Self-Assessment Self-Assessment examination of the American Academy of Dermatology Identification No. 891-211 Learningobjectives: Attheconclusion of this self-assessment learning activity, physician participants should be able to assess their own diagnostic and patient management skills with respect to those of their colleagues inthe field, use the results oftheself-assessment tohelp determine personalleaming needs that can be addressed through subsequent CME involvement, and enhance their ability tocomply with the requirements for certification inthespecialty ofdermatology. Instructions for Category I CME credit appear inthefrontadvertising section. Seelast page of Contents for page number. Instructions: Inanswering each question, refer tothespecific directions provided. Because itisoften necessary toprovide information in questions occurring later ina series that give away answers toearlier questions, please answer the ques- tions in each series insequence. QUESTIONS 1·10 A 28-year-old black man had asymptomatic crops of umbilicated erythematous papules on his chest, back, and arms during the past 6 months (Fig. 1). The original papules persisted as new ones erupted; some of the original papules developed central white atrophic scars surrounded by a thin raised erythematous rim (Fig. 2). In the past month, the patient has experienced crampy abdominal pain, nausea, diarrhea, and a 5 pound weight loss. L The most likely diagnosis is (Choose single best response.] a. pyoderma gangrenosum b. Gardner's syndrome c. Peutz-J eghers syndrome d. Degos disease e. dermatitis herpetiformis 2. The man has malignant atrophic papulosis. Never- theless, the treating physician should exclude which of the following diseases? (Choose single best response] a. Lupus erythematosus b. Atrophie blanche c. Scleroderma d. Allof the above e. Noneof the above TheSelf-Assessment examination is supported inpart byan ucational grant from The Procter & Gamble Company, Cincinnati, Ohio. *Members ofthe Self-Assessment Committeeofthe American Acad- emyof Dermatology are: Kenneth J. Tomecki, MD, chairman, Bur- ton S. Belknap, MD, Mary R. Buchness, MD, Poinciano D. Cruz, MD, C. Ralph Daniel III, MD, Gary R. Kantor, MD, Cynthia E. Mayfield, MD, Melinda B. Musick, MD, Warren W. Piette, MD, Tobi B. Richman, MD, Theodore Rosen, MD,RobertA. Schwartz, MD, and Ronald G. Wheeland, MD. 3. The mosthelpful laboratorytest to confirm. the diag- nosis of malignant atrophicpapulosis is (Choose sin- gle best response} a. serum protein electrophoresis b. serum lymphocyte transformation test c. skin biopsy specimen for histologic examination d. skin biopsy specimen for direct immunofluores- cence e. x-rays of small and large bowel 4. Histologic changes in the porcelain-white atrophic papules shown in Fig, 2 should include (Choose two best responses.) a. sclerosis of dermal collagen b. leukocytoclastic vasculitis of dermal arterioles c. lymphocytic vasculitis of dermal blood vessels d. spongiosis and acanthosis e. nuclear dust 5. Besides the skin, what other organsmay beaffected by the vasculitis seenin malignantatrophic papule- sis? (Choose single best response.) a. Central nervous system b. Gastrointestinal system c. Heart and lungs d. Peripheral nervous system e. Allofthe above 6; Which ofthe following is true of malignantatrophic papulosis? (Choose singlebestresponse} a. Men are affected more than twice as often as women. b. Mucosal involvement of the mouth and eyes does not occur. c. The average age of onsetis 55 years. d. All of the above e. Noneof the above 7. Which ofthe following is true of the gastrointestinal involvement in malignant atrophic papulosis? (Choose single best r.esponse.) 871
Transcript
Self-Assessment
Self-Assessment examination of theAmerican Academy of Dermatology Identification No. 891-211
Learningobjectives: Attheconclusion ofthis self-assessment learning activity, physician participants should be able toassess their own diagnostic and patient management skills with respect to those oftheir colleagues inthefield, use theresults oftheself-assessment tohelp determine personalleaming needs thatcan beaddressed through subsequent CMEinvolvement, and enhance their ability tocomply with the requirements for certification inthespecialty ofdermatology.
Instructions for Category ICME creditappear inthefrontadvertising section. SeelastpageofContents for page number.
Instructions: Inanswering each question, refer tothespecific directions provided. Because itisoften necessary toprovideinformation in questions occurring later ina series that give away answers toearlier questions, please answer the questions in each series insequence.
QUESTIONS 1·10
A 28-year-old black man had asymptomaticcrops of umbilicated erythematous papules on hischest, back, and arms during the past 6 months (Fig.1). The original papules persisted as new oneserupted; some of the original papules developedcentral white atrophic scars surrounded by a thinraised erythematous rim (Fig. 2). In the past month,the patient has experiencedcrampy abdominal pain,nausea, diarrhea, and a 5 pound weight loss.
L The most likely diagnosis is (Choose single bestresponse.]a. pyoderma gangrenosumb. Gardner's syndromec. Peutz-Jeghers syndromed. Degos diseasee. dermatitis herpetiformis
2. The man has malignant atrophic papulosis. Nevertheless, the treatingphysician should exclude whichof the following diseases? (Choose single bestresponse]a. Lupus erythematosusb. Atrophie blanchec. Sclerodermad. Allof the abovee. Noneof the above
TheSelf-Assessment examination issupported inpart byanucational grant from The Procter & Gamble Company,
Cincinnati, Ohio.*Members ofthe Self-Assessment Committeeofthe American Acad
emyof Dermatology are: Kenneth J. Tomecki, MD,chairman, BurtonS. Belknap, MD, Mary R. Buchness, MD, Poinciano D. Cruz,MD,C. Ralph Daniel III, MD, Gary R. Kantor, MD,CynthiaE.Mayfield, MD, Melinda B. Musick, MD, Warren W. Piette,MD,Tobi B.Richman, MD,Theodore Rosen, MD,RobertA. Schwartz,MD,and RonaldG. Wheeland, MD.
3. Themosthelpful laboratorytest to confirm. thediagnosis ofmalignant atrophicpapulosis is (Choose singlebestresponse}a. serum protein electrophoresisb. serum lymphocyte transformation testc. skinbiopsy specimen for histologic examinationd. skin biopsy specimen for direct immunofluores
cencee. x-rays of small and large bowel
4. Histologic changes in the porcelain-white atrophicpapules shown in Fig,2 should include (Choose twobestresponses.)a. sclerosis of dermalcollagenb. leukocytoclastic vasculitis of dermalarteriolesc. lymphocytic vasculitis of dermal blood vesselsd. spongiosis and acanthosise. nuclear dust
5. Besides the skin, what otherorgansmaybeaffectedbythe vasculitis seenin malignantatrophic papulesis? (Choose single best response.)a. Central nervous systemb. Gastrointestinal systemc. Heart and lungsd. Peripheral nervous systeme. Allof the above
6; Which ofthe following is true of malignantatrophicpapulosis? (Choose singlebestresponse}a. Men are affected more than twice as often as
women.b. Mucosal involvement of the mouth and eyes does
not occur.c. The average age of onsetis 55 years.d. All of the abovee. Noneof the above
7. Which ofthe following is true of the gastrointestinalinvolvement in malignant atrophic papulosis?(Choose single best r.esponse.)
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a. The colon is themost commonly involvedsegment.b. Gastrointestinal involvement is inherited as an
autosomal dominant trait.c. Diagnosis is easier to establish with x-rays than
with laparoscopy.d. Subserosal infarcts can occur in the wall of the
small intestine.e. All of the above
8. Which of the following syndromes is associated withintestinal polyposis? (Choose single best response]a. Degos'diseaseb. Gardner-Diamond syndromec. Peutz-Jeghers syndromed. Unna-Thost syndromee. All of the above
9. Death is most likely to occur in malignant atrophicpapulosis from which of the following? (Choose twobest responses.)
a. Carcinoma of the colonb. Carcinoma of the lungc. Peritonitisd. Upper gastrointestinal tract hemorrhagee. Cerebral infarction
10. Which of the following types of therapy increase theS-year survival rate in malignant atrophic papulosis?(Choose single best response.]a. Intravenous high-dose pulse corticosteroidsb. Low-dose oral alternate-day corticosteroidsc. High-fiber and gluten-free dietd. Resection of the involved segment of bowele. None of the above
QUESTIONS 11-20
A 32-year-old woman who is 9 months pregnantpresents with "itchy bumps" of several days' duration. Examination reveals numerous erythematous
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papules on the abdomen, arms, and legs (Figs. 3 and4). KOH examination shows no evidence of scabies.A skin biopsy specimen shows a mild perivascularlymphocytic infiltrate with scattered eosinophils(Figs. 5 and 6). Direct immunofluorescence testingof the tissue is negative.
11. The mostcommon specific eruption of pregnancy is(Choose single best response.}a. papular dermatitis of pregnancyb. herpes gestationisc. prurigo gestationisd. impetigo herpetiformise. pruritic urticarial papules and plaques of preg
nancy (PUPPP)
12. A negative direct immunofluorescence studyessentially rules out (Choose single bestresponse]a. papular dermatitis of pregnancyb. herpes gestationisc. prurigo gestationisd. impetigo herpetiformise. puppp
13. The mostlikely diagnosis in this caseis (Choose single bestresponse.t
a. pruritic folliculitis of pregnancyb. herpes gestationisc. recurrentcholestasis ofpregnancy (prurigo gravi
darum)d. impetigo herpetiformise. PUPPP
14. The typical PUPPP patient is a (Choose single bestresponse]a. primigravida in the first trimesterb. primigravida in the second trimesterc. primigravida in the third trimesterd. primigravida in any trimestere. multigravida in the third trimester
15. Initial lesions of PUPPP characteristically arise(Choose single best response.)a. along the linea albab. within the abdominal striaec. on the upper chestd. near mucosal surfacese. on the palmsand sales
16. Maternal hormone testing in PUPPP when compared with normalpregnancies reveals (Choose single bestresponse]
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a. increased serum ,a-subunit of human chorionicgonadotropin
b. decreased serum ,a-subunit of human chorionicgonadotropin
c. increased serumcortisold. increased serumestradiole. no abnormalities
Directions for questions 17 through 20: For eachnumbered item, choose the appropriate lettereditem.
a. pupppb. Herpesgestationisc. Bothd. Neither
17. Recurs with subsequent pregnancies18. Facetypically involved19. Excoriations frequently seen20. Increased incidence of twin pregnancies
QUESTIONS 21-32
A l2-year-old Hispanic boy has had reddenedpatches and scarring alopecia of the eyebrows of 2years' duration (Figs. 7 and 8) and many keratoticpapules on the forehead, cheeks, and arms.21. Differential diagnosis includes (Choose single best
22. Helpful diagnostic tests include (Choose single bestresponse.}a. skinbiopsyb. serumvitamin Ac. thyroid function testsd. serologic test for syphilise. Wood's lightexamination
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23. Reportedassociations with ulerythema ophryogenesinclude each of the following except (Choose singlebestresponse]a. atopyb. Noonan's syndromec. ~odennaldefectsd. hyperhidrosise. woolly hair
Directions for questions 24-27:Foreachnumbereditem choose the appropriate lettered item.
a. Ulerythema ophryogenesb. Keratosis pilaris rubra atrophicans facieic. Bothd. Neither
24. Starts in the eyebrows25. Starts on the temples or cheeks26. Associated with keratosis pilaris27. Associated with scarring alopecia
Directions for questions 28-31:Foreachnumbereditem choose the appropriate lettered item.
a. Keratosis follicularis spinulosa decalvansb. Atrophoderma vermiculatumc. Bothd. Neither
28. Scarringalopecia of the scalp29. Most severe manifestations in men30. Cornealopacities31. Spontaneously improves in third and fourth decades
Directions for question 32: Choose single bestresponse.32. Helpfultherapyfor thesekeratoticdisorders includes
each of the following excepta. retinoidsb. emollientsc. topical corticosteroidsd. keratolyticse. methotrexate
