condition?

Accepted Answer

Explanation: 11ec2b69_be8f_5e94_8f63_3df640b45c3b_MD0005_00 Tinea capitis is a superficial dermatophyte (eg, Trichophyton) infection of the scalp. It classically presents as pruritic, scaly, erythematous patches that grow centrifugally and have hair loss. Proximal hair shafts may be visualized as small dots in the area of hair loss, and cervical lymphadenopathy may be present. Transmission occurs via direct contact with an infected individual or fomite (eg, shared hats or combs). Diagnosis is often clinical but can be confirmed with potassium hydroxide (KOH) examination of the hair shaft. First-line treatment for tinea capitis is a systemic antifungal, either oral griseofulvin or oral terbinafine. An oral agent must be used in the treatment of tinea capitis to penetrate hair follicles. Adjunctive treatments, such as ketoconazole shampoo, can also be used to help prevent spread of disease but are insufficient as monotherapy. (Choices A and C) Alopecia areata, an immune-mediated disease, is characterized by smooth areas of hair loss and is treated with topical or intralesional corticosteroids (eg, triamcinolone). Scaling and erythema are not seen, and pruritus is uncommon. Topical corticosteroids (eg, hydrocortisone) are also indicated in the treatment of eczema, which presents with dry, pruritic, erythematous patches. Distribution can involve the scalp in infants, but eczema typically affects flexural areas (eg, antecubital fossa) in older children and is not associated with hair loss. Alopecia areata (Choice D) Topical permethrin is the treatment for lice (Pediculus humanus capitis) infestation. Although lice can also spread by fomites and present with pruritus and lymphadenopathy, nits or live lice are visualized on examination and alopecia is not typical. live lice (Choice E) Topical terbinafine is effective against dermatophyte infections of the skin (eg, tinea corporis). An oral agent must be used in the treatment of tinea capitis to penetrate hair follicles. Educational objective: Tinea capitis is a dermatophytosis that causes scaly, erythematous patches of the scalp with hair loss. First-line treatment is oral griseofulvin or oral terbinafine. References: Management of tinea capitis in childhood. (http://www.ncbi.nlm.nih.gov/pubmed/21437064) Tinea capitis: current status. (http://www.ncbi.nlm.nih.gov/pubmed/27599708)

Question 20

A 47-year-old-man comes to the physician for a lesion on his foot.  He has a 2-month history of an enlarging, painful, and thickened papule on the plantar surface of his left great toe.  The patient attempted treatment for 2 weeks with a "corn pad" without relief.  He has no prior history of similar lesions, and his past medical history is unremarkable.  The patient returns in 10 days and has only partial improvement in the size of the lesion.  Which of the following is the most appropriate advice for this patient?

Accepted Answer

Explanation: Initial response to salicylic acid may take 2-3 weeks to become apparent. Patients are usually assessed at 2-3 week intervals for resolution. Treatment is continued for 1-2 weeks after clinical resolution to eradicate the virus and prevent recurrence. Some patients may require treatment for several weeks or months. Liquid nitrogen cryotherapy also often requires repeat treatment at regular intervals of 2-3 weeks. It is too soon to determine treatment failure in this patient, and he still needs continued treatment with salicylic acid before considering alternate options. (Choices A, B, and E) Topical imiquimod is an immunomodulator that induces local cytokines. It is used more commonly for anogenital warts but can be used for plantar warts that do not respond to or tolerate initial therapy (salicylic acid, liquid nitrogen). Patients who do not improve with medical therapy may need referral to a dermatologist for other options or surgical excision. (Choice D) Discarding and replacing footwear can prevent recurrence of plantar warts after successful treatment, but this patient first needs treatment with salicylic acid to eradicate the virus. Educational objective: The initial response to salicylic acid treatment for plantar warts may take 2-3 weeks to become apparent. Patients are usually assessed at 2-3 week intervals and treatment is continued for 1-2 weeks after clinical resolution to eradicate the virus and prevent recurrence. References: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae): a randomized controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/21652750)

Exam 1: Advanced Clinical Medicine

A 26-year-old woman comes to see you in the office. She has tattoo marks on the back of her neck and anterior chest wall. She has had these tattoos for 10 years and wants to remove them now. Which of the following is the correct statement regarding the removal of tattoo marks?