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NBME 21 Answers

nbme21/Block 1/Question#26 (36.1 difficulty score)
A 62-year-old man who is a farmer comes to ...
Actinic keratosisπŸ”

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submitted by sympathetikey(1265),
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hTe lwoeh iskp"c ta teh o.icsa..slneseu mose g,elie"ndb amde me khnit rsios.asPi dSoluh aevh oeng htwi nActcii Kssatroie desab no teh tiepnat iosrhty s(olt fo usn )ueposxe.r

cActini seoarKist

nantgamrePli nsielos decusa yb nsu .pseurexo Smll,a uhg,or rhmatuysteeo or oirhwbsn espalpu e.psr uqaol Risk fo qoasusum lcle niaomcacr si lroaopnrtipo ot greeed of ailltephie aa.ylpdiss

thisisfine   Same - the bleeding thing pushed me over to psoriasis as well. Oops. +5  
temmy  the distribution of the other lesions, forearm, face, ear, not characteristic for psoriasis. +6  
hyperfukus  the scalp and ear are actually very common for psoriasis IRL the key is more of the fact that its in areas with UV exposure...actually UV Therapy is found to be helpful in treating some pts w/Psoriasis. Lastly the appearance and lots of things bleed if they were trying to go for auspitz sign it would have tiny dots of bright red blood with slightly touching it +4  
hyperfukus  oh last thing psoriasis itches! they said no itching +4  
drzed  Those locations may be common IRL, but on step 1, if they want you to think psoriasis, the illness script is going to be someone in their 30s (autoimmune age) with symmetric cutaneous plaques that have a silvery scale on the extensor surfaces. In this case, the age and non-classic description (location, type of lesion) made me steer away from psoriasis. +1  

submitted by niboonsh(338),
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i khint fo htis as elo rerfma ejo no ihs ccainit fram ipnckig kraats ota(rr)cs iac(citn essrkita)o

bbr  haha good point +  

submitted by cry2mucheveryday(17),
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i lfel fro lgeindbe omfr insloe ta sceho posriassi tub sissairpo tps pxneceieer ig.tinhc Aso,l het nuottriidbis is ont tacrh.crcitsiae

makinallkindzofgainz  Yes it is. These areas are all sun-exposed areas, and he is a farmer. Multiple years of sun-exposure can lead to Actinic Keratosis, a precursor of SCC. +3  
mangotango  @makinallkindzofgainz -- I think cry2mucheveryday means "distribution is not characteristic" of psoriasis +1