Pance Final Exam Dermatology and HEENT Questions with Explained Answers 2023 uPDATE

Pance Final Exam Dermatology and HEENT Questions with Explained Answers 2023 uPDATE HEENT   A 34-year-old woman presents to the clinic with complaints of intermittent flushing and blushing that started 3 to 4 weeks ago. Since then, she has noticed several inflammatory papules on the cheeks, nose, and chin. Upon exam, you notice an overall rosy hue to the face and the absence of any comedones. Which of the following would be the best course of topical therapy at this time? metronidazole gel Metronidazole is the topical treatment of choice for rosacea, which is consistent with the clinical findings in this 34-year-old female patient. Mupirocin ointment is a treatment option for impetigo, whereas permethrin is indicated for scabies. Tretinoin is effective and is indicated for comedonal acne. Topical hydrocortisone has not been shown to be effective for rosacea. A 26-year-old female presents with a whitish coating on her tongue and lips. When you attempt to rub the plaque with a tongue depressor, a small amount of bleeding is noted from the oral mucosa. Her past medical history includes asthma. What diagnostic test would you perform to confirm your diagnosis? The history and physical are consistent with oral thrush. A wet mount potassium hydroxide preparation will reveal fungal spores and nonseptated mycelia. A culture and sensitivity is used for suspected bacterial infections. A gram stain is used to identify whether a bacterial pathogen is gram positive or gram negative. Which of the following is the third component of the atopic triad, besides allergic rhinitis and asthma? Atopic dermatits, or eczema, is the third chronic finding, along with asthma and allergic rhinitis, in patients who are atopic. Urticaria are common in acute and chronic allergies. A 63-year-old male presents with an asymptomaticlesion in his mouth that was discovered by his dentist at a check-up.It is ill marginated with pigment ranging from medium brown to black.Parts of the lesion are raised. What is the next appropriate stepin management? Oropharyngeal melanoma is characterized by varying pigment occurringin an irregularly shaped lesion. Although this is a rarely occurringmelanoma, a biopsy should be done and any pigmented oral lesionshould be excised. Areas which are raised within the lesion usuallyindicate sites of invasion. What is the appropriate first line treatment of lyme disease in a non-pregnant adult female with erythema migrans and no other symptoms of lyme disease and no known drug allergies? In patients over the age of 9 exhibiting skin or joint manifestations of lyme disease, the first line treatment is Doxycycline 100 mg bid. Patients less than 9 or those who are allergic to Doxycycline should be treated with amoxicillin. Erythromycin is fourth line treatment for all age groups. Ceftriaxone is first line for patients with nervous system involvement. (Wolf f & Johnson, pg 691) A two-year-old male presents with a noduleon the side of his index finger. His mother states that he has hadthis nodule on one prior occurrence during infancy, and it resolved onits own. What is the most likely diagnosis? This child has a recurrent digital fibroma. It is a smooth, firm,pink nodule that occurs on the fingers and toes up through earlychildhood. Surgical excision is recommended so that the functionof the digit is not impaired. A 12-year-old male presents with hyperkeratoticpapules located on both hands. What is the causative organism? This patient has verruca vulgaris orthe common wart. The causative organism is the human papillomavirus(HPV). They can affect patients of any age and can occur on anyskin surface. There is a predilection for the hands and fingers. A 12-year-old male presents with hyperkeratoticpapules located on both hands. What is the causative organism? This patient has verruca vulgaris orthe common wart. The causative organism is the human papillomavirus(HPV). They can affect patients of any age and can occur on anyskin surface. There is a predilection for the hands and fingers. A 60-year-old male presents with complaints of irritation and a white plaque on his tongue. He denies pain. During physical exam you are unable to remove the white plaque from the mucosa with a tongue depressor. What is the most likely diagnosis, represented as follows? Oral leukoplakia cannot be removed from the mucosa using a tongue depressor like oral thrush can. Lichen planus can mimic candidiasis, squamous cell carcinoma, or hyperkeratosis, and requires a biopsy to diagnose. Glossitis is a generalized inflammation, and loss of papillae of the tongue is caused by vitamin deficiencies, medication reactions, auto immune reactions, or psoriasis. Geographic tongue is an asymptomatic serpiginous area of atrophy and erythema of the anterior tongue. The condition is self-limiting. Digital Fibroma Acanthosis nigricans A 54 year old male presents with dark thickened skin and soft pedunculated papules around his neck. He states that the lesions are asymptomatic. What disease process are the findings commonly associated with? The thick dark plaque around the patient's neck is acanthosis nigricans. The papules are acrochordons (or skin tags). Both conditions are associated with metabolic syndrome. (Wolf f & Johnson, p231) A 45-year-old male presents with purulent discharge from his right ear for three weeks. He states that despite being treated by his family doctor for an ear infection one month ago, the problem continues to get worse. Upon exam, you note purulent discharge in the ear canal, an erythemic tympanic membrane, and a possible perforation. What are the pathogens most likely to culture positive? he clinical vignette describes a chronic otitis media. Usually, this refers to a complication of acute otits media with perforation. Pathogens that culture from these infections are usually pseudomonas, proteus, or staphylococcus aureus. Strep pneumoniae is often seen in acute otitis media. E.coli is a urinary tract pathogen. Candida albicans is a cause of vaginitis, and mycoplasma is a respiratory pathogen. A six-month-old male has recurrent diaper rashes, which are not responding to ketoconazole cream or zinc oxide diaper creams. Physical exam shows well demarcated perianal erythema, with scattered red papules on the buttocks. A KOH is negative. What would appropriate management include? This rash is consistent with a perianal staph or strep infection. This bacterial infection is easily treated with topical mupirocin. If the rash does not resolve after two weeks of topical treatment, treatment with an oral antibiotic such as Keflex is usually successful. Treatment with a topical steroid may worsen the infection. Tretinoin is a topical retinoid indicated to treat acne, and is not appropriate for this patient. Lotrisone is a combination medication that includes an antifungal and a topical steroid, neither of which is indicated in this patient. You are evaluating an 80-year-old female for the first time. She has a history of mild Alzheimer's disease, for which she takes Aricept. She states that she feels fine but her daughter feels she is depressed and has been complaining of not feeling well. Her daughter admits that the patient has a history of primary hyperparathyroidism. What laboratory results would be most consistent with her diagnosis of hyperparathyroidism? The hallmark of primary hyperparathyroidism is a high serum calcium and high intact PTH. A low intact PTH is consistent with hypoparathyroidism. The urine serum calcium is usually high in primary hyperparathyroidism. Cortisol is related to endocrine conditions affecting the adrenal cortex. A 65-year-old female presents with a red irritation in her right eye. She states that this has been occurring intermittently for about two years. She also states that her eyelids are "droopy," and that she needs plastic surgery. On physical exam you notice a diffusely injected conjunctiva and an outwardly tilted lower eyelid. What is the most likely diagnosis for the abnormal physical finding? Ectropion Ageing causes a relaxation of the obicularis oris muscle, and will cause the lower eyelid to sag outwardly. This prevents the lower lid from protecting the eye, and frequently results in exposure conjunctivitis and keratitis. Treatment is surgical. A patient presents with epistaxis from the right nares, along with direct pressure to the nares and elevation of the head. Which of the following is an appropriate initial treatment? Phenylephrine is a topical decongestant, and acts as a vasoconstrictor to aid in stopping minor anterior septal epistaxis. Triamcinolone and momentasone are nasal steroids used for allergic rhinitis. Cromolyn sodium is a mast cell stabilizer, and azelastine is a topical H1 selective antihistamine, used for allergic rhinitis. Keflex Cephalexin is a cephalosporin antibiotic used to treat certain infections caused by bacteria such as pneumonia and bone, ear, skin, and urinary tract infections. Antibiotics will not work for colds, flu, or other viral infections. A 15-year-old obese male presents with annularlyconfigured lesions in a generalized distribution. They are asymptomatic.What can these lesions be associated with? This patient presents with a generalized form of granuloma annulare(GA). Generalized GA can be associated with diabetes mellitus. A 25 year old female presents with multiple irregular brown macules on her upper back. They are asymptomatic. She has worked as a lifeguard for the past 7 years. She reports a couple of blistering sunburns and admits to maintaining a "healthy tan". What is the most likely diagnosis? Solar lentigines are a result of skin damage from the sun. Unlike ephiledes, they do not fade once exposure to the sun has stopped. There is no risk of malignancy associated with solar lentigines. A 12-year-old presents with sharply demarcated depigmented macules on bilateral knees. The parents report that this began about one year ago, after the child fell and skinned his knees. After healing, he was left with these markings. What is the most likely diagnosis? Vitiligo is the most likely diagnosis. Vitiligo is an autoimmune disorder that affects the melanocytes. There is often a history of trauma that can precede an occurrence of vitiligo. The course for vitiligo is variable. Sometimes it will resolve spontaneously. Other times, it will continue to progress despite treatment. Post-inflammatory hypopigmentation are areas of lighter pigment, not complete depigmentation, which result from a resolved inflammatory process. The pigment will return over time. A hypertrophic scar is one which is enlarged but stays within the borders of the original injury. No pigment changes are associated with these scars. Pityriasis alba is a yeast infection of the skin, and usually appears on the face. It usually occurs in elementary school aged children, and is more apparent in late summer or early fall. An 8-year-old male with hair loss, pruritus, and posterior cervical lymphadenopathy has a + culture on dermatophyte test medium (DTM). Which of the following is the most appropriate treatment? The positive DTM confirms the diagnosis of tinea capitis. The only approved treatment for tinea capitis is griseofulvin. In tinea capitis, the dermatophyte invades the hair shaft and topical treatment is not effective. An antifungal shampoo is often used as an adjunct to treatment. Keflex is an oral antibiotic, which will not help treat the fungal infection. Desonide is a topical steroid that will worsen the fungal infection. A patient has a 2-day history of an itchy red left eye and marked tearing. There is no history of injury. On physical exam the conjunctiva appear markedly erythemic. What physical finding would help most in differentiating this as a viral conjunctivitis? A palpable pre-auricular lymph node is most often seen with viral conjunctivitis and rarely seen in bacterial conjunctivitis. A 45-year-old male presents with a history of thick, adherent yellow scaling in his scalp, and red scaling patches with fissuring in post auricular areas bilaterally. Which of the following are other areas of potential involvement? The patient presents with seborrheic dermatitis. Other areas of potential involvement include the eyebrows, eyelashes, and beard area. Antecubital and popliteal fossae are common areas of involvement in atopic dermatitis; not seborrheic dermatitis. The palms and soles are not involved in seborrheic dermatitis. The trunk and neck are not usually affected in seborrheic dermatitis. A 6-year-old female presents with small erythematous papules grouped around the mouth. The mother reports that she tried to treat with over-the-counter hydrocortisone 1% cream. The condition has worsened. What is the best step in management of this condition? Metronidazole 0.75% gel bid is a first line treatment for perioral dermatitis. Topical steroids, such as hydrocortisone valerate cream, will actually worsen perioral dermatitis and create a granulomatous condition. Oral antibiotics, like Keflex 500 mg bid, are frequently used to treat perioral dermatitis. However, Keflex is not indicated for perioral dermatitis. Clotrimazole is an antifungal cream that is not used in perioral dermatitis. A 30 year old female complains of a dome shaped slightly erythematous nodule on her right thigh. Upon clinical examination it exhibits the "dimple sign". The patient states the lesion is not changing and is asymptomatic. What is the most likely diagnosis? This is the classic presentation of a Dermatofibroma. The dimple sign is when a depression forms after the lesion is laterally compressed between the fingers A 25-year-old female presents with a complaint of dry, cracking hands for two months. She has never had any rashes or similar problems. She does not work outside the home. She is the mother of a 6-month-old healthy female. Over-the- counter lotions have been tried, but they sting with application. What is the next appropriate step? The patient most likely has an irritant dermatitis, secondary to increased water exposure, from having an infant. Appropriate treatment includes a topical steroid, like triamcinolone. Ointments are better vehicles than creams, as they penetrate better and moisturize. Using petroleum based moisturizers are more effective than oil based in repairing the epidermis. There is no evidence at this point of an allergen causing the outbreak. If the disorder is resistant to treatment, then patch testing to determine the allergen may be an appropriate step. A punch biopsy is not indicated, unless there is no response to treatment. A KOH test would be indicated if the rash was suspicious for a fungal infection. If the patient does not respond to treatment with a topical steroid, KOH testing may be indicated. Your patient has symptoms consistent with perennial allergic rhinitis, and after performing a history and physical examination, you elect to perform an IgE-specific serum antibody test for both food and respiratory allergens. The results return and the patient does not have an IgE positive response to a single allergen tested, yet the patient's total serum IgE is elevated dramatically. What would be the most appropriate next step in the diagnosis and treatment of this patient? Allergen-specific serum IgE testing is an easy and accurate method for determining the presence of atopic allergy, and with newer in vitro technology available, in vitro testing is at least equivalent to skin testing in efficacy. In vitro assays are safe, specific, cost-effective, and reproducible, and do not require the patient to be free of antihistamines and other medications that may interfere with skin testing. They are also easy and quick and are therefore preferred, especially in children and in anxious patients. A 26-year-old female presents with a history of a rash around her neck, off and on for several years. It has been treated with mid potency prescription topical steroids, only to recur again. She reports that during treatment she will discontinue wearing jewelry until the rash resolves. The patient complains of pruritis but no other symptoms. What is the most likely diagnosis? This is a classic contact dermatitis, secondary to nickel allergy. Nickel is a very common metal that is contained in metals, clothing, and jewelry. It is a delayed, cell mediated hypersensitivity reaction, so it takes multiple exposures before an allergic response is exhibited. Atopic dermatitis is usually manifested prior to the age of six. The classic distribution is the flexural surfaces of the extremities. Herpes zoster presents with prodromal neuralgic pain two to three weeks prior to outbreak. The rash has vesicles and erythema in a dermatomal distribution that crust over after three to five days. The pain may last after resolution of the lesions. Presentation of tinea corporis is pruritic, annular scaling patches that enlarge with central clearing. A 4 year old male presents with a fever for 3 days. His highest temperature was 39.4C. His mother brings him to the ED because she noticed this morning that his palms and soles were red. Now, there is blotchy erythema on the trunk with bulbar conjunctivitis and diffuse erythema on the tongue and prominent papillae. CBC shows leukocytosis. What is the appropriate management of this patient? This patient is exhibiting classic signs and symptoms of Kawasaki Disease. Complications of Kawasaki Disease include coronary artery aneurysms, myocarditis, myocardial ischemia or infarction, and stroke. Recommended treatment is hospitalization to monitor for complications and administration of IvIg with aspirin. A patient presents complaining of a painful rash on his lips. What is the causative pathogen for the rash shown in the image? Herpes simplex type 1 causes an orolabial and gingival vesicular rash. Herpes simplex type 2 causes genital lesions and is sexually transmitted. Herpes zoster or shingles causes a dermatomal, unilateral, and painful vesicular rash. Staphylococcus aureus and beta hemolytic streptococci cause bacterial skin infections. A 6-year-old male presents with crusted erythematous lesions on the nose, mouth, and chin. He has a history of atopic dermatitis. Which of the following should be part of an appropriate treatment regimen? This patient is suffering from impetigo. Impetigo is easily treated with a topical antibiotic, such as mupirocin. Hydrocortisone is a topical steroid and may worsen the infection. Lotrisone is a combination medication that includes an antifungal and a topical steroid, neither of which is indicated in this patient. Ketoconazole cream is used to treat fungal infections, not bacterial infections. A 45-year-old female presents with a sudden onset of vertigo, nausea, and vomiting. Upon physical exam, you note that she is holding on to the rails of the bed, and her pain gets worse when you attempt any movement of her head. Neurologic exam is grossly normal. Which combination of the following medications is indicated to treat the patient's symptoms? All other combinations include an ototoxic medication: furosemide, gentamycin, aspirin, and cisplatin. Treatment of acute vertigo is more effective using a combination of vestibular suppressants (benzodiazepines), anti-emetics (prochlorperazine), and anticholinergics (diphenhydramine or scopolamine). A 63-year-old female complains of a 5-day history of a persistent left-sided headache, which she has not experienced before. She also notes a tender swollen area around her left temple, which appeared around the same time. On examination you note tenderness and prominence of the left temporal artery. You order an ESR, which is 75 mm/h. What is your best course of action at this time? The patient's history and physical examination findings point to giant cell arteritis (temporal arteritis) as the most likely cause, prompting immediate treatment with high-dose prednisone to prevent visual loss. The patient meets the criteria for clinical diagnosis of giant cell arteritis without a temporal artery biopsy, but it is recommended for definitive diagnosis due to the complications associated with long-term corticosteroid treatment. Treatment with prednisone should not be withheld while waiting for a temporal artery biopsy. NSAIDs and hydrocodone do not prevent the complications of temporal arteritis. Which of the following conditions is a cause for central vertigo? Meniere syndrome, labyrinthitis, vestibular neuronitis, and perilymphatic fistula are causes of peripheral vertigo. Acoustic neuroma, or eight cranial nerve schwannomas, are among the most common intracranial tumors, and a cause for central vertigo. is vertigo due to a disease originating from the central nervous system (CNS). In clinical practice, it often includes lesions of cranial nerve VIII as well. Individuals with vertigo experience hallucinations of motion of their surroundings. Central vertigo Vertigo caused by problems with the inner ear or vestibular system, which is composed of the semicircular canals, the otolith (utricle and saccule), and the vestibular nerve is called "peripheral", "otologic" or "vestibular" vertigo.The most common cause is benign paroxysmal positional vertigo (BPPV), which accounts for 32% of all peripheral vertigo.Other causes include Ménière's disease (12%), superior canal dehiscence syndrome, labyrinthitis and visual vertigo. ... An 8-year-old female presents with numerous discrete, skin colored papules with a central umbilication. The lesions are mildly pruritic. What is the most likely diagnosis? This is classic presentation of Molluscum contagiosum. Molluscum primarily affects younger children, from infancy through elementary age. Lesions appear as pearly, skin colored papules with a central umbilication. They can be pruritic. Herpes simplex virus is described as a vesicle that crusts after a few days. Neurogenic pain is associated with the outbreak. The varicella zoster virus is chicken pox. These lesions are described as "a dew drop on a rose petal," due to the characteristic vesicle on a red base. They occur in crops, with some being vesicular and some being crusted. There is no umbilication. Comedonal acne primarily affects teens. These lesions are located on the face, back, and chest. An 18 month old female is brought to the pediatricians office with a history of cough, fever of 102, and decreased fluid intake. Her immunizations are not up to date as the family just moved to the United States from out of the country. On physical exam she is drooling and sitting up in a "tripod position" with mild stridor. What is the most appropriate treatment indicated for this condition? The clinical presentation suggests epiglotitis. This is an emergent airway condition. The anesthesiologist , or the pediatric otolaryngologist must be called to stand by to intubate or insert a tracheostomy if the patients airway closes. Racemic epinephrine via nebulizer relieves much of the edema to the upper airway in a patient with epiglotitis. It is a stabilizing measure until definitive care can be arranged. Oxygen and antibiotics should administered emergently also. No x-rays are indicated when the presentation is classic. Albuterol is a beta-agonist used for treatment of asthma. Budesonide,a steroid and ipratropium, an anticholinergic agent are most often used in combination with albuterol for treatment emphysema and asthma. Which of the following concerning changes in nevi can be associated with melanoma? The ABCDE's of moles are asymmetry, border irregularity, color change or irregularity, diameter >5mm, and evolving (changing in some way). These are all signs that the mole should be evaluated for possible dysplastic or malignant changes. You are treating a 20-year-old female with multiple aphthous ulcers. She complains of a moderate amount of pain. You decide to prescribe "magic mouthwash" for the patient to swish and spit. Which of the following combinations of medicines is appropriate? A very commonly used combination of medicines to promote relief of discomfort and healing include liquid diphenhydramine, antacid, tetracycline, and 2% viscous xylocaine. While you are doing a funduscopic exam on an 80-year-old female with progressive vision loss, you notice drusen formations on her retinas. What is the most likely diagnosis? Drusen are yellow colored collagen deposits in Bruch's membrane of the retina. They can be diffuse, discrete, or confluent. Retinal pigment changes and atrophy are see in "dry" macular degeneration. "Wet" macular degeneration demonstrates choroidal neovascularization, or serous retinal pigment hemorrhages and retinal detachments. A 45-year-old male who presents to the emergency department with sudden onset of lip swelling, which began shortly after awakening this morning. He denies any history of allergies and denies any new medications. His current medications include hydrochlorothiazide (HCTZ), captopril, atenolol, atorvastatin, and fexofenadine. What is the most likely cause of this gentleman's symptoms? ACE inhibitor angioedema is a potentially life-threatening known side effect of captopril. The patient may need emergency intubation to ensure that his airway remains patent. Patients with a history of ACE inhibitor angioedema should not be placed on any ACE inhibitor or an ARB due to the possibility of similar reaction. HCTZ (a diuretic) and atenolol (a beta blocker) are antihypertensives that are generally unlikely to be associated with angioedema. Atorvastatin (a statin) and Fexofenadine (an antihistamine) are unlikely to present with angioedema. Parents present with their 8-month-old childwith complaints of a new rash. This rash appears as monomorphic,flat, and red papules, some of which coalesce to form plaques. Theyare present on the face, buttocks, and extremities. What is theappropriate management of this condition? This patient has the rash of Gianotti-Crosti. It is also calledpapular acrodermatitis of childhood. This rash starts with classicmonomorphic, flat, and red papules that coalesce to form plaques.It is symmetric in its distribution and classically affects theface, elbows, and knees. It will resolve on its own; therefore,no treatment is necessary. An 18-year-old male presents with a rashconsisting of erythematous target-like lesions on his arms. Physicalexam shows a healing cold sore on his lips, but no other skin or mucosallesions are present. What is the most likely cause? This patient is exhibiting the classic rash of erythema multiformeminor. Etiology of this disorder can be traced to herpes simplexoutbreaks or other viral or bacterial infections. Recurrent diseaseis most often associated with herpes simplex outbreaks. A 60-year-old male presents with scaling feet for several months. The nails are spared. The patient has tried over-the-counter hydrocortisone cream with no help. KOH shows branching hyphae and spores. Which of the following should be part of an appropriate treatment regimen? The clinical presentation and KOH results are consistent with tinea pedis or athlete's foot. Since the nails are unaffected, topical treatment with clotrimazole is appropriate. Lotrisone contains an antifungal and a steroid; this combination medication is not appropriate for this patient. Fluticasone is a class 3 topical steroid that would worsen this patient's condition. Mupirocin is a topical antibiotic and will not help resolve a fungal infection. Since the introduction of the Haemophilus influenza B vaccine, which of the following diseases is in decline for the pediatric population, but is being seen more in adults? The H. influenza B vaccine has significantly decreased the incidence of epiglotitis in children, leaving the adult population with a higher incidence of epiglotitis. The course of the illness in adults is not as severe as in the pediatric population. Influenza B is a seasonal virus, and requires yearly immunizations. A six-month-old infant presents to the primary care provider with complaints of a spreading rash. The physical exam shows multiple yellow-brown macules and plaques that urticate when stroked. What would an appropriate treatment regimen include? This condition is consistent with urticarial pigmentosa, and it will resolve over time. However, certain things such as NSAIDS, codeine, and scopolamine, as well as extreme temperatures, can cause such reactions as anaphylaxis. This condition is frequently mistaken for child abuse, as the lesions can look like small finger sized bruises. It is consistent, however, with urticaria pigmentosa, which is an accumulation of mast cells in the skin, as indicated by urtication of the lesion after gentle stroking. Urticaria pigmentosa will resolve; however, it will take longer than a week to resolve. Ketoconazole cream is an antifungal that is used to treat fungal infections. A 16-year-old male was hit on the left side of his face by a line drive baseball. Marked swelling is noted externally to the left eye. There was no loss of consciousness. Upon physical exam, he complains of diplopia during extraocular motion testing. Enophthalmos is noted, as well as decreased sensation of the left cheek. Plain x-rays of the face demonstrate an air-fluid level in the left maxillary sinus, and a fracture of the orbit. Based on this information, what is the most likely diagnosis? Diplopia is common in an orbital blow out fracture, due to entrapment of the inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs from disruption or swelling of the infraorbital nerve. A Le Fort I fracture describes a transverse fracture separating the body of the maxilla from the pterygoid plate and nasal septum. A Le Fort II fracture describes a pyramidal through the central maxilla and hard palate. Movement of the hard palate and nose occurs, but not the eyes. A Le Fort III fracture describes a craniofacial disjunction, wherein the entire face is separated from the skull due to fractures of the frontozygomatic suture line, across the orbit and through the base of the nose, and ethmoids. The entire face shifts, with the globes held in place only by the optic nerve. A 10-year-old male who plays soccer presentswith annularly configured dermal papules that are skin colored andshiny, and are located on his shins. His mother states that the lesionsstarted as nodules, and have since enlarged. There is no scale presentand they are asymptomatic. No one else in his home has similar findings.What is the most likely diagnosis? Granuloma annulare (GA) is a self-limited condition that mayappear as solitary lesions or in a more generalized distribution.They begin as small, shiny skin colored dermal papules that enlargeover time with central clearing. There are no epidermal manifestations.GA commonly occurs over bony surfaces, such as the shins or dorsaof the hands. It is frequently misdiagnosed as tinea corporis; however,the absence of epidermal scaling helps rule out this diagnosis. What is the most appropriate management for the lesion shown, which is noticed on a 50-year-old female? The lesion is asymmetric with irregular margins. The optimal treatment of this lesion would be excision with 1 cm margins. A punch biopsy would only be performed if excision cannot be performed. Cryotherapy would destroy the lesion and prohibit a diagnosis and staging. An 8-year-old male with a history of atopicdermatitis presents with a widespread rash consisting of vesiclesand eroded lesions. What is the causative organism? This patient has eczema herpeticum. This is caused by the herpessimplex virus. Transmission can occur innocuously via the parent.Atopic dermatitis is a risk factor for eczema herpeticum, secondaryto the impaired barrier function of the skin. This impaired barrier functionallows the virus to spread rapidly. The parents of a four-month-old child present with concern regarding a birthmark on the child's scalp and left side of face. The lesion has been present since birth and is growing. It has an orange, pebbly appearance. What is the appropriate treatment? This lesion is consistent with a nevus sebaceous. It will grow as the child grows. After puberty, the lesion becomes thicker with a warty appearance. There is a slight increase in incidence of basal cell carcinoma as the patient ages. It is recommended that the lesion be excised prior to puberty, when these changes occur in response to hormone secretion. It is confined entirely to the skin; therefore, a CT is not necessary. Laser therapy is not an effective treatment for a nevus sebaceous. It requires complete excision. It also has an increased risk of basal cell carcinoma. It will not spontaneously resolve. Taking vitamin C, E, zinc, and beta carotene, and stopping smoking, have a preventative effect on the progression of which of the following diseases? Smoking cessation and taking supplements, including vitamin C, E, zinc, and beta carotene, have shown an eight percent decrease in progression of late stage macular degeneration. Smokers or previous smokers should not take beta carotene, due to its link with lung cancer in smokers. A 50 year old female presents multiple episodes of sudden onset of vertigo over the past few months. She states this began after turning her head suddenly. The events last for about 30 seconds. She complained of nausea during the spells. She denies headaches, hearing problems, focal weakness or recent illnesses. What is the most appropriate clinical intervention. The clinical history suggests benign paroxysmal positional vertigo (BPPV). The Dix- Halpike test and Nylen Barany test are physical exam techniques to diagnose positional vertigo. The Epley maneuver is a therapeutic canalith repositioning maneuver for debris in the posterior semicircular canal, which is the cause of BPPV. The maneuver works in 80% of the patients with BPPV. A head CT would be indicated for any patient with neurologic symptoms or a new onset of headache. A 28-year-old male presents with a rashon his hands that is unresponsive to topical steroids. On physicalexam you notice periocular violaceous erythema and edema. He also exhibitssignificant proximal muscle weakness. What is the most likely diagnosis? Dermatomyositis is an autoimmune disease that targets the skinand skeletal muscle. Skin lesions usually consist of a periorbitalheliotrope rash, which can have associated edema. There can alsobe flat topped violaceous papules (Gottron papules) located on theneck, shoulders, and knuckles. Periungual erythema with telangiectasiasmay also occur. Possible muscular symptoms include muscle tenderness,muscle atrophy, and progressive proximal muscle weakness. A mother presents with a 2-month-old infantwith a concern of bald spots in the child's scalp. Shestates that there were ulcerated areas present at birth that healedwithin a few days. What is the most likely diagnosis? Aplasia cutis congenita is a rare condition that is present atbirth, and presents as asymptomatic ulcerations of the scalp. Theseulcerations heal with scarring in a matter of weeks. The cause isbelieved to be incomplete neural tube closure or cessation of skindevelopment of the embryo. A 66-year-old male patient complains of pain and swelling in his left foot intermittently over the past year. He denies any current symptoms. On examination you note the following findings. His left foot is unremarkable. Laboratory finding include an elevated uric acid. What is the most likely diagnosis? His uric acid level is elevated, which further supports a diagnosis of gout. It is suspected that the intermittent left-foot swelling is related to acute flares of gout, which usually affects the first MCP joint. Choices (A), (C), (D), and (E) are not associated with elevated uric acid level or tophi. The patient may have osteoarthritis, but this does not explain the high uric acid level and the tophi on exam. A 66-year-old female has a chief complaint of vision loss in her left eye. She denies pain and states that this occurred over the past few hours. Her past medical history includes hypertension, high cholesterol, and peripheral vascular disease. Upon funduscopic exam, you note marked hemorrhages in all quadrants and disc edema. The contralateral eye shows only mild hypertensive vascular changes. What is your diagnosis? A central retinal vein occlusion is characterized by a "blood and thunder" fundus, with marked hemorrhages, tortuous vessels, and optic disc edema. A 45-year-old male presents with a non-tender nodule protruding from his lower eyelid. There is some surrounding erythema to the conjunctiva, but no discharge is seen. He states that it has been there for one month. He has no visual problems. What is your diagnosis? A chalazion is a sterile, chronic, and non-painful granulomatous nodule, caused by a previous acute infection in a meibomian gland. It can develop over a period of a few weeks. Treatment is intralesional steroids or surgical curettage. A 35-year-old homeless male presents with a painful red right eye and decreased visual acuity, which occured over the past 48 hours. He doesn't recall any trauma, and prior to this his vision was good. His past history includes alcoholism and liver disease. On physical exam you notice a white opacity in the center of his right cornea. You are unable to do an ophthalmoscopic exam due to the opacity, and a fluorescein staining is strongly positive. What is the likely etiology of the white opacity? A rapidly progressing central corneal ulcer must be considered first and treated aggressively. An ulcer will show fluorescein staining, due to a break in the corneal epithelium. Pseudomonas, strep pneumonia, herpes, and fungus must be considered as possible causes. An emergent ophthalmology consult can be sight saving. An 18-year-old female presents with two weeks of severe sore throat and fatigue. Her exam shows an exudative tonsillitis. A mono-spot test is positive, and a rapid strep test is positive. Which of the following medications should be avoided? Ampicillin should be avoided, because a high percentage of mononucleosis patients develop a fine, non-allergic maculopapular rash when given ampicillin class drugs. The remaining antibiotics are appropriate for treating group A strep. Prednisone is used to reduce the pain and inflammation associated with severe tonsillitis. The source of most cases of epistaxis comes from what anatomic location? Anterior nasal septum. 95 percent of epistaxis come from Kesselbach's plexus, which is a superficial, fragile group of arterioles and veins that are the most likely cause of nosebleeds. Five percent are posterior bleeds that originate along the sphenopalentine artery. Use of which of the following medications can result in hearing loss? Gentamycin is an aminoglycoside, and can cause ototoxicity. Peak and trough levels must be drawn to determine the lowest effective dose. The remaining medications do not interfere with vestibular function. A 12 year old female found a tick on her leg after a camping trip. The tick was removed without incident. According to CDC recommendations, what is the appropriate testing for Lyme disease? The CDC recommends first using ELISA to test for Lyme disease. If this is positive, then a Western Blot should be performed as confirmation. Acute and convalescent titers should be tested as only 20-30% of patients have a positive response in the acute phase. That percentage rises to 70-80% in the convalescent phase. A 30-year-old male presents to your office complaining of sinus and facial pain, congestion, and purulent nasal discharge for one month. He has been treated with two courses of different antibiotics by another provider, and does not feel any improvement in his symptoms. What diagnostic test is indicated? A CT scan is the current preferred method for sinus imaging of chronic sinusitis. CT imaging has better visualization of mucosal thickening air-fluid levels and bone structures. Plain radiographs and CT scans are of limited use in acute sinusitis, because viral pathogens that cause sinus abnormalities are indistinguishable from bacterial causes. A 7-year-old presents with vesicles withsurrounding erythema, located on the sides of his fingers and toesand in his mouth. He has a low-grade fever and has difficulty eating,secondary to pain. What is the most likely cause of this rash? This is the classic eruption of hand-foot-and-mouth (HFM) disease,which is caused by the Coxsackie A16 virus. HFM is highly contagious.Patients will present with painful ulcerative lesions, which maymake it difficult to eat. There are also vesicles on the hands and feetthat are relatively asymptomatic. HFM may be associated with a low-gradefever, malaise, abdominal pain, and respiratory symptoms. A 25-year-old female presents for a skin exam. She has no family history of skin cancer, and has no moles that itch, bleed, or ulcerate. She is concerned about a mole on her arm that is surrounded by a hypopigmented area. She states that the mole appears to be decreasing in size. What would appropriate management of the lesion include? This lesion is consistent with a halo nevus. The depigmented macule that surrounds the nevus is similar to vitiligo and may consume the nevus; therefore, reassurance that this will resolve is appropriate for this patient. There is no need for excision with margins as this is not indicative of malignant changes. Hydrocortisone 2.5% ointment is a low potency topical steroid. This treatment is not indicated for a halo nevus. Ketoconazole is an antifungal used to treat fungal infections. There are no indications of fungal infection in this halo nevus. A mother presents with a four-month-old male infant complaining of a dry, itchy rash that never seems to completely resolve. There are days when it appears to improve. She currently uses baby wash and baby lotion to care for his skin. She recently discontinued the lotion because he screams when it is applied. Which of the following is this condition exacerbated by? This patient has the classic presentation of infantile atopic dermatitis. There are numerous factors that can irritate this condition including frequent (more than once a day) or long baths, soap based cleansers, cold dry environments, illness, stress, itchy clothing, and allergies. Lotions may sting, especially if the skin is dry and the skin barrier is broken. Atopic dermatitis usually improves in warm, humid environments. Petroleum based moisturizers are an important part of the treatment of atopic dermatitis. Soap free cleansers are recommended for patients with atopic dermatitis, as they are less irritating and drying. Topical steroids are the first line treatment of atopic dermatitis. A 24-year-old female comes into the clinic complaining of a severe sore throat. She was seen three days ago at an urgent care facility, and was given amoxicillin. She states that the pain is worse, she is unable to drink fluids, and is now having difficulty swallowing. She talks with a muffled voice. A physical exam reveals a markedly swollen and erythemic right tonsil and tonsillar pillar, with the uvula deviating to the left. The patient has extreme difficulty opening her mouth. What is the most likely diagnosis? The physical exam is highly suspicious for peritonsillar abcess, which must be considered first. Tonisllar cellulitis, or phlegmon, is swelling and enlargement of the tonsil and peritonsillar tissue, without the presence of fluctuant abcess. Uvulitis can exist with a peritonsillar abcess or tonsillitis, but isolated uvulitis usually includes symmetric swelling and erythema as a result of irritation (snoring), allergy (angioedema), or infection from upper respiratory pathogens. Diphtheria is a tonsillitis, with a characteristic gray pseudomembrane on the tonsils and upper airway, caused by corneybacterium diphtheriae. A 12 year old male presents with lesions on the palmar surface. They have been present for less than a week. Prior to the lesion appearing there was a small lesion that was assumed to be a bug bite. The lesion bleeds profusely with minimal provocation. What is the most likely diagnosis? A pyogenic granuloma (PG) occurs at the site of minor trauma such as a bug bite or scratch. The PG grows rapidly forming a popular lesion with a collarette of scale. It will bleed profusely with minimal provocation. The only effective treatment is shave excision with curetting and ablation of the blood vessels that form the base of the PG. You are asked to examine an 88-year-old female resident of a nursing home, who presents with a red eye. Her notes from the nursing home say that the patient has had this problem for six months, but now seems to be getting worse despite using daily artificial tears and occasional topical antibiotic drops. On physical exam you notice markedly injected conjunctiva to the right eye, with no discharge. The lower lid appears to be curled in toward the bulbar conjunctiva, with the eyelashes pointing inward. What is the name of this condition? Aging causes a relaxation in the lower lid retractors, resulting in an entropion. This causes chronic irritation to the bulbar conjunctiva and corneal abrasions. Treatments include taping the lower lid to the cheek, botulinum toxin injection, or surgery. You are examining a 65-year-old male who complains of partial vision loss in his right eye. Besides obtaining visual acuity, what is the most important physical exam to perform in order to evaluate his condition? When a patient complains of vision loss, all of the choices are important parts of the eye examination; the visual field by confrontation exam is a screen to detect visual field defects. Which of the following diagnostic studies is indicated for a patient with amaurosis fugax? Amaurosis fugax is a monocular vision loss that appears like a curtain passing over the eye, and comes from carotid artery disease. A CT of the head is indicated for lateralizing stroke symptoms. Intraocular pressure is taken for evaluation of chronic or acute glaucoma. A temporal artery biopsy is taken if giant cell arteritis is suspected. An ocular fluorescein angiogram is done to evaluate retinal disorders. A 71 year old female presents with complaint of a severe headache for 2 days. The patient denies a history of headaches in the past. She complains of a 2 week periods of morning shoulder and pelvic stiffness. There also a history of jaw pain when she chews her food. The past medical history is remarkable for well controlled hypertension, hyperlipidemia. On physical exam there is a markedly tender scalp and left temporal artery. The neurologic exam is normal. Besides a temporal artery biopsy what other diagnostic test is most indicated? The clinical scenario suggests giant cell arteritis (GCA) or temporal arteritis. An erythrocyte sedimentation rate( ESR) or C-reactive protein( CRP) can aid in the diagnosis of GCA when evaluating an inflammatory vasculitis such as GCA. Treatment is based on history and physical and not the result of the ESR. Temporal artery biopsy is the gold standard for diagnosis. Which of the following will cause conductive hearing loss? A. Mumps B. Syphilis C. Multiple sclerosis D. Otitis media E. Medications Conductive hearing loss is the result of blockage of sound waves from the external canal to the inner ear. Causes include cerumen, middle ear effusion, otitis media, and occiscle disruption. Multiple sclerosis causes VIIIth cranial nerve disruption and neural hearing loss. Mumps and syphilis can cause sensoryneural hearing loss. A 62-year-old female diabetic patient complains of a pruritic rash under her breasts. A physical exam shows an eroded red plaque with satellite papules. What is the most likely cause? This is consistent with a yeast infection of the skin, caused by Candida albicans. Diabetic patients are particularly susceptible to these infections. A staph infection of the skin will have either honey colored crusting or inflammatory papules and pustules with erythema of the skin. A strep infection of the skin will have inflammatory papules and pustules with erythema of the skin. A herpes simplex infection will have vesicles that crust over after a few days. There is often preceding neurogenic pain prior to the outbreak. A mother presents with her 6-year-old childwho has a rash on his arm. The rash has remained unchanged despitethe use of topical steroids for one month. The lesion is asymptomatic.What is the most likely diagnosis? Lichen striatus is a benign rash consisting of linearly configured,shiny, and flat lesions that occur on any skin surface. This rashoccurs suddenly and resolves on its own in several weeks. The etiologyis unknown. Which of the following is a result of untreated or partially treated otitis media, which presents with fever, ear pain, otorrhea, tenderness behind the ear, fluid collection, and destruction of air cells seen on head CT? Untreated or partially otitis media can result in mastoiditis. Tenderness, redness, and fluctuance over the mastoid bone is characteristic. Peritonsillar abcess symptoms include severe sore throat, drooling, dysphonia, and outpouching of the tonsillar pillar on the affected side and trismus. Ethmoid sinusitis presents with nasal congestion, discharge, and headache. Suppurative otits media is contained in the middle ear, without spreading to adjacent structures. In a patient whom you suspect has giant cell arteritis, which of the following medication and dosage combinations is indicated? Giant cell arteritis (GCA) or temporal arteritis is a large vessel vasculitis that can cause ischemic optic neuropathy and blindness. The first line treatment of high dose prednisone 60 mg/day for one month is sight saving. The lower dose of prednisone 20mg per day is effective in treating polymyalgia rheumatic (PMR). Methylprednisolone dose-pack is a very low dose of steroid and would be ineffective in treating GCA. Infliximab is a tumor necrosis factor inhibitor used for treating ankylosing spondylitis, rheumatoid arthritis and crohn's disease. A 15 year old male presents with lesions on his palms, dorsum of his hands and lower arm. They began as red macules that developed a central vesicle of a few days. The lesions are pruritic with no other symptoms. What is the most common etiology? This patient presents with the classic iris or target lesion of erythema multiforme (EM). The most common cause of recurrent EM is herpes simplex outbreak which usually precedes EM by a few days. A two-month-old bottle fed infant female presents with a sharply demarcated scaling red rash on the face and in the diaper area. The mother reports that her child has been irritable and has had diarrhea. The primary care provider has treated with hydrocortisone 2.5% ointment bid for two weeks with no improvement. What should be the next step in confirming the diagnosis? This infant is displaying classic signs of zinc deficiency. This disorder can occur in infants who are bottle fed. Treatment with topical steroids will not improve the condition until the zinc level is corrected. A punch biopsy would not help in diagnosing the zinc deficiency that this patient is exhibiting. Bacterial and viral cultures will not be helpful in establishing the diagnosis. A KOH is used to diagnose fungal infections. The KOH and bacterial culture will not be helpful in establishing the diagnosis of zinc deficiency. As a diver descends for a deep water dive, at about 10 feet of depth he begins to feel nausea, severe ear pain, and develops vertigo and vomiting. What is the most likely cause of his symptoms? Boyle's law states that as a diver descends, the increasing external pressure causes an equal decrease in pressure in the middle ear, which must be equalized during the descent. If the middle ear pressure is not equalized, the tympanic membrane becomes severely retracted, due to the negative middle ear pressure. This can result in hemotympanum, hemorrhage, or tympanic membrane perforation. Ascent causes increased pressure in the middle ear as the external pressure is decreased. Equalization techniques must also be used to prevent a tympanic membrane perforation. Decompression sickness occurs on ascent, when nitrogen gas bubbles are forced into the middle ear, and vascular and lymphatic spaces. You are evaluating a patient who is complaining of facial drooping , and inability to close his eye. During the cranial nerve exam you notice he is unable to wrinkle his forehead. Based on this information what is the most likely diagnosis? Bell's palsy affects cranial nerve VII, the facial paralysis conforms to the all branches of the peripheral nerve including the side of the face, eyelid and forehead muscles. An acute cerebrovascular accident would present only with a facial droop, the ability to close the eye and wrinkle the forehead would be preserved and there would likely be other focal weakness on physical exam. Horner's syndrome is miosis, ptosis and facial flushing and hyperhydrosis caused by abnormalities of the supercervical ganglion along the internal carotid artery. A patient presents with a cerumen impaction. Which of the following is true when performing the Rinne- Weber test? For conductive hearing loss, the Weber will lateralize to the affected ear and bone conduction will be greater than air conduction. Conductive hear loss prevents sound from entering the inner ear due to obstruction in the external auditor canal and middle ear. Examples would be cerumen impaction and otitis media. Sensory neural hearing loss affects the inner ear and cranial nerve VIII. Weber will lateralize to the unaffected ear (normal ear) and Rinne will reveal Air conduction > Bone conduction. A 45-year-old female presents with a rashthat started on her ankles two days ago and is spreading up herleg. The lesions are asymptomatic; however, she has abdominal painand joint pain. The lesions are palpable and non-blanchable whencompressed. What is the most likely diagnosis? Henoch-Schonlein Purpura (HSP) is a hypersensitivity vasculitisthat occurs most frequently after an infection with group A streptococcus.This rash consists of the classic palpable purpura, and can be accompaniedby abdominal pain that is worse after meals secondary, bowel ischemia,bloody diarrhea, and arthritis. These lesions are visible on a 14-year-old female's forehead. What medication is this disorder best treated with? The lesions are comedones (open and closed). Optimal treatment should be with topical retinoids such as tretinoin and adapalene, as these are comedolytic. Topical erythromycin is indicated in inflammatory acne, not comedonal acne as pictured. Benzoyl peroxide only has mild comedolytic activity and erythromycin has none. This combination medication would be more appropriate for inflammatory acne. Doxycycline has no comedolytic activity. An 8-year-old male with a history of atopicdermatitis presents with a localized rash, consisting of vesiclesand eroded lesions. He has a low-grade fever, but no other symptoms. Whatis the appropriate treatment? The classic lesion of eczema herpeticum is described as a "punchedout" lesion, which refers to vesicles that have becomeeroded. Mild cases of eczema herpeticum can be treated on an outpatientbasis with oral acyclovir. More severe cases must be treated onan inpatient basis with IV acyclovir and oral antibiotics if superinfected. An 8-year-old male presents to his primary care provider with the onset of a new rash, consisting of small, oval, discrete scaling plaques on his trunk, and a large red plaque with overlying thin, silvery scales in the gluteal cleft. Which of the following is a potentially important historical finding in this patient? This is a classic guttate psoriasis. An acute strep infection is a known precipitating factor of guttate psoriasis. All patients need to be checked and treated for a strep infection. Atopy has no correlation with guttate psoriasis. It is not caused by contact with an allergen or irritant. It is also not caused by an allergic reaction. A 16-year-old female has tried topical clindamycin and tretinoin. In addition, she recently finished a six-month course of doxycycline 100 mg bid. She has not noticed much improvement in her acne. The patient continues to complain of large, painful lesions, as well as numerous comedonal lesions. What is the next appropriate step in treatment? Isotretinoin is indicated for nodulocystic acne, as well as acne that is resistant to topical treatments and oral antibiotics. Clotrimazole is an antifungal medication that is indicated for the treatment of cutaneous candidiasis and tinea. Keflex is a first generation Cephalosporin. It is not a first line treatment for acne. Elidel is indicated as a second line treatment for atopic dermatitis in patients over two years of age. It does not treat acne. A 48-year-old female complains of ear fullness, episodes of tinnitus, and vertigo. She also complains that her hearing is not as good as it used to be. She states that this has occurred sporadically over the past year. What is the most likely diagnosis? BPPV is characterized by sudden vertigo, made worse with head position change, and accompanied by nausea and vomiting. Meniere syndrome is characterized by episodic severe vertigo, fluctuating sensorineural hearing loss, tinnitus, and ear "fullness." Pathologically, there is distention of the endolymphatic system throughout the inner ear, presumably due to dysfunction of the endolymphatic sac. Labyrinthitis is characterized by severe vertigo and hearing loss, and is likely a result of a viral inner ear infection. Vestibular neuronitis is also a result of a viral inner ear infection, with symptoms of severe vertigo, nausea, and vomiting, without hearing loss. Both labyrinthitis and vestibular neuronitis resolve in one to two weeks. Presbycusis is age related hearing loss. Jane, a 21-year-old female, was seen in the office 10 days ago and was diagnosed with perennial allergic rhinitis and sent home with instructions for increased fluids, decongestants, and nasal steroids. She returns today with worsened symptoms of malaise, low-grade fever, nasal discharge, cough that is worse at night, mouth breathing, early morning unilateral pain over sinuses, and congestion. Physical examination reveals thick purulent nasal discharge, postnasal discharge visible in the posterior pharynx, periorbital swelling, and tenderness of sinuses upon palpation. She is 36-weeks pregnant and allergic to penicillin. Of the following, what is the most appropriate antibiotic? Most patients with a diagnosis of acute rhinosinusitis based on clinical grounds improve without antibiotic therapy. The preferred initial approach in patients with mild to moderate symptoms of short duration is therapy aimed at facilitating sinus drainage, such as oral and topical decongestants, nasal saline lavage, and—in patients with a history of chronic sinusitis or allergies—nasal glucocorticoids. Adult patients who do not improve after seven days, children who do not improve after 10 to 14 days, and patients with more severe symptoms (regardless of duration) should be treated with antibiotics. Empirical therapy should consist of the narrowest- spectrum agent active against the most common bacterial pathogens, including S. pneumoniae and H. influenzae—e.g., amoxicillin. But amoxicillin is contraindicated in patients with urticarial reactions to penicillins, and quinolones are similarly contraindicated in pregnancy. trimethoprim-sulfamethoxazole is contraindicated in the third trimester of pregnancy. The best choice is clindamycin. A mother presents with her four-month-old infant for a well child check. While examining the child, you notice ill defined bluish macules on the back and lumbosacral regions. What is the appropriate next step? This is a common presentation of hypermelanosis, sometimes commonly referred to as Mongolian spots. These usually occur in patients with more pigmented complexions. They usually spontaneously resolve prior to the child entering grade school. Hypermelanosis can sometimes be mistaken for child abuse by an inexperienced practitioner; however, hypermelanosis is a common benign condition that occurs in patients with pigmented skin. There is no increased incidence associated with hypermelanosis, and no treatment is required or available. A 22-year-old complains of a spreading rash. He states it began about a week ago, with one large spot on his abdomen. Very shortly thereafter, the rash rapidly spread on his torso. The lesions are small oval red plaques with a collarette of scale. He states they are only mildly pruritic. What is the most likely diagnosis? This is the classic presentation of pityriasis rosea. The large initial lesion is the herald patch. The ensuing lesions are small, oval, and have a collarette of scale. The lesions are distributed along Blaschkoe's lines, which is the "Christmas tree" distribution. Presentation of tinea corporis is pruritic, annular scaling patches that enlarge with central clearing. Guttate psoriasis presents as salmon-pink papules or small plaques with overlying fine silvery scales. Atopic dermatitis is usually manifested prior to the age of six. The classic distribution is the flexural surfaces of the extremities. A 50-year-old male states that his eye is bothering him since yesterday. He complains of pain and redness. He states that he mowed his lawn yesterday and that it was windy outside. He attempted to irrigate the eye but still has significant irritation. He notes that it hurts to blink his eyes. What is the correct sequence of steps to treat this condition? The history suggests a retained foreign body to the upper eyelid. A fluorescein stain will reveal significant superficial vertical scratches on the cornea. An upper eyelid eversion must be done, to inspect for and remove the foreign body. If the practitioner is successful in removing the foreign body, relief of the irritation will be immediate. Which physical exam finding differentiatesacne rosacea from acne vulgaris? The characteristic lesions of acne rosacea are small papules,papulopustules, and telangiectasias with flushing. There are nocomedones present in acne rosacea. A 10 year old male presents with bright red, well-demarcated petechiae and palpable purpura located on bilateral lower extremities. He also complains of abdominal pain and mild joint pain. His mother report the child had an upper respiratory infection about a week ago. Punch biopsy shows IgA immunoreactivity around post-capillary venules. What is the most likely diagnosis? Henoch Schonlein purpura (HSP) is commonly described as palpable purpura. It is precipitated by an upper respiratory infection and can also be associated with abdominal pain and joint pain. An 18-year-old female presents with a history of draining abscesses in the axilla and groin, with large, open comedones. Currently, she has multiple scars in the axillae. What is the most likely diagnosis? Hidradenitis suppurtiva affects females more than males, and may show a family history of nodulocystic acne and/or hidradenitis suppurtiva. Skin lesions are usually tender nodules and abscesses that may spontaneously drain. Open comedones, including double comedones, are common. Eventually, sinus tracts may form. Nodulocystic acne consists of nodules and cysts, ranging in size from 1 to 4 cm in diameter. These lesions are distributed on the face, back, and chest. Acanthosis nigricans is described as a velvety, hyperpigmented plaque distributed around the neck, in the axillae, and in the groin. MRSA can have several different presentations, ranging from erythrasma to the presence of papules and pustules. Comedones are not associated with MRSA. An 18-year-old female presents with a history of large open comedones and painful abscesses in both axillae. She has been treated by her primary care provider with oral antibiotics. A thorough physical exam may show which other affected sites? Common areas of involvement in hydradenitis suppurtiva include the axillae, breasts, anogenital region, perineum, and scalp. A 5-year-old boy presents with a tense,fluid filled blister on his fingertip. What organism is most likelyto be found when the lesion is cultured? This child has blistering distal dactylitis. This is a form ofimpetigo, and is caused by either streptococcuspyogenes or staphylococcus aureus. A 24-year-old female presents with hyperpigmented macules on her cheeks, nose, and upper lip. They have been present for a couple of months. Her current medications include oral LoEstrin 24 Fe, cetirizine, and a multivitamin daily. What is the most likely diagnosis? The patient is experiencing melasma secondary to the use of oral contraceptives. This is a frequent cause of melasma.