Dermatology Rosh Questions
A 5-year-old girl presents to the clinic with exophytic, dome-shaped, skin-colored papules on the dorsal aspect of her right hand. Which of the following is a first-line treatment for this condition?
Salicylic acid (Verruca vulgaris)
A 19-year-old woman presents to her primary care provider with concerns about a lesion on her finger for 2 months. She reports no symptoms other than mild tenderness with pressure over the lesion. She states she is very self-conscious about the lesion and would like to get rid of it as soon as possible. Physical examination reveals the presence of the lesion shown in the image above. Which of the following is the most appropriate initial clinical intervention?
Salicylic acid plaster after paring (Verrucae Vulgaris - Wart)
Which of the following exanthema is teratogenic in the first trimester and may result in fetal decreased hearing, infantile glaucoma, and cardiac disease?
Rubella
What is the most common type of psoriasis in children?
Chronic plaque psoriasis
A 45M presents to the ED after sustaining a laceration to the scalp following a minor fall at home. He reports he slipped on a wet floor and struck his head against the edge of a table. His hx is significant for well-controlled HTN, for which he takes lisinopril. He reports no loss of consciousness, visual disturbances, or vomiting. On exam, there is a clean, jagged laceration approximately 6 cm in length on the vertex of the scalp without signs of infection or significant bleeding. The wound edges are not approximated, and there is no evidence of foreign bodies. After thorough irrigation and wound cleansing, the laceration is repaired w/ simple interrupted sutures using a nonabsorbable suture material. His tetanus immunization is UTD. The patient understands wound care instructions and asks when he should return for suture removal. What is the most appropriate time for suture removal for this laceration?
10-14 days
A 9-month-old boy is rescued from a burning building and presents to the ED for evaluation. On physical examination, there are superficial burns covering the anterior surface of the trunk and the entire right arm, partial-thickness burns covering the entire left arm, and a full-thickness burn covering the entire left leg. Which of the following best represents the estimated burn size?
17.5% (Only partial-thickness and full-thickness burns are included in the estimation)
A 42-year-old man presents to the emergency department after being rescued from a house fire. Vital signs are weight 100 kg, T 98.6°F, BP 132/88 mm Hg, HR 110 bpm, RR 20 breaths per minute, and oxygen saturation 98% on room air. During the primary survey, deep partial-thickness burns are seen on the entire right arm and the anterior aspect of the right leg. Which of the following is the correct amount of fluids to give in the first 8 hours according to the Parkland formula?
3600 mL
A 72-year-old man with a history of hypertension, emphysema, and depression presents to the emergency department after a house fire. He is awake and alert but screaming in pain due to multiple burns across his body. His exam reveals a 100 kg man with superficial burns of his entire chest, superficial partial thickness burns of his entire left arm and half of his right arm, and deep partial thickness burns of the anterior left lower extremity. Along with admission to a burn unit and wound care, using the Parkland formula, what fluid resuscitation should be started in the emergency department?
4500 mL of lactated ringer over the first 8 hours
A 7-year-old boy presents to the urgent care clinic for evaluation of the rash over his body. On physical exam, there is blistering and large areas of peeling skin. The patient's mother states he recently began treatment for epilepsy. Physical evaluation further reveals lesions on the oral mucosa, and sloughing of the skin is noted with gentle lateral pressure. Which of the following is likely additionally noted on history and physical exam findings?
>30% of body surface area involved (TEN)
A 63-year-old man presents to his primary care provider with his spouse, who is concerned about a slow-growing nodule on his nose that has been present for the past 3 years. The patient has no significant past medical history. Physical examination reveals a well-developed, well-nourished, fair-skinned man who appears his stated age. A waxy nodule measuring 1.5 cm x 1.5 cm is present on the lateral aspect of the patient's nose and is shown above. The clinician suspects the nodule is a form of skin cancer and performs a punch biopsy. Which of the following is the most likely diagnosis?
Basal cell carcinoma
A 21-year-old man presents to his primary care provider with complaints of right ankle pain for 12 hours. He is a competitive swimmer and has a history of tinea pedis. He has a fever of 102°F and a complete blood count significant for leukocytosis with a left shift. He is not on any medications. Which of the following physical examination findings is most consistent with the suspected diagnosis?
A single, erythematous patch with overlying warmth (Cellulitis)
A 14-year-old boy presents to the ED with severe abdominal pain. You notice a painful papule on his right arm where he said he was bit by something when he was working in the garage. On physical exam, his abdomen is rigid. Vital signs are BP 140/90 mm Hg, HR 120 bpm, RR 18/min, and T 98.4°F (36.7°C). Which of the following is the most appropriate next step in management?
Administer intravenous lorazepam
A previously healthy 18-year-old man presents to a primary care provider with complaints of fever, chills, malaise, and left lower extremity pain that began 2 days ago. The patient reports that he has been traveling this past month with his collegiate swim team and frequently uses public showers. He states that the pain has been worsening and that the redness was initially a small patch near his ankle. His vital signs are T 102.5 F°, BP 106/76 mm Hg, HR 100 bpm, RR 18 breaths per minute, and oxygen saturation 99% on room air. Physical examination is significant for interdigital tinea pedis, toe web intertrigo with fissuring, and an erythematous, edematous left lower extremity that is painful to the touch. No ulcerations or pustules are visible, and there are no signs of an abscess. A CBC reveals leukocytosis of 16,000 cells/µL with 24% bands. What is the most appropriate treatment at this time?
Admit for intravenous vancomycin (meets SIRS sepsis criteria)
A 42-year-old man presents to his primary care provider with complaints of an intensely pruritic rash on both of his arms for 2 days. He reports he has been hiking for the past 3 days and was wearing pants and short sleeves. Physical examination reveals the presence of tiny, weeping vesicles and crusted lesions in a linear distribution on both arms bilaterally. There are also erythematous, maculopapular lesions extending outward from the vesicular lesions. His rash is shown in the image above. A Gram stain and culture are negative. What is the most likely diagnosis?
Allergic contact dermatitis
A 45-year-old man presents to the office with patchy hair loss that started suddenly about 1 month ago. The patient has not noticed any hair regrowth. Upon physical examination, there are three discrete smooth oval patches throughout the scalp that are flesh colored. The patches are neither tender nor pruritic. There was a death in his family about 3 months ago. Which of the following is the most likely diagnosis?
Alopecia areata
A 64-year-old man presents to his dermatologist for concerns about a lesion on his upper lip. The lesion is shown in the image above. A shave biopsy reveals multifocal nests of basophilic staining cells with peripheral palisading nuclei. What is the most likely diagnosis?
Basal cell carcinoma
A 32-year-old woman presents to the office due to a rash that has gotten worse over the past several weeks. Upon physical exam, there are several large, erythematous, well-demarcated plaques with overlying silvery scales present to the extensor surfaces of the elbows and knees. Which additional finding is likely to be found on a physical exam, given the most likely diagnosis?
Auspitz sign (appearance of punctate bleeding spots that are seen when psoriasis scales are scraped off, seen with Psoriasis)
A 9-year-old boy presents to his pediatrician with concern for bumps on his feet that have been increasing in size and number. His parents think these appear to be warts and have been applying salicylic acid at home with some improvement, but they would like advice about how to prevent them from getting worse or coming back. He is otherwise previously healthy, his immunizations are up to date, and they have no other acute concerns. On exam, there are three pale white lesions on his right foot, one on his left foot, and all are < 1 cm in diameter. They are tender with deep but not superficial palpation. Each is raised with a dry appearance due to dried salicylic acid. When the salicylic acid is gently debrided, cauliflower-like lesions that obliterate skin lines with embedded small thrombosed capillaries are revealed underneath. Which of the following is the most appropriate preventive advice?
Avoid deliberately manipulating the lesion
A 65-year-old man with hypertension presents to the emergency department for a progressive skin nodule on his face for several months. Examination reveals a 1 cm skin-colored lesion with raised pearly margins and visible vessels on his left cheek. He reports no other associated symptoms or lesions. Which of the following is the most likely diagnosis?
Basal cell carcinoma
Which of the following organisms is most often associated with acne vulgaris?
Cutibacterium acnes
A 12-week-old boy presents to the pediatric clinic with his mother for concerns about a rash on his buttocks. The patient has been afebrile and has had regular stools and six wet diapers per day. Evaluation of the rash reveals beefy red plaques involving the inguinal and gluteal folds, with satellite pustules on the buttocks. Which of the following is the most likely diagnosis?
Candidal diaper dermatitis
A 52-year-old woman presents to the clinic with a 2-day history of increasing redness, warmth, and pain in her left lower leg. She mentions the symptoms started after she experienced a minor abrasion while gardening. She has a history of type 2 diabetes mellitus and is currently on metformin. On examination, her vital signs are a blood pressure of 135/85 mm Hg, heart rate of 88 bpm, respiratory rate of 16 breaths/minute, oxygen saturation of 97% on room air, and temperature of 38.3°C (100.9°F). The left lower leg is erythematous, edematous, and tender to palpation, with ill-defined borders extending from the area of the abrasion. There is no purulent drainage or formation of vesicles, and the right leg appears normal. Which of the following is the most likely diagnosis?
Cellulitis
A 12-year-old boy presents to the clinic for evaluation of a new-onset pruritic rash that appeared in symmetric crops on his palms, soles, and the extensor aspect of his forearms. He recently recovered from a viral upper respiratory infection, for which he was treated conservatively using nonsteroidal anti-inflammatory drugs. The patient reports no current systemic symptoms, but he does have some oral discomfort with associated bullae noted in the oral cavity. Which of the following most likely describes the patient's skin findings?
Central erythematous area surrounded by pale edematous skin and a sharp discrete ring of erythema (erythema multiforme)
A 35-year-old man presents to the emergency department with an injury to his tongue that occurred 2 hours ago from a fall while playing basketball. The patient reports significant pain and difficulty speaking. He has no significant medical history, does not take any medications regularly, and has no known allergies. Vital signs include a blood pressure of 118/84 mm Hg, heart rate of 75 bpm, respiratory rate of 16/minute, oxygen saturation of 98% on room air, and a temperature of 37.2°C. The physical exam reveals a 2.5 cm laceration on the right lateral side of the tongue that is actively bleeding with visible underlying musculature. Which of the following is the most appropriate next step in the treatment of this patient's injury?
Close with 4-0 chromic gut suture
A 4-year-old boy presents to his pediatrician with several lesions on his arms and trunk over the past 2 months. His mother states she has noticed other children at his daycare with similar lesions. She has noticed her son occasionally scratches the lesions and there seems to have been two new lesions that appeared this week. Physical examination reveals the lesion shown above. The clinician reassures the mother and patient and recommends observation with follow-up as needed. Which of the following is considered first line for the patient's condition if treatment is needed?
Cryotherapy (Molluscum contagiosum)
A 58-year-old man presents to the emergency department 1 week after undergoing abdominal surgery for a perforated appendix. He reports increasing pain and purulent discharge from his surgical incision site over the past few days. He reports no fevers but states that he is feeling generally unwell. Vital signs are as follows: temperature 98.5°F (36.9°C), blood pressure 114/73 mm Hg, heart rate 82 bpm, respiratory rate 16 breaths/min, and oxygen saturation of 97% on room air. On physical examination, the surgical incision site appears slightly gaping with purulent drainage, but there is no erythema or warmth around the wound edges. There is tenderness and increased pain upon palpation of the incision area without evidence of fluctuance, induration, or abscess formation. The wound is opened and irrigated. What is the most appropriate clinical intervention for this patient?
Daily wound care with saline irrigation and packing
A 62-year-old man presents to the emergency department with redness and blistering to his entire chest and bilateral thighs. He states he was walking to the kitchen sink to drain boiling water from his pasta when his dog ran in front of him, causing him to slip and drop the entire pot onto his chest. The affected area is only painful when pressure is applied. It appears as red blisters that make up approximately 36% of the patient's total body surface area. When the blisters are touched, they easily burst open. The patient's vaccines are up to date, including a tetanus booster he received 2 years ago. Which of the following is the correct staging for this patient's burn?
Deep partial-thickness burn
A 65-year-old man presents with left leg pain. He reports progressive erythema and pain of his left lower leg after cutting it while working on his car. His examination is notable for a 5 x 5 cm area of induration and erythema with yellow purulent drainage. The area is warm to touch and tender to palpation. Which of the following is the most appropriate medication for outpatient management of this patient's condition?
Doxycycline (d/t purulence you want to cover for MRSA)
A 53-year-old man is 6 days status post bilateral fasciotomy of the lower extremities after a severe motor vehicle collision and develops a fever of 100.5°F. His vitals are BP 122/72 mm Hg, HR 72 bpm, RR 18 breaths per minute, and pulse oximetry 98% on room air. His WBC count is 14,800/µL. Physical examination is significant for erythema, swelling, and fluctuance over the incision site on the left lower extremity with a small amount of purulent drainage. Which one of the following is the best next step in the management of this patient?
Draining the abscess, obtaining wound cultures, and initiating antibiotics (surgical site infection)
A 35-year-old man presents to the clinic with a slowly growing, painless lump on his upper back that he first noticed several months ago. He reports no recent trauma to the area, fever, chills, or drainage from the lesion. He has a past medical history of acne during adolescence but has had no significant skin issues since. Vital signs today are a blood pressure of 124/76 mm Hg, heart rate of 76 bpm, respiration rate of 11/min, and temperature of 98.7°F. On physical examination, the lesion is a well-defined, mobile, subcutaneous nodule measuring 2 cm in diameter. It is flesh colored and has a central punctum. An image of the lesion is shown above. No fluctuance or erythema is noted, and there are no similar lesions elsewhere on his body. What is the most likely diagnosis?
Epidermal inclusion cyst
A 3-day-old baby girl born at 41 weeks gestation via a normal spontaneous vaginal delivery is evaluated in the labor and delivery unit for a new rash. Her mother states she noticed the small bumps for the first time today when changing her diaper. Physical examination reveals multiple erythematous macules and papules on the cheek, anterior trunk, upper arm, and thighs. The rash on the cheek is shown above. No lesions are noted anywhere else on the body. Which of the following is the most likely diagnosis, given the timing, location, and appearance of the infant's lesions?
Erythema toxicum neonatorum
A 19-year-old G2P1 woman at 12 weeks gestation presents to her primary care provider with complaints of worsening pustules on her face. Physical examination reveals the presence of cystic, inflammatory lesions on the face, neck, upper chest, and back. Which of the following treatments, along with a benzoyl peroxide wash, is most appropriate at this time?
Erythromycin
A 44-year-old man presents to the clinic with a concerning mole on his right upper arm. He states that, over the past month, the mole has been growing and changing in size. In addition, he states the mole has started to itch. Physical exam reveals a 1.5 cm lesion, which is pictured above. What is the most appropriate next step in management for this condition?
Excisional biopsy with skin margins of at least 2mm
A 3mo boy presents to his pediatrician for skin concerns. Mom reports red, scaly skin on his cheeks, scalp, chest, and arms that seems irritating to him. He has a hx of reflux and has been getting rice cereal mixed in with his milk since he was a few weeks old. He lives w/ his parents on a farm. His dad is a crop farmer&mom's a teacher. They have chickens, goats,2 dogs, & a cat. He has been in daycare since he was 2mo old & seems to have a chronically runny nose. FHx is notable only for maternal and paternal asthma. On exam, red, scaly, papular lesions are noted on his face, scalp, chest, and back of his arms, w/some areas of serous crusting on his scalp. No vesicles or pustules noted. His neck, axilla, flexural surfaces, and diaper area are clear. He has mild, clear rhinorrhea and otherwise appears well,&is growing & developing well. Which of the following elements of this child's hx is supportive of his diagnosis?
Family history of asthma (Atopic dermatitis)
A 7-month-old girl presents to the office with her parents, who are concerned about recurrent diaper rashes. They have noticed more skin irritation recently, and she sometimes cries during diaper changes. They recently started giving her solid foods, and she has had some loose stools. She is otherwise healthy and is on track with her developmental milestones. Physical examination reveals erythematous papules over the buttocks, perineum, and upper thighs with sparing of the skin folds. There is mild maceration without erosion of the skin. The dermatitis is localized to the diaper area, and findings on the remainder of her skin examination are normal. Which of the following is the most appropriate initial treatment?
Frequently changing the diaper and leaving it off for a few hours each day
A previously healthy 4-year-old girl presents to the ED with fever, concerning skin changes, and pain. Other than fever and tachycardia, her vital signs are unremarkable. On exam, she appears ill, with obvious erythema over her face down to her shoulders. Her eyes are red and watery, and her lips are cracked and bleeding. A few vesicles can be seen around her mouth and over the skin on her neck. Examination of the skin demonstrates positive Nikolsky sign. An estimated 9% of her body surface area is affected. She is extremely agitated, screams with exam, and is difficult to console. Her parents report she was recently diagnosed with a urinary tract infection and was started on trimethoprim-sulfamethoxazole, which she had not taken previously. She completed the 7-day course today. She is admitted for additional workup and supportive care. Which of the following found on skin biopsy supports the suspected diagnosis?
Full-thickness keratinocyte epidermal necrosis
A 22-year-old man presents to his primary care provider with a nonpruritic, nontender rash on his hands and the soles of his feet that appeared yesterday. He reports hiking in the northeastern United States 2 weeks ago. His past sexual history is significant for unprotected intercourse with multiple male and female partners. His physical examination is unremarkable except for the rash on his palms and soles, which is shown in the image above. Which of the following infections in the patient's history is associated with the most likely diagnosis?
Herpes simplex virus (Erythema Multiforme)
An 8-year-old girl presents to her pediatrician's office with multiple rashes on her palms and soles. Her father states the rash began suddenly 3 days ago, shortly after returning from a 2-day hiking trip in North Carolina. He has not seen his daughter scratching the rash, and the patient reports no pain or burning. She attends daycare, but her father is unsure whether other children have similar symptoms. Family history is significant for a mother who recently had a positive rapid plasma reagin test. Physical examination of the palms reveals the finding shown above. Similar lesions are observed on the soles of her feet. No other lesions are noted on physical examination. Which of the following is the most likely cause of the patient's symptoms?
Herpes simplex virus (Erythema multiforme)
A 14-year-old girl presents to the office due to a 1-week history of pain, redness, and swelling to the right middle finger adjacent to the lateral nail. She states she had a hangnail there that she ripped off about 1 week ago, and a few days later, she developed pain and swelling to the area. Upon physical examination, there is erythema, moderate edema, and exquisite tenderness to palpation of the lateral aspect of the nail, with noticeable fluctuance and purulence. Which of the following is the best next step in treatment for this patient?
Immediate incision and drainage (Acute paronychia)
A 30-year-old healthy woman presents to the emergency department for a painful mass. Examination is significant for normal vital signs and a 3 cm inflamed abscess in the midline superior natal cleft with no surrounding erythema. The patient states she has had nontender swelling in the same location previously, but now it is very painful for her to lay down. Which of the following is the most appropriate management of this patient's condition?
Incision and drainage and outpatient surgery follow-up (only give abx if signs of cellulitis)
A 21-year-old man presents to the urgent care with complaints of a pruritic rash that comes and goes. He reports the rash started 3 days ago and occurs on his trunk and lower extremities. Stroking of the skin results in localized erythematous plaques. Which of the following in the patient's history is consistent with the most likely diagnosis?
Individual lesions last < 24 hours
A 5yo boy presents w/a rash that looks/feels like a sunburn,but hasn't been in the sun. It started on the back of his neck&spread to his trunk & face within the last few hours. Areas are starting to blister. His parents report he was fussier than usual yesterday, had a low-grade fever, &didn't eat well, but the rash didn't appear until today. He didn't improve w/Tylenol or ibuprofen and hasn't received any new meds. On exam, he appears miserable but in NAD as long as he isn't touched.Exam shows diffuse symmetrical erythema w/a sunburned appearance on his neck to his trunk, including axillae and gluteal cleft. Areas w/flaccid bullae are present,w/some desquamating bullae on neck&upperback. He has crusting around mouth&nose w/dried oatmeal appearance but no sloughing, cracking, or bleeding of his mucous membranes. A nasal swab is are sent for culture. What is the recommended empiric first-line treatment?
Intravenous nafcillin (Staphylococcal scalded skin syndrome (SSSS))
A 12-year-old boy presents to the clinic with a rash characterized by erythematous and well-demarcated plaques that have an overlying silvery scale. Which of the following features would most support a diagnosis of chronic plaque psoriasis?
Involvement most commonly on bilateral elbows and knees (Chronic Plaque Psoriasis)
A 52-year-old woman presents to her primary care provider with concerns about a skin lesion on her face. She reports the frequent use of tanning beds and states that she burns easily in the sun. Her dermatologist diagnosed an actinic keratosis on her face 3 years ago, for which she never had treatment. Which of the following physical exam findings is most consistent with the suspected diagnosis?
Irregular, erythematous plaque with a hemorrhagic crust (Squamous Cell Carcinoma)
A 5-year-old girl presents to the urgent care clinic with her father. The father is concerned about an enlarging rash on the patient's arm. He states the patient spent the night in a tent in their backyard last night, and this morning, she woke up with a small lesion on her left arm that was very itchy. Over the last 2 hours, the lesion has progressively enlarged. Physical examination of the left arm reveals an erythematous, raised, circular plaque that is 6 cm in diameter. The rest of her physical examination is normal. The patient is prescribed cetirizine, and a follow-up call the next morning reveals the lesion has resolved entirely. Which of the following best describes the pathophysiology of the patient's condition?
Mast cell release of histamine in the superficial dermis (Urticaria)
A 1-month-old infant presents for a well-child visit. On exam, yellow, greasy, adherent plaques are found on the child's head. Which of the following is the best initial treatment?
Mineral Oil (Seborrheic Dermatitis)
A 60-year-old man presents with a red bump on the end of his nose that has gotten larger over the past several months. The patient states the lesion is not painful or ulcerating. On physical exam, there is an 8 mm pink, dome-shaped papule with prominent telangiectatic surface vessels on the tip of the nose. The patient has not had a lesion like this in the past. Punch biopsy reveals a basal cell carcinoma. Which of the following is the most appropriate next step in management?
Mohs micrographic surgery
A 25-year-old woman is one hour postappendectomy. The patient reports she feels like she has an itchy rash over her whole body. On physical exam, there is no erythema, rash, dermatitis, or urticaria. The patient has no known drug allergies. No complications were noted during surgery. Which of the following medications is the most likely cause of her pruritus?
Morphine (with narcotics, patents report feeling a rash without one present)
A 3-year-old boy presents with his parent for a pruritic facial rash that has been present for 1 week. The parent reports that the rash started as small vesicles that ruptured and formed a crust. The examination is significant for the skin findings shown above. Which of the following is the most appropriate treatment for this patient?
Mupirocin
A 38-year-old man presents to the ED with a new-onset rash. He has a medical history significant for epilepsy and hypertension, for which he currently takes levetiracetam and lisinopril. The patient was feeling well until 2 days ago when he started developing fevers, chills, malaise, and body aches. Yesterday, he noticed a rash had started on his face and trunk. He states the rash has since spread to all four extremities. A review of systems is positive for recently completing a course of azithromycin for walking pneumonia. Vital signs are remarkable for a T of 40°C, HR of 138 bpm, BP of 90/60 mm Hg, RR of 29/min, and SpO2 of 98%. Physical examination is remarkable for a toxic-appearing man with blisters and erythematous macules with a purple core covering the trunk, face, and extremities. Mucositis is noted on examination as well as a (+) Nikolsky sign. Which of the following is most related to his likely diagnosis?
Mycoplasma infection
A 46F presents to ED w/severe pain,redness, swelling around surgical site incision from a partial colectomy 3d ago. The sx's started last night& are worse today. Medical hx of DM2, takes metformin, liraglutide, & canagliflozin, & hx of ulcerative colitis (she recently underwent a colectomy). Vitals:BP of 100/61 mmHg, HR 118 bpm, RR of 22/min, T of 101.8°F, and SpO2 of 96%RA. Phys exam shows a regular tachycardic rate w/ lungs CTA. She has moderate skin erythema around one of her surgical incisions w/palpable crepitus, a large bulla, &edema that extends beyond the erythema. No fluctuance. Labs:WBC count of 18k cells/μL, glucose of 312 mg/dL, creatinine of 1.7 mg/dL, bicarb of 21 mEq/L, beta-hydroxybutyrate of 0.3 mmol/L, ESR of 114 mm/hour, and lactate of 3.9 mmol/L. CT of the abd pelvis w/IV contrast shows gas in the soft tissues, no organized fluid collection,& no dilated fluid-filled loops of bowel. What is the dx?
Necrotizing fasciitis
A healthy 20-year-old woman presents to the ED for evaluation of a hand laceration caused by her pet cat's teeth 2 hours prior to arrival. Examination reveals a 2 cm laceration to the dorsum of her hand, involving the skin and subcutaneous tissues without significant bleeding or surrounding erythema. Her hand is neurovascularly intact. Assessment for tetanus and rabies immunization and copious wound irrigation are performed. Which of the following would be the most appropriate treatment for the laceration?
No wound closure and oral amoxicillin-clavulanic acid
A 22-year-old woman who is otherwise healthy presents to the office due to red, raised, and painful bumps to the inside of the thighs, starting about 2 days ago. She works as a physical trainer and typically wears tight-fitting workout leggings and has been sweating in the affected areas due to warmer weather. A physical exam shows multiple erythematous pustules to the inner aspect of the thighs with hair emanating from the center of each pustule. Which of the following is the most likely diagnosis?
Nonbacterial folliculitis
A 6-year-old girl presents for a well-child check with pruritic lesions on her legs and forearms. The round, coin-shaped patches are primarily dull red with exudate and crust present. A few lesions appear dry and scaly with a central clearing. Potassium hydroxide test is negative. Which of the following is the most likely diagnosis?
Nummular eczema
A 32-year-old woman presents to the clinic for painful, recurrent skin lesions in both axillae over the past 6 months. She describes the lesions as tender lumps that intermittently drain pus and blood. She states that she smokes one pack of cigarettes per day. Vital signs include a blood pressure of 120/80 mm Hg, heart rate of 78 beats/min, respiratory rate of 16/minute, oxygen saturation of 98% on room air, a temperature of 98.2°F, and a BMI of 33 kg/m2. Physical examination reveals 2-3 nodules in the bilateral axillae that are fluctuant and tender to palpation. There are no visible scars or palpable sinus tracts. Which of the following is the most appropriate next step in management for the suspected diagnosis?
Oral doxycycline (Hidradenitis suppurativa)
A 7-year-old boy presents to the office with itchy hands and knees. He states his symptoms are worse at night. Physical examination of the hands reveals multiple red papules along the sides of the fingers and the webs of the fingers in a linear pattern. Multiple excoriations are also present on the extensor surfaces of the knees. Which of the following in the patient's history is the most likely contributing factor for his condition?
Other family members with similar symptoms (scabies)
A 30-year-old man presents to the clinic with a painful, swollen area on his mid back. He states that the area has been tender for the past week and has progressively increased in size. He reports no fevers, chills, or other systemic symptoms. His medical history is unremarkable, and he is not currently taking any medications. His vital signs include a blood pressure of 130/80 mm Hg, heart rate of 78 bpm, respiratory rate of 16 breaths/minute, oxygen saturation of 98% on room air, and a temperature of 37.0°C (98.6°F). On examination, the patient has a 3 cm erythematous, fluctuant, and warm nodule on the mid back without any surrounding cellulitis. Which of the following is the best next step?
Perform incision and drainage at the bedside with local anesthesia
A 7-year-old girl presents to her pediatrician due to an itchy scalp and neck. Her mother notes the symptoms are becoming increasingly irritating to the patient, and they have tried many different shampoos with no improvement. On close systematic inspection with a fine-toothed comb, white casts, a few millimeters in length at the base of her hair follicles, are visualized and are not easily removed. Adult parasites are also visualized, confirming the diagnosis. Which of the following is the recommended first-line treatment for this infestation?
Permethrin (for lice)
A 45-year-old woman who does not have housing presents with an intensely pruritic generalized rash that is worse at night. Excoriations and wavy scaly lines are present in some of the finger web spaces, and papules are present elsewhere except for the neck and face. Scabies mites are present on a wet mount of a skin scraping. Which of the following is a first-line treatment approved by the FDA for this condition?
Permethrin 5% cream on day 1, then reapply in 1 week
A 29-year-old man presents to clinic with buttock pain and fluid drainage that started 1 week ago. Visual inspection reveals a tender, red, and fluctuant mass in the sacrococcygeal region, approximately 6 cm cephalad to the rectum. The patient states this same lesion has occured on several occasions in the same location. What is the most likely diagnosis?
Pilonidal abscess
A 14-year-old girl presents to her dermatologist for follow-up of her acne management. She has been using topical washes and oral antibiotics for treatment, but she is not satisfied with the degree of improvement. She feels that acne is leaving behind scars, and this is highly upsetting. On a previous visit, baseline labs, education, and screening were done in preparation for starting isotretinoin treatment. All of the labs were unremarkable, and at this visit, the plan is to prescribe the medication. As part of recommended anticipatory guidance, it is important to give the family realistic expectations about potential side effects and monitoring requirements. Which of the following monthly monitoring measures is most important for this patient?
Pregnancy testing
A 64-year-old woman presents to the office due to some bumps on her forearms that have been present for several months and have not resolved. She reports no pain or itching to the lesions. Upon physical exam, she has multiple light brown to dark brown macules and papules that have well-defined borders. The smallest ones are about 0.5 cm in diameter and the largest are about 1.5 cm in diameter. Some have a "stuck on" appearance and are nodular and rough to touch. Which of the following is the recommended treatment for this condition?
Reassurance and observation (Seborrheic keratosis - brown spots on old people)
A 75-year-old man was admitted to the hospital from a long-term care facility for fever and an elevated WBC count. A stage 3 sacral decubitus injury with superficial necrosis is discovered. He is on sequential compression devices for deep vein thrombosis prophylaxis and is not on any anticoagulants. Which of the following is an appropriate clinical intervention?
Sharp debridement (Pressure ulcer)
A 40-year-old woman with a medical history of hyperthyroidism presents to her dermatologist for a skin check. She reports it has been 5 years since her last skin exam because she was living abroad in Australia and was not established with a dermatologist while she was there. She has concerns about a suspicious bump on her face that appeared 2 months ago and bleeds intermittently. She adds that she has cosmetic concerns because of the location of the lesion. Her vital signs include a T of 98.6°F (37°C), HR of 64 bpm, RR of 16 breaths per minute, and BP of 120/78 mm Hg. On physical exam, the dermatologist notes a shiny, pink-colored nodule on the patient's right nasolabial fold with telangiectasias. What is the most appropriate diagnostic test for this patient's suspected skin condition?
Shave Biopsy (Basal Cell Carcinoma)
A 67-year-old man presents to the clinic with a lesion on his lower lip that has been persistent for 6 months. He reports that the lesion began as a small, rough patch of skin but has progressively become larger and more irregular in shape. He also notes occasional bleeding from the area, especially when he shaves. His medical history is significant for extensive sun exposure due to his lifelong occupation as a fisherman. He has a history of smoking one pack of cigarettes per day for 40 years, but he quit 5 years ago. On physical examination, the lesion is 1.5 cm in diameter, with a raised, hyperkeratotic border. There is no palpable lymphadenopathy. Which of the following is the most likely diagnosis?
Squamous Cell Carcinoma
An 88-year-old woman in a nursing home facility started to report pain to her coccyx. She has been refusing to participate in group activities and physical therapy this past week and has spent the majority of her days sitting up in bed. On exam, the patient has a shallow wound overlying her coccyx that extends slightly into the dermis. There is no evidence of the wound extending through the subcutaneous tissue, nor is there any visualization of bone, tendons, or tissue. Which of the following is the correct staging for this patient's pressure ulcer?
Stage II
A 22-year-old man with a medical history of diabetes mellitus is seen in the emergency department for worsening redness and bloody drainage developing rapidly over the past day. The patient reports he was recently hospitalized for treatment of a full-thickness burn covering 27% total body surface area. His vital signs include blood pressure of 90/60 mm Hg, heart rate of 126 bpm, respiratory rate of 26 breaths/min, oxygen saturation of 99%, and temperature of 102.6°F. On physical examination, discoloration of burn eschar with breakdown of degranulation tissue is noted on the right forearm. There are new surrounding areas of necrotic tissue noted on the right forearm. A wound culture is obtained and reveals gram-negative, aerobic bacilli. What is the best next clinical intervention for this patient following stabilization and aggressive fluid resuscitation?
Start IV ciprofloxacin and gentamicin followed by surgical debridement
A 6-year-old girl presents to your office with her parents for follow-up of a burn injury to her right forearm that occurred 48 hours ago. She bumped the arm against a wood stove while playing at her friend's house and was seen in the emergency department immediately. The burn was cleaned, and her parents were instructed to apply cold compresses and give her acetaminophen for pain. On physical examination, she has an area of erythema over her lateral upper forearm, about 4 cm in diameter. There is a blister leaking a small amount of serous fluid. The area is extremely painful and blanches with pressure. Which of the following best describes the patient's injury?
Superficial partial-thickness burn
A 65-year-old man presents with a changing skin lesion on the trunk. On exam, you note a raised discolored plaque with irregular borders on the trunk. You suspect melanoma. Which of the following subtypes of melanoma is described above?
Superficial spreading (MC type of Melanoma)
A 55-year-old man is status post emergency open reduction internal fixation of a right humeral shaft fracture and comminuted right tibial and fibular fractures as the result of a severe motor vehicle collision. He has multiple abrasions all over his body as a result of being ejected from his vehicle and is receiving intravenous ceftriaxone. The patient begins to experience severe pain in his right lower extremity 2 hours after his surgery. He is toxic appearing and has a fever of 103.6°F. His right leg is erythematous, swollen, and warm to the touch. Right lower extremity anterior compartment pressure is 10 mm Hg. D-dimer is 230 ng/dL. Which of the following is the best next clinical intervention at this time?
Surgical debridement (Necrotizing fasciitis)
A 54-year-old man presents to the clinic after noticing a lump on his upper back. He has had the lump for 2 years, and its size has gradually increased. He does not have associated pain and has not noticed any other lumps. He has a medical history of hidradenitis suppurativa, which is treated with adalimumab. Vital signs include a BP of 122/73 mm Hg, HR of 80 bpm, RR of 20/min, T of 98.2°F, and SpO2 of 98% on room air. Physical examination findings include a regular heart rate and rhythm, lungs clear to auscultation, and a soft, nontender, and mobile 6-centimeter mass without a central punctum on his left upper back. He is requesting treatment of the lump due to cosmetic concerns. Which of the following is the recommended treatment?
Surgical removal (Lipoma)
A 12-year-old girl presents to the clinic due to facial lesions. Physical exam reveals several papules and pustules with surrounding inflammation over the cheeks, forehead, and chin. There are no nodules or scarring noted. The lesions have not resolved with twice-daily facial hygiene practices, including applying topical salicylic acid and sulfur products. She is subsequently refractory to first-line topical treatment strategies, and oral treatment is initiated. Which of the following is the best initial agent?
Tetracycline (acne vulgaris)
A 25-year-old woman presents with patches of skin discoloration on her chest and abdomen that she noticed about 2 weeks ago. She does not report pain or itching to the skin. Upon physical exam, there are scattered hypopigmented, velvety, white, oval-shaped macules around the patient's trunk. A topical scraping examined under potassium hydroxide preparation reveals short hyphae with spores. Which of the following is the most likely diagnosis?
Tinea versicolor (fungal infection)
A 25-year-old woman presents with a rash for the last 2 weeks. She reports it started with an approximately 2 cm oval salmon-colored patch on her anterior abdomen that began to clear about 1 week before more lesions appeared on her trunk. Lesions are pruritic. On physical exam, the patient has multiple oval-shaped salmon-colored patches with a collarette of scale over her trunk that follow the lines of cleavage in the skin. An image of her rash is shown above. Physical exam is otherwise unremarkable. Which of the following is the best therapy, given the suspected diagnosis?
Topical corticosteroid (Pityriasis Rosea, herald patch)
A 12-month-old boy presents to the pediatrician for his first visit. His foster parents received him into their home 2 days ago, and they have little information on his medical, family, or social history. Since he has been in their home, he has been quite fussy, and they are concerned about what seems to be an itchy rash on both of his hands and feet. On exam, there are multiple small, erythematous papules and vesicles on both of his hands, with surrounding excoriations. Tracts that appear to be small burrows are also present and measure about 5 mm in length. Which of the following is the most appropriate treatment?
Topical permethrin
A 23-year-old woman presents to her primary care provider with a complaint of an itchy rash. She states that the rash appeared on her trunk and arms this morning. Upon further inquiry, she reports that she had a minor outpatient surgical procedure last week and was given a short course of cephalexin, which she finished yesterday. She states that she is not taking any other medications, has no known drug allergies, and has not had any reactions like this in the past. Physical examination reveals a morbilliform rash on the trunk and upper extremities, as shown in the image above. The face, palms, and lower extremities are spared. Which of the following clinical interventions is most appropriate?
Topical triamcinolone and hydroxyzine 25 mg PO tid for 7 days (Postoperative drug eruption)
A 10-year-old girl presents to her pediatrician's office with a rash on her left forearm for the past 2 days. She went on a hiking trip with her father 3 days ago and cut her forearm while playing in the woods. Her father washed the wound out with some water and placed some antimicrobial ointment on the wound, covering it with an adhesive bandage. She states the same area is now mildly itchy and red. She has no history of similar symptoms. Physical examination of her forearm reveals discrete red papules with scaling along the edges. Which of the following clinical interventions is most appropriate at this time?
Topical triamcinolone for 2-3 weeks (allergic contact dermatitis)
A 54-year-old man presents to the office with a nonhealing, painful lesion on his left thigh for 7 days. He reports no fever or chills. He enjoys karate and is concerned about a fungal infection. He is at the gym 5 days a week and uses the mats frequently. On exam, there is a 3 cm firm, erythematous, tender nodule with small ulceration, with 4 cm of circumferential erythema on his left thigh. There is purulent drainage that is collected and sent for culture. There is no lymphadenopathy. A potassium hydroxide preparation is negative. What is the first-line treatment of choice, given this patient's suspected condition?
Trimethoprim-Sulfamethoxazole (Bactrim for MRSA coverage)
A 2yo boy presents to the ED with a new-onset rash. His vital signs are within normal limits, and he is in no acute distress, though he does appear irritated. His parents report no know allergies and there is no personal or family history of asthma, eczema, or environmental allergies. He attends daycare and has a prior history of ear infections, most recently completing a 7-day course of amoxicillin 2 days ago for a right ear infection. Otherwise, his medical history is unremarkable. On exam, he has a diffuse, morbilliform rash over his trunk and bilateral upper extremities. There are no pustules or vesicles. A few spots seem to be cropping up on his face, and his palms and soles are spared. There is no mucosal involvement, and there is no swelling or erythema over his joints. Other than the rash, he has a normal exam, is consolable, and appears well. Which of the following is the type of reaction causing this rash?
Type IV hypersensitivity (Drug eruptions/exanthems)
A 27-year-old man presents to the emergency department with a rash. He states that he noticed these lesions, seen above, as he was going to bed, and they felt warm and itchy. Physical exam is otherwise unremarkable. The patient has a medical history of asthma. Which of the following is the most likely diagnosis?
Urticaria
A 17-year-old boy presents to his pediatrician with concerns about hair loss over the past 2 years. He states there have been sporadic intervals of increased hair loss at certain times, followed by periods of minimal hair loss. He reports no itching, burning, or tenderness of the scalp. His father and grandfather had a similar condition. The hair pull test is negative. On close physical examination, follicular miniaturization and loss of terminal hair fibers are noted, but inflammatory signs and scarring of the scalp are absent. In which of the following locations on the scalp would the earliest changes of hair loss be seen?
Vertex (Androgenic alopecia)
A 9-year-old boy presents to his pediatrician's office with an intensely itchy rash. He states the rash started 2 weeks ago on his ankles and wrists. He reports no lesions on his trunk. No other family members have similar symptoms. Close examination of the ankles and wrists reveals multiple lesions with fine white lines on the surface. No other lesions are observed on the body. Which of the following findings on physical examination is most consistent with the suspected diagnosis?
Violaceous lesions at sites of trauma (Cutaneous lichen planus)
