Question 1

A 23-year-old woman comes to the physician with skin lesions.  She noticed a small papule 2 weeks ago and now has additional similar lesions.  There is no associated pain.  The patient has had no systemic symptoms except 1 day of diarrhea that resolved 3 weeks ago.  She has no previous medical problems and works as an assistant at a veterinary facility.  The patient has been sexually active with a new partner.  She drinks alcohol socially, but does not use tobacco or illicit drugs.  Her vital signs are normal.  Physical examination is normal except for the lesions as shown below.  Which of the following is the most likely cause of her skin lesions?
A)Autoimmune condition
B)Fungal infection
C)Insulin resistance
D)Occupational exposure
E)Skin-to-skin contact

Accepted Answer

Explanation: Molluscum contagiosum (MC) is a self-limited, localized skin infection caused by a poxvirus. It is characterized by small skin-colored papules with indented centers that may occur anywhere except the palms and soles. The lesions may be accompanied by pruritus and surrounding dermatitis. Children are most commonly affected, but adolescents, adults, and immunocompromised individuals can also develop MC. Transmission is through skin-to-skin contact or contact with contaminated fomites. MC is often transmitted through sexual contact and may be seen in association with other sexually-transmitted diseases. It is also frequently seen in patients with HIV and may be more widely disseminated and persistent in these patients. HIV testing should be considered in patients with MC, especially for lesions that are widespread or involve the face. MC diagnosis is clinical and based on characteristic findings. The condition is typically self-limited, but treatment may be considered to prevent further spread, reduce symptoms, or improve cosmesis. There are a number of techniques to remove lesions including physical destruction via curettage/cryotherapy or chemical removal with topical agents (eg, podophyllotoxin). (Choice A) Gottron's papules are red/purple papules or plaques associated with dermatomyositis. These typically involve the dorsal and radial surfaces of the metacarpophalangeal joints, proximal interphalangeal joints, and proximal phalanx. Gottron's papules (Choice B) Extrapulmonary blastomycosis is an uncommon cause of skin papules that may be seen with or without an acute pulmonary syndrome. Lesions are typically wart-like or pustular. Blastomycosis follows a characteristic geographic distribution. Sporotrichosis causes ulcerating nodular lesions that are most commonly seen on the hands or arms. geographic distribution Sporotrichosis (Choice C) Common cutaneous signs of insulin resistance include skin tags, acanthosis nigricans, and xanthelasma. skin tags acanthosis nigricans xanthelasma (Choice D) Contagious ecthyma (orf) is caused by a poxvirus of sheep and goats and begins as a single erythematous papule on the hand. Milker's nodules are maculopapular/vesicular lesions caused by a parapoxvirus of cows. Both of these conditions are self-limited and very uncommon. Educational objective: Molluscum contagiosum (MC) causes single or multiple skin-colored, small papules with indented centers and is transmitted via skin-to-skin contact. The lesions can be either asymptomatic or pruritic and can occasionally be accompanied by surrounding dermatitis. Treatment is usually conservative. HIV testing should be considered in patients with MC, especially if they have lesions involving the face. References: Molluscum contagiosum virus infection. (http://www.ncbi.nlm.nih.gov/pubmed/23972567)

Question 2

A 19-year-old woman comes to the office due to a bothersome rash on her shoulders and upper arms for the last 5 years that is associated with significant itching during cold, dry weather.  The patient says, "I had eczema when I was a baby that got better when I got older.  I kept thinking this would go away too, but it just gets worse."  Medical history is otherwise unremarkable, and she takes no medications.  Skin examination findings are shown in the exhibit.  Which of the following is the most appropriate next step in management of this patient's skin condition?
A)Gluten-free diet
B)HIV testing
C)Oral minocycline
D)Skin biopsy
E)Urea cream

Accepted Answer

Explanation: This patient has a papular rash consistent with keratosis pilaris (KP). KP ("chicken skin") is a benign condition characterized by retained keratin plugs in the hair follicles. It presents with small, painless papules, a roughened skin texture, and mottled perifollicular erythema. KP can occur anywhere but is most common on the posterior surface of the upper arm. It is usually asymptomatic but can become pruritic in cold, dry weather and can occasionally form small pustules. KP can occur alone or in association with atopic disorders (eg, atopic dermatitis, asthma). The diagnosis is typically obvious based on appearance; biopsy can reveal keratin plugs, dilated hair follicles, and a sterile lymphocytic infiltrate but is rarely needed for diagnosis (Choice D). Treatment, when necessary, includes emollients and topical keratolytics (eg, salicylic acid, urea), which can help soften the papules. (Choice A) Dermatitis herpetiformis is a skin disorder associated with celiac disease that generally improves with a gluten-free diet. It presents with intensely pruritic papules, vesicles, and bullae on the elbows, back, knees, and buttocks. (Choice B) HIV increases the risk for infectious skin diseases, such as molluscum contagiosum. Patients with HIV can develop numerous molluscum lesions, but these papules are smooth, firm, and umbilicated; would not be limited to the shoulders and arms; and usually resolve spontaneously. (Choice C) Oral minocycline is used for treatment of inflammatory acne, which presents with inflamed papules and pustules. Although the shoulders and upper arms can be affected, the central face is usually also involved. Educational objective: Keratosis pilaris is characterized by retained keratin plugs in the hair follicles. It presents with small papules; a roughened skin texture; and mottled, perifollicular erythema, most commonly on the posterior surface of the upper arm. Treatment includes emollients and topical keratolytics (eg, salicylic acid, urea).

Question 3

A 62-year-old man comes to the community health center due to a "flaky and itchy" scalp.  He is uncertain when the symptoms began and believes his brother has a similar problem.  The patient has not attempted any specific treatments but washes his hair with a mild shampoo every other day and washes his face with cold water once daily.  Medical history is notable for coronary artery disease, type 2 diabetes mellitus, benign prostatic hyperplasia, and diverticulosis.  The patient is a recovering alcoholic and has lived in a group home for the last 3 months.  Vital signs are normal.  Physical examination shows oily skin with faint erythema and scaling of the scalp, eyebrows, and ears, as shown below.  During the course of the visit, the patient repeatedly scratches his head and eyebrows, but the remainder of the skin examination is normal.  
Which of the following is the best initial treatment for this patient?
A)Oral griseofulvin
B)Oral ketoconazole
C)Permethrin cream
D)Selenium sulfide shampoo
E)Topical nystatin

Accepted Answer

Explanation: 11ec2b69_c129_4372_8f63_f1f9a09a4dfe_MD0005_00 This patient's erythematous, scaly rash has the typical appearance of seborrheic dermatitis (SD). SD predominantly affects areas with heavy concentrations of sebaceous glands, including the scalp (where it is referred to as "dandruff"), central face (eg, eyebrows, nasolabial folds), and ears. In addition, SD may occasionally be seen on the chest, upper back, axilla, and inguinal/pubic area. SD is most common in the first year of life and again in adulthood. The diagnosis of SD is primarily clinical, with typical findings characterized by pruritic, erythematous plaques with loose, greasy-looking scales. Malassezia species may play a role in the pathogenesis of SD, and topical antifungal agents (eg, ketoconazole, selenium sulfide) are effective in treating this condition. Other treatments that can be helpful include topical glucocorticoids, keratolytic agents (eg, salicylic acid), coal tar shampoo, and topical calcineurin inhibitors (eg, pimecrolimus, tacrolimus). (Choice A) Griseofulvin is used in tinea capitis, a dermatophyte infection most commonly seen in children, and tinea corporis, which causes annular plaques with peripheral scaling and central clearing. Griseofulvin is not effective against Malassezia species and can worsen SD. tinea corporis (Choice B) Oral antifungals (eg, itraconazole, ketoconazole) are occasionally used in SD, but they are not first-line treatments and are used primarily in severe, refractory cases. (Choice C) Permethrin is used to treat scabies, which presents with intensely pruritic papules and vesicles between the fingers as well as on the volar wrists, elbows, axillae, lower abdomen, or genitalia. Crusted scabies can cause large, scaly patches but is not pruritic and occurs most commonly in immunocompromised patients (eg, lymphoma, AIDS). scaly patches (Choice E) Topical nystatin is used primarily to treat intertrigo and other disorders caused by Candida species yeasts; it is not used in SD. Educational objective: Seborrheic dermatitis is characterized by erythematous plaques with loose, greasy-looking scales on the scalp ("dandruff"), central face, and ears. Treatment options include topical antifungal agents (eg, ketoconazole, selenium sulfide), keratolytic agents (eg, salicylic acid), coal tar, topical glucocorticoids, and topical calcineurin inhibitors (eg, pimecrolimus, tacrolimus). References: Diagnosis and treatment of seborrheic dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/25822272)

Question 4

A 64-year-old woman comes to the physician due to thickening and discoloration of her toenails.  Her nails are rough, and this is starting to cause pain and making it difficult to wear shoes with socks.  A few months ago, she first noticed that the big toes of both feet were affected, subsequently several other nails became affected as well.  On physical examination, the affected nails appear rough, brittle, and discolored as shown in the image below.  Potassium hydroxide preparation of nail scrapings shows dermatophytic hyphae and arthrospores.  Which of the following is the most effective treatment regimen for this patient's condition?
A)Ciclopirox
B)Fluconazole
C)Griseofulvin
D)Ketoconazole
E)Terbinafine

Accepted Answer

Explanation: 11ec2b69_c128_8020_8f63_3d8445d78e23_MD0005_00 Onychomycosis is a fungal infection of the toenails or fingernails. The most common form of onychomycosis is distal subungual onychomycosis, which is caused by the dermatophyte Trichophyton rubrum. Because nail dystrophies caused by other diseases (eg, psoriasis, lichen planus, eczematous conditions) can mimic the appearance of onychomycosis, confirmation with potassium hydroxide (KOH) preparation or periodic acid-Schiff staining of nail scrapings is recommended. If KOH examination is negative, then evaluation by culture is appropriate. Patients often request treatment of onychomycosis for cosmetic reasons; such treatment may be considered in carefully selected patients. However, patients should be advised about the risks of treatment (primarily hepatotoxicity), and the potential of treatment failure and recurrence. Medical indications for treatment of onychomycosis include significant pain or functional limitation, history of cellulitis in the affected extremity, or additional risk factors for cellulitis (eg, diabetes). Oral terbinafine is considered first-line therapy, and oral itraconazole is an acceptable alternative. Infection of the fingernails requires 6 weeks of therapy, and infection of the toenails requires 12 weeks. (Choice A) Ciclopirox is a topical antifungal nail lacquer approved for the treatment of mild-to-moderate onychomycosis. Although ciclopirox is considered safe, studies show its efficacy to be minimal. (Choice B) Fluconazole is an option in the treatment of onychomycosis, and its weekly dosage may be particularly appealing for those patients with complex medication regimens. However, it is less effective and more expensive than terbinafine and itraconazole. (Choices C and D) Griseofulvin and ketoconazole are rarely used now that terbinafine and itraconazole are available. These older medications required lengthy treatment regimens (often up to 18 months) with frequent laboratory monitoring, and were associated with high relapse rates and numerous adverse effects. Educational objective: Because nail dystrophies caused by other diseases (eg, psoriasis, lichen planus) can mimic the appearance of onychomycosis, confirmation with potassium hydroxide (KOH) preparation or culture of nail scrapings is recommended. Terbinafine is the preferred first-line therapy. References: Oral therapy for onychomycosis: an evidence-based review. (http://www.ncbi.nlm.nih.gov/pubmed/24352873) Onychomycosis: Current trends in diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/24364524)

Question 5

A 65-year-old Caucasian male presents to your office and complains of a hearing impairment.  He is a manager and runs his own business.  He noticed that it is now difficult for him to understand his employees during business meetings.  He hears well and speaks fluently while on the phone or when talking to his wife, but he poorly understands 'the people talking on TV shows'.  His past medical history is insignificant.  He is physically active, and works out in the gym three times a week.  He does not smoke or consume alcohol.  He is not taking any medications.  You perform a speech discrimination test that turns out to be normal.  Which of the following actions will most likely reveal an impaired speech discrimination in this patient?
A)Speaking slowly
B)Decreasing visual stimulation
C)Creating background noise
D)Decreasing the intensity of sounds
E)Using more familiar vocabulary

Accepted Answer

Explanation: This patient presents with symptoms and signs suggestive of presbycusis, a sensorineural hearing impairment in elderly individuals. Usually, the disease is gradually progressive, and initially affects the high-frequency range of hearing. The decreased ability to discriminate speech is especially obvious in a noisy, distracting environment. This is why the patient can participate in a phone conversation and talk to his wife, but has difficulties in understanding spoken language during business meetings and while watching TV shows. The speech discrimination score may be normal in these patients; however, introducing background noise can reveal the hearing loss. (Choices A and E)Patients with presbycusis have difficulties understanding rapid speech and a complex or less familiar vocabulary. (Choices D and B)Decreasing the intensity of sounds and decreasing visual stimulation are less useful in eliciting the hearing problem in this patient. Educational Objective: The decreased ability to discriminate speech in patients with presbycusis is especially obvious in a noisy, distracting environment.

Question 6

A 49-year-old woman comes to the emergency department due to hearing loss.  Upon awakening this morning, she was unable to hear out of her right ear.  She also hears a loud ringing noise in her right ear.  The patient has no ear pain or dizziness.  This has never occurred before.  She has no other medical conditions and takes no medications.  Vital signs are within normal limits.  On examination, the ear canals and tympanic membranes are clear.  There is no middle ear effusion.  Weber tuning fork examination lateralizes to the left.  Air conduction is greater than bone conduction bilaterally.  The remainder of the neurologic examination is normal.  Which of the following is the most appropriate next step in management of this patient?
A)Amoxicillin-clavulanic acid
B)Aural irrigation
C)Ciprofloxacin ear drops
D)Reassurance and follow-up in 6 weeks
E)Urgent otolaryngology evaluation

Accepted Answer

Explanation: 11ec2b69_c12b_b477_8f63_2549e7e984d1_MD0005_00 This patient has a sudden hearing loss with no history of trauma or pain, a normal ear examination, and an otherwise normal neurologic examination. Tuning fork examination shows the hearing loss is sensorineural rather than conductive (Table). The etiology of sudden sensorineural hearing loss (SSNHL) is often not determined. Most cases likely represent viral infection, microvascular events, or an autoimmune process; in some cases, a tumor (eg, schwannoma) or other cause of sensorineural hearing loss is identified. SSNHL can lead to permanent hearing loss. Therefore, once isolated SSNHL (ie, otherwise normal examination) is recognized, urgent otolaryngology evaluation is indicated. Although study results have not been definitive, high-dose corticosteroids (and/or corticosteroids injected into the middle ear) are recommended soon after the onset of SSNHL (ideally within 24 hours) as they may improve hearing outcomes, particularly among patients with severe hearing loss. Their efficacy decreases over time, with no effect after 6 weeks; therefore, reassurance is inappropriate (Choice D). Many patients recover at least some (but often not all) hearing over a few weeks. Antiviral therapy (eg, valacyclovir) in combination with corticosteroids was not found to improve outcomes but is sometimes used if a viral etiology (eg, herpes simplex) is suspected. In addition, an MRI should be obtained to exclude vestibular schwannoma, and a formal audiogram should be performed for full characterization of the hearing loss and follow-up. (Choice A) Amoxicillin-clavulanic acid is often used to treat acute otitis media, which can cause a sudden hearing loss. However, the hearing loss would be conductive rather than sensorineural, the patient would likely have significant pain, and examination of the ears would show an opaque, bulging tympanic membrane. (Choice B) Aural irrigation is sometimes used to remove cerumen. Cerumen impaction can cause acute hearing loss, but it would be conductive rather than sensorineural, and the impaction would prevent examination of the tympanic membranes. (Choice C) Ciprofloxacin ear drops may be used to treat otitis externa. Although it can cause an acute conductive hearing loss, patients would have pain and itching of the ear, and examination would show a swollen, erythematous external auditory canal. Educational objective: Sudden hearing loss should be evaluated to determine if it is conductive or sensorineural. Sudden sensorineural hearing loss should be evaluated urgently by otolaryngology with a formal audiogram, MRI, and corticosteroid therapy. References: Clinical practice guideline: sudden hearing loss. (http://www.ncbi.nlm.nih.gov/pubmed/22383545)

Question 7

A 65-year-old man comes to the office due to a rough lesion on the left cheek for the past 6 months.  The lesion has not changed and is painless and nonpruritic.  Medical history includes type 2 diabetes mellitus.  The patient lived most of his life in Florida and has a history of several sunburns.  Household pets include a dog and a cat.  Skin examination findings are shown in the exhibit.  Which of the following is the most appropriate treatment for this patient's skin condition?
A)Reassurance and no additional therapy
B)Topical clotrimazole
C)Topical lactic acid
D)Topical liquid nitrogen
E)Topical triamcinolone

Accepted Answer

Explanation: 11ec2b69_c123_c529_8f63_6f7b053f67fa_MD0005_00 This patient's rough, asymptomatic facial lesion is most likely actinic keratosis (AK), a precursor to squamous cell carcinoma. AK presents as chronic, scaly papules or plaques and is most common in fair-skinned patients. Lesions are located primarily in sun-damaged areas (eg, face, dorsal hands). Although the papules are typically erythematous, nonerythematous lesions are easily distinguished from dry skin by the characteristic sandpaper-like texture. Other clinical variants of AK include the following: Hypertrophic AK, which presents with thick scales on a red base Atrophic AK, which presents with soft, red macules that lack scales AK associated with a cutaneous horn, which presents as a cone of keratin (straight or curved), typically with AK or SCC at its base The diagnosis is based on clinical examination; hypertrophic AK and cutaneous horns typically require biopsy to rule out SCC. Isolated AKs can be treated effectively with liquid nitrogen cryotherapy. In contrast, numerous or diffuse lesions should be treated with topical therapy (eg, 5-fluorouracil, tirbanibulin), which can cover a large area. Treatment should not be delayed because of the risk for progression to SCC (Choice A). (Choice B) Topical clotrimazole is used to treat tinea facialis, which presents as an erythematous, scaly, annular patch or plaque that spreads without treatment. tinea facialis (Choice C) Topical lactic acid is a keratolytic used to treat ichthyosis, which presents with diffuse, rough, dry skin with fish-like scales usually on the extensor extremities and trunk. An isolated scaly lesion is not characteristic. ichthyosis (Choice E) Topical triamcinolone is used to treat a variety of inflammatory skin lesions (eg, contact dermatitis, atopic dermatitis); most of these disorders are associated with significant pruritus and other inflammatory features (eg, erythema, papule/vesicle formation). This patient's scaly, nonerythematous, nonpruritic lesion is more characteristic of AK, which does not respond to topical corticosteroids. Educational objective: Actinic keratosis typically presents as chronic, scaly papules or plaques with a sandpaper-like texture in sun-damaged areas. Isolated lesions can be effectively managed with liquid nitrogen cryotherapy. References: Actinic keratoses: review of clinical, dermoscopic, and therapeutic aspects (http://www.ncbi.nlm.nih.gov/pubmed/31789244)

Question 8

A 60-year-old male with hypertension and hypercholesterolemia comes for a follow-up visit.  His blood pressure in the office is 160/100 mmHg, and his readings are consistently elevated when he checks his blood pressure at home.  An antihypertensive agent is added to his current regimen.  He takes a brief vacation in Florida, and calls after a few days because he has developed an erythematous rash on the exposed parts of his body.  Which of the following agents is most likely responsible for his rash?
A)Furosemide
B)Hydrochlorothiazide
C)Lisinopril
D)Amlodipine
E)Metoprolol

Accepted Answer

Explanation: The patient is likely to have a photosensitivity reaction, which is most commonly associated with the use of hydrochlorothiazide. Thiazides are sulfonamides; therefore, these can cause photosensitivity or generalized dermatitis. Treatment of the rash includes discontinuation of hydrochlorothiazide, use of sunscreen, and avoidance of sun exposure. (Choice A) Furosemide can cause a Stevens-Johnson syndrome type of reaction that is seen with the use of sulfonamide antibiotics. Urticarial rash can also occur; however, furosemide is not usually recommended for the management of hypertension alone. (Choice C) Lisinopril is an ACE inhibitor and can be associated with angioedema and urticaria. Photosensitivity rash is uncommon. Occasionally, lisinopril can lead to aggravation of psoriatic rash. (Choice D) Amlodipine therapy can be associated with significant fluid retention and urticarial rash. (Choice E) Metoprolol can cause urticaria in up to 5% of patients. Photosensitivity rash can occur, but it is much more uncommon compared to hydrochlorothiazide. Educational objective: Thiazides are sulfonamides; therefore, hydrochlorothiazide use can cause photosensitivity rash, and treatment of this rash includes discontinuation of the thiazide, use of sunscreen, and avoiding sun exposure.

Question 9

A 59-year-old man comes to the office complaining of a vague upper abdominal discomfort.  The pain has been present for most of the past 3 months but has never been severe enough to make him seek immediate medical attention.  The discomfort is not associated with eating or performing any activities.  He has no other medical problems.  His blood pressure is 120/60 mm Hg, pulse is 84/min, and respirations are 14/min.  Abdominal examination reveals the presence of multiple scars from previous surgical procedures around the epigastric area.  A 3 x 5-cm, oblong-shaped, firm, and deeply seated mass is palpable in the epigastric area.  There is no tenderness on direct palpation of the mass and surrounding epigastric area.  The patient says that he previously had similar "things" in the same area "but they were taken out."  Which of the following is the most likely diagnosis?
A)Dermatofibroma
B)Desmoid tumor
C)Epidermoid cyst
D)Lipoma
E)Pyogenic granuloma

Accepted Answer

Explanation: This patient presents with an abdominal mass and mild pain consistent with a likely desmoid tumor, which is a locally aggressive benign tumor arising from fibroplastic elements within the muscle or fascial planes with very low potential for metastasis or differentiation. Desmoid tumors are rare but increased in patients with familial adenomatosis polyposis (i.e., Gardner syndrome) and thought to be due to abnormal wound healing or clonal chromosomal abnormalities causing a neoplastic behavior. This tumor has a variable clinical course, can range from slow to rapid growth, and has varying sizes. Desmoid tumors typically present as deeply seated painless or sometimes painful masses in the trunk/extremity, intraabdominal bowel and mesentery, and abdominal wall. They can cause intestinal obstruction and bowel ischemia and have a high rate of recurrence, even after aggressive surgery (as in this patient). Computed tomography scan or MRI should be done to evaluate the size of the mass, with biopsy for histologic diagnosis. Surgery is the definitive therapy for desmoid tumors that are symptomatic, cause risk to adjacent structures or cosmetic issues for the patient, or are recurrent. Patients who are not surgical candidates can be treated with radiation therapy. Close observation is an alternative strategy in patients who are asymptomatic, have stable masses, or have intraabdominal masses seen in Gardner syndrome. This mildly symptomatic patient has had multiple surgeries to remove his likely recurrent desmoid tumor and can be treated with close observation, another surgery, or possibly radiation therapy, depending on his preference and surgical risk. (Choice A) A dermatofibroma is a benign proliferation of fibroblasts that usually occurs after trauma or insect bite and can also be idiopathic. It is usually a firm hyperpigmented nodule located on the lower extremities rather than the abdomen. (Choice C) An epidermoid cyst is a discrete nodule that is usually located on the skin and a result of the normal epidermal keratin becoming lodged in the dermis. Epidermoid cysts can be seen in Gardner syndrome but are usually located on the extremities rather than the trunk or abdomen and resolve spontaneously without treatment. (Choice D) A lipoma is an asymptomatic and benign subcutaneous collection of fat cells. It is usually soft without rapid enlargement or recurrence after resection, making it less likely in this patient. (Choice E) A pyogenic granuloma (granuloma telangiectaticum) is caused by capillary proliferation after trauma and usually presents as a dome-shaped papule with recurrent bleeding. It is more commonly seen in pregnant women and a less likely cause in this patient. Educational objective: Desmoid tumors are slow-growing and locally aggressive benign neoplasms with a high rate of local recurrence, even after surgical excision. References: The enigma of desmoid tumors. (http://www.ncbi.nlm.nih.gov/pubmed/10363901) Desmoid tumor: from surgical extirpation to molecular dissection (http://www.ncbi.nlm.nih.gov/pubmed/19436199)

Question 10

A 76-year-old woman is brought to the physician by her son.  He is concerned that his mother, who was previously outgoing, does not want to leave her home.  She lives alone and works as a part-time volunteer at a local library.  Although she continues to work shelving books, she has stopped attending her weekly meetings at a senior center where she socialized with friends.  The patient also seems quieter and more difficult to engage in conversation when he calls her on the telephone.  One week ago, he found her sitting on a chair pulled up close to the television.  She did not notice his presence immediately but then smiled and nodded as if following the conversation.  He became concerned when she asked about her grandchild's upcoming birthday party even though he had just told her the details.  Her past medical history is significant for hypertension.  The patient reports that her sleep and appetite are fine.  She does not use tobacco, alcohol, or illicit drugs.  Her medications include valsartan and hydrochlorothiazide.  Which of the following is the most likely diagnosis?
A)Delirium
B)Dementia
C)Depression
D)Normal aging
E)Presbycusis

Accepted Answer

Explanation: This patient's clinical features are most consistent with presbycusis, or age-related hearing loss, which has resulted in progressive social withdrawal. Presbycusis is a gradual, symmetrical, sensorineural hearing loss that affects more than 50% of adults by age 75 and can significantly impair quality of life. Patients typically withdraw from their social lives and may stop leaving home to avoid conversations. Their social interactions deteriorate and they often must listen to the radio or television at high volumes. Physical examination may show no abnormalities except for the hearing loss itself. Although audiometry is used to confirm the diagnosis, the whispered voice test, a simple procedure that can be performed in the office without equipment, can be used. In this test, the examiner stands behind the patient and whispers letters/numbers while occluding the non-tested ear. Repeating 3 out of 6 letters/numbers correctly is passing. Progressive social withdrawal may contribute to feelings of depression and low self-esteem. However, apart from decreased motivation to socialize, this patient does not exhibit features of major depression (ie, >5 of following 9 symptoms: depressed mood, anhedonia, sleep disturbance, appetite disturbance, psychomotor abnormalities, impaired concentration, fatigue, guilt, suicidality) (Choice C). Most patients with presbycusis benefit from the use of hearing aids, which should decrease social isolation. (Choice A) Delirium is a reversible, acute confusional state involving fluctuating levels of consciousness and inattention. It is most commonly seen in elderly patients with medical illness. (Choice B) Dementia involves an irreversible, global deterioration in cognitive abilities and functioning, which frequently includes short-term memory problems, impaired communication skills, and a decline in activities of daily living. Although this patient could be experiencing very early signs of dementia, there is insufficient information to support this diagnosis. (Choice D) Although the prevalence of presbycusis increases with age, progressive social isolation should not be attributed to normal aging. Appropriate diagnosis and treatment with a hearing aid should reverse this patient's social withdrawal and improve her quality of life. Educational objective: Hearing loss due to presbycusis is one of the most frequent causes of social withdrawal and isolation in the elderly. It must be differentiated from depression and dementia. Screening can be accomplished through simple hearing tests performed in the office. References: Hearing loss and depressive symptoms in elderly patients. (http://www.ncbi.nlm.nih.gov/pubmed/22212622)

Question 11

A 42-year-old Caucasian woman comes to the physician because of "patchy hair loss" for the past six weeks.  Her other medical problems include hypothyroidism, gastroesophageal reflux disease, and bipolar disorder.  She has smoked one pack of cigarettes daily for the past 15 years.  She drinks 1-2 ounces of alcohol daily, and is a vegetarian.  Her mother has thyroid disease, bipolar disorder and breast cancer.  The patient's medications include lansoprazole, L-thyroxine and valproic acid.  On physical examination, her vital signs are within normal limits.  Scalp exam reveals several well-demarcated circular areas of complete hair loss.  Fingernail pitting is also present.  Which of the following is the most likely cause of her hair loss?
A)Alopecia areata
B)Medication side effect
C)Psoriasis
D)Tinea capitis
E)Trichotillomania

Accepted Answer

Explanation: Alopecia areata is a type of non-scarring hair loss that can affect any hair-bearing area. It is thought to be an autoimmune process that targets genetically predisposed individuals. The classic clinical description is of a well-demarcated, often round, non-scarred patch of complete hair loss. The presence of so-called "exclamation point hairs" (hairs which are tapered near the insertion into the scalp), especially at the periphery of an alopecic plaque, is considered pathognomonic of, but not necessary for, the diagnosis. Areas of involvement may be single or multiple. Nail pitting is a commonly associated finding. The affected areas of skin are typically asymptomatic, but the disease can be emotionally traumatic and socially stigmatizing. Alopecia areata is often self-limited, but may be relapsing and remitting or chronic and progressive. Patients with alopecia areata are at increased risk for other autoimmune conditions including autoimmune thyroid disease, vitiligo, and pernicious anemia. (Choice B) Certain medications may cause hair loss via a telogen or anagen effluvium. Medication-related hair loss typically manifests as diffuse non-scarring thinning, rather than as discrete bald patches. Telogen effluvium usually begins about 3 months after some precipitating event, such as an illness, stressor, or new medication. Beta-blockers, anti-coagulants, systemic retinoids, anti-convulsants, and anti-thyroid medications are frequently implicated causes of telogen effluvium. Chemotherapeutics (e.g. antimetabolites, alkylating agents, mitotic inhibitors) can cause anagen effluvium, which usually begins within 1-2 weeks of chemotherapy initiation. (Choice C) Psoriasis is a chronic inflammatory skin disorder characterized by well-demarcated erythematous plaques with silvery scale. The extensor extremities, periumbilical area, gluteal cleft, lumbosacral area, and scalp are among the areas most commonly involved. Associated hair loss is usually minimal. Nail changes are common in psoriasis and may include pitting, onycholysis, as well as thickening and yellowing of the nail plate. (Choice D)Tinea capitis is a dermatophyte infection of the scalp that affects children most commonly. Trichophyton tonsurans and Microsporum canis are the most common causes of tinea capitis in the United States. The clinical presentation varies by causative organism, but may consist of erythema, scaling, "black dot" alopecia (secondary to breakage of hairs near the scalp), pustules, or boggy plaques with posterior cervical or posterior auricular lymphadenopathy. While patchy or diffuse alopecia is common, the accompanying inflammation, scale, and lymphadenopathy are typically sufficient to distinguish tinea capitis from alopecia areata. Trichophyton tonsurans Microsporum canis (Choice E) Trichotillomania is a psychiatric impulse control disorder where hairs are plucked, twisted, or otherwise broken from the scalp. On physical examination, irregularly shaped areas of hair loss containing hairs of many different lengths are typical. Educational objective: The classic presentation of alopecia areata consists of well-demarcated, non-scarred, round patches of hair loss, which may have "exclamation point" hairs. Affected patients are more likely to have a personal or family history of other autoimmune conditions, including autoimmune thyroid disease, pernicious anemia, and vitiligo. References: Diagnosing and treating hair loss. (http://www.ncbi.nlm.nih.gov/pubmed/19678603)

Question 12

A 41-year-old woman comes to the office due to a pruritic rash on her legs for the past 2 weeks.  The rash started after she returned from a hiking trip.  The patient lives with her husband, who does not have a similar rash.  She has no medical conditions and takes no medications.  Vital signs are normal.  Skin examination findings are shown in the exhibit.  Which of the following is the most likely diagnosis of this patient's condition?
A)Guttate psoriasis
B)Lichen planus
C)Nummular eczema
D)Papular urticaria
E)Pityriasis rosea

Accepted Answer

Explanation: 11ec2b69_c12a_7bf6_8f63_733607d878b2_MD0005_00 This patient has papular urticaria, likely caused by insect bites (eg, ticks, mites) acquired during her hiking trip. Contrary to the name, papular urticaria is a delayed hypersensitivity reaction to insect bites and is not true urticaria. Unlike the more common local reaction caused by irritants in insect saliva, which generally is immediate and resolves within a few hours, papular urticaria may have a delayed onset and a prolonged and sometimes recurrent course over weeks to months. Papular urticaria can occur at any age but is more common in children than in adults, likely due to desensitization with age. Papular urticaria presents as 0.5- to 1-cm erythematous and pruritic papules on exposed skin, most commonly on the legs. Lesions may be surrounded by pale halos due to dermal edema. Because papular urticaria is a hypersensitivity reaction, household contacts typically do not have a similar rash. Treatment includes second-generation (ie, nonsedating) H₁ blockers (eg, cetirizine) to alleviate severe pruritus and topical corticosteroids applied to individual lesions. In addition, patients with ongoing exposure should be isolated from the source of the bites (eg, use insect repellent, treat pet flea infestation). Spontaneous resolution is expected within months. pale halos (Choice A) Guttate (drop-like) psoriasis presents with an acute eruption of erythematous papules and small plaques with fine scales, findings absent in this patient. plaques (Choice B) Lichen planus is a chronic inflammatory condition that presents with pruritic, purple/pink, polygonal papules and plaques. Acute onset and halos around lesions are not characteristic. Lichen planus (Choice C) Nummular eczema is a pruritic eruption of 1- to 10-cm coin-shaped (nummular) eczematous patches typically involving the extremities. Subcentimeter papules are not characteristic. Nummular eczema (Choice E) Pityriasis rosea begins as a solitary herald patch that appears pink or peach on light skin and violet to brown on darker skin. The appearance of this patch is followed by eruption of multiple pruritic, ovoid papules and plaques with a collarette of scales on the trunk and proximal extremities. Involvement limited to the distal legs is atypical. herald patch trunk Educational objective: Papular urticaria is a delayed hypersensitivity reaction to insect bites that results in prolonged and recurrent pruritic papules on exposed skin. Treatment includes second-generation H₁ blockers and topical corticosteroids. Spontaneous resolution is expected within months. References: Papular urticaria. (http://www.ncbi.nlm.nih.gov/pubmed/11534921)

Question 13

A 41-year-old man comes to the physician with a faint skin rash over his upper body.  He first noticed it in the spring season, but it worsened during the summer.  The patient has mild itching, but otherwise the rash is asymptomatic.  He takes omeprazole for acid reflux but his medical history is otherwise unremarkable.  He does not use tobacco, alcohol, or illicit drugs.  The patient has been sexually active with 2 partners during the last year, and uses condoms on most occasions.  The physical examination findings are shown below.  
Which of the following is the most likely diagnosis in this patient?
A)Atopic dermatitis
B)Pityriasis rosea
C)Seborrheic dermatitis
D)Secondary syphilis
E)Tinea versicolor

Accepted Answer

Explanation: Tinea versicolor (TV) is a non-invasive fungal infection of the skin caused by Malassezia species (Malassezia furfur, Malassezia globosa, Malassezia sympodialis). Clinical findings are usually very characteristic and include multiple, often coalescing, small circular maculae that may vary in color (white, pink, or brown). The rash is typically more prominent in the summer as the organism inhibits pigment transfer to keratinocytes and makes the affected skin paler than the unaffected tanned skin. Lesions may occasionally exhibit hyperpigmentation compared to surrounding skin due to a localized mild inflammatory response. Other than cosmetic effects, TV is usually asymptomatic, although mild pruritus may be present. Typically, the lesions are located on the upper trunk, but the rash may also involve the upper arms, neck, and abdomen. TV diagnosis can be confirmed with a potassium hydroxide (KOH) preparation showing hyphae and yeast. (Choice A) Atopic dermatitis (eczema) typically affects the extremities and produces scaling and severe pruritus. Atopic dermatitis (Choice B) Pityriasis rosea is an acute inflammatory (presumed post-viral) rash characterized by an initial "herald patch" on the trunk that is followed by smaller pink/tan lesions on the trunk and proximal extremities. Pityriasis rosea (Choice C) Seborrheic dermatitis is an inflammatory disorder characterized by erythematous patches with oily scales, predominantly involving areas with many sebaceous glands (especially the face and scalp). It is also associated with Malassezia species, though the exact pathophysiology is unclear. Seborrheic dermatitis (Choice D) Secondary syphilis causes widespread mucocutaneous lesions. It has a highly variable appearance, but typical lesions are erythematous or pale pink macules that predominantly involve the flexor surfaces of the extremities as well as the palms and soles. Secondary syphilis Educational objective: Tinea versicolor is a non-invasive fungal infection of the skin characterized by multiple, often coalescing, small circular maculae that may vary in color (white, pink, or brown). It is often more apparent in the spring and summer months. Diagnosis is confirmed by potassium hydroxide preparation of skin scrapings showing yeast and hyphae. References: Superficial fungal infections. (http://www.ncbi.nlm.nih.gov/pubmed/15451228)

Question 14

A 13-year-old boy is brought to the office for an itchy rash he developed yesterday during a camping trip with his father.  The rash started on his legs and spread to his arm this morning.  His father developed a similar rash on his legs and face.  They came to the office immediately after returning early from the trip due to the boy's pain and intense itching.  The patient's father applied topical diphenhydramine, which did not provide relief.  He has no other medical issues and takes no other medications.  Other than a family trip to Europe last month, the patient has not traveled out of the United States.  Physical examination shows an uncomfortable-appearing boy.  Scattered areas of erythematous papules are present on the right arm, with several overlying vesicles filled with clear fluid.  Many linear erythematous lesions are also found on the anterior lower extremities, some of which have vesicles oozing a serous fluid.  Which of the following is the best recommendation for reducing the spread of this patient's condition?
A)Begin topical antibiotic therapy
B)Prescribe oral ivermectin for patient and household contacts
C)Promptly administer oral antihistamines
D)Remove contaminated apparel
E)Treat infected bedding with insecticide

Accepted Answer

Explanation: 11ec2b69_c124_fdab_8f63_016837ca5fb0_MD0005_00 Poison ivy contact dermatitis is a type IV (cell-mediated) hypersensitivity reaction that classically presents with linear papules and clear, fluid-filled vesicles on exposed areas. Pain and intense pruritus are typical. Nonlinear lesions can also be present from subsequent spread via contact with residual plant resin on contaminated clothing. Immediate removal of contaminated apparel and gentle cleansing of exposed areas are recommended to minimize spread of dermatitis. Treatment is supportive (eg, cool compress, topical corticosteroids). Oral corticosteroids are indicated in severe dermatitis or dermatitis involving the face or genitalia to reduce inflammation. Antihistamines (eg, diphenhydramine) are not effective as the pruritus in poison ivy dermatitis is not histamine-mediated (Choice C). (Choice A) Topical antibiotic therapy is indicated for bacterial superinfection of poison ivy contact dermatitis. Presentation includes honey-crusted lesions or an exudative discharge. This patient's vesicles are filled with clear fluid and oozing serous fluid. (Choice B) Oral ivermectin is the treatment for scabies, which also presents with an intensely pruritic rash. Distribution of the rash, however, classically involves the web spaces of the hands and feet, axillary folds, and genitalia. (Choice E) Insecticides are indicated in the management of bedbug infestation. Presentation includes small (2-3 mm) erythematous papules, often in a linear pattern, on exposed areas. Pruritus is common, but pain and vesicular lesions are atypical. In addition, this patient's recent camping history makes poison ivy contact dermatitis more likely. Educational objective: Poison ivy contact dermatitis presents as pruritic, linear papules and/or vesicles on exposed areas. Reduction of spread is achieved by avoiding both direct (eg, skin-to-plant contact) and indirect (eg, clothing) exposure to the allergen. References: Diagnosis and management of contact dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/20672788)

Question 15

A 28-year-old Caucasian woman presents to the primary care physician complaining of a painless blistering on the backs of her hands.  The blisters appeared one week ago after she spent some time gardening outdoors, and are accompanied by an increased fragility of the surrounding skin.  The woman states that she has never before had such symptoms, though she suspects her mother may occasionally have had a similar presentation that eventually resolved without treatment.  Past medical history is significant for chronic infection with Hepatitis C virus.  Current medications include oral contraceptives, which were begun last month.  Physical examination also reveals mild hyperpigmentation of the face.  What is the most likely diagnosis?
A)Allergic contact dermatitis
B)Porphyria cutanea tarda
C)Herpes zoster
D)Dermatitis herpetiformis
E)Impetigo

Accepted Answer

Explanation: Porphyria cutanea tarda (Choice B) is a condition that arises from the deficiency of uroporphyrinogen decarboxylase, an enzyme in the heme synthesis pathway. This condition is characterized by painless blisters, an increased fragility of the skin on the dorsal surfaces of the hands, and facial hypertrichosis and hyperpigmentation. It can be triggered by the ingestion of certain substances (e.g., ethanol, estrogens) that should be discontinued if suspect. Diagnosis is confirmed with an elevation of the urinary uroporphyrins. Phlebotomy or hydroxychloroquine may provide relief, as can interferon alpha in those patients simultaneously infected with Hepatitis C virus. Allergic contact dermatitis (Choice A) results from direct skin contact with chemicals or allergens. It is characterized by pruritus, erythema, and edema, often followed by the development of vesicles and bullae in the irritated region. Herpes zoster (Choice C) is characterized by painful vesicular lesions clustered unilaterally along the course of a nerve. The lesions are typically found on the face or trunk, and will be Tzanck smear positive. Dermatitis herpetiformis (Choice D) is characterized by pruritic papules and vesicles that appear mainly on the elbows, knees, buttocks, posterior neck, and scalp. The condition arises in the context of gluten-sensitive enteropathy, which may be subclinical. Impetigo (Choice E) is characterized by pruritic and honey-colored macules, vesicles, and bullae on the face and other exposed parts. The condition is caused by Staphylococcus aureus or group A streptococcus. Staphylococcus aureus Educational Objective: Porphyria cutanea tarda is a condition characterized by painless blisters, hypertrichosis, and hyperpigmentation. It is often associated with Hepatitis C infection and can be triggered by the ingestion of certain substances (e.g., ethanol, estrogens), which should be discontinued if suspect.

Question 16

A 62-year-old man comes to the community health center due to a "flaky and itchy" scalp.  He is uncertain when the symptoms began and believes his brother has a similar problem.  The patient has not attempted any specific treatments but washes his hair with a mild shampoo every other day and washes his face with cold water once daily.  Medical history is notable for coronary artery disease, type 2 diabetes mellitus, benign prostatic hyperplasia, and diverticulosis.  The patient is a recovering alcoholic and has lived in a group home for the last 3 months.  Vital signs are normal.  Physical examination shows oily skin with faint erythema and scaling of the scalp, eyebrows, and ears, as shown below.  During the course of the visit, the patient repeatedly scratches his head and eyebrows, but the remainder of the skin examination is normal.  The patient returns to the clinic after 4 weeks of treatment.  His rash has nearly resolved, but he is concerned because his brother developed recurrent symptoms after similar treatment.  Which of the following is the most appropriate guidance for long-term management of this patient's condition?
A)Avoiding contact with the offending agent is needed to prevent recurrence.
B)Clothing and bed linens should be laundered to eliminate the causative agent.
C)Household members should be treated to prevent relapse.
D)One course of treatment usually leads to long-term remission.
E)Weekly re-treatment may be needed to prevent recurrence.

Accepted Answer

Explanation: Seborrheic dermatitis (SD) is a chronic, relapsing condition. Initial treatment can provide significant improvement in symptoms but is rarely adequate to induce long-term remission (Choice D). As a result, patients usually benefit from intermittent re-treatment. Typical regimens include topical ketoconazole or ciclopirox every 1-2 weeks. (Choice A) Contact dermatitis usually presents with pruritic vesicles, papules, or plaques on exposed skin. Distribution typically follows characteristic patterns depending on the causative agent (eg, linear streaks on the legs in poison ivy dermatitis). SD is not triggered by contact with an external irritant or allergen. (Choices B and C) Management of scabies requires the treatment of household contacts, as well as the laundering of bedding and clothing. These measures are not effective in SD. Educational objective: Seborrheic dermatitis is a chronic, relapsing condition. Initial treatment can provide significant improvement in symptoms, but patients usually benefit from intermittent re-treatment.

Question 17

A 65-year-old man comes to the office due to multiple hand lesions. Pink, white, and gray spots have been present on his hands for several years and are slowly increasing in number and size. The lesions do not itch or hurt. Medical and family histories are unremarkable. The patient takes no medications. BMI is 27 kg/m². Skin examination of the right hand is shown in the exhibit, and the left hand has similar lesions. This patient is at greatest risk of developing which of the following? A)Cutaneous basal cell carcinoma B)Cutaneous squamous cell carcinoma C)Inflammatory arthritis D)Pulmonary hypertension E)Visceral malignancy

Accepted Answer

Explanation: 11ec2b69_c128_0aee_8f63_ede371e2b564_MD0005_00 This patient has multiple scaly papules on the dorsal hands, concerning for actinic keratosis (AK). AK is a premalignant condition caused by UV radiation exposure that most commonly occurs in sun-exposed areas (eg, face, scalp, dorsal hands). It presents as chronic, erythematous, scaly papules, sometimes with a background of chronically photodamaged skin. In particular, dyspigmentation, rough texture, atrophy, and telangiectasia indicate cellular carcinogenic changes; this diffuse surface involvement is termed field cancerization. presents AK can transform to squamous cell carcinoma (SCC), and the majority of SCCs develop from preexisting AK; therefore, patients should be treated without delay. Isolated lesions can be treated effectively with liquid nitrogen cryotherapy. However, diffuse or numerous lesions should be treated with topical therapy (eg, 5-fluoruracil, tirbanibulin), which can cover a large area. (Choice A) Unlike SCC, basal cell carcinoma does not have a precursor lesion; it typically presents with pearly, skin-colored papules with telangiectasia. skin-colored papules (Choice C) Inflammatory arthritis is associated with psoriasis, which typically presents with erythematous plaques with diffuse silvery scales, predominantly at extensor surfaces (eg, knees). Scaly papules at the dorsal hands are more suggestive of AK. erythematous plaques (Choice D) Pulmonary hypertension is associated with scleroderma, which manifests with skin thickening and tightening, features absent in this patient; scaly papules are not characteristic. tightening (Choice E) Dermatomyositis is often seen as a paraneoplastic manifestation of visceral malignancy. On the hands, dermatomyositis can present with Gottron papules, violaceous lesions over the dorsal interphalangeal and metacarpophalangeal joints. Gottron papules Educational objective: Actinic keratosis can present as diffuse scaly papules, often in a background of photodamaged skin (eg, dyspigmentation, telangiectasia, atrophy) that has undergone carcinogenic changes. Treatment with topical therapy (eg, 5-fluoruracil) is indicated to prevent progression to squamous cell carcinoma. References: Actinic keratoses: review of clinical, dermoscopic, and therapeutic aspects. (http://www.ncbi.nlm.nih.gov/pubmed/31789244)

Question 18

A 41-year-old man comes to the physician with a faint skin rash over his upper body.  He first noticed it in the spring season, but it worsened during the summer.  The patient has mild itching, but otherwise the rash is asymptomatic.  He takes omeprazole for acid reflux but his medical history is otherwise unremarkable.  He does not use tobacco, alcohol, or illicit drugs.  The patient has been sexually active with 2 partners during the last year, and uses condoms on most occasions.  The physical examination findings are shown below.  Which of the following is the best treatment for this patient?
A)Intramuscular penicillin
B)Oral erythromycin
C)Oral griseofulvin
D)Topical corticosteroids
E)Topical ketoconazole

Accepted Answer

Explanation: The treatment of choice for patients with tinea versicolor is topical anti-fungal therapy. Any anti-yeast topical agent (eg, selenium sulfide, terbinafine, clotrimazole, ketoconazole) can be used. The success rate with topical anti-fungal agents exceeds 80%. With extensive disease or recalcitrant infection, oral antifungals (ketoconazole, itraconazole, or fluconazole) are preferred. Topical terbinafine is effective, but oral terbinafine and oral griseofulvin are ineffective (Choice C). (Choice A) Intramuscular benzathine penicillin G is used for the treatment of primary, secondary, and early latent syphilis. (Choice B) Oral erythromycin has been advocated for use in patients with pityriasis rosea. However, evidence for this practice is mixed and it is not currently recommended. (Choice D) Topical corticosteroids are commonly used in patients with eczema and other non-infectious inflammatory dermatoses. Educational objective: The treatment of choice for tinea versicolor is topical anti-fungal therapy. References: Pityriasis versicolor: a systematic review of interventions. (http://www.ncbi.nlm.nih.gov/pubmed/20956647)

Question 19

A 20-year-old woman comes to the office due to a rash on the face for 2 days.  The rash started abruptly as mildly painful vesicles on the eyelids and cheeks.  Medical history includes atopic dermatitis involving the face, arms, and legs that has been well controlled with an emollient and low-potency topical corticosteroid as needed.  Temperature is 38 C (100.4 F), blood pressure is 115/75 mm Hg, and pulse is 95/min.  Examination findings are shown in the exhibit.  Tender cervical lymphadenopathy is present.  The remainder of the examination is unremarkable.  Which of the following is the most likely etiology of this patient's rash?
A)Allergic contact dermatitis
B)Group A Streptococcus
C)Herpes simplex virus
D)Poxvirus
E)Trichophyton rubrum

Accepted Answer

Explanation: 11ec2b69_c124_616a_8f63_7d28dd8e11d4_MD0005_00 This patient has a painful, vesicular rash in addition to fever and lymphadenopathy. These findings are concerning for eczema herpeticum, a primary or reactivated herpes simplex virus (HSV) infection associated with atopic dermatitis. Increased susceptibility to infectious complications is seen in atopic dermatitis due to innate skin barrier dysfunction and immune dysregulation. Eczema herpeticum typically begins as painful vesicles on an erythematous base, most commonly involving the face, neck, and trunk. These vesicles are monomorphic (uniform in morphology) and evolve into "punched-out" erosions that later become covered with hemorrhagic crusts. Systemic symptoms (eg, fever, lymphadenopathy) are common. "punched-out" erosions Although infection may be localized, eczema herpeticum can spread to noneczematous areas, as well as to the eyes and visceral organs (eg, hepatitis, encephalitis). In this case, the patient's periocular lesions increase the risk for local spread and HSV keratitis or for corneal infection, which can lead to blindness. Therefore, all patients with eczema herpeticum warrant immediate systemic antiviral (eg, acyclovir) therapy. (Choice A) Facial and eyelid allergic contact dermatitis may develop following environmental or topical exposures (eg, cosmetics, medications). It presents with intense pruritus, erythema, and, when severe, vesicles and bullae. However, this patient's fever and hemorrhagic erosions are inconsistent with this condition. vesicles and bullae (Choice B) Impetigo caused by Staphylococcus aureus or group A Streptococcus is a common infectious complication of atopic dermatitis and typically presents as erythematous papules, pustules, or vesicles with honey-colored crusts. "Punched-out" erosions and fever make this diagnosis unlikely. honey-colored crusts (Choice D) Molluscum contagiosum, caused by a poxvirus, presents with umbilicated, skin-colored papules, not painful vesicles. Fever and lymphadenopathy are not seen. Molluscum contagiosum (Choice E) Trichophyton rubrum is the most frequent cause of tinea corporis (ringworm), and lesions present as pruritic, scaly annular patches, not vesicles. annular patches Educational objective: Eczema herpeticum is a herpes simplex virus infection associated with atopic dermatitis. Lesions present as painful vesicles that evolve into "punched-out" erosions with hemorrhagic crusting. Disseminated disease (eg, keratitis, hepatitis) is a complication, and systemic antiviral therapy (eg, acyclovir) should be initiated immediately. References: A corneal dendritic lesion with a skin eruption: eczema herpeticum, an important differential diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/25636633)

Question 20

A 43-year-old woman comes to the physician for a rash on her hands.  The rash began 8-10 weeks ago.  She moved to the community approximately 4 months ago and works as a nurse in the dialysis unit at a nearby hospital.  The patient's past medical history is significant for hypertension treated with hydrochlorothiazide.  She also takes naproxen regularly for headaches.  Her hands are shown in the image below:  Which of the following is the most likely diagnosis?
A)Contact dermatitis
B)Phototoxic dermatitis
C)Psoriasis
D)Scabies
E)Tinea manuum

Accepted Answer

Explanation: This patient has typical features of irritant contact dermatitis (ICD). Clinical findings characteristic of ICD include pruritus, erythema, and scaling of the skin. As symptoms become chronic, hyperkeratosis and painful fissuring are also commonly seen. Symptoms are often worst where skin is the thinnest, at the dorsum of the hands, fingertips, and finger webs. The diagnosis is primarily clinical, but patch testing to rule out allergic dermatitis may be useful on occasion. ICD is the cause of 80% of all cases of occupational hand dermatitis. It is due to repeated exposure to irritants (eg, detergents, solvents, oxidizing agents) over time and may occur after days, weeks, or months of exposure to the irritant. ICD is especially common in patients with underlying atopic dermatitis and in health care workers who use occlusive gloves frequently. atopic dermatitis Other causes of hand dermatitis with similar features include allergic contact dermatitis, which is immune mediated, and dyshidrotic eczema, which is characterized by vesicular lesions involving the palms and soles. In practice, all of these disorders are initially managed in similar fashion with: allergic contact dermatitis dyshidrotic eczema Identification and avoidance of the offending agents Washing hands with lukewarm water and mild cleansers Frequent use of emollients Topical glucocorticoids (Choice B) Phototoxic dermatitis can be induced by systemic medications such as diuretics, antibiotics, nonsteroidal anti-inflammatory drugs, and various other drugs. The reaction consists of erythema with or without bullae and vesiculation over sun-exposed areas such as the dorsal hands, forearms, upper chest, and face. Phototoxic dermatitis (Choice C) Psoriasis is an inflammatory disorder characterized by localized plaques with erythema and scaling. It may involve the hands, but is most common at the extensor surfaces of the elbows and knees. Psoriasis (Choice D) Scabies manifests with pruritic papules, possibly with an associated scale and thin linear burrows, in the finger webs, lateral palms, wrists, ankles, and genital region. Scabies (Choice E) Tinea manuum causes annular erythema with a trailing scale on the dorsal or ventral hands. Mild itching is typically present. Classically only one hand is involved, although tinea pedis is often present as well. Tinea manuum Educational objective: Irritant contact dermatitis (ICD) is the most common cause of occupational hand dermatitis. Chronic exposure to mild irritants, such as solvents and detergents, can result in pruritus, erythema, hyperkeratosis, and fissuring of the hands. Occlusion of irritants under rubber gloves is a typical cause of ICD in health care workers. References: Hand dermatitis: review of etiology, diagnosis, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19429739)

Exam 2: Foundations of Independent Practice