Pance Final Exam Dermatology and HEENT
Questions with Explained Answers 2023
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. (Wolff & 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. (Wolff & 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.
Questions with Explained Answers 2023
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. (Wolff & 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. (Wolff & 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.
