Dermatology

Question 1

As a result of an accident in the kitchen, a 20-month-old toddler had boiling pasta and water spilled onto her head, face, and upper body. Physical examination reveals blistering sloughing skin with underlying wet, tender erythema.

Answer 1

Burns injury

Question 2

A 50-year-old electrician was servicing a high-voltage transformer when a distant switch inadvertently sent current to the transformer, with a resulting arc and electrocution. The worker was thrown back by the force and his clothing was ignited. Physical examination reveals charring of the dominant hand, with deep arching injury across the antecubital fossa and axilla, consistent with passage of high-voltage current. The upper torso demonstrates leathery deep burns consistent with flame injury.

Answer 2

Burns injury

Question 3

A 52-year-old woman with a history of Crohn’s disease developed fevers while receiving total parenteral nutrition for 2 weeks. She underwent a small bowel resection followed by prolonged intravenous antibiotics for intra-abdominal abscess and fistulae. Examination reveals a temperature of 38.5°C (101°F), normal heart sounds without murmur, central venous catheter site without erythema or drainage, and no rash.

Answer 3

Systemic candidiasis

Question 4

A 78-year-old man, who has insulin-dependent diabetes, presents with a neurogenic bladder, and is admitted with hypotension (BP 80/40), pulse 120 bpm, temperature of 39°C (102°F), and confusion. Urine examination reveals pyuria, and numerous budding yeast are visualised on urine microscopy.

Answer 4

Systemic candidiasis

Question 5

A 28-year-old man presents with pain on swallowing. He has no oral symptoms, but clinically has abundant, creamy white, loosely adherent plaques throughout his mouth. Lesions are especially prominent in his buccal, palatal, and pharyngeal mucosa. HIV infection was diagnosed 2 years ago, but he has not yet started anti-retroviral treatment. His last CD4 count and viral load measurement was 8 months ago.

Answer 5

Oral candidiasis

Question 6

A 64-year-old man presents with a complaint of burning under his maxillary denture. He has hypertension and osteoarthritis. His medications include a thiazide diuretic, a non-selective beta-blocker, and an OTC analgesic. Intra-orally, he has severely erythematous palatal mucosa, with a distinct granular appearance. His mucosa is dry and his salivary flow is minimal.

Answer 6

Oral candidiasis

Question 7

A 12-year-old female presents with dry, itchy skin that involves the flexures in front of her elbows, behind her knees and in front of her ankles. Her cheeks also have patches of dry, scaly skin. She has symptoms of hay fever and has recently been diagnosed with egg and milk allergy. She has a brother with asthma and an uncle and several cousins who have been diagnosed with eczema.

Answer 7

Eczema

Question 8

A 16-year-old girl presents with a progressively worsening pruritic eruption in the peri-umbilical region. She reports wearing blue jeans with metal buttons and a belt with a metal buckle on an almost daily basis. She previously developed pruritic eruptions around the neck and earlobes when wearing costume jewellery. Physical examination reveals erythematous to hyperpigmented peri-umbilical papules and plaques with sharp demarcation, and hyperpigmented patches on the neckline and ear lobes.

Answer 8

Contact dermatitis

Question 9

A 45-year-old male factory worker presents with pruritic eruption of his hands, which has been present for several months. He works in a manufacturing plant where cutting oils are used. While at work, he wears protective clothing that covers his trunk, arms, and legs, but he often neglects to wear gloves. He noticed an improvement when he was on holiday for 2 weeks. Physical examination shows hyperpigmented scaly plaques and fissuring, confined to the dorsal hands and digits, with sharp demarcation at the wrist.

Answer 9

Contact dermatitis

Question 10

A 40-year-old woman presents with intensely pruritic rash of the hands and feet that is relapsing-remitting. She recalls that, 1 or 2 days prior to an eruption, she will notice an itching sensation in her palms and soles. The rash consists of small vesicles on the palms, soles, and lateral fingers. It lasts for a couple of weeks before desquamation, leaving no trace. She has several episodes a year and cannot cite specific triggers, although she does note that washing dishes makes it worse. Her medical history is otherwise unremarkable.

Answer 10

Dyshidrotic dermatitis

Question 11

A middle-aged man complains of greasy scaling in the nasolabial folds and on his anterior scalp. In the past 6 months, his symptoms have waxed and waned, flaring in times of stress. Itchy, irritating scaly and flaky lesions are also present on his posterior scalp.

Answer 11

Seborrhoeic dermatitis

Question 12

A 2-month-old infant is brought for evaluation of scalp scaling. The infant is otherwise in good health, was born at a normal full-term birth, and has healthy parents. On examination, there is diffuse scaling of the occipital scalp. The nasolabial folds and other cutaneous surfaces appear normal.

Answer 12

Seborrhoeic dermatitis

Question 13

A 35-year-old female presents to her GP with a firm round mobile lump on the side of her face. The lump is whitish with a central punctum.

Answer 13

Pilar cyst (sebaceous cyst)

Question 14

A 18-year old male presents to his GP with a firm round mobile lump on his scalp. The lump is whitish with a central punctum.

Answer 14

Epidermoid cyst (sebaceous cyst)

Question 15

An otherwise healthy, white, 10-year-old boy complains of a sore throat. He is running a low-grade fever of 38.0°C (100.6°F). Red lesions have developed on his extremities, and he is having some difficulty breathing after exertion. Oral erosions have limited his food and fluid intake. On physical examination, there are target lesions on his upper and lower extremities with erosions on his lower lip and palate. High-pitched wheezing is heard over the lower lungs bilaterally, and the patient is in mild discomfort when sitting upright. He is unable to open his mouth fully due to crusted oral lesions.

Answer 15

Erythema multiforme

Question 16

A 23-year-old man presents with a history of recurrent erythematous lesions over the extremities with each outbreak of herpes labialis. The episodes have become more frequent, and each recurrence is more severe with time. He was prescribed oral valaciclovir 3 weeks previously, to be taken at the first sign of an oral herpes simplex virus outbreak. On examination he has target lesions over the extremities and a mild cold sore over his upper lip.

Answer 16

Erythema multiforme

Question 17

A 25-year-old otherwise healthy woman awakens with a mild sore throat, fatigue, pain in both ankles, and red lesions on her legs. She reports weakness and fatigue for the past 2 days, but denies fever, chills, nausea, or night sweats. There is no history of using recreational drugs, oral contraceptives, or other medications. She has not travelled abroad for 3 years. Physical examination reveals red, tender, fixed, deep-seated nodules on both shins. Her ankles are mildly swollen and tender and she reports difficulty bearing weight. Chest, cardiovascular and ophthalmological examinations are normal. A chest x-ray shows left lower lobe infiltration. Her tuberculin skin test is negative. She is diagnosed with pneumococcal pneumonia.

Answer 17

Erythema nodosum

Question 18

A 28-year-old woman awakens with red eyes, photophobia, and nodules on her legs. She denies fever, malaise, cough, or joint pains. She enjoys dairy products, but denies recent consumption of raw milk or cheese. She does not take recreational drugs. Physical examination shows bilateral iritis and enlarged lachrymal glands. Chest and cardiovascular examinations are normal, though the skin examination reveals many dark red nodules on her legs and lower thighs. These skin nodules are tender and non-mobile. Her tuberculin test is negative, but a chest x-ray shows bilateral hilar adenopathy consistent with the diagnosis of sarcoidosis.

Answer 18

Erythema nodosum

Question 19

A 24-year-old woman presents with a 3-day history of painful sores in the genital area, dysuria, fever, and headache. She is sexually active with men and has a new partner within the past month. She does not use condoms. Physical examination reveals a temperature of 38.3°C (100.9°F), stable vital signs, slight nuchal rigidity (implying aseptic meningitis), bilateral tender inguinal lymphadenopathy, and multiple tender 1- to 2-cm erythematous ulcerations without labial crusts. The cervix is oedematous with pustules and clear discharge. Cervical motion tenderness is also present.

Answer 19

Herpes Simplex Virus

Question 20

A 25-year-old man presents for STD screen. He is sexually active with men, has had 4 partners in the past year, and uses condoms ‘most of the time’. He was HIV-negative 6 months ago and denies a history of urethral discharge, dysuria, or genital ulcers. He does have occasional genital itching and mild sores on the penile shaft. Genitourinary examination reveals a circumcised male with no inguinal lymphadenopathy, no lesions on the penile shaft or perianal area, and no urethral discharge.

Answer 20

Herpes Simplex Virus

Question 21

A 55-year-old woman presents with a right flank mass. She states she was recently diagnosed with diabetes mellitus, which she has been able to control with diet modifications. She lost 9 kg (20 pounds) within 3 months and then noticed a mass over her right lower rib cage. She denies pain but does report discomfort when she wears a jogging bra. On physical examination, the mass is soft, superficial, and mobile, and it measures 5 cm in diameter.

Answer 21

Lipoma

Question 22

A 35-year-old man presents with a right thigh nodule and a recurrent left chest wall nodule at the site of a prior scar. He states that he noticed a bump on his right lateral thigh 2 years previously and that the left chest wall lesion had been removed in clinic 3 years prior. The nodules have grown slightly over recent months. He also states that they bother him when he touches them. On physical examination, the nodules are 1 cm x 2 cm, soft, and mobile, and they feel subcutaneous.

Answer 22

Lipoma

Question 23

A 36-year-old fair-skinned woman presents with a dark, irregular, pigmented patch that she noted 4 months ago on the right posterior calf. It has gradually increased in size. She reports approximately 6 sunburns in the past and has been using tanning beds several times yearly for the past few years. Family history is positive for melanoma in her uncle. On physical examination, approximately 15 normal-appearing naevi, ranging in size from 3 mm to 5 mm, with symmetry, uniform brown coloration, and regular borders are noted elsewhere on the torso and extremities. The pigmented lesion on the right calf is asymmetrical along 2 axes, measures 1 cm x 0.8 cm, is deeply pigmented with several shades of brown, and has a jagged border. The popliteal nodes are not clinically palpable

Answer 23

Melanoma

Question 24

A 51-year-old man presents with a large, dark, bleeding nodule on his back. He reports that it has been present and growing in size for at least 2 years, but he did not seek medical attention until now. On examination, a 2-cm ulcerated black nodule with an irregular border is present overlying the left posterior scapula. The left axillary nodes are clinically palpable.

Answer 24

Melanoma

Question 25

A 39-year-old woman with no personal history of skin cancer presents for a skin examination after her sister was recently diagnosed with melanoma. She states that she is concerned that she may have skin cancer because she has a history of several blistering sunburns as a child, and that she has lots of moles. One lesion on her back, in particular, appears to have become darker and more raised, and she would like it checked. On full body skin examination, she has freckling of sun-exposed surfaces of her face, chest, upper back, and arms, in addition to numerous dark-brown to pink, 3- to 5-mm, evenly bordered macules and papules scattered on her face, back, and arms. The nevus in question on her back is an evenly pigmented, dark brown, dome-shaped 5-mm papule with a mamillated surface and circumscribed border.

Answer 25

Melanocytic lesion (nevi)

Question 26

A 5-year-old white boy presents with a history of 2 months of bumps in the left axilla. Initially there was just 1 lesion; now the parents note that the child has 6 lesions. Some of the areas have been inflamed, and the child has pruritus, which keeps him up at night. One of his cousins, with whom he swam, may have such lesions as well. The child also suffers from seasonal allergies.

Answer 26

Molluscum contagiosum

Question 27

A sexually active female university student presents complaining of itchy growths on the escutcheon and the inner thighs, of 1 month’s duration. The patient has been using a condom when she is sexually active with her boyfriend of 3 months. She is seen every 6 months by her gynaecologist, and had a negative Pap smear 2 months ago. Pearly papules with a central dell can be observed on the escutcheon and inner thighs. Some have surrounding erythema and excoriations.

Answer 27

Molluscum contagiosum

Question 28

A 65-year-old man presents with fever and respiratory distress. He rapidly develops progressive hypoxia and hypotension requiring ventilator support and pressors. Efforts to reposition the patient result in marked desaturations. One week later, following stabilisation of his medical condition, he is noted to have an extensive area of tissue damage over his sacral region. The damage around the margin of the wound appears relatively superficial, with some signs of partial skin loss. Towards the centre, directly over the sacrum, is an area of necrotic tissue, which is starting to separate spontaneously, exposing a cavity containing viscous yellow slough. A purulent discharge is draining from this cavity.

Answer 28

Pressure ulcer

Question 29

An 80-year-old woman in a residential care facility, who has recently suffered a stroke with a resulting right hemiplegia, presents with a painful area on right heel. On examination the heel is found to be covered with a layer of hard, black, necrotic tissue with a leathery appearance.

Answer 29

Pressure ulcer

Question 30

A middle-aged man with a known history of psoriasis presents with white scaly papules and plaques on his elbows, extensor arms, knees, and shins. In the past 6 months, these lesions have become much worse and have started to appear on his waist and hip. Scaly and flaky eruptions are also present on his scalp, ears, and eyebrows. He describes the lesions as being itchy and irritating. He is a heavy smoker and has been unsuccessful in a previous attempt at smoking cessation.

Answer 30

Psoriasis

Question 31

A young man without a known history of psoriasis or skin disorder had a sudden onset of wide-spreading, white-scaly, oval- to round-shaped erythematous papules, which have been present for 2 weeks. Lesions are primarily on his trunk but also appear scattered on his arms and legs. He recalls a recent episode of sore throat and upper respiratory tract infection. A short course of antibiotics seemed to help, but did not clear the lesions.

Answer 31

Psoriasis

Question 32

A 50-year-old man with a past medical history of HTN and a recent diagnosis of osteoarthritis presents to his primary care physician with complaints of hives over the past 2 weeks. He reports red and raised lesions that are intensely pruritic and involve his torso and bilateral extremities. He denies any swelling or pain associated with the episodes. The patient also denies any unusual food ingestions or recent changes in his environment (e.g., soaps, detergents). However, he has recently started using scheduled ibuprofen for osteoarthritis.

Answer 32

Urticaria

Question 33

A 33-year-old woman with a past medical history of hypothyroidism presents with complaints of hives for the past 4 months. She describes red, raised, itchy lesions that involve her entire body, including her face. She also reports 2 episodes of face and tongue swelling, each of which prompted her to report to the nearest emergency department. In addition to itching, the lesions sometimes cause a burning sensation. The lesions and symptoms resolve over 24 to 36 hours. Despite countless attempts, she has not been able to associate the hives with any specific triggers. The patient voices extreme frustration and feelings of depression, which she attributes to her recent condition.

Answer 33

Urticaria

Question 34

A 6-year-old boy presents with fever, headache, and a diffuse, pruritic, vesicular rash, which is most prominent on the face and chest. He has had generalised malaise and low-grade fever for a few days prior to presentation. He developed high fever and a rash in the last 48 hours. Physical examination demonstrates a temperature of 39°C (102°F) and heart rate of 140 beats/minute. He has a few scattered vesicular lesions in his oropharynx and his lung fields are clear. The lesions are prominent on the face and chest, but all extremities are also involved. In some areas the lesions are crusted, while in others they appear newly formed. He has no nuchal rigidity or other meningeal signs.

Answer 34

Varicella Zoster

Question 35

A 36-year-old man undergoing chemotherapy for non-Hodgkin’s lymphoma presents with fever, shortness of breath, haemoptysis, and a diffuse rash. His family recalls that he had a fever the previous day, and that the rash started on his chest and progressed rapidly. In a review of recent exposures, his wife recounts that she was told that a child who visited their home later developed ‘chickenpox’. His current medications are levofloxacin and an antidepressant. A review of his medical history indicates he has never had chicken pox. On examination he has a temperature of 40.1°C (104.2°F), a heart rate of 145 bpm, and an O2 saturation of 83%. Lung examination demonstrates bilateral crackles, and the patient has diffuse vesicular lesions, some of which appear to be haemorrhagic. Initial laboratory testing indicates a low haematocrit and platelets, a low absolute lymphocyte count (<100 cells/mL), and mild transaminitis. A chest x-ray demonstrates ground glass opacities or diffuse small nodular infiltrates.

Answer 35

Varicella Zoster