M1- -1-1 -: M1 --1-1- : M1 --1-1-: . -- --... -- --.... -- --.. ~. ~. ~. Roger Allen Dermatology Springer-Verlag London Berlin Heidelberg New York Paris Tokyo Hong Kong Bernard Roger Allen, MB ChB, FRCP Consultant Dermatologist, Department of Dermatology, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK Publisher's note: The "Brainscan" logo is reproduced by courtesy of The Editor, Geriatric Medicine, Modern Medicine GB Ltd. ISBN -l3: 978-3-540-19607-5 e-ISBN -l3 :978-1-4471-1772-8 DOl: 10.1007/978-1-4471-1772-8 British Library Cataloguing in Publication Data Allen, Roger, 1940- Dermatology. 1. Medicine. Dermatology I. Title 616.5 ISBN-13:978-3-540-19607 -5 Library of Congress Cataloging-in-Publication Data Allen, Roger, 1940- Dermatology/Roger Allen. p. cm. ISBN -13 :978-3-540-19607-5 1. Dermatology-Examinations, questions, etc. I. Title. [DNLM: 1. Skin Diseases-examination questions. WR 18 A428d] RL74.2.A44 1990 616.5'0076-<1c20 DNLM/oLc for Library of Congress 90-9651 CIP Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. © Springer-Verlag London Limited 1990 The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Produce liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Typeset by Photo·graphics, Honiton, Devon 2128/3916-543210 Printed on acid-free paper Preface Dermatology is a fascinating subject. This is a statement you might expect from a dermatologist, but what is the justification? It is a highly clinical specialty and sophisticated techniques of diagnosis are very much of secondary importance compared with clinical skills. The skin is important not only as an organ with vital physiological functions but also as a flag by which we communicate with the outside world. A perfect skin is desired by all, and upon this wish is based the multi-million pound cosmetics industry. Skin disease therefore places a strain on sufferers out of proportion to the disturbances in function which the pathology produces. A "leper" complex is frequent, and social and sexual contact may be shunned because of the embarrassment caused. It is also easy to overlook the contribution that cutaneous physical signs make towards diagnoses of internal disorders. Even straightforward factors such as the pallor of anaemia, the icterus of biliary obstruction or, quite simply, the age and sex of the patient are recognised immediately from visible signs in the skin. Like most other organs the skin has a limited repertoire of reactions, but these can occur in patients of all ages, combined together in an almost infinite number of permutations; hence the fascination referred to above. It has been estimated that 10% of consultations with general practioners are because of a skin-related problem, and therefore a working knowledge of dermatology is essential for anyone who has regular clinical contact with patients. This book is aimed not only at medical students but also at those undertaking a VTS course for general practice or studying for the MRCP diploma, for whom it should provide a useful revision guide. Nottingham Roger Allen 1989 How to Use This Book As a method of examination the use of multiple choice questions is likely to be a permanent and expanding feature on the educational scene. MCQs have their critics, but because of the wide range of topics which can be covered in one paper, and the ease with which responses can be marked by computer and analysed for effectiveness using such systems as the Kuder-Richardson reliability index, they have, in many fields, replaced more traditional examinations. They also lend them selves admirably to an efficient method of revision, and that is what has prompted this series of MCQs in dermatology. There is no doubt that the best method of revision is not to read repeatedly through notes or texts but to answer questions ("What are the clinical features of Ehlers-Danlos syndrome?" "What are the symptoms of acute vitamin A toxicity?"). An attempt to apply a combination of knowledge and logic to a question followed then by reference to a book or notes will fix the subject in the mind to a degree surpassed only by having to carry out the same exercise in front of others. (To make a mistake in public greatly sharpens the mind.) It is with this approach that this series of multiple choice questions should be tackled. By considering and working through the 200 stems and 1000 suggested answers contained in this book it should be possible to acquire a reasonable basic grounding in the field of dermatology. Many of the questions have been derived from a series of examination papers developed to assess the students at Nottingham University Medical School, where a two-month attachment to the Department of Dermatology is part of the middle-year curriculum. Most of the questions can be answered with a knowledge of one of the shorter undergraduate textbooks such as Essentials of Dermatology by J.L. Burton (Churchill Livingstone) or Clinical Dermatology: Illustrated Textbook by R.M. Mackie (Oxford University Press), but not all of them. There has to be an element of challenge, and reference to a larger work such as Textbook of Dermatology edited by A. Rook, 0.5. Wilkinson, F.J.G. Ebling and J.L. Burton (Blackwell Scientific Publications) may occasionally be required. Each question consists of a stem followed by five statements, none of which derives from or excludes any of the others. At least one correct and one incorrect answer follows each stem. A correct answer, either true or false, should be scored as + 1, an abstention as 0 and an incorrect answer as -1. Two medical aphorisms are that one should never say "Never" and that the more one knows about a subject the more difficult it is to give a straight "Yes" or "No" answer to a multiple choice question. Bear this in mind and use these questions sensibly, without looking for tricks and without believing that you should know about every exception to the general rule. It is worth remembering that examiners setting MCQs will tend to give false examples that are well outside the normal findings so that there can be less argument about whether the response is correct or not. Go through the papers with a friend and argue about the answers - it is a good way to learn and can be fun, though that might depend on the friend. General guidelines for answering these and other MCQs are: 1. Read the question carefully. This seems obvious but it is often a source of simple mistakes. For example, is the question asking for a positive or a negative answer (" All 'x' do show 'y'" or "All 'x' do not show 'y''')? After reading the stem it is worth thinking about the topic for a moment or two before looking at the alternatives presented. For example, if the stem says "In basal cell carcinomata ..." think briefly about what you know about the lesions. Then look at what is given; some of the things you have thought about may be in front of you. 2. Do not guess. Most multiple choice wrong answers are included because they have a certain familiar ring about them; they are close to the truth but not quite close enough. Therefore, if you are totally ignorant about a subject do not try to answer the questions. 3. Be decisive. If you think an answer is correct mark it as such and move on. If you spend too long on thinking about an answer you can almost always persuade yourself that it is right, or wrong as the case may be. 4. If the answer is not obvious after careful reading miss the question out and come back to it at the end. 5. Ignore statistics. Just answer each question as it is set and do not try to work on the basis either of how many marks you have already scored or how many right or wrong answers have been presented. The questions in this book have been divided into 10 revision papers of 20 questions each. Each paper covers a wide range of topics. Many of the answers are followed by brief explanatory comments, but when tackling the questions it is a good idea to have a textbook to hand so that you can carry out further reading on an immediate basis whilst the subject is still fresh in your mind. Contents Paper 1 .................................................................................. 2 Paper 2 .................................................................................. 14 Paper 3 .................................................................................. 24 Paper 4 .................................................................................. 34 Paper 5 .................................................................................. 44 Paper 6 .................................................................................. 54 Paper 7 .................................................................................. 64 Paper 8 .................................................................................. 74 Paper 9 .................................................................................. 84 Paper 10 ................................................................................ 94 Paper 1 Questions Q.l.l Psoriasis a. may involve the external auditory meatus b. is likely to be more severe if close relatives have the disease c. may be associated with an ankylosing spondylitis type of arthritis d. can cause actual disappearance of the phalanges e. occurs in a pustular form only on the hands and feet Q.l.2 Neurofibromatosis a. is an autosomal recessive condition b. may start with cafe au lait patches c. produces characteristic hard nodules in the skin d. usually first becomes evident at the time of puberty e. is a cosmetic problem only in the vast majority of patients Q.l.3 Purpura may be a feature of a. Henoch-Schonlein disease b. excessive use of 1 % hydrocortisone c. lichen planus d. amyloidosis e. a positive Hess test Q.1.4 Venous insufficiency of the lower limb a. is always the result of damage to the veins b. causes an eczema in most cases c. is defined as occurring when tissue osmotic pressure exceeds venous capillary pressure d. may produce "atrophie blanche" even in the absence of ulceration e. may damage the muscles For answers see over 3