A 48-year-old man comes to the physician with a red skin lesion on his abdomen.  He first noticed it 6 months ago and says that it has been enlarging recently.  The lesion bleeds occasionally when disturbed but is otherwise asymptomatic.  The patient has a history of hypertension and actinic keratosis.  He has a 25-pack-year smoking history and drinks a 6-pack of beer daily.  Physical examination findings are shown in the image below.

Which of the following is the most appropriate next step in management of this patient’s skin lesion?

A 25-year-old African-American medical student comes to see you in the office.  His girlfriend noticed an area of circular hair loss over the back of his head.  He is concerned that he is losing his hair and will be bald soon.  He is otherwise in good health and denies any history of smoking, alcohol, or illicit drug use.  He has had a monogamous relationship with his girlfriend for the past three years.  On examination, there is a 1 cm area of complete, smooth and circular hair loss with distinct margins.  There is no scaling or inflammation present in or around the area of hair loss.

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Which of the following is the most likely cause of the above findings?

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Which of the following statements is true regarding the above condition?

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Which of the following is the most appropriate treatment for this condition?

A 46-year-old man comes to the physician’s office for a pruritic rash.  The patient was in his usual state of health until 2 months ago, when dark red lesions appeared over his wrists.  The lesions progressed, and a few weeks later he developed similar lesions on his lower legs.  This morning, the patient saw some “white lines” in his mouth and called for an urgent appointment.  He has no fevers, chills, weight loss, or diarrhea.  The patient has a history of hypertension, which is controlled with lisinopril.  He does not use tobacco or alcohol, but has a remote history of intravenous drug use.  Physical examination shows multiple, discrete violaceous papules and plaques over the flexural surfaces of the patient’s wrists and lower legs as shown in the image below.  Examination of the buccal mucosa shows whitish lacy streaks with a slight background erythema.  The rest of his physical examination is unremarkable.

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Which of the following is the best next step in diagnosing this patient’s condition?

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The diagnosis is confirmed with the appropriate studies.  Which of the following is the most appropriate next step in evaluation of this patient?

A 62-year-old Caucasian woman presents to her primary care physician complaining about her facial appearance.  She says she dislikes “looking so much worse than all my friends.”  Specifically, she mentions that the deep wrinkles and brown spots on her face are what she finds most disturbing.  Her past medical history is significant for breast cancer, hypothyroidism, and diverticulosis.  Her only medications are levothyroxine, tamoxifen, and a multivitamin.  She is a divorced mother of two and has recently retired from working as the supervising gardener of a large estate.  She has a forty-year history of smoking one pack of tobacco per day and consumes one or two glasses of wine each night.  She admits to occasional marijuana usage when she was a younger adult.  Examination of her facial skin is remarkable for a general leathery appearance with many deep furrows and wrinkles.  The wrinkles are especially prominent on the forehead and at the lateral corners of the eyes.  The skin is sallow and has variable pigmentation.  The surface texture is rough in areas.  There are scattered flesh-colored scaly patches with slightly irregular margins and occasional clusters of what appear to be dilated superficial capillaries and venules.

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Which of the following is the most likely diagnosis?

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The diagnosis is made.  Which of the following factors is most likely to be responsible for worsening this woman’s condition?

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Which of the following would be the most appropriate treatment for this woman’s condition?

A 62-year-old man comes to the physician for a preventive visit.  He is being treated for mild hypertension and has no other known medical problems.  He drinks alcohol occasionally but does not use tobacco.  He works as a rancher.  The patient has some lesions on his head, which are pictured below:

Palpation of these lesions reveals small, rough-textured papules.  Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old man comes to the physician due to pain in his left earlobe.  He pierced his earlobe to be able to wear earrings 3 months ago.  The puncture wound never healed well, and he has experienced itching and sharp pains there ever since.  His medical history is otherwise unremarkable.  He is currently not taking any medications.  On physical examination, there is excessive scar tissue formation on the earlobe at the site of the piercing as shown.

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What is the most appropriate means of treating this patient’s lesion?

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Prior to treatment, what potential complications should be reviewed with the patient?

A 49-year-old woman comes to the physician requesting treatment for “this unattractive redness of my skin.”  In the past 3 months, she developed blemishes on her nose, cheeks, and chin.  She now flushes intensely in response to hot or cold temperatures, emotion, and the consumption of spicy foods or alcohol.  She has no history of dermatological problems.  Physical examination shows a reddening of the central face, erythematous papules on the nose, and sporadic telangiectasias on the nose and cheeks as shown below.

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Which of the following is the most appropriate treatment for this condition?

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The appropriate action was taken.  Which of the following complications is most frequently associated with this condition?

A 16-year-old boy comes to the office due to an itchy rash on his back and shoulders.  The rash has been present for the last 3 months, but he has had similar symptoms intermittently in other body areas over the last 10 years.  The patient has no fever and has had no recent illnesses.  Current medications include daily cetirizine for seasonal allergies and topical benzoyl peroxide for acne.  Vital signs are normal.  On skin examination, there are excoriated lichenified plaques on the back and right shoulder, as shown in the exhibit.

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Which of the following is the most appropriate advice to reduce this patient’s symptoms?

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The patient returns to the office in 4 weeks with only modest improvement.  The rash continues to itch and is disrupting his sleep.  Examination findings are largely unchanged.  Which of the following is the most appropriate next step in management of this patient’s symptoms?

An 8-year-old boy is brought to the office by his parents due to changes in his hair.  For the past 7 months, he has had a patch of white hair at the frontal midline scalp.  The abnormal area was slowly enlarging at first but has been stable for the past month.  The patient is otherwise asymptomatic.  No one in the family has a similar condition.  Examination findings are shown in the exhibit.  The remainder of the examination is normal.

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Which of the following best explains the pathogenesis of this patient’s condition?

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The patient’s parents ask about long-term prognosis of the disorder.  Which of the following is the most likely outcome of this patient’s condition?

A 30-year-old man comes to the office with a rash on his left wrist for the past 3 weeks.  The rash is associated with an itching and burning sensation.  The patient has not used any new skin care products but has been wearing a watch he bought during a recent vacation.  Medical history is unremarkable, and he takes no medications.  The patient does not use recreational drugs.  Temperature is 36.9 C (98.4 F), blood pressure is 118/76 mm Hg, pulse is 64/min, and respirations are 12/min.  Skin examination findings are shown in the image below:

There are no other skin lesions or lymphadenopathy.  Histologic examination would most likely reveal which of the following?

A 75-year-old woman is brought to the emergency department by paramedics after falling on a snow-covered sidewalk.  The patient fell backward onto her hands while trying to maintain her balance and immediately felt a sharp, excruciating pain in her right arm.  She also notes mild tenderness and bruising on the right flank and right buttock.  The patient has a history of osteoporosis and hypertension and takes valsartan, alendronate, and a vitamin D supplement.  She does not use tobacco, alcohol, or recreational drugs.  In the emergency department, radiograph reveals a displaced fracture of the right distal radius.  The patient is admitted to the hospital and undergoes open reduction and internal fixation of the radius fracture.  On postoperative day 2, she reports severe, constant, burning pain over her right flank.  The postsurgical pain in the right arm is mild and well controlled with low-dose morphine as needed.  Temperature is 37.8 C (100 F), blood pressure is 145/84 mm Hg, pulse is 97/min, and respirations are 16/min.  Mucous membranes are moist and the oropharynx is without lesions.  Cardiopulmonary auscultation reveals clear lungs and normal heart sounds.  The abdomen is soft, nontender, and nondistended.  The right flank is tender to light touch with a rash over the area, as shown in the exhibit.  The surgical wound is healing normally without signs of infection.

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What is the most appropriate treatment for this patient?

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A diagnosis of herpes zoster is made and the patient is started on oral valacyclovir.  The patient’s nurse comes to the office due to concern that she may have been exposed.  The nurse is pregnant and in her first trimester.  She had documented varicella as a child and has never received a varicella or zoster immunization.  What is the most appropriate treatment for this nurse?

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The patient has an otherwise uncomplicated postoperative course and is ready for discharge.  Her skin lesions are crusted, and she will continue oral valacyclovir as an outpatient.  The patient plans to host a small family dinner tonight and is concerned about the risk of disease transmission.  There will be no infants, pregnant women, or immunocompromised individuals at this gathering.  Which of the following is the most appropriate recommendation for this patient?

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Four months later, the patient visits her primary care provider.  She is going to physical therapy for her arm injury, and all the lesions on her right flank have resolved.  However, the patient continues to have burning pain in the area where the rash occurred.  In addition, she says that light touch of the area results in severe pain, and that the pain is making it difficult to sleep at night.  Which of the following is the most appropriate treatment for this patient?

A 62-year-old man comes to the community health center due to a “flaky and itchy” scalp.  He is uncertain when the symptoms began and believes his brother has a similar problem.  The patient has not attempted any specific treatments but washes his hair with a mild shampoo every other day and washes his face with cold water once daily.  Medical history is notable for coronary artery disease, type 2 diabetes mellitus, benign prostatic hyperplasia, and diverticulosis.  The patient is a recovering alcoholic and has lived in a group home for the last 3 months.  Vital signs are normal.  Physical examination shows oily skin with faint erythema and scaling of the scalp, eyebrows, and ears, as shown below.  During the course of the visit, the patient repeatedly scratches his head and eyebrows, but the remainder of the skin examination is normal.

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Which of the following is the best initial treatment for this patient?

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The patient returns to the clinic after 4 weeks of treatment.  His rash has nearly resolved, but he is concerned because his brother developed recurrent symptoms after similar treatment.  Which of the following is the most appropriate guidance for long-term management of this patient’s condition?

A 28-year-old man comes to the office because his girlfriend noticed an area of hair loss over the back of his head a month ago.  The patient is otherwise healthy and takes no medications.  Physical examination findings are shown in the exhibit.  There are no other areas of hair loss, and the remainder of the examination is normal.  The patient asks whether treatment can prevent complete baldness.

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Which of the following is the most appropriate response by the physician?

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After counseling about the prognosis of the condition, the patient elects treatment.  Which of the following is the most appropriate treatment option?

A 47-year-old man comes to the office for a lesion on his foot.  He reports an enlarging lesion on the plantar surface of his left great toe for the past 2 months.  The patient is using an over-the-counter “corn cushion” for pain relief while ambulating.  He has no history of similar lesions and has no other medical conditions.  Physical examination findings are shown in the exhibit.

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Which of the following is the best next step in management of this patient?

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The patient returns in 10 days with only partial improvement in the size of the lesion.  Which of the following is the most appropriate advice for this patient?

A 35-year-old man comes to the office due to painful bumps on his neck.  For the last 6 months, he has had a progressive rash on his anterior neck that has not improved with over-the-counter emollients.  Medical history is unremarkable.  Vital signs are within normal limits.  Skin examination findings are as shown:

The remainder of the examination is normal.  Which of the following is the most appropriate management for this patient’s skin condition?