Quiz Integumentary

Integumentary

06Apr2009

Integumentary #1 – Histology Match the epithelial type with the common locations: 1) Simple squamous a) Small intestine, colon, stomach lining, gallbladder 2) Simple cuboidal b) Largest ducts of exocrine glands, anorectal junction 3) Simple columnar c) Vascular system, Bowman capsule, respiratory spaces 4) Pseudostratified d) Renal calyces, ureters, bladder, urethra 5) Stratified squamous e) Epidermis oral cavity, esophagus, vagina 6) Stratified cuboidal f) Small ducts of exocrine glands, kidney tubules, ovaries 7) Stratified columnar g) Trachea, bronchial tree, ductus deferens, epididymis 8) Transitional h) Sweat gland ducts, anorectal junction, exocrine glands 9) The basement membrane is an extracellular matrix found under epithelial cells and is comprised of the basal lamina (lamina densa) and reticular lamina. The reticular lamina is made by fibroblasts and contains fibrillar collagen. The basal lamina is made by epithelial cells and contains what type of collagen? a) Type XVII b) Type I c) Type III d) Type IV e) Type VII 10) Receptors for which of the following are found within the lamina lucida and are a member of a large family of transmembrane proteins called integrins? a) Proteoglycan b) Laminin c) Fibronectin d) Hemidesmosomes e) Anchoring fibrils (type VII collagen) 11) Which of the following makes up much of the volume of the basal lamina and plays a large role in the regulation of the passage of ions across the basal membrane? a) Proteoglycan b) Laminin c) Fibronectin d) Hemidesmosomes e) Anchoring fibrils (type VII collagen) 12) Which of the following is found in the intestine, separates the luminal space from the intracellular space and connective tissue compartment, and restricts the diffusion of water and solutes between cells? a) Macula adherens b) Hemidesmosomes c) Zonula occludens d) Zonula adherens 13) The functional and morphological integrity of the zonula adherens is dependent on what ion? a) Na+ b) Ca++ c) K+ d) Mg++

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Integumentary

06Apr2009

e) Cl14) Which of the following contains adhesion plaques that contain desmoplakins and plakiglobins, which are capable of anchoring the intermediate filaments? a) Macula adherens b) Hemidesmosomes c) Zonula occludens d) Zonula adherens 15) Which of the following is found in certain epithelia subject to abrasion and mechanical forces and contains type IV and type XVII collagen? a) Macula adherens b) Hemidesmosomes c) Zonula occludens d) Zonula adherens e) None of the above Match the gland type with the example: 16) Unicellular gland a) Pancreas glands 17) Cellular sheet b) Goblet cells in intestines and airway 18) Compound tubular c) Submandibular salivary gland 19) Compound acinar d) Stomach lining with gastric pits 20) Tubuloacinar e) Brunner glands in duodenum 21) How often is the stratified squamous epithelium of the skin replaced? a) Every day b) Every 7 days c) Every 14 days d) Every 21 days e) Every 28 days 22) Which of the following is true of the embryological origin of the skin? a) Epidermis and dermis arise from ectoderm b) Epidermis and dermis arise from mesoderm c) Epidermis arises from ectoderm and dermis arises from mesoderm d) Epidermis arises from mesoderm and dermis arises from ectoderm 23) Which of the following contains keratohyalin, which contains cysteine-rich and histidine-rich proteins, precursors of the protein filagrin? a) Stratum basale b) Stratum spinosum c) Stratum granulosum d) Stratum corneum e) Stratum lucidum 24) Which of the following is found only in thick skin and contains eosinophilic cells in which the process of keratinization is well advanced? a) Stratum basale b) Stratum spinosum c) Stratum granulosum d) Stratum corneum e) Stratum lucidum 25) Which of the following contains stem cells for which new cells (keratinocytes) arise?

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Integumentary

06Apr2009

a) Stratum basale b) Stratum spinosum c) Stratum granulosum d) Stratum corneum e) Stratum lucidum 26) Which of the following forms the majority of the water barrier in the skin? a) Stratum basale b) Stratum spinosum c) Stratum granulosum d) Stratum corneum e) Stratum lucidum 27) In which location would one find the thickest dermis, although the epidermis is mostly the same (thin and thick skin refer to the epidermis)? a) Eyelid b) Forearm c) Achilles d) Upper back e) Finger pads 28) Which is true of the dermal papillae (and epidermal ridges) at the epidermal-dermal junction (ED junction) in areas of increased mechanical stress? a) More papillae and more closely spaced b) More papillae and spaced further apart c) Less papillae and more closely spaced d) Less papillae and spaced further apart 29) The papillary layer of the dermis, which is right underneath the epidermis, contains type I collagen and type III collagen. The reticular layer forms Langer lines from elastic fibers and what type of collagen? a) Type XVII b) Type I c) Type III d) Type IV e) Type VII 30) The oxidation of tyrosine to 3,4-dihydroxyphenylalanine by tyrosinase occurs within which of the following cells? a) Goblet cell b) Melanocyte c) Merkel cell d) Keratinocyte e) Langerhans cell 31) Which of the following contains dendritic processes, tennis racket-shaped Birbeck granules, a characteristically indented uneven nuclear profile, and act as antigen presenting cells expressing MHC I and II molecules as well as Fc receptors for IgG? a) Goblet cell b) Melanocyte c) Merkel cell d) Keratinocyte

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Integumentary

06Apr2009

e) Langerhans cell 32) Which of the following are found densely in the fingertips and are characterized by the presence of 80nm dense-cored neurosecretory granules that resemble those found in the adrenal medulla and carotid body? a) Goblet cell b) Melanocyte c) Merkel cell d) Keratinocyte e) Langerhans cell 33) Pheomelanin takes on what pigment? a) Brownish black b) Reddish yellow c) Greenish gold d) Bluish tan e) White 34) Which of the following responds to deep pressure touch and high-frequency vibration through the displacement of the capsular lamellae, causing depolarization? a) Pacinian corpuscles b) Meissner corpuscles c) Ruffini end organ d) Free nerve endings e) Merkel cell 35) Which of the following respond to mechanical displacement of adjacent collagen fibers (skin stretch) and are spindle shaped? a) Pacinian corpuscles b) Meissner corpuscles c) Ruffini end organ d) Free nerve endings e) Merkel cell 36) Which of the following penetrates the epidermis, ends in the stratum granulosum, has fast-adapting A! fibers, has slowly adapting C fibers, and expresses polymodality in the sensation of temperature, mechanical stimuli (touch, pressure, stretch), and pain (nociception)? a) Pacinian corpuscles b) Meissner corpuscles c) Ruffini end organ d) Free nerve endings e) Merkel cell 37) Which of the following are light touch receptors responsive to low-frequency stimuli and are found in the papillary layer of hairless skin? a) Pacinian corpuscles b) Meissner corpuscles c) Ruffini end organ d) Free nerve endings e) Merkel cell 38) Which of the following forms the middle plate of the internal root shaft of hair?

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Integumentary

06Apr2009

a) Infundibulum b) Isthmus c) Cuticle d) Huxley layer e) Henle layer 39) Which of the following extends from the insertion of the arrector pili muscle to the entrance of the sebaceous gland duct? a) Infundibulum b) Isthmus c) Cuticle d) Huxley layer e) Henle layer 40) Sebaceous glands produce sebum via what type of secretion? a) Merocrine b) Apocrine c) Holocrine d) Endocrine e) Eccrine 41) Eccrine sweat glands contain clear cells, dark cells, and myoepithelial cells. Unlike coiled tubular apocrine sweat glands, eccrine glands are found: a) In the axilla b) In the skin around the anus c) In the areola and nipple of the mammary gland d) In the eyelashes e) Over the entire body surface except lips and external genitalia 42) The crescent-shaped area near the root of the nail, the lunula, is white because the matrix cells (corneocytes) in this region are: a) Non-keratinized b) Partially keratinized c) Completely keratinized d) Non-existent e) Desquamated 43) Which of the following contains epithelial cells that are continuous with the stratum basale and stratum spinosum of the epidermis? a) Eponychium (cuticle) b) Lunula c) Hyponychium d) Nail plate e) Nail bed Integumentary #2 – Biochemistry 1) Which component of the extra-cellular matrix makes up the major component of the ground substance? a) Proteoglycans b) Fibronectin c) Laminin

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Integumentary

06Apr2009

d) Collagen e) Elastin f) Fibrillin 2) What type of collagen is the most abundant, has glycine every third amino acid, and is formed by three left-handed helices intertwined into a triple right-handed matrix? a) Type I b) Type II & III c) Type IV d) Type VII e) Type XVII 3) Which of the following is encoded by one gene and is especially prevalent in lungs, arterial walls, skin, and ligaments? a) Proteoglycans b) Fibronectin c) Laminin d) Collagen e) Elastin f) Fibrillin 4) The formation of collagen involves the hydroxylation of proline and lysine residues. This requires oxygen, alpha-ketogluterate, and what vitamin? a) Vitamin A b) Vitamin E c) Vitamin B6 d) Vitamin B12 e) Vitamin C 5) An infant is brought in due to difficulty feeding. Physical exam reveals abnormally kinky hair. Menkes syndrome, which is X-linked recessive, is diagnosed. This child is unable to create tropocollagen bonds because the required cofactor for the activity of lysine oxidase is missing. What is this cofactor? a) Alpha-ketoglutarate b) Iron c) Copper d) Magnesium e) Zinc 6) A defect in type VII collagen, which forms anchoring fibers, would lead to which of the following? a) Osteogenesis imperfecta b) Ehlers-Danlos syndrome c) Alport syndrome d) Epidermolysis bullosa dystrophica e) Menkes syndrome 7) Which form of autosomal dominant osteogenesis imperfecta (OI) is the most severe and has a mutation that leads to bulky amino acids substituting glycine? a) Type I b) Type II c) Type III

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Integumentary

06Apr2009

d) Type IV 8) Which of the following is NOT seen in the collagen disorder Ehlers-Danlos syndrome? a) Hyperextensibility of the skin b) Aneurysms c) Retinal detachment d) Corneal rupture e) Loss of hearing 9) A child presents with hematuria, proteinuria, and kidney failure (Alport syndrome). What type of collagen is involved? a) Type I b) Type II & III c) Type IV d) Type VII e) Type XVII 10) Which of the following is due to an accumulation of defective elastin? a) Alpha1-antitrypsin deficiency b) Marfan syndrome c) Scleroderma d) Williams syndrome e) Ehlers-Danlos syndrome 11) Williams syndrome is an elastin disorder that affects connective tissue, CNS, and can lead to aortic stenosis. How is it acquired? a) Viral infection b) Autosomal dominant c) Autosomal recessive d) X-linked e) Spontaneous mutation 12) Alpha1-antitrypsin is a normal inhibitor of elastase, which breaks down alveolar tissue. A deficiency would thus lead to emphysema. How is this deficiency acquired? a) Autosomal dominant b) Autosomal recessive c) X-linked dominant d) X-linked recessive e) Mitochondrial 13) A tall high-school basketball player presents with a ripping chest pain that radiates to his back. Otoscopic exam reveals an abnormality (shown). Physical exam reveals arachnodactyly. The clinician suspects an autosomal dominant disorder affecting: a) Proteoglycans (GAGs) b) Laminin c) Collagen d) Fibrillin e) Elastin f) Fibronectin 14) Which of the following plays a key role in healing by attracting fibroblasts and endothelial cells, and also helps to “glue” cells together? a) Proteoglycans

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Integumentary

06Apr2009

b) Fibronectin c) Collagen d) Laminin e) Elastin f) Fibrillin 15) Which of the following provides structural support, glues components of the membrane to overlying cells, and induces physiologic responses in cells? a) Elastin b) Fibronectin c) Laminin d) Collagen e) Proteoglycans f) Fibrillin 16) Which of the following acts as a cushion in joints and is prevalent in bone, cartilage, and the vitreous humor? a) Proteoglycans b) Laminin c) Collagen d) Fibrillin e) Elastin f) Fibronectin 17) Which of the following is NOT true of mucopolysaccharidoses? a) They are lysosomal storage diseases b) Are autosomal recessive or X-linked c) Are apparent at birth d) Affect all organ systems e) May involve defects in degrading keratan sulfate and dermatan sulfate 18) What enzyme is deficient in mucolipidosis VII disease? a) Iduronate sulfatase b) Alpha-L-iduronidase c) N-acetylgalactosamine sulfatase d) Beta-glucuronidase e) Heparan sulfamidase 19) What enzyme is deficient in Hunter disease? a) Iduronate sulfatase b) Alpha-L-iduronidase c) N-acetylgalactosamine sulfatase d) Beta-glucuronidase e) Heparan sulfamidase 20) What enzyme is deficient in Hurler disease and Scheie disease? a) Iduronate sulfatase b) Alpha-L-iduronidase c) N-acetylgalactosamine sulfatase d) Beta-glucuronidase e) Heparan sulfamidase

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Integumentary

06Apr2009

21) Prior to helix formation in collagen synthesis, what is added to certain lysine residues? a) Glucose and lactose b) Lactose and sucrose c) Sucrose and maltose d) Maltose and galactose e) Galactose and glucose 22) Collagen fibers are arranged in what pattern within the cornea to minimize light scatter? a) Parallel bundles b) Angled to the eye axis c) Layered at many angles d) Planar sheets e) No distinct arrangement 23) What form of Ehlers-Danlos syndrome (EDS) involves a mutation in the gene encoding tenascin X? a) Hypermobility form (Type III) b) Classic form (Type I) c) Classic form (Type II) d) Vascular form (Type IV) 24) What type of glycosaminoglycan is the major proteoglycan in cartilage? a) Syndecan b) Aggrecan c) Thrombomodulin d) Neurocan and brevican e) Cerebrocan and phosphacan 25) What type of glycosaminoglycan is associated with the actin cytoskeleton inside the cell and interacts with fibronectin outside the cell? a) Syndecan b) Aggrecan c) Thrombomodulin d) Neurocan and brevican e) Cerebrocan and phosphacan Integumentary #3 – Microbiology: Infections of the Skin 1.1) Which of the following is a localized collection of pus in part of the body (e.g. perineum), is commonly caused by S. aureus (coagulase +, catalase +), and is formed by tissue disintegration with a surrounding inflamed area? a) Cellulitis b) Impetigo c) Abscess d) Gangrene e) Folliculitis f) Erysipelas g) Necrotizing fasciitis

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Integumentary

06Apr2009

1.2) Which of the following is a superficial infection in and around a hair strand (shown), forms a boil, and is commonly caused by S. aureus (grows golden colonies)? a) Cellulitis b) Impetigo c) Abscess d) Gangrene e) Folliculitis f) Erysipelas g) Necrotizing fasciitis 1.3) Which of the following usually affects children, is characterized by the eruption of contagious superficial pustules and the formation of thick yellow crusts, commonly affects the face (shown), and is often caused by Staphylococcus and sometimes Streptococcus (catalase -)? a) Cellulitis b) Impetigo c) Abscess d) Gangrene e) Folliculitis f) Erysipelas g) Necrotizing fasciitis 1.4) Which of the following is an acute febrile disease associated with intense often vesicular erythematous local inflammation of the skin, often affects the face (shown), and is associated with hemolytic Streptococcus? a) Cellulitis b) Impetigo c) Abscess d) Gangrene e) Folliculitis f) Erysipelas g) Necrotizing fasciitis 1.5) A child presents with an reddened area of the skin (shown). The area is warm, swollen, and painful. The child has intermittent fever and chills along with some enlarged lymph nodes. Cellulitis is suspected. Lab results show grown on chocolate agar with factor X an V+. Which of the following causes of cellulitis is most likely? a) Staphylococcus aureus b) Streptococcus pyogenes c) Hemophilus influenzae d) Aeromonas hydrophila e) Streptococcus pneumoniae 1.6) Which of the following is an infection of the subcutaneous tissue that results in destruction of fascia and fat, is polymicrobial in 90% of cases, may have dark boil-like blisters, and may show high lab values of C-reactive protein and creatinine kinase? a) Cellulitis b) Impetigo c) Abscess

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Integumentary

06Apr2009

d) Gangrene e) Folliculitis f) Erysipelas g) Necrotizing fasciitis 1.7) Which of the following is death and decay of body tissue usually at the distal part of the limb due to ischemia, often occurs in the toes and feet of elderly patients due to arteriosclerosis or diabetes, and may involve Staphylococcus, Streptococcus, or anaerobes? a) Cellulitis b) Impetigo c) Abscess d) Gangrene e) Folliculitis f) Erysipelas g) Necrotizing fasciitis 2) A staphylococcal skin infection develops from a superficial infection to an abscess and may drain externally or seed inward, leading to peritonitis, empyema, or meningitis. What is the most common site of initial infection? a) Around a hair follicle b) Genitals c) Eye d) CNS e) Nails 3) A strain of S. aureus is found to have the MecA gene. Which of the following drugs does this gene provide resistance against? a) Vancomycin b) Metronidazole c) Acyclovir d) Cefotaxime e) Methicillin 4) Which of the following skin lesions is raised and red with marked inflammation due to infiltration of neighboring tissue? a) Papilloma b) Macule c) Papule d) Vesicle e) Ulcer 5.1) Toxic shock syndrome is caused by the TSS1 toxin of S. aureus or the pyrogenic exotoxins in the case of S. pyogenes toxic shock-like syndrome. How do these toxins produce their toxic effects? a) Inhibit T-cell proliferation b) Inhibit B-cell proliferation c) Destroy IL-2 cytokines d) Act as a superantigen e) Via an exfoliative toxin 5.2) How does Staphylococcal scalded skin syndrome cause its effects?

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Integumentary

06Apr2009

a) Inhibits T-cell proliferation b) Inhibits B-cell proliferation c) Destroys IL-2 cytokines d) Acts as a superantigen e) Via an exfoliative toxin 6) A child presents with blood in the urine. History reveals a recent throat infection. Which of the following is the NOT true? a) Streptococcus pyogenes is most likely to blame b) Staphylococcus aureus is not likely involved c) The bacterium involved are beta hemolytic d) The bacterium involved will not grow on mannitol salt e) Erysipelothrix rhusiopathiae is a likely cause 7) A patient presents with cellulitis of the leg. If Staphylococcus aureus were suspected, which of the following would NOT be helpful in the diagnosis? a) Gram stain positive b) Oxidase test negative c) Growth on mannitol salt d) Beta hemolysis on TSA agar e) Coagulase and catalase positive 8) Infections involving Clostridium perfringens often progress rapidly, requiring immediate surgery and possibly amputation. Which of the following signs or symptoms is commonly associated with this infection? a) Nikolsky sign b) Auspitz sign c) Subcutaneous emphysema d) Köbner phenomenon e) Bleeding buboes 9) What is the causative agent of comedones? a) Erysipelothrix rhusiopathiae b) Propionibacterium acnes c) Staphylococcus aureus d) Streptococcus pyogenes e) Clostridium perfringens 10) Which of the following is characteristic of tuberculoid leprosy (TT), and not of lepromatous leprosy (LL)? a) Acid fast intracellular bacteria b) Vigorous cell-mediated response c) Leonine “lion” face appearance d) Damage to sensory nerve sheath e) Worse prognosis 11) A marine shop worker presents with a small papular lesion on his hand. The lesions have become enlarged over the past week and now ulcerate, causing pain. History reveals he scraped his hand on some coral while rearranging a saltwater fish tank. If M. marinum is suspected, how should diagnosis be made? a) Granulomas on histology of lesion b) Microscopy of Gram-positive tumbling rods

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Integumentary

06Apr2009

c) Tram-track appearance on electron microscopy d) Growth on chocolate agar with V and X factors e) Multinucleated giant cells on histology 12) Which of the following is true of fungi? a) Mold is filamentous, yeast is spherical, dimorphic is mold at low temp b) Mold is filamentous, yeast is spherical, dimorphic is mold at high temp c) Mold is spherical, yeast is filamentous, dimorphic is mold at low temp d) Mold is spherical, yeast is filamentous, dimorphic is mold at high temp 13.1) Tinea (ringworm) is classified as what type of fungal infection? a) Superficial b) Cutaneous c) Subcutaneous d) Systemic mycosis e) Opportunistic 13.2) Sporotrichosis is classified as what type of fungal infection? a) Superficial b) Cutaneous c) Subcutaneous d) Systemic mycosis e) Opportunistic 14) A patient presents with a skin infection involving their back and proximal limbs. A scraping is found to grown on Sabouraud dextrose agar (SDA). The microbe is isolated (shown). Tinea versicolor is suspected. Which of the following is most likely? a) Microsporum audouinii b) Trichophyton rubrum c) Epidermophyton floccosum d) Candida albicans e) Malassezia furfur 15) Which of the following describes a dermatophyte infection (fungi that can cause parasite skin infection) that is acquired by humans? a) Anthropophilic b) Arthrophilic c) Zoophilic d) Geophilic 16) Which of the following tinea infections affects the nails? a) Tinea capitis b) Tinea corporis c) Tinea cruris d) Tinea magnuum e) Tinea unguium f) Tinea pedis 17) Which of the following causes of dermatophytoses fluoresces under UV Wood lamp? a) Microsporum b) Trichophyton c) Epidermophyton d) Candida

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Integumentary

06Apr2009

e) Malassezia 18) An AIDS patient presents with complaints of a white substance in her mouth. History reveals a cottage cheese discharge from the vagina as well. Labs show neutropenia. Which of the following is most likely? a) Microsporum audouinii b) Trichophyton rubrum c) Epidermophyton floccosum d) Candida albicans e) Malassezia furfur 19) A 55-year-old electrical engineer presents with a small papule on the hand. On physical exam, several subcutaneous nodules are found, which follow the lymph vessels up the affected forearm. History reveals the man takes care of a few gardens in his back yard as a hobby and to “get away from the wife.” Which of the following is most likely? a) Microsporum audouinii b) Trichophyton rubrum c) Epidermophyton floccosum d) Mycobacterium marinum e) Sporotrix schenckii Match the virus with the nuclear type: 20.1) Papilloma virus a) dsDNA (double-stranded DNA) 20.2) Molluscum contagiosum virus b) ssDNA (single-stranded DNA) 20.3) Orf virus c) dsRNA (double-stranded RNA) 20.4) Herpes simplex virus d) (+)ssRNA (positive-sense single-stranded RNA) 20.5) Varicella zoster virus e) (-)ssRNA (negative-sense single-stranded RNA) 20.6) Coxsackie A virus f) ssRNA-RT (reverse transcribing ssRNA) 20.7) Echovirus g) dsDNA-RT (reverse transcribing dsDNA) 20.8) Erythrovirus B19 (parvovirus) 20.9) HHV-6, HHV-7, HHV-8 20.10) A medical student presents to the primary care office with a lesion on her foot. History reveals he walks barefoot in the shower at the local wellness center (gym). The lesion on the bottom of the foot is flat and has grown inward. There is another lesion on the side of the foot that appears filiform. Which of the following is most likely? a) Varicella zoster virus b) Measles virus c) Rubella virus d) Papilloma virus e) Molluscum contagiosum virus 20.11) A man presents with a single fleshy, umbilicated lesion near his genitals. History is negative for contact with animals. Poxvirus is suspected. Which of the following is most likely? a) Varicella zoster virus b) Measles virus c) Rubella virus d) Papilloma virus e) Molluscum contagiosum virus

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Integumentary

06Apr2009

20.12) All of the following cause vesicular lesions. Which of the following, when reactivated from a dorsal root ganglion, causes lesions along a dermatomal pattern? a) Herpes simplex 1 virus b) Varicella-zoster virus c) Coxsackievirus A9 d) Coxsackievirus A16 e) Coxsackievirus A23 20.13) A patient presents with vesicular lesions in the mouth. Further examination reveals similar lesions on the distal extremities. Which of the following is most likey? a) Herpes simplex 1 virus b) Varicella-zoster virus c) Coxsackievirus A9 d) Coxsackievirus A16 e) Coxsackievirus A23 20.14) Which of the following describes the viral lesion seen in rubella and echovirus 4, 6, 9, and 16? a) Vesicular b) Fleshy papule c) Macular d) Maculopapular e) Pustular 20.15) A child presents with a fever and red face. The emergency department technician thinks the child was slapped in the face and suggests child abuse. Physical exam reveals a lacy, reticulated rash. Which of the following is most likely? a) HHV-6 b) HHV-7 c) HHV-8 d) Erythrovirus B19 e) Echovirus 20.16) An immunocompromised patient presents with complains of a lesion on his arm (shown). Which of the following is most likely? a) HHV-6 (exanthema subitum) b) HHV-7 c) HHV-8 (Kaposi sarcoma) d) Erythrovirus B19 e) Echovirus 20.17) A child presents with white koplick spots in his mouth. Testing finds an enveloped virus that has respiratory transmission. Which of the following is most likely? a) Measles b) Mumps c) Rubella d) Smallpox e) Chickenpox 21) Which of the following describes human papilloma virus (HPV)? a) Enveloped DNA b) Non-enveloped DNA

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Integumentary

06Apr2009

c) Enveloped RNA d) Non-enveloped RNA 22.1) Which serotypes of HPV cause plantar warts? a) 1 & 4 b) 2, 3, & 10 c) 6 & 11 d) 16 & 18 e) 6, 11, 16, & 18 22.2) Which serotypes of HPV cause warts on the knees and fingers? a) 1 & 4 b) 2, 3, & 10 c) 6 & 11 d) 16 & 18 e) 6, 11, 16, & 18 23) What is the common method of transmission for HPV 4? a) Bloodborne b) Fecal oral c) Respiratory d) Direct skin contact e) Penetrating sexual contact 24) Molluscum contagiosum and orf are poxviruses. How is orf acquired? a) Bats b) Fleas c) Goats d) Ticks e) Rabbits 25.1) A child is brought to the primary care office with a very scared mother. The mother, who spent time on the Internet researching her child’s current condition, is 100% sure her child has smallpox. She presents several pages of printed information including pictures. Physical exam of the child reveals crops of vesicles, mostly on the torso and face, which are at different stages of growth including pustules and scabs. What is the diagnosis? a) HSV-1 (herpes simplex virus 1) b) HSV-2 (herpes simplex virus 2) c) VZV (varicella zoster virus) d) EBV (Epstein-Barr virus) e) CMV (cytomegalovirus) f) Smallpox (variola) 25.2) HSV-1 lies dormant in the dorsal root ganglion (DRG) of what nerve? a) CN V b) CN VII c) CN IX d) CN X e) CN XII 26) What family does coxsackie virus A16 belong to? a) Coronaviridae

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Integumentary

06Apr2009

b) Caliciviridae c) Luteoviridae d) Picornaviridae e) Togaviridae f) Caliciviridae 27) How is coxsackie virus A16 most commonly transmitted? a) Bloodborne b) Fecal oral c) Respiratory d) Direct skin contact e) Penetrating sexual contact 28) How is erythrovirus B19 (Slapped Cheek Syndrome, Fifth Disease, Erythema infectiosum) is most commonly transmitted? a) Bloodborne b) Fecal oral c) Respiratory d) Direct skin contact e) Penetrating sexual contact 29) Pregnant patient carry a 10% fetal mortality risk with an erythrovirus (parvovirus) B19 infection. What other patient population is at high risk for complications with a B19 infection? a) Diabetics b) Paraplegics c) Patients with rheumatoid arthritis d) Chronic alcoholics e) Sickle cell anemics 30) A young child presents with a body rash. History reveals a high fever a few days prior. The mother states the rash started on the child’s trunk and then spread to the arms. Physical exam reveals a faint pink maculopapular rash that does not appear lacy (reticulated). Which of the following is most likely? a) HHV-6 b) HHV-7 c) HHV-8 d) Erythrovirus B19 e) Echovirus 31) How does poxvirus differ from most DNA viruses? a) It replicates within the nucleus b) It replicates in the cytoplasm c) It cannot replicate within a host cell d) It requires mass amounts of ATP energy e) It destroys over 50% of cell lysosomes 32) Poxvirus is commonly transmitted via: a) Direct skin contact and respiratory b) Respiratory and fecal oral c) Fecal oral and bloodborne d) Bloodborne, goats, and sheep

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Integumentary

06Apr2009

33) A man presents with vesicles scattered around his body (shown). The man states it started after a classified terrorism mission with the military. During the mission, the man was exposed to an unknown agent. Military documentation reveals the patient received a vaccinia vaccination prior to the mission. Which of the following is most likely? a) HSV-1 (herpes simplex virus 1) b) HSV-2 (herpes simplex virus 2) c) VZV (varicella zoster virus) d) EBV (Epstein-Barr virus) e) CMV (cytomegalovirus) f) Smallpox (variola) 34) Which of the following is NOT a helpful factor in the eradication of smallpox? a) The disease has no sub-clinical infection b) The virus is eliminated from the body on recovery c) Human are the only host for smallpox d) Vaccination was effective using live human smallpox 35) In June 2003, a poxvirus similar to smallpox had infected a few people in the United States. What animal was the original carrier for this virus? a) Cows b) Armadillos c) Monkeys d) Goats e) Squirrels 36) Which of the following describes measles (paramyxovirus)? a) (+)ssRNA, enveloped b) (+)ssRNA, non-enveloped c) (-)ssRNA, enveloped d) (-)ssRNA, non-enveloped e) dsDNA 37) What is the first observed sign of measles? a) Koplik spots b) Conjunctivitis c) Respiratory illness d) Maculopapular rash e) Splenomegaly 38) Which of the following describes rubella (togavirus)? a) (+)ssRNA, enveloped b) (+)ssRNA, non-enveloped c) (-)ssRNA, enveloped d) (-)ssRNA, non-enveloped e) dsDNA 39) Where does the rash begin in cases of rubella? a) Forehead b) Chest c) Wrist

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Integumentary

06Apr2009

d) Back e) Inguinal region Integumentary #4 – Microbiology: Vector-Borne, Zoonoses, Nematodes, Arthropods 1) Rocky mountain spotted fever (Rickettsia rickettsii) most commonly starts on the distal extremities as a maculopapular rash and spreads toward the trunk. Currently, where is it most commonly found? a) Colorado b) Northern U.S. c) Southern U.S. d) Western U.S. e) Eastern U.S. 2) Which of the following best describes the skin lesion, erythema chronicum migrans, seen in Lyme disease (Borrelia burgdorferi)? a) Maculopapular across trunk and head b) Maculopapular along extremities c) Vesicular lesions at different stages of development d) Macular with area of central clearing e) Macular with area of intense central pigmentation 3.1) Anthrax (Bacillus anthracis) is excreted in the feces and urine of herbivores, thus is may affect those handling animal pelts. Which of the following describes anthrax? a) Gram-negative diplococci b) Gram-positive diplococci c) Gram-negative rod d) Gram-positive rod e) Gram-negative spirochete 3.2) Yersinia pestis (plague) and Pasteurella multocida (cat bites) show bipolar staining, appearing as a “safety pin” under the microscope. Which of the following describes these bacterium further? a) Gram-negative diplococci b) Gram-positive diplococci c) Gram-negative rods d) Gram-positive rods e) Gram-negative spirochetes 4.1) A Florida man presents with an apparent skin infection (shown). He says it started after cleaning out some cat droppings from his children’s sandbox. Physical exam reveals likely cutaneous larva migrans. The man says the rash itches and he is concerned that “it is moving.” Thiabendazole treatment is started. Which of the following is most likely? a) Ascaris lumbricoides b) Dracunculus medinensis c) Echinococcus granulosus d) Ancylostoma braziliense e) Strongyloides stercoralis

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4.2) A clinician travels to Sudan for a mission trip. One of his patients is found to have a lower extremity skin lesion with a nematode protruding. The child is told to wrap the nematode with a stick (shown). Which of the following is most likely? a) Ascaris lumbricoides b) Dracunculus medinensis c) Echinococcus granulosus d) Ancylostoma braziliense e) Strongyloides stercoralis 5.1) Which of the following can cause systemic arachnidism, which involves an intense pain with agitation followed by stupor and somnolence? a) Brown recluse spider b) Black widow spider c) Tarantula spider d) A & B e) B & C 5.2) A man presents to the emergency department after being “stung” in his cabin outhouse. The man says he saw the spider from above and that it was large, had a rounded black abdomen, but denies seeing any red markings and is positive he did not see a “red hourglass” on top of the spider. Physical exam reveals local redness, swelling, and diaphoresis. The patient complains of muscle cramps and nausea. Which of the following is most likely? a) Brown recluse spider b) Black widow spider c) Tarantula spider d) Wolf spider e) House spider 5.3) Which of the following may cause necrotic arachnidism? a) Brown recluse spider b) Black widow spider c) Tarantula spider d) Wolf spider e) House spider 6) What is the cause of the intense pruritus seen in scabies? a) Scabies toxin b) Skin necrosis c) Allergic reaction d) Desensitization e) Sensation of mite moving 7) Which of the following cannot be seen without a microscope and is usually treated with gamma benzene hexachloride (lindane) or permethrin cream? a) Scabies (Sarcoptes scabiei) b) Lice (Pediculus humanus) c) Crabs (Phthirus pubis) d) Bedbugs (Cimex lectularius) e) Bot fly (Dermatobia hominis)

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Integumentary

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Integumentary #5 – Pharmacology 1) Which of the following is NOT true when applying topical agents? a) Certain areas, such as the scrotum and face, are more penetrable and thus require less drug b) Increased drug concentration leads to a greater mass of drug transferred c) Skin is a reservoir for many drugs so usually decreases half-life of a drug d) Good vehicles maximize penetrance through layers of skin e) Occlusion, such as plastic wrap, is very effective 2) What effect will hydration by topical agent vehicles have on the stratum corneum? a) Enhanced penetration b) Reduced penetration c) Increased occlusion d) Decreased half life e) Less mass of drug transferred 3.1) Which of the following would be a poor choice for dermatologic application on the scalp or hair? a) Tinctures b) Wet dressings c) Lotions d) Gels e) Aerosols 3.2) Which of the following are the best for chronic inflammation, xerosing scaling, or licheniformation? a) Wet dressings b) Tinctures and lotions c) Gels and aerosols d) Power and pastes e) Creams and ointments 3.3) Which of the following would be a poor choice for dermatologic application involving acute inflammation with oozing, vesiculation, and crusting? a) Tinctures b) Wet dressings c) Lotions d) Ointments 4) Which of the following is NOT an indication for topical treatment with antibacterial agents? a) Preventing infection in clean wounds b) Reducing colonization of nares by staph c) In axillary deodorization d) Acne management e) Late treatment of infected dermatomes and wounds 5) Which of the following is NOT sensitive to mupirocin (Bactroban, Centany)? a) MRSA b) Gram-negative spirochetes c) Impetigo by staph infection

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Integumentary

06Apr2009

d) Graph A beta hemolytic streptococci 6) A patient with a Gram-negative infection involving Pseudomonas, E. coli, and Klebsiella is given a high dose of polymyxin B sulfate. What adverse effect may occur? a) Ototoxicity and neurotoxicity b) Neurotoxicity and nephrotoxicity c) Nephrotoxicity and hepatotoxicity d) Hepatotoxicity and cardiotoxicity e) Cardiotoxicity and ototoxicity 7) Gentamicin and neomycin are used for Gram-negative microbes. Which patients are at the greatest risk for multiple-organ toxicity, especially with water miscible preps used in burned skin patients? a) Renal impairment b) Hepatic impairment c) Cardiac dysfunction d) Neural impairment e) Gastrointestinal impairment 8) Metronidazole, used for acne rosacea, is contraindicated in which of the following? a) Uncontrolled blood glucose (DM II) b) Hypercoagulative states c) Pregnancy or nursing d) Anemia (e.g. sickle cell anemia) e) Very pale skin or albinism 9) Which of the following is NOT used for vulvovaginal candidiasis (yeast infection)? a) Miconazole (Monistat) b) Clotrimazole (Lotrimin) c) Miconazole (Micatin) d) Clotrimazole (Mycelex) e) Tolnaftate (Tinactin) 10) Ciclopirox olamine 8% (penlac) is used for which of the following? a) Conjunctivitis b) Vulvovaginal candidiasis c) Onychomycosis d) Tinea cruris e) Tinea versicolor 11) Which of the following, like allylamine agents, inhibits epoxidation of squalene, thus blocking the synthesis of ergosterol, an essential component of the fungal cell membranes? a) Amphotericin B b) Fluconazole c) Imiquimod d) Butenafine e) Griseofulvin 12) How is thrush (candidiasis) treated with nystatin? a) Hold oral suspension in mouth for several minutes before swallowing b) Hold oral suspension in mouth for several minutes then spit c) Gargle oral suspension for 30-60 seconds then spit or swallow

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d) Slow IV push (SIVP) over 3-5 minutes e) Oral tablets, QID (four times per day) 13) Topical fluconazole, 100mg, can be used for mucocutaneous candidiasis and dermatophyte infection. What is the half-life and dosing for this drug? a) 4-hours, 6 times per day b) 8-hours, QID c) 14-hours, BID d) 30-hours, QD e) 50-hours, every other day 14) Griseofulvin is ineffective against P. orbiculare (Malassezia) and which of the following?

a) Epidermophyton b) Candida c) Microsporum d) Trichophyton 15) Topical acyclovir and penciclovir and indicated for: a) Varicella zoster (chickenpox) b) Varicella zoster reactivation (shingles) c) Epstein-Barr virus d) Herpes (1 & 2) e) HPV (warts) 16) Which of the following stimulates mononuclear cells to release IFN-alpha, stimulates macrophages to make IL-1, IL-6, IL-8, and TNF-alpha, and is used for genital warts, actinic keratoses, and basal cell carcinoma? a) Etanercept b) Fluconazole c) Imiquimod d) Butenafine e) Griseofulvin 17) Lindane is used as a shampoo or lotion for oediculosis capitis or pubis. Which of the following is an adverse effect listed on the label for this drug? a) Ototoxicity b) Hepatotoxicity c) Cardiotoxicity d) Nephrotoxicity e) Neurotoxicity 18) Hydroquinone and monbezone help to depigment the skin by inhibiting which of the following, which decreases the synthesis of melanin? a) Hydroxylase b) Glutinase c) Tyrosinase d) Arginase e) Carboxylase 19) Which of the following is NOT true of retinoic acid? a) Increases ribonucleic acid polymerase activity b) Increases prostaglandin-E2, cAMP, and cGMP c) Increases incorporation of thymidine into DNA DO NOT DISTRIBUTE

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d) Destabilizes lysosomes 20) Tazarotene is teratogenic if applied in what manner? a) Over the abdomen and umbilical region b) Near mucous membranes c) On thin-skin areas (eyelids, genitals) d) Over move than 20% of body surface area e) In high sweat areas (armpits, perineum) 21) Which of the following drugs is used for plaque psoriasis, binds to TNF alpha and beta, and blocks the interaction with cell surface TNF receptors that play a role in inflammatory processes? a) Etanercept b) Fluconazole c) Imiquimod d) Butenafine e) Griseofulvin 22) What side effect of the hydrocortisone 9alpha-fluoro derivative makes it undesirable for topical use? a) Isomerizes to 9beta-fluoro b) Breaks down under direct sunlight c) Has salt retaining properties d) Is miscible in non-lipid solutions e) Does not spread evenly in solution 23) Which of the following is considered ineffective as a topical corticosteroid preparation? a) Methylprednisone acetate 0.25% (Medrol) b) Betamethasone dipropionate 0.05% (Diprolene) c) Diflorasodone diacetate 0.05% (Psorcon) d) Halobetasol propionate 0.05% (Ultravate) e) Clobetasol propionate 0.05% (Temovate) 24) What condition can occur with long-term (protracted) use of large quantities of topic corticosteroids? a) Addison disease b) Cushing syndrome c) Hemolytic anemia d) Bone marrow suppression e) Severe leukopenia 25) Aminoleuvulinic acid (ALA) gets to the cell and causes a buildup of protoporphyrin IX. When exposed to blue light, PpIX produces a photodynamic reaction, causing the formation of superoxide and hydroxyl radicals. This is a useful treatment for: a) Prurigo nodularis b) Acne cysts c) Alopecia areata d) Actinic keratoses e) Kaposi sarcoma 26) What side effect may be seen with the use of finasteride, which is a 5alpha-reductase inhibitor that blocks the conversion of testosterone to dihydrotestosterone (DHT)?

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Integumentary

06Apr2009

a) Hair loss b) High volume ejaculation c) Erectile dysfunction d) Increased libido e) Destruction of sperm 27) Alitretinoin, a 9-cis-retinoic acid, is indicated for: a) Prurigo nodularis b) Acne cysts c) Alopecia areata d) Actinic keratoses e) Kaposi sarcoma Integumentary #6 – Dermapathology Match the macroscopic dermatologic lesion with the description: 1.1) Flat, colored, circumscribed, diameter < 5mm a) Blister 1.2) Flat, colored, circumscribed, diameter > 5mm b) Bulla 1.3) Elevated, dome-shaped, diameter < 5mm c) Lichenification 1.4) Elevated, spherical contour, diameter > 5mm d) Macule 1.5) Elevated, flat-topped, diameter > 5mm e) Nodule 1.6) Fluid-filled, raised, diameter < 5mm f) Onycholysis 1.7) Fluid-filled, raised, diameter > 5mm g) Papule 1.8) Common term used for vesicle or bulla h) Patch 1.9) Discrete, pus-filled, raised i) Plaque 1.10) Itchy, translucent, elevated, blanching, edema j) Pustule 1.11) Dry, horny, plate-like excrescence k) Scale 1.12) Thick, rough skin, prominent markings l) Vesicle 1.13) Separation of the nail from the nail bed m) Wheal Match the microscopic dermatologic lesion with the description: 1.14) Thickening of the stratum corneum a) Acanthosis 1.15) Retention of nuclei in stratum corneum b) Acantholysis 1.16) Hyperplasia of the stratum granulosum c) Dyskeratosis 1.17) Diffuse epidermal hyperplasia d) Erosion 1.18) Elevation caused by hyperplasia e) Exocytosis 1.19) Keratinization below the stratum granulosum f) Hydropic swelling 1.20) Loss of intracellular keratinocyte connections g) Hypergranulosis 1.21) Intracellular edema of the epidermis h) Hyperkeratosis 1.22) Intracellular edema of the keratinocytes i) Lentiginosis 1.23) Epidermal infiltration by inflammatory blood cells j) Papillomatosis 1.24) Skin discontinuity with incomplete loss of epidermis k) Parakeratosis 1.25) Skin discontinuity with complete loss of epidermis l) Spongiosis 1.26) Formation of vacuoles within or adjacent to cells m) Ulceration 1.27) Epidermal basal cell membrane melanocyte proliferation n) Vacuolization 2) A child presents with multiple pigmented lesions on the body. The lesions are round to oval, red-brown, non-scaling papules and small plaques. Testing reveals a point mutation of the c-KIT proto-oncogene leading to activation of a tyrosine kinase expressed by mast cells. Which of the following types of mastocytosis is most likely?

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Integumentary

06Apr2009

a) Urticaria pigmentosa b) Diffuse cutaneous mastocytosis c) Erythrodermic mastocytosis d) Telangiectasia macularis eruptiva perstans e) Extracutaneous mastocytoma 3) Urticaria (hives) is a common disorder of the skin that has localized mast cell degranulation with microvascular hyperpermeability leading to pruritic wheals. Which of the following causes of urticaria is IgE dependent? a) Curare b) Radiographic contract media c) Antibiotics d) Pollen e) Opiates 4) A 30-year-old man presents with a rash on his abdomen (shown). Physical exam reveals a red, papulovesicular, oozing, and crusted lesion just below the umbilicus. The lesion has a spongy appearance. History is negative for poison ivy, medications, or sun exposure. The patient states he has been gaining weight recently and had to buy new pants. Which of the following is most likely? a) Allergic contact dermatitis b) Drug-related eczematous dermatitis c) Primary irritant dermatitis d) Atopic dermatitis e) Photoeczematous dermatitis 5) Which of the following is NOT true of psoriasis? a) Parakeratosis with neutrophils b) Pink to salmon colored plaque lesion c) Nail changes with yellow-brown discoloration d) Dermal papillae with an absence of blood vessels e) Adherent scales that are silver-white 6) Which of the following is NOT true of lichen planus? a) Hypergranulosis with lymphocytic infiltration b) Flat-topped purple papules c) Pruritic polygonal lesions with white dots (Wickham striae) d) Necrosis of stratum spinosum via basal keratinocytes e) Most often caused by allergic reaction and immediately resolves 7) Which of the following is NOT true of acne vulgaris? a) Comedones (blackheads) are formed by dirt b) Possibly caused by physiologic hormonal alterations c) Is often exacerbated by drugs, such as steroids or contraceptives d) Involves keratinization with an oxidized melanin plug e) Castrated males almost never develop acne 8) Which of the following is characteristic of verrucae (warts)? a) Dermal hyperplasia with lichenification b) Epidermal hyperplasia with koiloctosis c) Hypokaratosis and thinning of the epidermis d) Hypergranulosis with epidermal hardening

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e) Hydropic swelling and papillomatosis 9) A patient presents with multiple skin lesions on the trunk and anus. The lesions are firm, pruritic, and pink. A curd-like material can be expressed from the central umbilication. Under microscope with Giemsa staining, the curd-like material reveals inclusion bodies (shown). What virus is responsible? b) Caliciviridae c) Luteoviridae d) Picornaviridae e) Togaviridae f) Poxviridae 10) A teenage boy presents with a skin infection. The lesion has a dry, scaly, honeycolored crust. A scraping reveals neutrophils under the stratum corneum and a Grampositive, catalase-positive, coagulase-positive bacterium. Which of the following is most likely? a) Molluscum contagiosum b) Psoriasis c) Impetigo d) Tinea corpus e) Eczematous dermatitis 11) An adult man presents with facial lesions. Testing of the lesion reveals the dermatophyte T. mentagrophytes. The lesion began after visiting a hair stylist who used a straight razor for his face. Which of the following is most likely? a) Tinea capitis b) Tinea barbae c) Tinea corporis d) Tinea cruris e) Tinea pedis f) Onychomycosis g) Tinea versicolor 12) The majority of patients with the pattern of superficial spreading melanoma give a history of: a) A pigmented lesion at the site since childhood b) Previous hypopigmentation of the site c) A pigmented lesion at the site of less than 3 years duration d) Incomplete excision of a nevus 13) A slightly elevated, tan lesion, 1.0 cm in size and containing hairs is removed from the trunk of a 10-year-old child. Microscopic sections reveal nests of melanocytes at the dermal-epidermal junction and involving the upper half of the reticular dermis. The melanocytes in the reticular dermis have a tendency to be arranged around blood vessels and adnexal structures with splaying of strands of melanocytes between collagen bundles in foci in the reticular dermis. The most likely diagnosis is: a) Blue nevus b) Congenital nevus, superficial type c) Melanoma d) Spitz nevus e) Follicular nevus

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14) According to Clark's criteria, a malignant melanoma which is invasive into the reticular dermis is termed level: a) I b) II c) III d) IV e) V 15) Which type of melanoma is most commonly associated with satellitosis? a) Acrolentiginous b) Lentigo maligna c) Nodular d) Superficial spreading Integumentary #7 – Clinical: General Dermatology 1) Cure rate for non-melanoma skin cancer, which occurs mostly in sun-exposed areas, is more than 90% with early detection and treatment. What is the ratio of squamous cell to basal cell skin cancer in immunocompetent people? a) 4:1, squamous cell four times more common than basal cell b) 2:1, squamous cell twice as common as basal cell c) 1:1, equal likelihood of both types d) 1:2, basal cell twice as common as squamous cell e) 1:4, basal cell four times more common than squamous cell 2) Which of the following would be a likely factor leading to an increased incidence of non-melanoma skin cancer? a) Atmospheric ozone depletion b) Increased UV light exposure c) Changes in clothing style d) Increased life longevity e) All of the above 3) Which of the following is more characteristic of squamous cell carcinoma, not basal cell carcinoma? a) Slow-growing b) Regional lymph node metastasis c) Invasion of vital structures d) Can cause significant disfigurement e) Locally invasive 4) What is the strongest risk factor for melanoma? a) Fair skin and freckling b) Blonde or red hair c) Family history d) Sun sensitivity e) Tanning bed use 5) Which of the following is the most indicative of poorer prognosis with melanoma? a) Lesion asymmetry b) Lesion border irregularity c) Lesion color variation

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d) Lesion thickness (depth) e) Lesion diameter (width) 6) Which of the following is only sometimes used as part of the integumentary examination? a) Lesion asymmetry b) Lesion border irregularity c) Lesion color variation d) Lesion diameter e) Lesion evolution 7) What stage of malignant melanoma involves a primary skin lesion plus microscopic or macroscopic lymph node involvement? a) Stage I b) Stage II c) Stage III d) Stage IV 8) Which of the following describes the management of primary melanoma? a) Sentinel lymph node biopsy with tumor excision plus 1-3cm past margin b) Sentinel lymph node biopsy with tumor excision at margin c) Tumor excision plus 1-3cm past margin without biopsy d) Tumor excision at margin without biopsy e) Chemotherapy 9) Regular use of sunscreens with SPF of at least 30 is recommended for all children. This is because exposure during the first 18-years of life accounts for what percentage of cumulative lifetime sun exposure? a) 80% b) 60% c) 40% d) 20% e) 10% 10) What is the most common form of cutaneous T-cell lymphoma, which may be treated with topical nitrogen mustard, psoralen with UV-A (PUVA), radiotherapy, or systemic chemotherapy? a) Angioimmunoblastic T-cell lymphoma (AILT) b) Extranodal NK-T-cell lymphoma c) Anaplastic large cell lymphoma (ALCL) d) Mycosis fungoides e) Epstein Barr virus lymphoma 11) A patient presents with severe pruritus and generalized erythroderma and keratoderma of the palms and soles. Blood smear reveals an abnormality (shown) and the presence of CD3 and CD4 antigens. This abnormality is: a) Howell-Jolly body b) Basophilic stippling c) Pappenheimer body d) Heinz body e) Sézary body 12) Which of the following would exacerbate psoriasis?

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a) Topical corticosteroids, topical tar, topical synthetic vitamin D b) Antimalarials, beta blocks, lithium c) Topical retinoid (tazarotene), methotrexate, acitretin, cyclosporine d) Alefacept, narrow band UV-B exposure e) PUVA 13) Which of the following is true of UV-A and UV-B light? a) UVA (320-400nm) and UVB (280-320nm) cause burn reactions b) UVA (320-400nm) and UVB (280-320nm) do not cause burn reactions c) UVA (320-400nm) causes burn reactions d) UVB (280-320nm) causes burn reactions 14) Atophy (atopic syndrome) is an allergic hypersensitivity affecting parts of the body not in direct contact with the allergen. It may involve all of the following EXCEPT: a) Eczema b) Asthma c) Glomerulonephritis d) Rhinitis e) Conjunctivitis 15) A child presents with erythema of the scalp and face (shown). Similar erythema is seen on the anterior/flexor portion of the elbows. Which of the following is most likely? a) Atopic dermatitis b) Bullous pemphigoid c) Necrotizing fasciitis d) Sunburn e) Acne 16) A patient with atopic dermatitis is found to have weeping, crusting dermatitis (impetiginization). Labs show a bacteria that Gram stains. Which of the following is most likely? a) Staphylococcus aureus b) Molluscum contagiosum c) HPV d) Herpes simplex virus e) Pseudomonas aeruginosa 17) A young boy presents with erythema and pruritus after playing in the woods. History finds it is very likely the child was in contact with poison ivy. What type of hypersensitivity reaction is involved? a) Type I b) Type II c) Type III d) Type IV e) Type V 18) A patch test is performed by placing a substance under an aluminum disk covered with adhesive tape. The disk is left on the back for how long? a) 1 to 2 hours b) 6 to 12 hours c) 12 to 36 hours

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d) 48 to 96 hours e) 100 hours 19) All of the following may show positive reactions from a patch test. Which one is commonly found in cheap jewelry? a) Nickel sulfate b) Potassium dichromate c) Thimerosal and thirum d) Paraphenylenedimine and ethylenediamine e) Formaldehyde and fragrance f) Neomycin sulfate g) Benzocaine 20) What population is most commonly affected by acne? a) Infants b) Children during puberty c) Adult males d) Adult females e) Elderly and immunocompromised 21) Which of the following factors is involved in the development of acne? a) Inheritance b) Hormonal influences c) Bacterial infections d) Keratinization disturbances e) All of the above 22) Which of the following acne lesions are commonly known as whiteheads? a) Microcomedones b) Closed comedones c) Open comedones d) Papules e) Pustules 23) What is the treatment of choice for comedonal acne? a) Topical tretinoin and benzoyl peroxide b) Topical tretinoin, benzoyl peroxide, and topical antibiotic c) Topical tretinoin, benzoyl peroxide, and systemic antibiotic d) Systemic antibiotics only e) Isotretinoin 24) Systemic retinoids (isotretinoin, Accutane) are used for severe nodulocystic acne vulgaris. What is the major side effect associated with these drugs? a) Xerosis and dermatitis b) Cheilitis and sticky skin c) Peeling skin and epistaxis d) Hyperlipidemia and myalgias e) Teratogenicity 25) An elderly patient presents with body lesions (shown). Physical exam reveals large, tense bullae on an erythematous base with a predilection for flexural areas. Labs show a deposition of C3 in a linear pattern at the basement membrane zone and IgG. Systemic

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corticosteroids are administered. Which of the following is most likely? a) Cicatricial pemphigoid b) Bullous pemphigoid c) Necrotizing fasciitis d) Epidermolysis bullosa e) Atopic dermatitis 26) A child is born with a skin disorder. The child’s skin appears to be peeling off, particularly at the distal extremities. On return visits, the child has blisters and erosions in areas of trauma. Testing shows IgG with an absence of C3. Immunosuppressive therapy, which was started earlier, does not seem to be working. Which of the following is most likely? a) Cicatricial pemphigoid b) Bullous pemphigoid c) Dermatitis herpetiformis d) Epidermolysis bullosa e) Atopic dermatitis 27) A 74-year-old retired policeman noticed red, itchy eyes associated with whitish discharge that worsened over the past six weeks. Two weeks later, the patient consulted his ophthalmologist, who treated him antibiotic eye drops without a favorable response. The patient did not respond to the antibiotic and states he was biopsied. He was then placed on "two round white pills three times a day." Physical exam reveals a buccal mucosal ulcer and no cutaneous lesions. Which of the following is most likely? a) Cicatricial pemphigoid b) Bullous pemphigoid c) Dermatitis herpetiformis d) Epidermolysis bullosa e) IgA bullous dermatosis 28) An elderly patient presents with vesicles on an erythematous based with generalized distribution. Physical exam reveals mucosal involvement. History reveals the patient was recently started on vancomycin for a MRSA infection. Which of the following is most likely? a) Cicatricial pemphigoid b) Bullous pemphigoid c) Dermatitis herpetiformis d) Epidermolysis bullosa e) IgA bullous dermatosis 29) A 30-year-old man presents with extremely pruritic lesions. The lesions are mostly on his elbows and knees. History reveals thyroid disease and celiac disease. Lab testing with direct immunofluorescence shows IgA deposits along the basement membrane and the presence of IgA anti-endomysial antibodies. The patient is started on dapsone and told to continue a gluten-free diet. Which of the following is most likely? a) Cicatricial pemphigoid b) Bullous pemphigoid c) Dermatitis herpetiformis d) Epidermolysis bullosa e) IgA bullous dermatosis

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30) A patient presents with eruption of pruritic lesions on the elbows and knees. Testing shows basement membrane deposits of IgG, IgM, IgA, and C3 in a linear pattern. History reveals the patient is taking prednisone. Which of the following underlying disorders may be causing this bullous eruption? a) Sjögren syndrome b) Dermatitis herpetiformis c) Systemic lupus erythematosus d) Myasthenia gravis e) Type II diabetes mellitus 31) A patient presents with coalescing blisters and erosions on their body. Physical exam reveals oral lesions involving more than 90% of the oral mucosa. Labs reveal deposits of IgG and C3 at the intracellular (epidermal) space. Labs also reveal IgG anti-ICS antibodies. High dose corticosteroids are started. Which of the following is most likely? a) Cicatricial pemphigoid b) Pemphigoid vulgaris c) Epidermolysis bullosa d) Erythema multiforme e) Bullous pemphigoid 32) A man presents with skin lesions (shown). The lesions are maculopapular, urticarial, and some are bullous. The lesions have target morphology. History reveals the patient has HSV and was recently started on sulfonamides. Physical exam reveals involvement of the lips. Which of the following is most likely? a) Erythema nodosum b) Erythema infectiosum c) Erythema migrans d) Erythema multiforme e) Stevens-Johnson syndrome 33) A patient presents with target lesions on the body. They are maculopapular, urticarial, and some are bullous. There is extensive cutaneous involvement including mucosal lesions. The clinician feels the patient has a milder form of toxic epidermal necrolysis (TEN). Which of the following is most likely? a) Erythema nodosum b) Erythema infectiosum c) Erythema migrans d) Erythema multiforme e) Stevens-Johnson syndrome 34) What is the most common triggering factor for erythema nodosum, which presents with tender, erythematous, subcutaneous nodules localized to the pretibial areas? a) Streptococcal pharyngitis b) Yersinia enterocolitica infection c) Oral contraceptive use d) Behçet syndrome e) Sarcoidosis f) None of the above

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Integumentary

06Apr2009

Match the cutaneous reaction with the causative agents: 35.1) Aspirin, penicillin, blood products a) Slate-gray discoloration 35.2) Sulfonamides, thiazides, griseofulvin b) Slate-blue discoloration 35.3) Tetracyclines c) Urticarial 35.4) Chlorpromazine d) Yellow or blue-gray pigmentation 35.5) Amiodarone e) Phototoxic 35.6) Anti-malarials f) Photoallergic Integumentary #8 – Clinical: Cutaneous Signs of Underlying Malignancy 1) Cutaneous metastasis of cancer, such as lung, breast, kidney, GI, melanoma, or ovary, occurs in about 1% to 5% of all cases. Where are the common locations of metastasis? a) Scalp, face, and trunk b) Shoulders, trunk, and back c) Trunk and back d) Back, elbows, knees e) There are no common metastasis sites 2) Paget disease of the breast is nearly always associated with an underlying ductal carcinoma. In extra-mammary Paget disease, there is underlying malignancy 50% of the time. Where is the common site of extra-mammary Paget disease? a) Face and scalp b) Chest and back c) Abdomen d) Flexor surfaces e) Anogenital region 3) Acanthosis nigricans involves velvety brown plaques of the intertriginous regions. It is associated with all of the following EXCEPT: a) Obesity b) Adenocarcinoma of the GI tract c) Cigarette smoking d) Type II diabetes e) Prednisone 4) A patient with rheumatoid arthritis (RA) and irritable bowel disease (IBD) presents with an ulcer (shown). The lesion is irregular, inflammatory, and shows cribriform scaring. Which of the following is most likely? a) Gardner syndrome b) Pyoderma gangrenosum c) Acquired ichthyosis d) Acanthosis nigricans e) Sweet syndrome 5) A patient presents with soft tissue tumors. Sebaceous cysts of the face and scalp are seen. Testing shows an autosomal dominant disorder involving colon polyps. Which of the following is most likely? a) Gardner syndrome b) Pyoderma gangrenosum c) Acquired ichthyosis d) Acanthosis nigricans

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Integumentary

06Apr2009

e) Sweet syndrome 6) Which of the following is NOT associated with acquired ichthyosis vulgaris? a) Multiple myeloma b) Lymphoma c) Colon cancer d) Hodgkin lymphoma 7.1) A patient presents with a skin lesion that consists of erythematous plaques and nodules, mostly located on the proximal extremities and face. Testing reveals acute myelogenous leukemia (AML). Which of the following is most likely? a) Autoimmune bullous disease b) Dermatomyositis c) Hypertrichosis d) Cutaneous amyloidosis e) Sweet syndrome 7.2) A patient presents with a pruritic and photosensitive heliotrope rash. Physical exam reveals proximal muscle inflammation and Gottron papules of the fingers. The clinician worries about underlying malignancy. Which of the following is most likely? a) Autoimmune bullous disease b) Dermatomyositis c) Hypertrichosis d) Cutaneous amyloidosis e) Sweet syndrome 7.3) A patient with multiple myeloma presents with waxy papules on the eyelids. Physical exam reveals pinch purpura and macroglossia. Which of the following is most likely? a) Autoimmune bullous disease b) Dermatomyositis c) Hypertrichosis d) Cutaneous amyloidosis e) Sweet syndrome Integumentary #9 – Clinical: Dermatology, An Internist’s Perspective 1.1) A patient is found to have papules around the eyes and nasal erythematous swelling (lupus pernio). There are annular lesions with central atrophy and nodules on the trunk and extremities. Which of the following is most likely? a) ANCA-related granulomatosis b) Churg-Strauss granulomatosis c) Sarcoidosis d) Relapsing polychondritis e) SLE 1.2) Relapsing polychondritis involves episodic destructive inflammation of cartilage of the ear, nose, and throat. Thus it may lead to saddle nose. It is mediated by antibodies to what type of collagen? a) Type I b) Type II c) Type III

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Integumentary

06Apr2009

d) Type IV e) Type V 2.1) A patient presents to the emergency department with a suspected acute myocardial infarction. Physical exam reveals yellow papules on the neck, giving the appearance of plucked chicken skin. Which of the following is most likely? a) Pseudoxanthoma elasticum b) Churg-Strauss granulomatosis c) Ehlers-Danlos syndrome d) Relapsing polychondritis e) Erythema marginatum 2.2) Which of the following is a diagnostic criteria for rheumatic fever? a) Pseudoxanthoma elasticum b) Churg-Strauss granulomatosis c) Ehlers-Danlos syndrome d) Relapsing polychondritis e) Erythema marginatum 3.1) Which of the following presents with nosebleeds, GI bleeds, and cutaneous telangiectasias? a) Crohn disease b) Gluten-sensitive enteropathy c) Osler-Weber-Rendu syndrome d) Gardner syndrome e) Glucagonoma syndrome f) Peutz-Jeghers syndrome g) Acrodermatitis enteropathica h) Bowel bypass syndrome 3.2) Which of the following is associated with angular cheilitis (corner of the mouth), eruptions, blisters, alopecia, zinc deficiency, and diarrhea? a) Crohn disease b) Gluten-sensitive enteropathy c) Osler-Weber-Rendu syndrome d) Gardner syndrome e) Glucagonoma syndrome f) Peutz-Jeghers syndrome g) Acrodermatitis enteropathica h) Bowel bypass syndrome 3.3) A patient presents with macular pigmentation (freckles, shown) of the lips, periungual skin, fingers, and toes. Which of the following is most likely? a) Crohn disease b) Gluten-sensitive enteropathy c) Osler-Weber-Rendu syndrome d) Gardner syndrome e) Glucagonoma syndrome f) Peutz-Jeghers syndrome g) Acrodermatitis enteropathica h) Bowel bypass syndrome

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Integumentary

06Apr2009

3.4) Which of the following is associated with pyostomatitis vegetans, an inflammation of the gingival surfaces? a) Crohn disease b) Gluten-sensitive enteropathy c) Osler-Weber-Rendu syndrome d) Gardner syndrome e) Glucagonoma syndrome f) Peutz-Jeghers syndrome g) Acrodermatitis enteropathica h) Bowel bypass syndrome 4.1) Which of the following is associated with C3 deficiency and nephritis syndrome? a) Partial lipodystrophy b) Relapsing polychondritis c) Erythema multiforme d) Uremic pruritus e) Stevens-Johnson syndrome 4.2) Which of the following is associated with end stage renal disease and responds to UVB therapy? a) Partial lipodystrophy b) Relapsing polychondritis c) Erythema multiforme d) Uremic pruritus e) Stevens-Johnson syndrome 5.1) A child presents with vision problems and parasthesia. Testing reveals corneal opacities, numerous vascular tumors (angiokeratomas), and an X-linked recessive deficiency of alpha-galactosidase. Which of the following is most likely? a) Sturge-Weber-Dimitri syndrome b) Fabry disease c) Tuberous sclerosis d) Ataxia-telangiectasia e) Neurofibromatosis 5.2) A patient presents with hypopigmented macules. Physical exam reveals adenoma sebaceum, subungual fibromas, and a shagreen patch (connective tissue nevus, shown). The patient has a history of epilepsy. Which of the following is most likely? a) Sturge-Weber-Dimitri syndrome b) Fabry disease c) Tuberous sclerosis d) Ataxia-telangiectasia e) Neurofibromatosis 5.3) Which of the following is associated with café au lait spots, Lische nodules of the iris, and axillary freckling (Crowe sign)? a) Sturge-Weber-Dimitri syndrome b) Fabry disease c) Tuberous sclerosis d) Ataxia-telangiectasia

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Integumentary

06Apr2009

e) Neurofibromatosis 5.4) Which of the following is associated with capillary angiomas (port wine stain, shown) in the distribution of the upper or middle trigeminal nerve branch as well as intracranial calcification? a) Sturge-Weber-Dimitri syndrome b) Fabry disease c) Tuberous sclerosis d) Ataxia-telangiectasia e) Neurofibromatosis 6.1) Although psoriatic arthritis is associated with all of the following, which involves urethritis, conjunctivitis, arthritis, HLA-B27, circinate balanitis (erythematous plaques of the penis), and keratoderma blennorrhagicum (pustular psoriasiform eruptions of the palms and soles, shown)? a) Lyme disease b) Morphea c) Basic psoriatic arthritis d) Reiter syndrome e) Scleroderma f) Lupus erythematosus g) Eosinophilic fasciitis 6.2) Which of the following involves calcinosis cutis, Raynaud phenomenon, esophageal problems, sclerodactyly, telangiectases, and anti-centromere antibodies? a) Lyme disease b) Morphea c) Basic psoriatic arthritis d) Reiter syndrome e) Scleroderma f) Lupus erythematosus g) Eosinophilic fasciitis 6.3) Which of the following manifests as a tight bound thickening of the skin underlying soft tissue of the extremities and may have arthralgias and hypergammaglobinemia? a) Lyme disease b) Morphea c) Basic psoriatic arthritis d) Reiter syndrome e) Scleroderma f) Lupus erythematosus g) Eosinophilic fasciitis 6.4) Which of the following involves discrete sclerotic plaques with a white, shiny center and erythematous or violaceous periphery (shown)? a) Lyme disease b) Morphea c) Basic psoriatic arthritis d) Reiter syndrome e) Scleroderma f) Lupus erythematosus

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Integumentary

06Apr2009

g) Eosinophilic fasciitis 7) A patient presents to the emergency room with complaints of new lesions. History reveals the patient is on an immunosuppression regimen that started about a month ago. Physical exam reveals a lichenoid reaction with cutaneous and oral lesions (like lichen planus), coalescing violaceous papules on the skin, and poikilodermatous-reticulated lesions. Which of the following is most likely? a) Urticaria pigmentosa b) Systemic mast cell disease c) Acute graft versus host disease d) Chronic graft versus host disease e) Mast cell leukemia 8) During an examination, a patient is found to have yellow-brown atrophic telangiectatic plaques that ulcerate on the anterior shins (necrobiosis lipoidica). Further exam reveals eruption of small, firm, flesh-colored annular papules (granuloma annulare). What underlying disease is most likely? a) Systemic lupus erythematosus b) Lyme disease c) Diabetes d) Reiter syndrome e) Graft versus host disease 9.1) A patient presents with a progressive history of blisters, photosensitivity, scarring, and alopecia (shown). Physical exam reveals red-stained teeth and splenomegaly. Blood tests show hemolytic anemia. Which of the following is most likely? a) Acute intermittent porphyria b) Erythropoietic protoporphyria c) Variegate porphyria d) Porphyria cutanea tarda e) Erythropoietic porphyria 9.2) Which of the following is associated with a ferrochelatase deficiency? a) Acute intermittent porphyria b) Erythropoietic protoporphyria c) Variegate porphyria d) Porphyria cutanea tarda e) Erythropoietic porphyria 9.3) A 30-year-old patient presents to the emergency department with skin blistering. History reveals he was on vacation, drinking with friends on the beach most of the week. Physical exam reveals milia, hypertrichosis, skin fragility, and hyperpigmentation. Testing reveals a defect in uroporphyrinogen decarboxylase. Which of the following is most likely? a) Acute intermittent porphyria b) Erythropoietic protoporphyria c) Variegate porphyria d) Porphyria cutanea tarda e) Erythropoietic porphyria

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Integumentary

06Apr2009

Integumentary #10 – Clinical: Nail Clues to Systemic Disease 1) Onycholysis is the distal and lateral separation of the nail plate form the nail bed and is seen in which of the following? a) Psoriasis b) Lichen planus c) Infection (candida or pseudomonas) d) Nail cosmetic or drug reaction e) All of the above 2) Nail pitting is associated with alopecia areata and more commonly with: a) Thyroid disease b) Pseudomonas infection c) Hypoalbuminemia d) Psoriasis e) Renal failure Match the nail disorder with the associated diseases: 3.1) Cirrhosis a) Beau lines (transverse grooves) 3.2) Hypoalbuminemia b) Blue lunula 3.3) Renal failure c) Lindsay nails (red distal) 3.4) Chronic edema, pulmonary disease d) Mee lines (horizontal white bands) 3.5) High fever, chemotherapy, drugs e) Muehrcke lines (white parallel bands) 3.6) Iron deficiency anemia, trauma f) Spoon nails (koilonychias) 3.7) Hepatolenticular degeneration, argyria g) Terry nails (proximal nail whitening) 3.8) Arsenic poisoning h) Yellow nails 3.9) What is shown here? a) Beau lines b) Lindsay nails c) Terry nails d) Mee lines e) Muehrcke nails 3.10) What is shown here? a) Beau lines b) Lindsay nails c) Terry nails d) Mee lines e) Muehrcke nails 3.11) What is shown here? a) Beau lines b) Lindsay nails c) Terry nails d) Mee lines e) Muehrcke nails 4) An AIDS patient presents with dark oval papules oriented along skin lines of the trunk, extremities, face, and mucosa. Which manifestation of AIDS is most likely? a) Molluscum contagiosum b) Bacillary angiomatosis c) Kaposi sarcoma

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Integumentary

06Apr2009

d) Candidiasis with oral hair leukoplakia e) Herpes zoster and herpes simplex Integumentary #11 – Thermal Burns 1) Which of the following is NOT a major factor that influences the clinical significance of a burn? a) Burn depth b) Body surface area involved c) Use of broad-spectrum antibiotics d) Possible presence of internal injuries e) Promptness and efficacy of therapy 2) Which of the following is NOT characteristic of a full-thickness (third degree) burn? a) White b) Dry c) Charred d) Painful 3) Which of the following is affected in a partial thickness (second degree) burn, which usually blisters? a) Epidermis only b) Epidermis and superficial dermis c) Epidermis and complete dermis d) Epidermis, dermis, and subcutaneous tissue e) Epidermis down to muscle tissue 4) The prognosis is grave and potentially fatal for burns exceeding what percentage of total body surface area? a) 50% b) 40% c) 35% d) 30% e) 20% 5) Due to a rapid shift of body fluids to the interstitial compartments both at the burn site and systemically, hypovolemic shock can occur with burns covering what percentage of the body surface area? a) 50% b) 40% c) 35% d) 30% e) 20% 6) Which of the following, along with burning plastics, is lipid soluble and thus is more likely to reach deeper airways and cause pneumonitis? a) Chlorine gas b) Sulfur oxide gases c) Nitric oxide gas d) Ammonia gas 7.1) What is the most common organism seen in second-degree burn infection? a) Staphylococcus aureus

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Integumentary

06Apr2009

b) Streptococcus pyogenes c) Pseudomonas aeruginosa d) Aeromonas hydrophila e) Streptococcus pneumoniae 7.2) What is the most likely nosocomial infection seen in second-degree burns? a) Staphylococcus aureus b) Streptococcus pyogenes c) Pseudomonas aeruginosa d) Aeromonas hydrophila e) Streptococcus pneumoniae 8.1) A 54-year-old man receives burns to his right arm, his head, and his back torso. What percentage of total body surface area is involved? a) 9% b) 18% c) 27% d) 36% e) 45% 8.2) Which of the following is NOT considered 18% of total body surface area for the adult Rule of Nines? a) Front torso b) Back torso c) Both arms d) Head e) One leg James Lamberg

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Integumentary AnswerKey Derm #1 1) C 2) F 3) A 4) G 5) E 6) H 7) B 8) D 9) D 10) C 11) A 12) C 13) B 14) A 15) B 16) B 17) D 18) E 19) A 20) C 21) E 22) C 23) C 24) E 25) A 26) D 27) D 28) A 29) B 30) B 31) E 32) C 33) B 34) A 35) C 36) D 37) B 38) D 39) B 40) C 41) E 42) B 43) E

06Apr2009 Derm #2 1) A 2) A 3) E 4) E 5) C 6) D 7) B 8) E 9) C 10) C 11) E 12) B 13) D 14) B 15) C 16) A 17) C 18) D 19) A 20) B 21) E 22) D 23) A 24) B 25) A Derm #3 1.1) C 1.2) E 1.3) B 1.4) F 1.5) C 1.6) G 1.7) D 2) A 3) E 4) C 5.1) D 5.2) E 6) E 7) D 8) C 9) B 10) B 11) A

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12) A 13.1) B 13.2) C 14) E 15) A 16) E 17) A 18) D 19) E 20.1) A 20.2) A 20.3) A 20.4) A 20.5) A 20.6) D 20.7) D 20.8) B 20.9) A 20.10) D 20.11) E 20.12) B 20.13) D 20.14) D 20.15) D 20.16) C 20.17) A 21) B 22.1) A 22.2) B 23) D 24) C 25.1) C 25.2) A 26) D 27) B 28) C 29) E 30) A 31) B 32) A 33) F 34) D 35) C 36) C 37) C 38) A

39) A Derm #4 1) E 2) D 3.1) D 3.2) C 4.1) D 4.2) B 5.1) E 5.2) B 5.3) A 6) C 7) A Derm #5 1) C 2) A 3.1) B 3.2) E 3.3) D 4) E 5) B 6) B 7) A 8) C 9) E 10) C 11) D 12) A 13) D 14) B 15) D 16) C 17) E 18) C 19) D 20) D 21) A 22) C 23) A 24) B 25) D 26) C 27) E

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Integumentary Derm #6 1.1) D 1.2) H 1.3) G 1.4) E 1.5) I 1.6) L 1.7) B 1.8) A 1.9) J 1.10) M 1.11) K 1.12) C 1.13) F 1.14) H 1.15) K 1.16) G 1.17) A 1.18) J 1.19) C 1.20) B 1.21) L 1.22) F 1.23) E 1.24) D 1.25) M 1.26) N 1.27) I 2) A 3) D 4) A 5) D 6) E 7) A 8) B 9) F 10) C 11) B 12) C 13) B 14) D 15) C Derm #7 1) E 2) E

06Apr2009 3) B 4) C 5) D 6) E 7) C 8) A 9) A 10) D 11) E 12) B 13) D 14) C 15) A 16) A 17) D 18) D 19) A 20) B 21) E 22) B 23) A 24) E 25) B 26) D 27) A 28) E 29) C 30) C 31) B 32) D 33) E 34) A 35.1) C 35.2) F 35.3) E 35.4) A 35.5) B 35.6) D Derm #8 1) A 2) E 3) C 4) B 5) A 6) C

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7.1) E 7.2) B 7.3) D Derm #9 1.1) C 1.2) B 2.1) A 2.2) E 3.1) C 3.2) G 3.3) F 3.4) A 4.1) A 4.2) D 5.1) B 5.2) C 5.3) E 5.4) A 6.1) D 6.2) E 6.3) G 6.4) B 7) D 8) C 9.1) E 9.2) B 9.3) D

Derm #11 1) C 2) D 3) B 4) A 5) E 6) C 7.1) C 7.2) A 8.1) D 8.2) D

Derm #10 1) E 2) D 3.1) G 3.2) E 3.3) C 3.4) H 3.5) A 3.6) F 3.7) B 3.8) D 3.9) C 3.10) A 3.11) B 4) C

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