Test Bank for Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 4th Edition, Mary Jo Goolsby, Laurie Grubbs

Test Bank for Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 4th Edition, Mary Jo Goolsby, Laurie Grubbs Chapter 1. Assessment and Clinical Decision-Making: Overview Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which type of clinical decision-making is most reliable? A. B. C. D. 2. care providers must be: A. B. C. D. 3. A. B. C. D. 4. Intuitive Analytical Experiential Augenblick Which of the following is false? To obtain adequate history, healthMethodical and systematic Attentive to the patient’s verbal and nonverbal language Able to accurately interpret the patient’s responses Adept at reading into the patient’s statements Essential parts of a health history include all of the following except: Chief complaint History of the present illness Current vital signs All of the above are essential history components Which of the following is false? While performing the physical examination, the examiner must be able to: A. B. C. D. 5. diagnostic statistics: 1 Differentiate between normal and abnormal findings Recall knowledge of a range of conditions and their associated signs and symptoms Recognize how certain conditions affect the response to other conditions Foresee unpredictable findings The following is the least reliable source of information forA. B. C. Evidence-based investigations Primary reports of research Estimation based on a provider’s experience D. 6. A. B. C. D. 7. A. B. C. D. 8. : A. B. C. D. 9. A. B. C. D. Low percentage of healthy individuals will show a normal result High percentage of healthy individuals will show a normal result High percentage of individuals with a disorder will show a normal result Low percentage of individuals with a disorder will show an abnormal result A likelihood ratio above 1 indicates that a diagnostic test showing a: Positive result is strongly associated with the disease Negative result is strongly associated with absence of the disease Positive result is weakly associated with the disease Negative result is weakly associated with absence of the disease 10. Which of the following clinical reasoning tools is defined as evidence- based resource based on mathematical modeling to express the likelihood of a condition in select situations, settings, and/or patients? 2 Published meta-analyses The following can be used to assist in sound clinical decision-making: Algorithm published in a peer-reviewed journal article Clinical practice guidelines Evidence-based research All of the above If a diagnostic study has high sensitivity, this indicates a: High percentage of persons with the given condition will have an abnormal result Low percentage of persons with the given condition will have an abnormal result Low likelihood of normal result in persons without a given condition None of the above If a diagnostic study has high specificity, this indicates aA. B. C. D. Clinical practice guideline Clinical decision rule Clinical algorithm Clinical recommendation Chapter 1. Assessment and Clinical Decision-Making: Overview Answer Section MULTIPLE CHOICE 1. ANS: B Croskerry (2009) describes two major types of clinical diagnostic decision-making: intuitive and analytical. Intuitive decision-making (similar to Augenblink decision- making) is based on the experience and intuition of the clinician and is less reliable and paired with fairly common errors. In contrast, analytical decision-making is based on careful consideration and has greater reliability with rare errors. PTS: 1 2. ANS: D To obtain adequate history, providers must be well organized, attentive to the patient’s verbal and nonverbal language, and able to accurately interpret the patient’s responses to questions. Rather than reading into the patient’s statements, they clarify any areas of uncertainty. PTS: 1 3. ANS: C Vital signs are part of the physical examination portion of patient assessment, not part of the health history. PTS: 1 4. ANS: D While performing the physical examination, the examiner must be able to differentiate between normal and abnormal findings, recall knowledge of a range of conditions, including their associated signs and symptoms, recognize how certain conditions affect the response to other conditions, and distinguish the relevance of varied abnormal findings. PTS: 1 5. ANS: C Sources for diagnostic statistics include textbooks, primary reports of research, and published meta-analyses. Another source of statistics, the one that has been most widely used and available for application to the reasoning process, is the estimation based on a provider’s experience, although these are rarely accurate. Over the past decade, the availability of evidence on which to base clinical reasoning is improving, and there is an increasing expectation that clinical reasoning be based on scientific evidence. Evidence- based statistics are also increasingly being used to develop 3resources to facilitate clinical decision-making. PTS: 1 6. ANS: D To assist in clinical decision-making, a number of evidence-based resources have been developed to assist the clinician. Resources, such as algorithms and clinical practice guidelines, assist in clinical reasoning when properly applied. PTS: 1 7. ANS: A The sensitivity of a diagnostic study is the percentage of individuals with the target condition who show an abnormal, or positive, result. A high sensitivity indicates that a greater percentage of persons with the given condition will have an abnormal result. PTS: 1 8. ANS: B The specificity of a diagnostic study is the percentage of normal, healthy individuals who have a normal result. The greater the specificity, the greater the percentage of individuals who will have negative, or normal, results if they do not have the target condition. PTS: 1 9. ANS: A The likelihood ratio is the probability that a positive test result will be associated with a person who has the target condition and a negative result will be associated with a healthy person. A likelihood ratio above 1 indicates that a positive result is associated with the disease; a likelihood ratio less than 1 indicates that a negative result is associated with an absence of the disease. PTS: 1 10. ANS: B Clinical decision (or prediction) rules provide another support for clinical reasoning. Clinical decision rules are evidence-based resources that provide probabilistic statements regarding the likelihood that a condition exists if certain variables are met with regard to the prognosis of patients with specific findings. Decision rules use mathematical models and are specific to certain situations, settings, and/or patient characteristics. PTS: 1 Chapter 2. An Overview of Genetic Assessment Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The first step in the genomic assessment of a patient is obtaining information regarding: A. B. Family history Environmental exposures 4C. D. Lifestyle and behaviors Current medications 2. An affected individual who manifests symptoms of a particular condition through whom a family with a genetic disorder is ascertained is called a(n): A. Consultand B. C. D. 3. A. B. C. D. 4. a pedigree, draw: A. B. C. D. 5. A. B. C. D. 6. is common to see: Consulband Index patient Proband An autosomal dominant disorder involves the: X chromosome Y chromosome Mitochondrial DNA Non-sex chromosomes To illustrate a union between two second cousin family members in Arrows pointing to the male and female Brackets around the male and female Double horizontal lines between the male and female Circles around the male and female To illustrate two family members in an adoptive relationship in a pedigree: Arrows are drawn pointing to the male and female Brackets are drawn around the male and female Double horizontal lines are drawn between the male and female Circles are drawn around the male and female When analyzing the pedigree for autosomal dominant disorders, it 5A. B. C. Several generations of affected members Many consanguineous relationships More members of the maternal lineage affected than paternal D. 7. A. B. C. D. 8. A. B. C. D. 9. More members of the paternal lineage affected than maternal In autosomal recessive (AR) disorders, individuals need: Only one mutated gene on the sex chromosomes to acquire the disease Only one mutated gene to acquire the disease Two mutated genes to acquire the disease Two mutated genes to become carriers In autosomal recessive disorders, carriers have: Two mutated genes; one from each parent that cause disease A mutation on a sex chromosome that causes a disease A single gene mutation that causes the disease One copy of a gene mutation but not the disease With an autosomal recessive disorder, it is important that parents understand that if they both carry a mutation, the following are the risks to each of their offspring (each pregnancy): A. 50% chance that offspring will carry the disease B. C. D. 10. A. B. C. D. 11. 10% chance of offspring affected by disease 25% chance children will carry the disease 10% chance children will be disease free A woman with an X-linked dominant disorder will: Not be affected by the disorder herself Transmit the disorder to 50 % of her offspring (male or female) Not transmit the disorder to her daughters Transmit the disorder to only her daughters In creating your female patient’s pedigree, you note that she and both of her sisters were affected by the same genetic disorder. Although neither of her parents 6had indications of the disorder, her paternal grandmother and her paternal grandmother’s two sisters were affected by the same condition. This pattern suggests: A. Autosomal dominant disorder B. C. D. 12. A. B. C. D. Chromosomal disorder Mitochondrial DNA disorder X-linked dominant disorder A woman affected with an X-linked recessive disorder: Has one X chromosome affected by the mutation Will transmit the disorder to all of her children Will transmit the disorder to all of her sons Will not transmit the mutation to any of her daughters A. B. C. D. 14. that: A. B. C. D. in offspring? A. B. C. D. 16. gene mutation? A. 13. Which of the following are found in an individual with aneuploidy? An abnormal number of chromosomes An X-linked disorder Select cells containing abnormal- appearing chromosomes An autosomal recessive disorder The pedigree of a family with a mitochondrial DNA disorder is unique in None of the female offspring will have the disease All offspring from an affected female will have disease None of the offspring of an affected female will have the disease All the offspring from an affected male will have disease 15. Which population is at highest risk for the occurrence of aneuploidy Mothers younger than 18 Fathers younger than 18 Mothers over age 35 Fathers over age 35 Approximately what percentage of cancers is due to a single- 50% to 70% 7B. C. D. 30% to 40% 20% to 25% 5% to 10% 17. A. B. C. D. 18. A. B. C. D. According to the Genetic Information Nondiscrimination Act (GINA): NPs should keep all genetic information of patients confidential NPs must obtain informed consent prior to genetic testing of all patients Employers cannot inquire about an employee’s genetic information All of the above The leading causes of death in the United States are due to: Multifactorial inheritance Single gene mutations X-linked disorders Aneuploidy 19. Which of the following would be considered a “red flag” that requires more investigation in a patient assessment? A. Colon cancer in family member at age 70 B. C. D. this is due to: A. B. C. D. 21. Breast cancer in family member at age 75 Myocardial infarction in family member at age 35 All of the above 20. When patients express variable forms of the same hereditary disorder, Penetrance Aneuploidy De novo mutation Sporadic inheritance Your 2-year-old patient shows facial features, such as epicanthal folds, up- slanted palpebral fissures, single transverse palmar crease, and a low nasal bridge. These are referred to as: A. Variable expressivity related to inherited disease B. C. D. 22. Dysmorphic features related to genetic disease De novo mutations of genetic disease Different penetrant signs of genetic disease In order to provide a comprehensive genetic history of a patient, the NP 8should: A. Ask patients to complete a family history worksheet B. C. D. Seek out pathology reports related to the patient’s disorder Interview family members regarding genetic disorders All of the above Chapter 2. An Overview of Genetic Assessment Answer Section MULTIPLE CHOICE 1. ANS: A A critical first step in genomic assessment, including assessment of risk, is the use of family history. Family history is considered the first genetic screen (Berry & Shooner 2004) and is a critical component of care because it reflects shared genetic susceptibilities, shared environment, and common behaviors (Yoon, Scheuner, & Khoury 2003). PTS: 1 2. ANS: D A proband is defined as the affected individual who manifests symptoms of a particular condition through whom a family with a genetic disorder is ascertained (Pagon et al. 1993–2013). The proband is the affected individual that brings the family to medical attention. PTS: 1 3. ANS: D Autosomal dominant (AD) inheritance is a result of a gene mutation in one of the 22 autosomes. PTS: 1 4. ANS: C A consanguineous family is related by descent from a common ancestry and is defined as a “union between two individuals who are related as second cousins or closer” (Hamamy 2012). Consanguinity, if present in the family history, is portrayed using two horizontal lines to establish the relationship between the male and female partners. PTS: 1 5. ANS: B For adopted members of the family, use brackets as the appropriate standardized pedigree symbol ([e.g., brackets]). PTS: 1 6. ANS: A 9Pedigrees associated with autosomal dominant (AD) disorders typically reveal multiple affected family members with the disease or syndrome. When analyzing the pedigree for AD disorders or syndromes, it is common to see a “vertical” pattern denoting several generations of affected members. PTS: 1 7. ANS: C In autosomal recessive (AR) disorders, the offspring inherits the condition by receiving one copy of the gene mutation from each of the parents. Autosomal recessive disorders must be inherited through both parents (Nussbaum et al. 2007). Individuals who have an AR disorder have two mutated genes, one on each locus of the chromosome. Parents of an affected person are called carriers because each carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. PTS: 1 8. ANS: D Individuals who have an AR disorder have two mutated genes, one on each allele of the chromosome. Parents of an affected person are called carriers because each parent carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. In pedigrees with an AR inheritance patterns, males and females will be equally affected because the gene mutation is on an autosome. PTS: 1 9. ANS: A It is important that parents understand that if they both carry a mutation, the risk to each of their offspring (each pregnancy) is an independent event: 25% disease free, 25% affected, and 50% carrier. PTS: 1 10. ANS: B Everyone born with an X-linked dominant disorder will be affected with the disease. Transmission of the disorder to the next generation varies by gender, however. A woman will transmit the mutation to 50% of all her offspring (male or female). PTS: 1 11. ANS: D A man with an X-linked dominant disorder will transmit the mutation to 100% of his daughters (they receive his X chromosome) and none of his sons (they receive his Y chromosome). The pedigree of a family with an X-linked dominant disorder would reveal all the daughters and none of the sons affected with the disorder if the father has an X- linked disorder. PTS: 1 12. ANS: C An X-linked recessive disorder means that in a woman, both X chromosomes must 10have the mutation if she is to be affected. Because males have only one copy of the X chromosome, they will be affected if their X chromosome carries the mutation. PTS: 1 13. ANS: A An individual with an abnormal number of chromosomes has a condition called aneuploidy, which is frequently associated with mental problems or physical problems or both (Jorde, Carey, & Bamshad 2010; Nussbaum et al. 2007). PTS: 1 14. ANS: B Mitochondrial DNA is inherited from the ovum and, therefore, from the mother. The pedigree of a family with a mitochondrial DNA disorder is unique in that all offspring (regardless of gender) of an affected female will have the disease, and none of the offspring from an affected male will have the disease. PTS: 1 15. ANS: C Some individuals or couples have unique identifiable risks that should be discussed prior to conception whenever possible. For example, women who will be 35 years of age or older at delivery (advanced maternal age) are at increased risk for aneuploidy. PTS: 1 16. ANS: D The majority of cancers are sporadic or multifactorial due to a combination of genetic and environmental factors; however, approximately 5% to 10% of all cancers are due to a single-gene mutation (Garber & Offit 2005). PTS: 1 17. ANS: D On May 21, 2008, President George W. Bush signed the Genetic Information Nondiscrimination Act (GINA) to protect Americans against discrimination based upon their genetic information when it comes to health insurance and employment, paving the way for patient personalized genetic medicine without fear of discrimination (National Human Genome Research Institute 2012). PTS: 1 18. ANS: A Most disease-causing conditions are not due to a single-gene disorder but are due to multifactorial inheritance, a result of genomics and environmental or behavioral influences. In fact, the leading causes of mortality in the United States—heart disease, cerebrovascular disease, diabetes, and cancer—are all multifactorial. Most congenital malformation, hypertension, arthritis, asthma, obesity, epilepsy, Alzheimer’s, and mental health disorders are also multifactorial. PTS: 1 19. ANS: C 11Early onset cancer syndromes, heart disease, or dementia are red flags that warrant further investigation regarding hereditary disorders. PTS: 1 20. ANS: A Some disorders have a range of expression from mild to severe. This variability is referred to as the penetrance of genetic disease. For example, patients with neurofibromatosis (NF1), an AD disorder of the nervous system, may manifest with many forms of the disease. For instance, some patients with NF1 may have mild symptoms, like café-au-lait spots or freckling on the axillary or skin, while others may have life- threatening spinal cord tumors or malignancy (Jorde, Carey, & Bamshad 2010; Nussbaum et al. 2007). PTS: 1 21. ANS: B Assessing for dysmorphic features may enable identification of certain syndromes or genetic or chromosomal disorders (Jorde, Carey, & Bamshad 2010; Prichard & Korf 2008). Dysmorphology is defined as “the study of abnormal physical development” (Jorde, Carey, & Bamshad 2010, 302). PTS: 1 22. ANS: D Asking the patient to complete a family history worksheet prior to the appointment saves time in the visit while offering the patient an opportunity to contribute to the collection of an accurate family history. Reviewing the family information can also help establish family rapport while verifying medical conditions in individual family members. If a hereditary condition is being considered but family medical information is unclear or unknown, requesting medical records and pathology or autopsy reports may be warranted. PTS: 1 Chapter 3. Skin Multiple Choice Identify the choice that best completes the statement or answers the question. 1. When a patient presents with a skin-related complaint, it is important to first: A. B. Fully inspect all skin lesions before asking the patient how the lesion in question developed Obtain a full history about the development of the skin lesion prior to the physical examination C. Complete a full physical examination of the body prior to inspecting the skin lesion 12D. Examine the skin lesion without hearing a health history in order to not prejudice the diagnosis 2. Jaundice is a state of high bilirubin in the bloodstream. It is most commonly seen first in the: A. B. C. D. 3. A. B. C. D. 4. A. B. C. D. 5. Sclera Nailbeds Palms of the hands Unexposed skin areas Skin turgor is best assessed by pinching skin over the: Forehead Forearm Knees Dorsum of the hand What kind of lesions are caused by the herpes simplex virus? Scales Vesicles Plaques Urticaria A patient presents with vesicles on a reddened base in a symmetrical pattern on the lower neck and upper back, stating that he had noticed discomfort prior to the onset of the “rash.” Which of the following should be considered in your differential diagnosis? A. Dermatitis herpetiformis B. C. Herpes zoster Dishydrosis 13D. Contact dermatitis 6. A. B. C. D. 7. rose petal?” A. B. C. D. 8. A. B. C. D. 9. A. B. C. D. 10. Herpetic whitlow is commonly located on: The eyelid The scalp A finger Lip Which type of lesion is referred to as resembling “a dew drop on a Varicella zoster Measles Rubella Tinea Which lesions are typically located along the distribution of dermatome? Scabies Herpes zoster Tinea Dishydrosis Folliculitis is most commonly due to: Contact dermatitis Varicella zoster Dermatophytes Staphylococcal infection A patient presents with polymorphous lesions consisting of small, red papules and vesicles, with a few eroded and crusted lesions. Your differential diagnosis should include all except which of the following? A. Herpes simplex B. C. D. 11. A. B. C. D. 12. Varicella Bacterial folliculitis Contactdermatitis The following has been associated with cervical and anal cancer: Secondary syphilis Human papilloma virus Herpes simplex Epstein-Barr virus During a routine exam, you notice a 5 mm lesion on the right medial cheek. The border is raised and pearlescent in color and the area is crusted. The patient admits that it has been present for several months and has only recently become tender with the development of the crusting. This is most likely: 14A. Squamous cell carcinoma 15B. C. D. Epidermoid cyst Basal cell carcinoma Actinic keratosis 13. A patient has a tender, firm, nodular cystic lesion on his scalp that produces cheesy discharge with foul odor. This is most likely a: A. Bacterial folliculitis B. C. D. erythema multiforme? A. B. C. D. 15. Basal cell carcinoma Bullous impetigo Epidermoid cyst 14. Which of the following is not associated with development of Herpes virus Mycoplasms Medications Trauma Your patient complains of a progressive loss of pigment in various patches on the body. Affected skin surfaces are otherwise normal (e.g. no scaling, vesicles, elevation, or other changes). The most likely cause is: A. B. C. D. 16. Vitiligo Acanthosis nigricans Psoriasis Pityriasis alba A patient has an irregularly shaped, brown to black lesion on the upper arm that has changed color recently. The widest diameter is 6 mm. You should: A. Measure and record the dimensions and schedule follow-up to repeat measurement in 2 weeks B. C. D. A. B. C. D. Biopsy the lesion Obtain skin scraping for dermatophytes All of the above 17. Which of the following skin disorders is associated with diabetes? Acanthosis nigricans Vitiligo Impetigo Folliculitis 18. Which of the following disorders often presents in patients with café- au- lait spots ? A. Diabetes 16B. Malignancy 17C. D. Neurofibromatosis Autoimmune disease 19. Patient presents with complaint of a “swollen node” under his arm. The area is tender and the node has progressed in size over the past few days. Which of the following should be included in your differential diagnosis? A. Hidradenitis suppurativa B. C. D. anaphylactic reaction? A. B. C. D. 21. Epidermoid cyst Furuncle Both A and C 20. Which of the following skin conditions frequently heralds an Contact dermatitis Eczema Urticaria Erythema multiforme A patient with sarcoidosis has firm, tender, reddened nodules, along the anterior aspect of the leg. These lesions are called: A. Erythema multiforme B. C. D. 22. Erythema nodosum A discoid rash Lichen planus A patient suffered a laceration of the shin three days ago, and today presents with a painful, warm, red swollen region around the area. The laceration has a purulent exudate. The clinician should recognize that the infected region is called: A. Contact dermatitis B. C. D. 23. Folliculitis Hidradenitis suppurative Cellulitis A woman complains of malaise and arthralgias. You note a butterfly- shaped, macular, erythematous rash across her cheeks and nose. These conditions are common in: A. Psoriasis B. C. D. Lichen planus Systemic lupus erythematosus Erythema nodosum 24. Which of the following characteristics is not helpful in differentiating between psoriasis and atopic dermatitis? A. Distribution B. Family history 18C. Lesion morphology 19D. Chronicity 25. A patient presents complaining of recent onset of aching and malaise followed by the development of a generalized rash. He denies previous rash although he does admit that about a month ago he had an open sore on his right hand that was nonpainful. The exam reveals a maculopapular rash and lymphadenopathy. This presentation is most consistent with: A. Pityriasis rosea B. C. D. Chapter 3. Skin Answer Section MULTIPLE CHOICE 1. ANS: B When a patient presents with a skin-related complaint, there is an inclination to immediately examine the skin, as the lesion or change is often readily observable. However, it is crucial to obtain a history before proceeding to the examination in order to understand the background of the problem. A thorough symptom analysis is essential. PTS: 1 2. ANS: A Jaundice indicates an elevation in bilirubin and often is evident in the sclera and mucous membranes before it is obvious in the skin. PTS: 1 3. ANS: B The skin overlying the forehead or dorsal hand is more likely to provide a false impression of tenting or decreased elasticity; therefore, turgor should be tested by gently pinching a fold of skin over the abdomen, forearm, or sternum. PTS: 1 4. ANS: B The skin lesions of herpes consist of multiple vesicles, which cluster and are usually preceded by an area of tender erythema. The vesicles erode, forming ulcerations. PTS: 1 5. ANS: A Pruritus, burning, or stinging at the site often precedes the development of skin lesions. The lesions consist of clustered vesicles on a reddened base. The lesions have a herpetiform configuration, and the distribution is symmetrical. The extensor surfaces of the knees and elbows are often affected, as are the posterior scalp, neck, back, and thighs. 20 Secondary syphilis Herpetic whitlow Pyogenic granulomaPTS: 1 6. ANS: C Herpetic whitlow, a herpetic lesion on the finger, is usually a result of self-contamination of an infected patient to a skin break on the finger. PTS: 1 7. ANS: A Similar to other herpes lesions, varicella lesions progress from an area of redness to form a vesicle, then become pustular, and finally ulcerate. The vesicles look like a dewdrop on a rose petal. PTS: 1 8. ANS: B The distribution of herpes zoster lesions lie along a dermatome and are typically unilateral. There are many variations of the condition, depending on the affected dermatome. The healing of the lesions is frequently followed by development of postherpetic neuralgia. PTS: 1 9. . Folliculitis is an inflammation of the hair follicles and is typically associated with staphylococci. Other microorganisms and causes include pseudomonas (associated with hot tubs), Candida, tinea barbae, and herpes. PTS: 1 10. ANS: C While all of the conditions listed may progress from papules to erosive crusted lesions, folliculitis is associated with pustules, rather than vesicles. PTS: 1 11. ANS: B Human papilloma virus (HPV) is a viral cause of wart formation. In the perineal area, these are known as genital warts and they can lead to cancer of the cervix or anus. PTS: 1 12. ANS: C Basal cell carcinoma is the most common form of human malignancy and involves sun- exposed skin. This malignancy is generally very slow growing. However, it can become quite destructive and invasive if not diagnosed and treated in a timely manner. The typical complaint is of a nonhealing sore located on the face, ear, or other sun-exposed area. Although the lesions can vary, the typical lesion has a waxy/pearly appearance with a central indentation. 21 ANS: DPTS: 1 13. ANS: D With an epidermoid cyst, the patient complains of a cystic lesion that produces cheesy discharge with foul odor. The lesion is sometimes tender or painful. The lesion is nodular, round and firm, and subcutaneous; thus, it is flesh colored. The most common sites include the face, scalp, neck, upper trunk, and extremities. PTS: 1 14. ANS: D Erythema multiforme major usually occurs in association with herpes or mycoplasma infection or in response to medications, although a range of infections is implicated. PTS: 1 15. ANS: A With vitiligo, the patient often describes a history of the progressive development of small, multiple areas of depigmentation that, over time, become larger and confluent. There is no overlying scale or vesicle development. Any area of skin can be involved. The hair in the affected area may also lose pigmentation. There is a higher incidence of vitiligo in patients with autoimmune disorders, particularly those affecting the endocrine system, including hypothyroidism, diabetes mellitus, and Addison’s disease. PTS: 1 16. ANS: B In malignant melanoma, there is usually a history of a changing mole or other area of hyperpigmentation. The lesion is usually greater than 0.5 cm in diameter and has notched or irregular edges, irregular pigmentation, and asymmetry of shape. Like other skin disorders, there are variations in appearance, and there should be a high suspicion for melanoma in any changing pigmented skin lesion. Biopsy is diagnostic. PTS: 1 17. ANS: A Acanthosis nigricans is associated with insulin resistance. It is most prevalent in individuals who are obese and in Blacks and Hispanics. Onset is usually in youth. It is an area of darkly pigmented skin often within the skin folds. PTS: 1 18. ANS: C Café-au-lait spots are caused by increased melanin content and are associated with neurofibromatosis. The lesions vary in appearance and size, with color ranging from tan to brown. There frequently is a history of a variety of developmental and congenital conditions. The lesions are asymptomatic. They range in size from millimeters to over 10 cm and are usually flat macules or patches. Although the color varies, most are coffee colored. PTS: 1 19. ANS: D Hidradenitis suppurativa involves occlusions of hair follicles, which causes a red, 22fluctuant tender lesion. The site is commonly under the breast or in the axillae or groin. The clinician must differentiate this skin condition from an enlarged lymph node, which can appear similar. An enlarged lymph node is usually painless, whereas hidradenitis is usually tender. Furuncles are staphylococcal infections of hair follicles or sebaceous glands. Patients complain of pain, redness, and swelling at the affected site, commonly the axillae and groin. PTS: 1 20. ANS: C Urticaria, also commonly called hives, involves a histamine-mediated response that can be either acute or chronic. A wide range of situations are associated with hives, including a variety of infections, allergies to foods and medications, or underlying systemic disease. Urticaria are pink or red wheals that are very pruritic. Frequently they are associated with anaphylaxis and/or angioedema. PTS: 1 21. ANS: B Patients with autoimmune disease frequently experience isolated, multiple skin lesions that emerge as firm, tender, reddened nodules, usually along the anterior aspect of the leg, although other sites can be involved. Over a period of up to 2 weeks, the lesions fade in color and the degree of firmness decreases. PTS: 1 22. ANS: D In cellulitis, a patient often describes a history of a break in the skin from an injury, insect bite or sting, or previous procedure preceding the onset of redness, swelling, and pain at the site. The affected area is tender, swollen, reddened, and warm. Streptococcus or staphylococcal commonly causes the infection. The lower leg is a common site, usually unilateral. PTS: 1 23. ANS: C In systemic lupus erythematosus, the patient will have a range of symptoms relevant to the diagnosis, depending on the affected organs. There is often coexisting arthralgia and malaise. The rash is macular and erythematous. It is described as a “butterfly rash” because the distribution resembles a butterfly’s wings overlying the forehead and cheeks. PTS: 1 24. ANS: D While patients with psoriasis or atopic dermatitis are often able to provide related family history and the distribution and appearance of the lesions are different, both conditions tend to be chronic in nature. PTS: 1 25. ANS: B The patient may provide the history of a more generalized rash developing 2 or more 23weeks following the primary lesion, which may still be evident. The primary lesion is usually an isolated, single red lesion, which ultimately ulcerates, forming a nontender chancre. There may be a period of malaise preceding the eruption of secondary lesions. These lesions vary in appearance and distribution, but the typical finding is of red maculopapular lesions smaller than 1 cm in diameter. Any portion of skin can be involved, including the scalp, mucous membranes, perineum, and the soles and palms. There is generalized lymphadenopathy. PTS: 1 Chapter 4. Head, Face, and Neck Multiple Choice Identify the choice that best completes the statement or answers the question. 1. When obtaining a health history focusing on the patient’s head, face, and neck, which of the following is particularly important in regard to risk of disease? A. Past dental work B. C. D. 2. of numbness of the cheek? A. B. C. D. Use of alcohol and tobacco History of tension headaches Use of aspirin Which of the cranial nerves should be tested if the patient complains Cranial nerve III Cranial nerve V Cranial nerve VII Cranial nerve X 3. Which of the cranial nerves should be tested when a patient presents with right-sided facial droop and inability to close the right eye? A. Cranial nerve III B. C. D. 4. teeth when asleep. These are symptoms of: A. B. C. D. 5. following conditions? A. Cranial nerve V Cranial nerve VII Cranial nerve X A patient complains of pain with chewing, earache, and grinding her Temporomandibular joint syndrome Trigeminal neuralgia Facial nerve palsy Angina Inflammation of the parotid gland can cause which of the Trigeminal neuralgia 24B. C. D. Bruxism Mumps Temporomandibular joint syndrome 6. Calcium phosphate stones can develop within the salivary gland ducts. This can occur in the disorder called: A. B. C. Temporomandibular joint syndrome Mumps Trigeminal neuralgia 25