NMS Q&A Family Medicine

Dermatology 309Examination Answers1. The answer is C. The incorrect statement regardingscarlatina is that the rash spreads to the palms. Each of theother statements is true. The sandpaper rash has sometimesbeen called pampiniform. The strawberry tongue is classic;as a form of beta-hemolytic streptococcal pharyngitis, itmay manifest symptoms of systemic illness such as nauseaand vomiting. That said, the disease is much less frequentand more benign than it was two generations ago.2. The answer is E. Culture of Pseudomonas from thewater is unreliable is the incorrect statement. In fact, allreports on water exposure folliculitis, P. aeruginosa , hasbeen isolated. Although the infection in healthy people isself-limited, systemic symptoms occur in the majority ofcases as well as external otitis. Each of the other statementsis correct. Successful treatments include polymyxin Bspray and oral cipromycin.3. The answer is B. In RMSF, hepatocellular functionstests may be elevated. Serum sodium, hematocrit, plateletcount, and CSF glucose may each be lower than normal,the latter (hypoglycorrhachia) signaling meningitis in thisdisease, caused by Rickettsia ricketsii , carried by the dogtick in the east and the wood tick in the west. The petechialrash begins on the legs before spreading to the hands.Immunofluorescence titers do not rise until the 2nd weekof symptoms. Treatment in children under 9 years ischloramphenicol, otherwise doxycycline. Untreated caseshave a high risk of dying due to pulmonary hemorrhage.4. The answer is B. Infantile eczema. Psoriasis rarelyoccurs on the face, and the mean age at onset is between20 and 30 years. Compulsive licking followed by chafingthe lips usually occurs during the juvenile years, and thelesions in this case are farther from the mouth than thereach of the tongue. Candidiasis affects the intertriginousareas, opposite from the rash in this case, which involvesthe tops of the folds of skin. Cellulitis is a serious bacterialinfection that occurs in a focal area, not in separate distinctpatches, and it would not manifest chronicity as thepatient’s illness would bring the affair to an early crisis.Finally, statistically, not only the greater prevalence ofinfantile eczema but also the fact that this disorder is amanifestation of the heavily familial-inherited group ofatopic diseases mark this as eczema. The other membersof the group are allergic rhinitis and conjunctivitis (“hayfever”) and asthma.5. The answer is C. Infectious mononucleosis is notedfor an associated morbilliform rash when the patient hasbeen treated with ampicillin, the famous ampicillin rash.The mononucleosis test is not reliable until the illness hasbeen present for 5 to 7 days. Streptococcal pharyngitisnearly always manifests tender adenopathy if the nodesare enlarged. Rubeola causes indeed a morbilliform eruption,but the exudative pharynx is not part of the picture.Urticaria may be mixed with the rash of mononucleosis,which may account for the occasional pruritic aspect ofthe rash on the vignette but that would not account forthe remainder of the presentation.6. The answer is D. Infantile eczema, although geneticallydetermined, is often precipitated by a food allergy inthe first year of life. For a baby on a common formula(e.g., as opposed to breast feeding), the most likely causationis allergy to cow’s milk. Later, after advancement ofthe feeding schedule beyond liquid formula, commonoffenders are egg whites and wheat. Often, a simpleempiric change of formula to one based on soy will resultin total clearing of the eczema within 1 week. Systemicglucocorticoids would be a radical step for an infant whois not critically ill. Although topical glucocorticoids maybe employed for infantile eczema, preparations such astriamcinolone are too potent and carry a high rate ofcomplications of atrophy and scarring striae at the areasof application, particularly on infantile skin. Antibiotics,either systemic or topical, have no place in a noninfectiousinflammatory process such as infantile eczema.7. The answer is D. The patient has what is variouslycalled neuro eczema , nummular eczema , and neurodermatitis.There is a predisposition for atopic diseases in thesepatients. The skin is more sensitive and has a loweredthreshold for itching. In the accessible areas referred to inthe vignette, scratching and rubbing causes a thickening,called, by dermatologists, lichenification. Paradoxically,lichenification causes the threshold for pruritus to be furtherlowered and leads to further rubbing and the viciouscircle of itching and scratching. This cycle is effectivelyinterrupted in the vast majority of cases by topical glucocorticoids.Systemic glucosteroids are not effective, andsystemic antipruritics such as hydroxyzine (e.g., Vistaril)are usually not needed. Although some allergists may tryfood elimination in intractable cases, food allergy is rarelya factor and usually the elimination diet is ineffective.8. The answer is C. The most significant part of the treatmentof a weeping lesion is to apply a drying agent. Themost drying are the wettest upon application, such assaline or Burrow solution, and the most moistening areocclusive agents such as petrolatum (Vaseline). Creamsare positioned toward the moistening end of the spectrum