DONE: Minor Surgery Flashcards
Diagnosis this: a soft fluctuant mass, localized collection of pus, painful and tender, erythematous what bugs are most common? is a gram stain and culture recommended? recommended treatment? when would we give ABX?
abscess
S. aureus
usually yes
incision and drainage (#11 scalpel and hemostat) using a field block > break up the loculations and DO NOT CLOSE - pack with iodoform gauze
if there were symptoms of a systemic inflammatory response
Diagnosis this: infection of multiple hair follicles, a coalescent inflammatory mass with pus draining from multiple sites mc bug? mc place they appear? population in which they are common? how different from a furuncle? how is it treated?
carbuncle staph aureus back of the neck diabetes larger and deeper than furuncles incision and drainage
Diagnosis this: infection of the hair follicle, an inflammatory nodule with overlying pustules
mc bug?
treated?
how is it different from folliculitis?
furuncle/boil
s aureus
incision and drainage, can also apply moist heat and it could rupture and drain spontaneously
folliculitis is more superficial and the pus is limited to the epidermis, not the dermal or subQ layer
Diagnosis this: soft, painless mass that have a rancid odor, noncompressible. they are usu congenital and occur in lines of cleavage, and around eyes and on base of nose?
DX?
dermoid cyst
preop CT is recommended as they can extend intracranially
Diagnosis this: skin-colored nodule with a central punctum that is freely moveable and contains skin flora in a cheesy keratinous material
TX?
epidermoid cyst/epidermal inclusion cyst
incision and drainage if inflamed > break up the loculations!
Diagnosis this: soft and mobile, slow growing, firm, fluctuant nodule with a small central well?
what is it filled with?
common location?
treatment?
sebaceous cyst
filled with keratin, sebum
behind the ears, scalp, back of neck or shoulders, arm
incision and removal of the entire mass - removal of entire mass helps reduce recurrence (would make an elliptical incision, in a lipoma it would be an incision down the middle)
Diagnosis this: lumps that develops along tendons or joints of wrists or hands, pain with pressure, hard, fixed smooth lesion?
Tx?
ganglion cyst
TX: refer to someone: immobilize, aspirate, or excision
Diagnosis this: skin-colored, odorless cyst on the scalp, caused by protein buildup in a hair follicle. painless, firm, and smooth
TX?
trichilemmal/pilar cyst or wen
tx: minimal excision technique
Diagnosis this: firm, white papules 1-2 mm lesions
Tx?
milia
nick with a #11 blade and express keratinaceous white kernel
Diagnosis this: fibroepithelial polyp that ranges between 1-10 mm
acrocordon/skin tag
lift and snip, excision, electrodessication, or cryosurgery
Diagnosis this: rough, scaling skin with a risk of SCC, sandpaper like texture, hyperkeratotic, pearly gray white appearance?
how to DX?
TX?
actinic keratosis
biopsy any lesions that are resistant to treatment
tx: liquid nitrogen, 5FU, photodynamic therapy, excision
Diagnosis this: dome-shaped, 0.1-0.4 cm red lesions that blanch with pressure
TX?
cherry hemangioma
TX: we DO NOT cut into these lesions - esp if cavernous, but could be treated with: electrocautery and 1% lidocaine, shave excision and electrocautery, laser therapy, or cryo
Diagnosis this: cone-shaped lesion made of keratin
TX?
cutaneous horn
excision, liquid nitrogen
Diagnosis this: skin lesion that erupts in sun-damaged skin, a variant of SCC
tx?
keratoacanthoma
tx: surgical excision, electrotherapy and curettage, 5fu
Diagnosis this: liver spots, usually benign from excessive sun exposure
solar lentigo
tx: liquid nitrogen, excision and biopsy
Diagnosis this: dark spot
nevus
tx: cryo, cautery, hyfrecator, radiosurgery, laser (no scalpel)
Diagnosis this: small, red papule that grows rapidly over weeks to months and then stabilizes
pyogenic granuloma
tx: surgical excision, laser, cryo, etc
Diagnosis this: yellowish or skin colored soft small papules on the face - usu nose, cheeks, and forehead
tx?
sebaceous hyperplasia
tx: electrodessication, laser, cryo, phototherapy
Diagnosis this: initially a flat macule > waxy verrucous papule is usually described as stuck on
diagnosis?
treatment?
seborrheic keratosis
if unsure of DX, get a BX
curettage or liquid nitrogen
Diagnosis this: threadlike red lines or patterns
tx?
telangiectasia
tx: cautery, hyfrecator, radiosurgery, laser
Diagnosis this: hyperkeratotic flesh colored hard papules located near areas of trauma
diagnosed?
tx?
verrucae vulgaris/common warts (HPV
clinical dx
no treatment, liquid nitrogen, or salicylic acid, can also snip a pedunculated one
Diagnosis this: deep infection working under the nail bed
treated?
felon
I&D, ABX
how would you treat an ingrown toenail?
matricectomy
Diagnosis this: infection of the nail bed with painful swelling caused by?
treated?
paronychia
staph*, strep, or candida
warm compress + cephalexin, drain abscess if present
Diagnosis this: red or black or brown area formed under the nail bed
tx?
subungual hematoma
nail trephination
Diagnosis this: abnormal communication between the anal canal and perianal skin
tx?
anal fistula
tx: lay open and tract excision
Diagnosis this: cauliflower-like mass that is soft and sometimes friable
tx?
condyloma acuminata
tx: podophyllin, surgical excision, electro-dessication, cryotherapy
Diagnosis this: cyst that forms in the cleft at the top of the buttocks, It typically occurs after puberty, consists of a small hole or tunnel in the skin that may become infected and fill with fluid or pus.
tx?
pilonidal cyst - It’s believed to be caused by a combination of changing hormones, hair growth, and friction from clothes or from spending a long time sitting.
refer for tx
Diagnosis this: skin colored papule or nodule with a rolled translucent or pearlytelangiectatic border and a depressed center? caused by? favors what areas of body? aggressive? mets? what kind of BX? tx?
basal cell carcinoma - the most common skin cancer
chronic exposure to UVB
> 80 on face, favors upper lip
locally aggressive, but rarely mets
do a shave if it is shallow, and a punch or excisional when needed
TX: refer to an oncologist > shave excision with electrodessication, cryo, 5FU, radiation
Diagnosis this: brown firm, moveable between the layers, BB pellet under the skin? usu secondary to trauma, increased fibroblasts, often seen on the wrist
tx:
dermatofibroma
incision and removal (but delapp said we dont remove these because the scarring is worse)
Diagnosis this: benign soft tissue tumor that is slow growing, lobulated and enclosed by a thin fibrous capsule. it is soft, rubbery, and usu painless, often reoccuring?
diagnosed?
treatment?
lipoma
clinical - only BX if atypical features
refer for surgical removal (but i feel like we can also excise
Diagnosis this: neoplasia that is fast growing, metastasizes, and related to As exposure. indurated, ulcerated or crusty, and might bleed easily? caused by? precursor? where does it favor? how does it frequently present? aggressive? mets? tx?
squamous cell carcinoma
sun exposure, actinic keratosis
lower lip
“non-healing ulcer”
more rapid growth than BCC and mets easily
referral for surgical excision and biopsy, Mohs
Manage this: bite
most bites are from?
amox-clauv as it is effective against aerobic and anaerobic
secondary healing - let it close on its own. primary is not recommended, but you can approximate the wound
dogs
which pharmaceutical is generally safe during first TM? lidocaine, epinephrine, bupivacaine, or mepivacaine
lidocaine
what should be considered infectious in all patients?
blood and bodily fluids
what is the most commonly transmitted infection through blood and bodily fluids?
hepatitis B
difference between sterilization and disinfection?
we sterilize things that are dead (instruments), we disinfect skin
how long do we disinfect/sterilize with 2% glutaraldehyde?
10 minutes to disinfect
10 hours to sterilize
if we are going to choose to boil something, how long does it need to be boiled for?
> 30 minutes
if using dry heat (oven) to sterilize, what degree and for how long?
160 C or 320 F for 1 hour
steam autoclave is the most efficient and reliable method of sterilization, at what pressure? temp? minutes?
con?
15 psi at 121 C for 15 minutes
it dulls sharp instruments
intact skin should be disinfected with? for how long?
10% betadine X3
OR
0.4% chlorhexidine gluconate
for 2 minutes
we should never use ? on open skin, instead we should…
hydrogen peroxide - it slows wound healing
0.9% NS
when should we refer puncture wounds?
if any nerve, tendon, or joint involvement, or in the chest or abdomen
what do we do if something large is in the skin?
SECURE the item and REFER to the ED
what do we do with a puncture wound?
clean, debride, and leave open with sterile dressings to prevent infection. always consider their last tetanus shot. dont forget about rose bushes!
how to manage abrasions?
clean, debride, and dress
after how long do we not suture lacerations?
older than 8-12 hours OR > 24 hours if on the face
this is no longer true, but still tested on
what is the difference between a hypertrophic or keloid scar? tx?
hypertrophic = normal healing
keloid = extends beyond original wound more common in black people - can be TX with cryo
name the 4 stages of healing?
hemostasis, inflammation, proliferation, remodeling
describe hemostasis
the formation of a fibrin clot - coagulation
how long does inflammation stage last?
days 1-4
during this phase, platelets secrete cytokines, clot formation triggers the complement cascade
inflammation
during the inflammation phase, how long does it take neutrophils to show up and how long do they stay for?
5-6 hours
3-4 days
job is to destroy bacteria
during the inflammation phase, what is the job of the macrophages?
to transition from inflammation > repair and phagocytize
during the inflammation phase, describe re-epithelialization
basal cell migrate within 24-48 hours to repair the wound
during the inflammation phase, how long does it take keratinocytes to proliferate?
1-2 days
the proliferation/granulation phase takes place on what days?
3-21
what occurs in the proliferation phase?
new capillaries are surrounded by fibroblasts and form granulation tissue.
when does angiogenesis occur?
proliferation phase
how long does the remodeling phase take?
from week 3 - 6-18 months
name the percentage strength of skin and by how many weeks in the remodeling phase
3-4 weeks: 30-40%
1 year: 80%
what is the difference between contraction and contracture?
contraction = normal. myofibroblasts and orientation of collagen
contracture: abnormal = formation of a tight scar due to excessive contraction
describe the difference between the healing intentions:
primary: a sutured clean wound (may want to avoid in infection, DM, bites, immune suppression, chronic disease, malnutrition, obesity, or malignancy)
secondary: full thickness laceration (into the subQ), left open and eventual re-epithelialization - used when there is significant tissue lost or contamination/infection < 12 hours
tertiary (aka delayed primary): grossly contaminated wound without significant tissue loss: can be cleaned, packed, and covered and left open for 3-5 days. can be sutured at this point if not infected (like a gunshot wound)
this kind of suture could cause railroad track scarring and eversion could be difficult. it is the most frequently used
simple interrupted
this kind of suture is easier to evert edges under tension and is better for cosmesis, use on thin skin, flexural creases (fingers, palms), and areas of high stress
vertical mattress
this kind of suture is good for high tension wounds and fragile tissue, use it on the palms or soles
horizontal mattress
this kind of suture is for deep or larger wounds and requires what kind of sutures?
deep or buried
absorbable
this kind of suture is in the dermal layer, not visible, and eliminates tracts. use for linear wounds with little tensions. what kind of sutures are best?
subarticular/intradermal running
absorbable or nonabsorbable polypropylene
this kind of suture is rapid, not cosmetic, less secure and has a high risk of infection
continuous running
this kind of suture has triangular flaps without strangulation
3 point or half buried
this kind of suture is digested by enzymes
natural absorbable
this kind of suture is hydrolyzed by enzymes
synthetic absorbable
name the types of natural absorbable sutures, how much tissue reactivity they have and their half life
plain catgut: higher reactivity, 7-10 days
chromic catgut: (the chromic salt will delay absorption), lower reactivity, 2-3 week 1/2 life
name the 3 types of synthetic absorbable sutures and their half life
vicryl - braided and monofilament - 2-3 week
dexon - monofilament - 2-3 week
PDS - monofilament - 4-6 week
rank these sutures in order from most to least reactive: plain catgut, chromic catgut, synthetic sutures
plain > chromic > synthetic
name the three natural non-absorbable sutures, and tissue reactivity
silk: braided, easy to tie, but has high tissue reactivity
stainless steel: permanent, minimal tissue reactivity
polyester: high tissue reactivity
name the 2 synthetic non-absorbable sutures
nylon: monofilament, slips easily, low tissue reactivity and low infection risk
polypropylene/prolene: monofilament, similar to nylon, strongest with best wound security, best for a subcuticular pullout
what to remember with steri strips?
what helps steri strips stick better
DONT ENCIRCLE DIGITS - can create a tourniquet
benzoin
pros/cons of staples
fast and low risk of infection
uncomfortable
how many knots do you tie?
one more than the gauge of the suture
how do you remember which suture size is smaller?
the more 0s there are, the smaller the suture
when would you use a suture 6-0
face or neck
when would you use a suture 5-0
face or neck
arm or hands
when would you use a suture 4-0
arm or hands
trunk/legs/feet/scalp
when would you use a suture 3-0
trunk/legs/feet/scalp
when would you use conventional cutting needles?
cosmetic procedures
when would you use reverse cutting needles?
laceration, etc procedures
this one is the most common
when would you use tapered needles?
bowel, muscle, and fascia = pierces and spreads without cutting
when would you use blunt needles?
liver, kidney, cervix = dissect friable tissue instead of cutting
when would you remove sutures on the face? neck? scalp? arms? trunk? legs? hands/feet? palms/soles?
3-5 5-7 7-10 7-10 10-14 10-14 10-14 14-21
the point of dressings are to provide absorption of drainage from wound, provide support, moisture for re-epithelialization, and limits movement.
going from skin to external, how do we dress a wound?
non-adherent layer gauze elastic tape occlusive
post op care: how long to keep dry? how often redressed? how to remove sutures?
dry for 24 hours and limit movement
redress every 2-3 days
remove sutures with iris scissors or an 11 scalpel with knots pulled across
how many days post procedure does infection typically appear? most common pathogen?
4-10 days
staph aureus
how long after surgery would a hematoma appear? what is it? risks?
24-72 hours
blood collection
may lead to infection or dehiscence
what is dehiscence and how long after surgery can we re-suture?
wound rupture along the incision after the sutured closed. you can re-suture within 48-72 hours
local anesthetics blocks the re-uptake of? what does it prevent?
Na
depolarization and propagation of pain stimuli
called a non-depolarization block??
what is the cc, %, and mg ratio?
does the cc or the concentration(%) make something more risky in terms of toxicity?
(10 * cc) * % = mg, for example:
10cc of 1% = 100mg (less risky)
1cc of 1% = 10mg
5cc of 2% = 100mg (more risky)
the concentration makes the solution higher risk of toxicity
angles of injection?
90 deg IM
30-45deg subQ
5-10deg intradermal
where are amide and ester anesthetics metabolized? who has more reactions?
metabolized by the liver by microsomal enzymes- true allergies are rare
met by peripheral plasma - more allergic reactions
name 2 topical amide anesthetics
lidocaine and EMLA
name the 3 infiltrative amide anesthetics - what is their onset and duration in minutes?
bupivacaine/marcaine: 8-12, 3-4 hours
lidocaine/xylocaine: 1-10, 30-60
mepivacaine/carbocaine: 8-12, 2-2.5 hours
max dose of lidocaine for a child and adult?
child: not to exceed 75-110mg total (3.3-4.5 mg/kg)
adult: not to exceed 300 mg (30cc of 1%) 4.5mg/kg
which infiltrative amide anesthetic do we use for digit blocks? why?
bupivacaine/marcaine because it has a longer duration of action
10cc of 1% lidocaine contains how many mg?
100
max dose of bupivacaine in an adult?
4mg/kg of 0.25%, not to exceed 200mg
lidocaine is not to exceed 300mg
mepivacaine is not to exceed 400mg
max dose of mepivacaine for an adult? when is mepivacaine preferred?
5mg/kg of 1%, not to exceed 400 mg
preferred for longer surgeries, but does not come with epinephrine
too much bupivacaine can cause?
heart block
name 4 topical ester anesthetics? 1 infiltrative?
benzocaine, proparacaine, cocaine, TAC
procaine/novocain
what percent of benzocaine is needed and why
at least 10% because is it poorly absorbed
main use of proparacaine, onset and duration?
ophthalmologists, < 1 min, 15 min
main use of cocaine? onset and duration?
ENT procedures, <1 min, 1 hour duration
what is TAC? what are the pros?
tetracaine ester, epinephrine, and cocaine - it is cheap and fast
we do not use this in minor surgery, it is usually used for spinal blocks. however there is a topical form that can be used in lacerations/open wounds
compare procaine/novocain to lidocaine
procaine = ester, allergic reactions are common, slower onset, same duration of action (30-60min)
lidocaine = amide, allergic reactions not as common, quicker onset (1-10 min), same duration *most common
after anesthestic, someone is experiencing hypotension, then bradycardia or cardiac arrest > what is this called and how did it happen? what is it treated with?
toxic reaction - usually an inadvertent intravascular injection or excessive dose was given
treat with oxygen
t/f: allergic hypersensitivities to anesthetic are rare
true
if someone is having an allergic reaction to anesthetic after the first dose vs many frequent exposures, what type hypersensitivity are they experiencing?
I or IV
how are mild and severe allergic reactions to anesthetic treated?
benadryl > epinephrine and O2
what is the most common allergy to anesthetic
ester anesthetics
procaine, cocaine, TAC, benzocaine, proparicaine
this type of reaction to anesthetic looks like tachycardia, sweating, dizziness, and syncope. it resolves within minutes and requires minimal intervention
autonomic
what are 3 uses of epinephrine in minor surgery? how is it doing these things?
- help decrease oozing
- helps prolong duration by limiting absorption
- decrease risk of toxic reaction by reducing circulating anesthetic
via vasoconstriction
side effects of epinephrine include?
anxiety, restless, tremors, palpitations, tachycardia
concentration(%) and max dose(mg) of epinephrine for minor surgery procedures?
1:200,000 concentration with a MAX of 0.2mg
antidote of epinephrine
IV push of Mg and B6 to increase COMP metabolism
never use epi?
fingers, toes, nose, lobes, hoes
people on MAOIs, TCAs, thyrotoxicosis, or severe CVD
caution in pts with PVD or HTN
what kind of procedures can NDs perform?
uncomplicated procedures that involve superficial structures, cannot go into fascia, or muscle
can NDs remove suspicious malignant lesions?
they may
8 contraindications to minor surgery procedures for ND’s?
- Location: eyes, nose, axilla, groin, posterior neck
- Large Size/Blood Supply
- Depth
- Young Children
- Patients taking anticoagulants or with a bleeding disorder
- Pulsating lesion
- Keloid formers
- Systemic illness with depleted immune system
2 methods of destructing tissue?
cryotherapy or electrosurgery
what is cryotherpy?
freezing tissue with cryogen leading to anoxia and death
side effect of histofreeze?
aerosol can with a 3 year shelf life, if inhaled can cause CNS depression and chronic exposure to it is hepatotoxic
why is dry ice not used as much anymore?
simple, cheap, but not effective
pro/con of nitrous oxide?
can be stored indefinitely
expensive. prolonged exposure can cause infertility or abortion
most common form of cryotherapy?
liquid nitrogen
what is liquid nitrogen stored in and how long does it last?
dewar bottle
can last weeks or months
which form of cryo is most effective with rapid and deep freezing?
cryotherapy
how to do cryo therapy using liquid nitrogen?
freeze, thaw, and refreeze with a 2-3mm freezing zone around the lesions for 10-30 seconds
q tip is left on skin for 3-5 seconds
how long does it take a liquid nitrogen burn to heal?
blister within a few hours, scabs within a week, heals within 2-3 weeks
never use liquid nitrogen straight from bottle why?
warts can be put into the bottle
side effect of liquid cryo?
depigmentation
contraindications to liquid nitrogen?
malignancy, raynauds, and sensitive skin
forms of electrosurgery?
how does it work?
electrocautery and hyfrecation
a sterile + electrode destroys tissues and coagulates blood vessels
contraindications to electrosurgery?
flammable alcohol, metal implants, and jewelry
compare electrocautery and hyfrecation?
E: indirect current, very precise, no blood loss
H: direct, high frequency generates heat, quick and effective with minimal blood loss and great precision
tissue preserving method?
biopsy: when the tissue is examined histologically by a pathologist using various dyes
name 4 types of biopsy and when they would be used?
which ones are both DX and therapeutic?
excisional: complete removal of a superficial lesion, both DX and curative
incisional: narrow ellipse taken within a lesion to DX a large lesion
shave: DX and therapeutic, healing is rapid with minimal scarring
punch: trephine may obtain full thickness of dermis with minimal scarring - make sure to traction skin perpendicular to langers lines, and go 1-2 mm beyond border
most common BX type?
what do you need to useknow this
excisional
3-1 elliptical with 30 deg angle corners and #15 blade, parallel to langers line
most common size punch
4mm trephine
when would i use a ##11, 15, 10, and 3 blade scalpel?
11: puncturing abscess, incisions, stabbing
15: blunt dissection, excision, trimming
10: like 15 but for thicker skin
3: disposable, sterile and attached to a reusable handle
when would i use a toothed or toothless adson?
toothed does not crush skin, use for suturing
toothless crushes skin, use for a foreign body removal
when would i use an iris, metzenbaum, and suture scissors?
I: fine dissection, dont cut sutures (you can, but if they give you the option to use suture scissors, choose those)
M: blunt dissection
S: cutting sutures
describe a needle holder
tungsten carbide, blunt nose, rachets and is smooth
only used for suturing
describe a hemostat?
holding, clamping, can be used to break up tissue
describe this lesion: round coin-shaped lesion
nummular lesion, also known as a discoid lesion
discoid or malar rash can be seen in lupus
describe this lesion: a linear shaped lesion that often occurs for an external reason such as scratching
linear lesion
describe this lesion: concentric rings likes a dartboard
what disease is it seen in?
what is it caused by?
treatment?
target or iris lesion - seen in erythema multiforme
caused by HSV and mycoplasma pneumonia
self limiting
DDX: SJS
describe this lesion: a rash that appears to be whirling in a circle
gyrate rash
describe this lesion: lesions grouped in a circle
annular
granuloma annulare - small flesh papules increase in size on hands and feet
describe this lesion: small patch of skin that is altered in color, but not elevated
macule
describe this lesion: a large area of color change with a smooth surface
patch
describe this lesion: an elevated, solid, palpable lesion that is smaller than 1 cm
papule
describe this lesion: an elevated solid palpable lesion > 1 cm
nodule
describe this lesion: a papule or nodule that contains fluid or semi-fluid material and is fluctuant
cyst
describe this lesion: a palpable circumscribed lesion > 1 cm that is usu elevated and can be the result of coalesced papules
plaque
describe this lesion: a small blister < 1 cm with liquid
vesicle
describe this lesion: a circumscribed lesions with pus
pustule
describe this lesion: a large blister > 1 cm with liquid
bulla
describe the difference between hyperkeratosis, pankeratosis, acantholysis, and acanthosis
hyperkeratosis: thick stratum corneum
pankeratosis: nucleated keratinocytes in the stratum corneum
acantholysis: loss of intercellular cohesion between keratinocytes
acanthosis: overgrowth of stratum spinosum
how to tell if a dermal nevi is benign?
ABCDE: asymmetry, border, color, diameter, elevation
there is a 10% chance that this lesion turns into SCC?
AK
diagnose this: poorly defined velvety hyperpigmentation of flexural skin?
mc locations?
associated with?
acanthosis nigricans
neck, armpits, skin folds
hyperlipidemia, Cushings, and DM
what is this process called: thick, leathery skin usu caused by chronic scratching
it is a common consequence of?
lichenification
atopic derm/eczema
diagnose this: flakes and itching on scalp
treatment?
seborrheic dermatitis, dandruff, cradle cap
selenium sulfide shampoo
difference between open and closed comedones?
open = black closed = white
what should we avoid and use in acne vulgaris?
systemic ABX?
avoid B12 and iodine
use zinc and tea tree
clindamycin in mild, doxycycline in moderate, isotretinoin in severe
difference between vitiligo and melasma
V: pigment change, autoimmune destruction. TX: copper, vit D, phenylalanine
diagnose this: round or oval papules or plaques that are pink red or purple, usu on legs
kaposis sarcoma
where is erythema nodosum usually located?
what is it associated with?
anterior shins - it is a lesion of subQ fat
sarcoid, TB, leprosy, histoplasmosis (MW and SE), coccidiomycosis (SW), crohns
The presence of erythema nodosum in a case of coccidioidomycosis is a good prognostic indicator. It means that the symptoms are likely to resolve without serious sequelae.
more common neoplasia in women, associated with tumor marker S-100, metastasizes, grows and changes rapidly
how is it treated?
melanoma
refer for excisional biopsy
risks of melanoma?
family history, fair skin, AK, outdoor work, sun burns
most common form of melanoma?
superficial spreading
most aggressive form of melanoma?
nodular
melanoma seen in the elderly, slow growing?
lentigo
most common melanoma in dark skin, aggressive, seen in palms, soles, and nails
acral
diagnose this: diffuse, superficial, spreading infection of the dermis and sub Q fat?
bug?
diagnosed?
treated?
cellulitis > can lead to necrotizing fasciitis or erysipelas
GABHS (staph in large wounds)
usually clinical, but can get blood cultures
*must know that this is different than purulent collections of pus, where the mainstay treatment is I/D. the treatment for cellulitis is SYSTEMIC ANTIMICROBIAL THERAPY** - cephalexin** penicillin, amoxicillin, amox-clauv,f clindamycin
diagnose this: infection of the upper dermis including superficial lymphatics: orange peel appearance. usu due to IC, trauma, ulceration, or skin injury
bug?
diagnosed?
most common location?
erysipelas
streptococcus (A, as well as B, C, F, G)
usually clinical, but can get blood cultures
lower legs
red streaking along the LNs? usu deeper
lymphangitis
chronic venous insuff due to DM or bed ridden
stasis dermatitis
6th disease, HHV6/7, maculopapular rash with high fever
roseola infantum
cranial caudal macular papular rash with CLAD and fever
rubella/german measles
cough, coryza, koplik spots, subacute sclerosing panencephalitis
measles
diagnose this: honey colored crust
what 2 bugs are most common?
how do we usually DX?
tx?
impetigo
staph or strep B
gram stain and culture
topical mupirocin
diagnose this: prodrome with itch, possibly a fever or facial infection
what do you avoid/tx with?
what is seen on Tzanck?
herpes simplex
TX: lysine, acyclovir, valacyclovir AVOID: arg
multinucleated giant epithelial cells
dermatomal, neuritic pain, vesicular eruptions
tx?
zoster
TX: levodopa, UV light, ZOSTAVAX
diagnose this: viral infection, waxy pink rash with small central pit
how is it DX?
what virus is it?
treatment?
molluscum contagiousm
can BX to confirm, but none are required
poxvirus
TX: salicylic acid, electrodessiation, cryo, vit B9
diagnose this: brown or white scaling macules, dry and scaly, could itch?
diagnosed?
tx?
tinea/pityriasis versicolor
looks gold on a woods lamp or + on KOH - hypahe/spores
topical terbinafine or ketoconazole
IgE reaction to thinks like Nickel
dyshidrotic eczema, pomphylox
diagnose this: single, large oval scaly rose colored plaque > papular rash parallel to the ribs? what are these called?
common sites?
virus?
treatment?
pityriasis rosea Herald's patch christmas tree distribution trunk, proximal arms and legs HHV7 none > self-limiting
most common on flexor surfaces
AD: psorinum, sulphur, vit C
diagnose this: raised, discolored nail that is yellow thick or crumbly
how to DX?
TX?
tinea unguium/onychomycosis
can do KOH prep of scrapings > hypahe
terbinafine is most effective, can also do tea tree oil
diagnose this: vesicles and bulla, autoimmune blistering disease?
what is it called when sliding or rubbing pressure on the skin causes separation of the epidermis?
what is it called when pressure applied to the bulla causes it to spread laterally?
how do you DX?
what is seen on BX? serum?
treatment?
pemphigus vulgaris autoimmune - deadly
Nikolsky sign
Asboe-Hansen sign
Tzank, BX with immunoflorescence: IgG and C3 deposition in intraepidermally
intraepidermal bullae with antiepithelial cells against desmosomes, antidesmoglein 3 Abs
corticosteroids, immunosuppressive agents
diagnose this: pruritic, tense, intact subepidermal bulla, flexors and trunk affected what type of reaction? how is it DX? what is on BX? serum? TX?
bullous pemphgoid
type II hypersensitivity
immunoflorescence: linear deposition of IgG and C3 along the basement membrane
epidermal blisters and antibasement membrane auto IgGs
systemic steroids
bulls eye lesions, caused by burgdorgeri, ixodes tick
erythema migrans
measles like maculopapular rash
morbilliform drug eruption
emergency rash caused by SSRI?
SJS or toxic epidermal necrolysis
explain the difference between irritant and allergic contact dermatitis
treatment?
irritant: not immune related (laundry, soap, alcohols, oils, etc)
allergic: type IV hypersensitivity reaction (poison ivy, allergens)
avoid irritants, topical or oral steroids
associated with CD, IGA deposits causing papules or vesicles
dermatitis herpetiformis
diagnose this: dry skin with prolonged, severe pruritus, seen on extensor surfaces in infants and flexural in adults: IgE reaction, eosinophilia, asthma, hay fever?
how DX?
tx?
atopic dermatitis/eczema
clinical DX
topical corticosteroids
diagnose this: well-demarcated, flat, elevated erythematous papules and plaques with silvery scales?
what is pin point bleeding?
what is rash in areas of trauma?
what is seen on BX?
psoriasis
Auspitz sign
Koebners phenomenon
absent or diminished stratum granulosum, parakeratosis, epidermal thickening
diagnose this: associated with rhinopyema, worse with stress, hot and cold, food trigger, malar rash with pustules or papules on erythematous base w telangiectasia
first line treatment?
rosacea
oral tetracycline and topical metronidazole, topical azelaic acid
also trigger avoidance, avoid topical steroids and makeup
red scaling with prominent skin lines and constant itch
lichen simplex
diagnose this: wickhams striae, 6 Ps, palms and wrist, associated with Hep C
what are the 6 P’s?
what is koebner’s phenomenon?
what is there an increased risk of developing due to this?
TX?
lichen planus
polygonal, pruritic, planar, purple, papules, and plaques
when lesions develop in places of scratching
SCC
topical corticosteroids, immune suppressants
white, painless patches on tongue that can not be scraped off
hairy leukoplakia - EBV in HIV pts
painless bite that is neurotoxic
tx?
black widow
Lyovac = antivenom
painful bite that is necrotoxic
brown recluse
diagnose this: itching worse at night, doesnt go above neck
treatment?
scabies
permethrin
which HPV are dysplastic vs warts?
6, 11 warts
16, 18 dysplastic
what is the most common benign tumor in older individuals?
seb keratosis
patient characteristics: what age makes best candidate for minor surgery?
15-65
patient characteristics: which body type tends to heal quick? slower?
ectomorph - thinner
endomorph - heavier
patient characteristics: name two medications that should always be asked about before minor surgery and why?
aspirin or anticoagulants - could prolong clotting time
diuretics - could lower blood pressure
patient characteristics: name high risk candidates
those with diabetes - healing time is increased
blood dyscrasias, hemophilia, leukemia, anemia
those with heart problems or a history of them
asthmatics or those with COPD
serious nervous disorders like schizophrenia, etc
T/F? shaving should only be done on areas where the hair will grow back
FALSE - we dont shave anymore because it can cause a secondary infection
