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Test Bank For Bates’ Guide to Physical Examination and History Taking,10th Edition by Lynn S. Bickley

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Test Bank For Bates’ Guide to Physical Examination and History Taking,10th Edition by Lynn S. Bickley

Test Bank For Bates’ Guide to Physical Examination and History Taking,10th Edition by Lynn S. Bickley

Chapter 6: The Skin, Hair, and Nails

 

Multiple Choice

 

  1. A 35-year-old archaeologist comes to your office (located in Phoenix, Arizona) for a regular skin check-up. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this patient?
  2. A) Age
  3. B) Hair color
  4. C) Actinic lentigines
  5. D) Heavy sun exposure

 

Ans:  A

Chapter:  06

Page and Header:  165, Health Promotion and Counseling

Feedback:  The risk for melanoma is increased in people over the age of 50; our patient is 35 years old.  The other answers represent known risk factors for melanoma.  Especially with a family history of melanoma, she should be instructed to keep her skin covered when in the sun and use strong sunscreen on exposed areas.

 

 

 

 

  1. You are speaking to an 8th grade class about health prevention and are preparing to discuss the ABCDEs of melanoma. Which of the following descriptions correctly defines the ABCDEs?
  2. A) A = actinic; B = basal cell; C = color changes, especially blue; D = diameter >6 mm; E = evolution
  3. B) A = asymmetry; B = irregular borders; C = color changes, especially blue; D = diameter >6 mm; E = evolution
  4. C) A = actinic; B = irregular borders; C = keratoses; D = dystrophic nails; E = evolution
  5. D) A = asymmetry; B = regular borders; C = color changes, especially orange; D = diameter >6 mm; E = evolution

 

Ans:  B

Chapter:  06

Page and Header:  165, Health Promotion and Counseling

Feedback:  This is the correct description for the mnemonic.

 

 

 

 

  1. You are beginning the examination of the skin on a 25-year-old teacher. You have previously elicited that she came to the office for evaluation of fatigue, weight gain, and hair loss. You strongly suspect that she has hypothyroidism. What is the expected moisture and texture of the skin of a patient with hypothyroidism?
  2. A) Moist and smooth
  3. B) Moist and rough
  4. C) Dry and smooth
  5. D) Dry and rough

 

Ans:  D

Chapter:  06

Page and Header:  168, Techniques of Examination

Feedback:  A patient with hypothyroidism is expected to have skin that is dry as well as rough.  This is a good example of how the skin can give clues to systemic diseases.

 

 

 

 

  1. A 28-year-old patient comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. On physical examination, you note that the pattern of eruption is like a Christmas tree and that there are a variety of erythematous papules and macules on the cleavage lines of the back. Based on this description, what is the most likely diagnosis?
  2. A) Pityriasis rosea
  3. B) Tinea versicolor
  4. C) Psoriasis
  5. D) Atopic eczema

 

Ans:  A

Chapter:  06

Page and Header:  176, Table 6–2

Feedback:  This is a classic description of pityriasis rosea. The description of a large single or “herald” patch preceding the eruption is a good way to distinguish this rash from other conditions.

 

 

 

 

  1. A 19-year-old construction worker presents for evaluation of a rash. He notes that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He does sweat more than before because being outdoors is part of his job. On physical examination, you note dark tan patches with a reddish cast that has sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is your most likely diagnosis?
  2. A) Pityriasis rosea
  3. B) Tinea versicolor
  4. C) Psoriasis
  5. D) Atopic eczema

 

Ans:  B

Chapter:  06

Page and Header:  176, Table 6–2

Feedback:  This is a typical description of tinea versicolor. The information that the patient is sweating more also helps support this diagnosis, because tinea is a fungal infection and is promoted by moisture.

 

 

 

 

  1. A 68-year-old retired farmer comes to your office for evaluation of a skin lesion. On the right temporal area of the forehead, you see a flattened papule the same color as his skin, covered by a dry scale that is round and feels hard. He has several more of these scattered on the forehead, arms, and legs. Based on this description, what is your most likely diagnosis?
  2. A) Actinic keratosis
  3. B) Seborrheic keratosis
  4. C) Basal cell carcinoma
  5. D) Squamous cell carcinoma

 

Ans:  A

Chapter:  06

Page and Header:  185, Table 6–9

Feedback:  This is a typical description of actinic keratosis. Actinic keratosis may be easier to feel than to see. If left untreated, approximately 1% of cases can develop into squamous cell carcinoma.

 

 

 

 

  1. A 58-year-old gardener comes to your office for evaluation of a new lesion on her upper chest. The lesion appears to be “stuck on” and is oval, brown, and slightly elevated with a flat surface. It has a rough, wartlike texture on palpation. Based on this description, what is your most likely diagnosis?
  2. A) Actinic keratosis
  3. B) Seborrheic keratosis
  4. C) Basal cell carcinoma
  5. D) Squamous cell carcinoma

 

Ans:  B

Chapter:  06

Page and Header:  185, Table 6–9

Feedback:  This is a typical description for seborrheic keratosis. The “stuck on” appearance and the rough, wartlike texture are key features for the diagnosis. They often produce a greasy scale when scratched with a fingernail, which further helps to distinguish them from other lesions.  Frequently, these benign lesions actually meet several of the ABCDEs of melanoma, so it is important to distinguish these lesions to prevent unnecessary biopsy.  It is important to consider biopsy whenever there is any doubt, though.

 

 

 

 

  1. A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on the ventilator for 3 weeks. You are completing your initial assessment and are evaluating her skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter, with damage to the subcutaneous tissue. The underlying muscle is not affected. You diagnose this as a pressure ulcer. What is the stage of this ulcer?
  2. A) Stage 1
  3. B) Stage 2
  4. C) Stage 3
  5. D) Stage 4

 

Ans:  C

Chapter:  06

Page and Header:  191, Table 6–13

Feedback:  A stage 3 ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

 

 

 

 

  1. An 8-year-old girl comes with her mother for evaluation of hair loss. She denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her hair in braids. On physical examination, you note a clearly demarcated, round patch of hair loss without visible scaling or inflammation. There are no hair shafts visible. Based on this description, what is your most likely diagnosis?
  2. A) Alopecia areata
  3. B) Trichotillomania
  4. C) Tinea capitis
  5. D) Traction alopecia

 

Ans:  A

Chapter:  06

Page and Header:  192, Table 6–14

Feedback:  This is a typical description for alopecia areata. There are no risk factors for trichotillomania or for traction alopecia. The physical examination is not consistent with tinea capitis because the skin is intact.

 

 

 

 

  1. A mother brings her 11 month old to you because her mother-in-law and others have told her that her baby is jaundiced. She is eating and growing well and performing the developmental milestones she should for her age.  On examination you indeed notice a yellow tone to her skin from head to toe.  Her sclerae are white.  To which area should your next questions be related?
  2. A) Diet
  3. B) Family history of liver diseases
  4. C) Family history of blood diseases
  5. D) Ethnicity of the child

 

Ans:  A

Chapter:  06

Page and Header:  163, Anatomy and Physiology

Feedback:  The lack of jaundice in the sclerae is an important clue.  Typically, this is the first place where one sees jaundice.  This examination should also be carried out in natural light (sunlight) as opposed to fluorescent lighting, which can alter perceived colors.  Many infants this age have a large proportion of carrots, tomatoes, and yellow squash, which are rich in carotene.  Liver and blood diseases can cause jaundice, but this should involve the sclerae.  The ethnicity of the child should not cause a perceived change from her usual skin tone.

 

 

 

 

  1. A new mother is concerned that her child occasionally “turns blue.” On further questioning, she mentions that this is at her hands and feet.  She does not remember the child’s lips turning blue. She is otherwise eating and growing well.  What would you do now?
  2. A) Reassure her that this is normal
  3. B) Obtain an echocardiogram to check for structural heart disease and consult cardiology
  4. C) Admit the child to the hospital for further observation
  5. D) Question the validity of her story

 

Ans:  A

Chapter:  06

Page and Header:  163, Anatomy and Physiology

Feedback:  This is an example of peripheral cyanosis.  This is a very common and benign condition which typically occurs when the child is slightly cold and his peripheral circulation is adjusting to keep his core warm.  Without other problems, there is no need for further workup.  If the lips or other central locations are involved, you must consider other etiologies.

 

 

 

 

  1. You are examining an unconscious patient from another region and notice Beau’s lines, a transverse groove across all of her nails, about 1 cm from the proximal nail fold. What would you do next?
  2. A) Conclude this is caused by a cultural practice.
  3. B) Conclude this finding is most likely secondary to trauma.
  4. C) Look for information from family and records regarding any problems which occurred 3 months ago.
  5. D) Ask about dietary intake.

 

Ans:  C

Chapter:  06

Page and Header:  163, Anatomy and Physiology

Feedback:  These lines can provide valuable information about previous significant illnesses, some of which are forgotten or are not able to be reported by the patient.  Because the fingernails grow at about 0.1 mm per day, you would ask about an illness 100 days ago.  This patient may have been hospitalized for endocarditis or may have had another significant illness which should be sought.  Trauma to all 10 nails in the same location is unlikely.  Dietary intake at this time would not be related to this finding.  Do not assume a finding is necessarily related to a patient’s culture unless you have good knowledge of that culture.

 

 

 

 

  1. Dakota is a 14-year-old boy who just noticed a rash at his ankles. There is no history of exposure to ill people or other agents in the environment.  He has a slight fever in the office. The rash consists of small, bright red marks.  When they are pressed, the red color remains.  What should you do?
  2. A) Prescribe a steroid cream to decrease inflammation.
  3. B) Consider admitting the patient to the hospital.
  4. C) Reassure the parents and the patient that this should resolve within a week.
  5. D) Tell him not to scratch them, and follow up in 3 days.

 

Ans:  B

Chapter:  06

Page and Header:  184, Table 6–8

Feedback:  Although this may not be an impressive rash, the fact that they do not “blanch” with pressure is very concerning.  This generally means that there is pinpoint bleeding under the skin, and while this can be benign, it can be associated with life-threatening illnesses like meningococcemia and low platelet counts (thrombocytopenia) associated with serious blood disorders like leukemia.  You should always report this feature of a rash immediately to a supervisor or teacher.

 

 

 

 

  1. Mrs. Hill is a 28-year-old African-American with a history of SLE (systemic lupus erythematosus). She has noticed a raised, dark red rash on her legs. When you press on the rash, it doesn’t blanch.  What would you tell her regarding her rash?
  2. A) It is likely to be related to her lupus.
  3. B) It is likely to be related to an exposure to a chemical.
  4. C) It is likely to be related to an allergic reaction.
  5. D) It should not cause any problems.

 

Ans:  A

Chapter:  06

Page and Header:  184, Table 6–8

Feedback:  A “palpable purpura” is usually associated with a vasculitis.  This is an inflammatory condition of the blood vessels often associated with systemic rheumatic disease.  It can cut off circulation to any portion of the body and can mimic many other diseases in this manner.  While allergic and chemical exposures may be a possible cause of the rash, this patient’s SLE should make you consider vasculitis.

 

 

 

 

  1. Jacob, a 33-year-old construction worker, complains of a “lump on his back” over his scapula. It has been there for about a year and is getting larger.  He says his wife has been able to squeeze out a cheesy-textured substance on occasion.  He worries this may be cancer.  When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?
  2. A) An enlarged lymph node
  3. B) A sebaceous cyst
  4. C) An actinic keratosis
  5. D) A malignant lesion

 

Ans:  B

Chapter:  06

Page and Header:  178, Table 6–4

Feedback:  This is a classic description of an epidermal inclusion cyst resulting from a blocked sebaceous gland.  The fact that any lesion is enlarging is worrisome, but the other descriptors are so distinctive that cancer is highly unlikely.  This would be an unusual location for a lymph node, and these do not usually drain to the skin.

 

 

 

 

  1. A young man comes to you with an extremely pruritic rash over his knees and elbows which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure.  On examination, you notice scabbing and crusting with some silvery scale, and you are observant enough to notice small “pits” in his nails.  What would account for these findings?
  2. A) Eczema
  3. B) Pityriasis rosea
  4. C) Psoriasis
  5. D) Tinea infection

 

Ans:  C

Chapter:  06

Page and Header:  178, Table 6–4

Feedback:  This is a classic presentation of plaque psoriasis.  Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces.  Pityriasis usually is limited to the trunk and proximal extremities.  Tinea has a much finer scale associated with it, almost like powder, and is found in dark and moist areas.

 

 

 

 

  1. Mrs. Anderson presents with an itchy rash which is raised and appears and disappears in various locations.  Each lesion lasts for many minutes.  What most likely accounts for this rash?
  2. A) Insect bites
  3. B) Urticaria, or hives
  4. C) Psoriasis
  5. D) Purpura

 

Ans:  B

Chapter:  06

Page and Header:  178, Table 6–4

Feedback:  This is a typical case of urticaria.  The most unusual aspect of this condition is that the lesions “move” from place to place.  This would be distinctly unusual for the other causes listed.

 

 

 

 

  1. Ms. Whiting is a 68 year old who comes in for her usual follow-up visit. You notice a few flat red and purple lesions, about 6 centimeters in diameter, on the ulnar aspect of her forearms but nowhere else. She doesn’t mention them. They are tender when you examine them.  What should you do?
  2. A) Conclude that these are lesions she has had for a long time.
  3. B) Wait for her to mention them before asking further questions.
  4. C) Ask how she acquired them.
  5. D) Conduct the visit as usual for the patient.

 

Ans:  C

Chapter:  06

Page and Header:  184, Table 6–8

Feedback:  These are consistent with ecchymoses, or bruises.  It is important to ask about antiplatelet medications such as aspirin, trauma history, and history of blood disorders in the patient and her family.  Because of the different ages of the bruises and the isolation of them to the ulnar forearms, these may be a result of abuse or other violence.  It is your duty to investigate the cause of these lesions.

 

 

 

 

  1. A middle-aged man comes in because he has noticed multiple small, blood-red, raised lesions over his anterior chest and abdomen for the past several months. They are not painful and he has not noted any bleeding or bruising.  He is concerned this may be consistent with a dangerous condition.  What should you do?
  2. A) Reassure him that there is nothing to worry about.
  3. B) Do laboratory work to check for platelet problems.
  4. C) Obtain an extensive history regarding blood problems and bleeding disorders.
  5. D) Do a skin biopsy in the office.

 

Ans:  A

Chapter:  06

Page and Header:  184, Table 6–8

Feedback:  These represent cherry angiomas, which are very common, benign lesions.  Further workup such as laboratory work, skin biopsy, or even further questions are not necessary at this time.   It would be wise to ask the patient to report any changes in any of his skin lesions, and tell him that you would need to see him at that time.