Dermatology III scenarios

Question 1

A 65 year old white farmer presents with a reddish translucent (“pearly”) papule with a rolled border and telangiectasia in his nasolabial fold. He says it has grown slowly.

1) Likely Dx?
2) Testing?
3) Tx?

Answer 1

1) Nodular BCC
2) Clinical, confirmed microscopically with biopsy
3) Mohs (since it’s on his face)

Question 2

A 57 year old red-haired pilot presents with a brownish bluish oval papule in the post-auricular region.

1) Likely Dx?
2) DDxs?

Answer 2

1) Pigmented BCC
2) Superficial spreading melanoma, nodular melanoma

Question 3

An 86 year old man presents w a smooth, flesh-colored plaque with ill-defined borders on his chest. It has a scar-like appearance. He reports that he spent lots of time outside in the sun shirtless in his youth.

1) Likely Dx?
2) How common is this Dx?
3) Tx?

Answer 3

1) Morpheaform BCC (sclerosing BCC)
2) 5-10% of BCC cases
3) Mohs (must use for this type)

Question 4

An 83 year old retired trucker with a Dx of AK (actinic keratosis) on his face presents with a few scaling macules and hyperkeratotic patch at the site of the AK. He reports that these lesions have evolved quickly.

1) Likely Dx?
2) How would you Dx?

Answer 4

1) SCC
2) Biopsy (shave, punch, or excisional)

Question 5

A 74 year old organ transplant recipient presents with a group of small, slightly scaly, pinkish reddish patches and thin plaques on his trunk.

1) Potential Dx?
2) DDx?
3) Txs?

Answer 5

1) Superficial SCC
2) Actinic keratosis
3) In Situ: imiquimod or 5-fluorouracil, curettage & electrodessication
Invasive: excision or Mohs surgery

Question 6

A pt presents with a 1.5mm pigmented papule that fits all the ABCDE criteria for melanoma. There is no ulceration or bleeding, however.

1) How do you Dx?
2) How do you Tx this pt if the melanoma Dx is made?

Answer 6

1) Excisional biopsy: must take wide margin (1 cm margin for every 1mm of lesion depth.) or punch biopsy
2) Excision & histology, followed by re-excision with borders based on thickness of tumor (pathology report)
-Referral to centers with expertise in melanomas for intermediate-to-high risk patients
-Sentinal lymph node biopsy (since the lesion is >1 mm thickness)

Question 7

A pt with HIV presents with purple, brown, and black patches, plaques, & nodules around their ankle.

1) Potential Dx? What is this Dx linked with?
2) Tx options? Is their prognosis good?

Answer 7

1) Kaposi sarcoma; linked with HSV-8 infection
2) Radiation, chemotherapy, antivirals; typically responds to treatment

Question 8

An adult woman presents with a 25cm macular hyperpigmented patch that she has had since birth.

1) What is this?
2) Do you need to do anything?

Answer 8

1) Large/ giant congenital nevus (bc it’s >20cm)
2) For large/giant congenital nevi, the risk of developing melanoma is ~ 5-10%, so monitor yearly with photos

Question 9

Is your pt at an increased risk for melanoma if:
1) They have 40 nevi and 1 atypical nevi & 1 9mm nevus

Answer 9

1) No; criteria is: pts with >50 nevi with >1 atypical nevi & 1 nevus >8 mm

Question 10

A pt has a 6mm variegated (brown and pink) macule with a “fried egg” appearance on their chest.

1) Likely Dx? How do you Dx?
2) DDx?
3) Can you do a shave biopsy?

Answer 10

1) Atypical nevi; clinical, dermoscopy, biopsy if suspect melanoma
2) Melanoma
3) NOOOOO never do a superficial shave biopsy of a pigmented lesion that is a possible melanoma.

Question 11

A pt has an abscess.

1) What’s the most likely cause?
2) Tx?

Answer 11

1) S. aureus
2) Get the pt to stop poking it, and:
-Must perform incision and drainage (I&D)
-Irrigation
-Have patient apply heat/warm compress afterwards
(Do not typically need PO antibiotics)

Question 12

A pt has edema, erythema, extreme warmth and severe pain on their leg unilaterally.

1) Possible Dx?
2) DDxs?
3) What is are the common causes of this Dx?
4) Do you admit this pt?

Answer 12

1) Cellulitis
2) DVT, necrotizing fasciitis
3) Group A Beta-hemolytic streptococci or S. aureus
4) Yes, bc their localized Sx are extreme.

Question 13

How would you treat a pt with cellulitis if they came into your walk-in clinic?

Answer 13

1) Mark borders to track
2) Antibiotics (IV vs PO) ex/ PO Cephalexin 500mg PO BID IV/IM Cefazolin 0.5- 1 gm q6-8 hr

Question 14

When would you admit a pt with cellulitis?

Answer 14

Severe local symptoms, WBC > 10K, failure to respond to PO antibiotics, systemic symptoms

Question 15

A pregnant pt has erythema with a butterfly distribution on her face with decently well-defined borders. She has been experiencing chills and malaise.

1) Potential Dx? What is this Dx?
2) Tx options?

Answer 15

1) Erysipelas; superficial form of cellulitis due to beta-hemolytic strep
2) IV vs PO antibiotics:
Cephalexin 500mg PO q12hr OR
Cefazolin 0.5 – 1 gm q6-8 hr

Question 16

4 y/o male presents with papules, vesicles, and honey-colored crust below his nose.

1) Potential Dx? Is it contagious?
2) Tx?

Answer 16

1) Impetigo; contagious
2) Topical antibiotics (mupirocin) especially in nares BID x 5d
-PO Cephalexin PO x 5-7 d as indicated for underlying infection (will treat group A strep and S. aureus )

Question 17

An adult pt comes in with their both of their entire arms and half of one leg burnt.

What % of their TBSA is affected, and is it considered severe? Explain how you know.

Answer 17

27%; severe (over 20%)
-arms are each 9%, each leg is 18%

Question 18

What % of TBSA is affected if your pt’s entire torso and head are burnt? Explain.

Answer 18

45%
-front of torso is 18%, back is 18%, head is 9%

Question 19

A pt has a severe burn, and you need to stabilize them fast. What are the ABCs of burns?

Answer 19

Airway, Breathing, Circulation, Disability, Exposure

Question 20

An adult pt presents with a burn. What is the formula can you use to treat them?

Answer 20

Parkland formula

[4ml/kg x % TBSA, ½ given in first 8 hrs = MLs of fluid req. in first 24 hrs]

Question 21

Both of a pt’s palms are burnt, but nothing else. Do they need to be transferred to the burn unit?

Answer 21

No; palms are 1% of TBSA (transfer ~5-10% TBSA)

Question 22

Your burn pt now has hyperglycemia. What does this tell you?

Answer 22

Predictor of worse outcomes

Question 23

A pt had a firm, dermal papule or nodule with an overlying black comedone (punctum) on their scalp. When expressed, there was foul-smelling cheesy material. It later became red and drained.

1) Dx? What is this?
2) Tx options for this Dx?

Answer 23

1) Epidermal inclusion cyst (EIC); benign growth of upper hair follicle
2) None if asymptomatic-tell patients not to manipulate
-I&D
-Surgical excision if symptomatic

Question 24

A pt has a full-thickness pressure ulcer down to their SQ tissue. What stage is this?

Answer 24

Stage III

Question 25

A pt’s pressure ulcer has exposed muscle and bone. What stage is this?

Answer 25

Stage IV

Question 26

A pt has had random white macules begin spreading around their mouth and knuckles

1) Likely Dx?
2) Tx?

Answer 26

1) Vitiligo
2) Psychological; Oral PUVA psoralen (drug) and ultra-violet radiation
-Can use tinted creams/makeup to cover lesions in cosmetically sensitive areas

Question 27

A 35 year old female on OCP and anti-seizure meds has hyperpigmented sharply demarcated macules in sun exposed areas on her face.

1) Likely Dx?
2) Tx?
3) How is this condition prevented?

Answer 27

1) Melasma
2) Tx: hydroquinone 3% soln, 4% crm azelaic acid 20% crm
Can be compounded or in combo with tretinoin or glycolic acid. Lasers can worsen
3) Sun blocks, hats, UV protectant on car windows

Question 28

A pt, who just went to the beach, has a bunch of red macules and papules on the backs of their hands and on their face. What could this be?

Answer 28

Photoallergic rxn

Question 29

A pt has a painless chancre. Your first thought should be?

Answer 29

Syphilis

Question 30

A pt has a rash on their palms and soles and a painless chancre.

1) These are the classic Sx of what?
2) Tx?

Answer 30

1) Syphilis (Treponema pallidum (spirochete))
2) Penicillin G IM/IV QD x7d