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2011 American Board of Dermatology Recertification Examination Study Guide: Medical Dermatology Module 1 1.

Which of the following is a relative contraindication to beginning etanercept therapy? (A) Family history of retinitis pigmentosa (B) History of chronic renal failure (C) History of congestive heart failure (stage III) (D) History of positive PPD test and treatment with isoniazid (E) History of unexplained anemia

6 6. Antibodies to type VII collagen within anchoring fibrils are most closely associated with which of the following diseases? (A) Bullous pemphigoid (B) Chronic bullous disease of childhood (C) Dermatitis herpetiformis (D) Bullous lupus erythematosus (E) Subacute cutaneous lupus erythematosus

2 2. A 25-year-old woman is being evaluated because of fever, headache, and a generalized rash. Physical examination shows a papulovesicular eruption and an eschar on her arm. She says that she sees mice in her apartment. Which of the following is the most likely diagnosis? (A) Anthrax (B) Chickenpox (C) Q fever (D) Rickettsialpox (E) Scrub typhus

7 7. A 35-year-old woman has the onset of proximal muscle weakness and a heliotrope rash. Serum creatine kinase activity is greater than 3000 U/L. This patient is most likely to have a malignancy at which of the following sites? (A) Breast (B) Colon (C) Lung (D) Ovary (E) Stomach

3 3. Which of the following medications can cause mast cell degranulation and histamine release without requiring specific immunologic antigen-IgE complexes? (A) Codeine (B) Enalapril (C) Griseofulvin (D) Itraconazole (E) Niacinamide

8 8. A 52-year-old woman has had the gradual development of generalized pruritus, xerostomia, urticarial lesions, purpuric macules on her legs, and dyspareunia over the past month. Histologic evaluation of an urticarial lesion shows leukocytoclastic vasculitis. Which of the following studies in serum is most likely to confirm this diagnosis? (A) cANCA assay (B) p-ANCA assay (C) Protein electrophoresis (D) Ro (SS-A) antibody assay (E) Thyroid-stimulating hormone level 9 9. A 55-year-old woman has numerous acral keratoses and skincolored verrucous papules around facial orifices. Histologic examination of a biopsy specimen of a lesion shows a trichilemmoma. In addition to breast carcinoma, this patient is at greatest risk for developing which of the following types of cancer? (A) Hepatocellular carcinoma (B) Ovarian carcinoma (C) Thyroid carcinoma (D) Transitional cell carcinoma of the bladder (E) Uterine carcinoma 10 10. A 33-year-old man is being evaluated because of multiple skin tags and flesh-colored papules. Histopathologic examination shows fibrofolliculomas. This patient has the greatest risk for which of the following disorders? (A) Atherosclerosis (B) Cushing disease (C) Lymphoma (D) Renal cell carcinoma (E) Testicular carcinoma

4 4. Which of the following medications is most likely to cause acute generalized exanthematous pustulosis? (A) Bupropion (B) Erythromycin (C) Hydrochlorothiazide (D) Omeprazole (E) Phenytoin

5 5. A patient will begin intravenous immunoglobulin (IVIG) therapy for pemphigus vulgaris. Which of the following laboratory tests is most important before beginning this therapy? (A) Complete blood cell count (B) Hepatic function panel (C) HIV antibody (D) Serum IgA level (E) Urinalysis

11 11. A 57-year-old woman who has been taking prednisone for six months for dermatomyositis now has worsening pain in her right hip during activity. Which of the following is the most appropriate test to evaluate her pain? (A) Biopsy (B) Bone scan (C) CT scan (D) MRI (E) Radiograph

16 16. A 37-year-old man has biopsy-proven sebaceous adenomas on his face. Several family members have died of cancer. Which of the following is the most appropriate next diagnostic study in the evaluation of this patient? (A) Bone marrow biopsy (B) Colonoscopy (C) CT scan of the chest (D) Digital rectal examination (E) Serum protein immunoelectrophoresis

12 12. Patients with a deficiency of which of the following enzymes have an increased risk for severe bone marrow suppression with the use of azathioprine? (A) Alanine aminotransferase (B) Gamma-glutamyl transpeptidase (C) Lactic dehydrogenase (D) Methylene tetrahydrofolate reductase (E) Thiopurine methyltransferase

17 17. Infection with which of the following viruses typically results in an acute exanthem in young children and a symmetric, often prolonged, arthropathy in adults? (A) Coxsackievirus A16 (B) Enterovirus 71 (C) Epstein-Barr virus (D) Human herpesvirus 6 (E) Parvovirus B19

13 13. Which of the following allergens presents the highest risk of sensitization from the patch test procedure? (A) Mercaptobenzothiazole (B) Nickel (C) Paraben mix (D) Paraphenylenediamine (E) Quaternium-15

14 14. A patient with phenytoin hypersensitivity syndrome has the greatest risk for which of the following sequelae? (A) Anemia (B) Diabetes mellitus (C) Hypertension (D) Hypothyroidism (E) Sensory neuropathy

18 18. A 44-year-old woman has the acute onset of pain, warmth, swelling, and erythema of the skin of her hands and feet that is worse at night. She says that she has had difficulty sleeping because of the burning sensation, and that her symptoms improve by cooling the hands and feet. Which of the following is the most likely diagnosis? (A) Erythroderma (B) Erythromelalgia (C) Livedo reticularis (D) Raynaud phenomenon (E) Thromboangiitis obliterans

15 15. Which of the following corticosteroid-sparing agents should be included in the initial therapeutic regimen of a patient with ocular cicatricial pemphigoid? (A) Azathioprine (B) Cyclosporine (C) Cyclophosphamide (D) Methotrexate (E) Mycophenolate mofetil

19 19. A 14-year-old boy who is being treated for acne vulgaris develops fatigue and dyspnea on exertion. Laboratory studies show profound anemia, neutropenia, and low serum copper level. The most likely cause of these findings is an excessively high dose of which of the following medications? (A) Beta carotene (B) Doxycycline (C) Erythromycin (D) Niacinamide (E) Zinc

20. A 45-year-old African American woman is evaluated in the hospital because of a one-day history of facial edema, severe arthralgias, and a widespread morbilliform eruption without ocular or mucosal involvement. One month ago, she began taking carbamazepine for treatment of trigeminal neuralgia. Five days ago, she was admitted to the hospital because of fever and pain over the right upper quadrant of the abdomen. On admission, medications included lisinopril, metformin, and carbamazepine. She had no facial pain on admission and carbamazepine was discontinued. Evaluation at that time disclosed mild gastritis. Three days ago, treatment with cephalexin and pantoprazole was initiated. Cephalexin was discontinued one day ago. During the past five days, she has had temperatures to 39.4C (103.0F), serum AST and ALT levels that are approximately three times greater than normal, and a peripheral blood eosinophil count of 18%. Physical examination today discloses edema and a widespread erythematous desquamative eruption over the trunk. Which of the following drugs is the most likely cause of this eruption? (A) Carbamazepine (B) Cephalexin (C) Lisinopril (D) Metformin (E) Pantoprazole 21. A 50-year-old man develops this eruption seven weeks after starting oral terbinafine 250 mg daily for onychomycosis. Which of the following antibody tests is most likely to be positive? (A) Anti-nDNA (B) Anti-Ro/SSA (C) Anti-Sm (D) Anti-ssDNA (E) Anti-U1RNP 22. A 50-year-old woman comes to the office because of the widespread eruption shown. She has no other skin abnormalities. In the past 12 months, she has had three transient ischemic attacks. Which of the following is the most likely diagnosis? (A) Cholesterol emboli (B) Livedoid vasculopathy (C) Microscopic polyarteritis (D) Sneddon syndrome (E) Wegener granulomatosis 23. A 50-year-old man has the onset of the single cutaneous lesion shown 12 hours after taking an opioid analgesic that was prescribed following a facial surgical procedure. He reports that he had an identical lesion at the same site after administration of other analgesic drugs in the past. Which of the following is the most likely diagnosis? (A) Bullous erythema multiforme (B) Bullous fixed drug eruption (C) Bullous lichen planus (D) Interstitial granulomatous dermatitis (E) Leukocytoclastic vasculitis

24 24. Which of the following immunosuppressive medications is most appropriate for a patient with Kaposi sarcoma who has undergone a solid organ transplantation? (A) Azathioprine (B) Cyclosporine (C) Mycophenolate mofetil (D) Sirolimus (E) Tacrolimus

25 25. Concurrent use of which of the following herbal supplements is most likely to decrease the efficacy of oral contraceptives? (A) Garlic (B) Ginkgo biloba (C) Hawthorn (D) Peppermint (E) St. John's wort

26 26. Which of the following medications is most likely to cause a hypersensitivity syndrome with systemic symptoms in a patient who is seropositive for HIV? (A) Abacavir (B) Dapsone (C) Efavirenz (D) Saquinavir (E) Zidovudine (AZT)

27 27. A 40-year-old woman has a six-month history of tense vesicles and bullae on the dorsa of the hands that resolve with scars. Serum, urine, and stool examinations are negative for detectable porphyrins. Biopsy specimen of a new vesicle shows a cell-poor subepidermal blister. Which of the following drugs is the most likely cause of the lesions? (A) Amiodarone (B) Captopril (C) Naproxen (D) Penicillamine (E) Vancomycin

28 28. Which of the following diseases is most frequently associated with small bowel lymphoma? (A) Atopic dermatitis (B) Dermatitis herpetiformis (C) Erythema multiforme (D) Pemphigus vulgaris (E) Psoriasis vulgaris

29. A 45-year-old woman who smokes one pack of cigarettes daily is diagnosed with cutaneous lupus erythematosus. The efficacy of which of the following medications is most likely to be adversely affected by her smoking? (A) Azathioprine (B) Chloroquine (C) Dapsone (D) Etanercept (E) Methotrexate

34 34. Which of the following is an example of a drug-induced idiosyncratic adverse effect? (A) Agranulocytosis with dapsone (B) Hepatotoxicity with methotrexate (C) Hypercalcemia with topical calcipotriene (D) Hypertension with cyclosporine (E) Nausea with oral methoxsalen

30 30. A 30-year-old woman is being evaluated shortly after having a stroke. Physical examination shows livedo reticularis and an ulcer on the left medial lower leg. The skin changes had developed before she had the stroke. Which of the following laboratory tests is most useful in establishing the diagnosis? (A) Anti-dsDNA test (B) Antineutrophilic cytoplasmic antibody test (C) Antiphospholipid antibody panel (D) Rocky Mountain spotted fever assay (E) Serum protein electrophoresis

35 35. Hydroxychloroquine is most likely to cause a hypersensitivity rash when used to treat which of the following conditions? (A) Dermatomyositis (B) Discoid lupus erythematosus (C) Rheumatoid arthritis (D) Subacute cutaneous erythematosus (E) Systemic lupus erythematosus

31 31. An otherwise healthy 34-year-old woman has palpable purpura, sinusitis, pulmonary infiltrates, and rapidly progressing renal failure. She has no history of asthma. Skin biopsy shows perivascular granulomatous inflammation. Positive results are most likely on which of the following serologic tests? (A) Anti-Ro(SS-A) antibody (B) Anti-topoisomerase I (Scl-70) antibody (C) Anti-U1RNP antibody (D) cANCA (E) Cryoglobulin

36 36. A 55-year-old man has the onset of symmetric brawny plaques on the trunk and legs. He has diabetes mellitus with chronic renal insufficiency and recently began hemodialysis. During the ensuing weeks, the plaques develop an indurated, woody consistency. Which of the following is the most likely diagnosis? (A) Diabetic dermopathy (B) Lipodermatosclerosis (C) Nephrogenic systemic fibrosis (D) Scleromyxedema (E) Shulman syndrome

32. A 72-year-old man with esophageal carcinoma has red scaly plaques on the ears, hands, and feet. Which of the following is the most likely diagnosis? (A) Acanthosis nigricans (B) Bazex syndrome (C) Dermatomyositis (D) Necrolytic migratory erythema (E) Sweet syndrome

37 37. Evaluation of a patient with complex aphthous ulcers should include screening for a deficiency of which of the following vitamins? (A) A (B) B12 (C) C (D) D3 (E) E

33 33. Which of the following adverse effects is more likely during infliximab therapy than during therapy with etanercept? (A) Demyelinating disease (B) Drug-induced lupus erythematosus (C) Human anti-chimera antibodies (HACAs) (D) New-onset congestive heart failure (E) Pancytopenia

38 38. One week after cleaning a fish tank, a 24-year-old woman develops an ulcer on her hand and lymphangitis. Which of the following antimicrobial agents is the most appropriate first choice for the treatment of this condition? (A) Ciprofloxacin (B) Clarithromycin (C) Erythromycin (D) Minocycline (E) Potassium iodide

39. A patient with which of the following neoplasms should be evaluated for POEMS syndrome? (A) Desmoid tumor (B) Glomeruloid hemangioma (C) Psammomatous melanotic schwannoma (D) Sebaceous adenoma (E) Trichodiscoma 40. A 58-year-old man is being evaluated because of a flare-up of psoriasis. He has been treated with PUVA therapy for flare-ups for more than five years. He has also been treated for several actinic keratoses over the past year; none are seen on current examination. Which of the following treatments increases the risk of non-melanoma skin cancer in this patient? (A) Oral acitretin (B) Oral cyclosporine (C) Oral methotrexate (D) Topical calcipotriene (E) Topical tazarotene cream 41. Which of the following agents is most likely to result in systemic allergic contact dermatitis? (A) Balsam of Peru (B) Cocamidopropyl betaine (C) Thiuram (D) Toluene sulfonamide formaldehyde resin (E) Xylocaine 42. A patient with chronic dermatitis is patch test-positive to hydrocortisone-17-butyrate. To which of the following corticosteroids is she most likely allergic? (A) Amcinonide (B) Budesonide (C) Fluocinonide (D) Halcinonide (E) Triamcinolone diacetate 43. This condition responds best to therapy with which of the following? (A) Betamethasone dipropionate 0.05% cream (B) Clotrimazole (C) Minocycline (D) Narrowband UVB (E) Oral isotretinoin 44. These lesions are most likely to be seen in patients with which of the following diagnoses? (A) Alkaptonuria (B) Cushing's disease (C) Diabetes mellitus (D) Netherton syndrome (E) Osteogenesis imperfecta

45. Development of peripheral atherosclerotic vascular disease is most commonly associated with which of the following cutaneous disorders? (A) Atopic dermatitis (B) Dermatomyositis (C) Generalized granuloma annulare (D) Psoriasis vulgaris (E) Subacute cutaneous lupus erythematosus

46 46. A 40-year-old man who is seropositive for HIV begins thalidomide therapy for prurigo nodularis. Which of the following studies at regular intervals is the most appropriate follow-up care? (A) Electrocardiography (B) Examination of the stool for occult blood (C) Hearing test (D) Neurologic examination (E) Urinalysis

47 47. Which of the following immunosuppressive agents inhibits purine biosynthesis? (A) Cyclosporine (B) Hydroxyurea (C) Mycophenolate mofetil (D) Tacrolimus (E) Thalidomide

48 48. A 60-year-old man develops a generalized bullous eruption one week after undergoing coronary artery bypass grafting. His current medications include quinidine, vancomycin, digoxin, and furosemide. Histologic examination of a biopsy specimen of affected skin shows a subepidermal bulla with neutrophils and linear deposition of IgA at the basement membrane zone. Which of the following is the most appropriate next step in the management of this eruption? (A) Continue current medications and add dapsone (B) Continue current medications and add a high-dose corticosteroid (C) Discontinue furosemide (D) Discontinue quinidine and add sulfapyridine (E) Discontinue vancomycin 49. A 42-year-old man with rheumatoid arthritis has the rapid appearance of multiple small nodules on his fingers. Biopsy specimen of a nodule shows a palisaded granuloma with a dense central neutrophilic infiltrate. Which of the following drugs is the most likely cause of this eruption? (A) Azathioprine (B) Celecoxib (C) Hydroxychloroquine (D) Methotrexate (E) Sulfasalazine

50 50. A 40-year-old man is being evaluated because of symptoms of porphyria cutanea tarda. He has normal hepatic enzyme activities and is found to be homozygous for mutations in HFE C282Y. Which of the following is the most appropriate treatment? (A) Following a diabetic diet (B) Hydroxychloroquine therapy (C) Phlebotomy to maintain a serum ferritin level below 20 g/L (D) Monitoring of liver enzyme activities every three months (E) Sunscreen use

55 55. Compared with a healthy patient, a patient with a family history of familial melanoma syndrome has an increased risk for which of the following neoplasms? (A) Astrocytoma (B) Hodgkin lymphoma (C) Medulloblastoma (D) Pancreatic carcinoma (E) Small cell lung carcinoma

51 51. Which of the following medications is the most appropriate initial treatment of a patient with linear IgA disease? (A) Azathioprine (B) Cyclophosphamide (C) Dapsone (D) Methotrexate (E) Tetracycline

56 56. Which of the following diseases is most closely associated with multiple dermatofibromas? (A) Amyloidosis (B) Generalized eruptive histiocytosis (C) Lichen planus (D) Psoriasis (E) Systemic lupus erythematosus

52 52. Which of the following is the most common clinical course of neonatal lupus in infants? (A) Complete resolution only with administration of a systemic corticosteroid (B) Frequent relapses and remissions (C) Healing of lesions with significant scarring (D) Progression to systemic disease (E) Spontaneous resolution in 6 to12 months

57 57. Concomitant use of which of the following antibiotics is most likely to decrease the efficacy of oral contraception in women? (A) Cephalexin (B) Doxycycline (C) Erythromycin (D) Rifampin (E) Trimethoprimsulfamethoxazole

53 53. Direct immunofluorescence performed on a biopsy specimen from a patient with multiple purpuric lesions reveals IgA deposition in the cutaneous vasculature. This finding best supports which of the following diagnoses? (A) Henoch-Schnlein purpura (B) Mixed cryoglobulin-associated vasculitis (C) Rheumatoid factor-associated vasculitis (D) Urticarial vasculitis (E) Wegener granulomatosis

58 58. Which of the following laboratory tests should be performed on all patients prior to starting long-term therapy with methotrexate? (A) Cryoglobulin assay (B) Dihydrofolate reductase level (C) Hepatitis C antibody assay (D) Rheumatoid factor assay (E) Thiopurine methyltransferase level

54 54. A 22-year-old woman has acne, acanthosis nigricans, hirsutism, and oligomenorrhea. This patient has an increased likelihood of developing which of the following conditions? (A) Autoimmune glomerulonephritis (B) Insulin-resistant diabetes mellitus (C) Intraductal breast carcinoma (D) Pulmonary fibrosis (E) Uterine leiomyomas

59 59. A 22-year-old woman who began taking a new medication for acne three months ago has had fevers, weight loss, and joint pain since beginning the new medication. Laboratory findings include an ANA titer of 1:5120 and a positive antihistone antibody titer. Which of the following is the most likely cause of these findings? (A) Amoxicillin (B) Erythromycin (C) Isotretinoin (D) Minocycline (E) Trimethoprimsulfamethoxazole

60. A pregnant woman with which of the following dermatoses is most likely to develop Graves' disease? (A) Cholestasis of pregnancy (B) Pemphigoid gestationis (C) Prurigo gravidarum (D) Pruritic folliculitis of pregnancy (E) Pruritic urticarial papules and plaques of pregnancy 61. A 45-year-old woman with a history of uterine fibroids has cutaneous leiomyomas. This patient has an increased risk for which of the following types of cancer? (A) Breast cancer (B) Non-Hodgkin lymphoma (C) Renal cell cancer (D) Thyroid cancer (E) Uterine sarcoma 62. A patient is undergoing evaluation for a presumed bullous skin disease. Which of the following is the most appropriate site for obtaining a biopsy specimen for direct immunofluorescence? (A) Intact vesicle (B) Perilesional skin (C) Ruptured vesicle (D) Sun-exposed normal skin (E) Sun-protected normal skin

66. When applied to clothing, which of the following agents is most likely to provide the best protection against tick bites? (A) Citronella (B) IR 3535 (C) Permethrin (D) Soybean oil (E) 10% Sulfa

67 67. A 60-year-old man has retiform purpura in the distal lower extremities. Which of the following laboratory abnormalities is most suggestive of the presence of cholesterol emboli? (A) Eosinophilia (B) Lymphocytosis (C) Neutropenia (D) Polycythemia (E) Thrombocytopenia

63. A 60-year-old man has had a pruritic erythematous papular eruption on the trunk, arms, and legs for the past month. He had similar reactions after taking hydrochlorothiazide and after taking trimethoprimsulfamethoxazole. Which of the following medications is the most likely cause of the dermatitis? (A) Celecoxib (B) Fluconazole (C) Hydrocodone (D) Levofloxacin (E) Spironolactone

68 68. A 35-year-old woman has had this rash for the past six months. Which of the following is the most likely causal drug? (A) Captopril (B) Cyclophosphamide (C) Hydrochlorothiazide (D) Simvastatin (E) Terbinafine 69. In a patient who has received a Bacillus Calmette-Gurin (BCG) vaccination, which of the following is the most sensitive screening test for latent tuberculosis? (A) Purified protein derivative (PPD) skin test (B) Radiography of the chest (C) Single sputum acid-fast bacilli smears (D) T-cell interferon gamma release assay (E) Tine test

64 64. Which of the following tick-born illnesses is most likely to result in heart conduction abnormalities? (A) Babesiosis (B) Ehrlichiosis (C) Lyme disease (D) Rocky Mountain spotted fever (E) Tick paralysis

70 70. Which of the following is the most effective agent for both the gastrointestinal and skin disease in this patient? (A) Adalimumab (B) Alefacept (C) Etanercept (D) Interferon alfa (E) Rituximab

65 65. Patients taking drugs containing sulfhydryl groups are at increased risk for developing which of the following bullous disorders? (A) Bullous pemphigoid (B) IgA pemphigus (C) Linear IgA dermatosis (D) Pemphigus foliaceus (E) Pemphigus vegetans

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For each example of bias in a study, select the most accurate description (A-E). (A) Detection bias (B) Misclassification bias (C) Recall bias (D) Response bias (E) Withdrawal bias 71. Health-conscious people are more likely to attend skin cancer screenings. 72. The patients in poorest health drop out of a melanoma trial. 73. Patients who see dermatologists are more likely than patients who see primary care physicians to have the diagnosis of seborrheic keratosis in their medical records. 74. Patients who have melanoma are more likely to remember blistering sunburns than control subjects without melanoma. 75. A study reviewing medical records for exposures to a new "black-box" labeled drug fails to include 5% of patients who were importing the medicine from Mexico without a prescription.

72 For each systemic disease, select the most likely cutaneous disorder or disease (A-E). (A) Acute febrile neutrophilic dermatosis (B) Cuticular erythema (C) Pinched purpura of the eyelids (D) Pyoderma gangrenosum of the lower limbs (E) Ulcerations secondary to mixed cryoglobulinemia 76. Acute myelogenous leukemia 77. Systemic amyloidosis 78. Hepatitis C 79. Dermatomyositis 80. Crohn's disease

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