Final Take Home Test

Question 1

List below the usual (up to 10) types of instruments found in a surgical pack used to handle normal minor surgery in the office.

Answer 1

Needle holders, scissors, forceps and pickups, scalpels, syringes, hypodermic needles, hemostats, suture, gauze squares, anesthetics, gloves, sterile drapes, antiseptics, dressings, steri-strips, minor surgery tincture

Question 2

The best pre-surgical antiseptic mentioned is

Answer 2

Povidone-iodine (Betadine).

Question 3

List at least three surgical uses of a hemostat.

Answer 3

Retrieving foreign bodies in a wound
Hemostasis: clamping bleeding vessels/ oozers
undermining

Question 4

Why is shaving of hairy areas of the body prior to surgery no longer recommended?

Answer 4

Shaving causes multiple areas of nicking of the skin which opens a portal of entry for secondary infections

Question 5

What is meant by the term “Sterile Field”?

Answer 5

The area immediately around a patient that has been prepared for a surgical procedure. The sterile field includes the scrubbed team members, who are properly attired, and all furniture and fixtures in the area. Also, the space created around a wound that would need to be surgically repaired. Sterile field is also the air space immediately above the stand. Only the gloved hands of the surgeon should touch the stand.

Question 6

Why is it necessary to scrub hands prior to inserting them in sterile gloves?

Answer 6

It reduces the number of microbes on the hands, which are the part of the physician’s body that comes into direct contact with the surgical site, despite being gloved.

Question 7

What do you need to include in the description of the procedure section of the report?

Answer 7

SOAP notes, PARQ and detailed description of what the surgery will be and how it was performed.

Size, shape, #of stitches, which kind of suture technique used

Question 8

Which class of anesthetics is primarily metabolized by the liver - ester or amide? Why is this important?

Answer 8

Amides. They are metabolized by the endoplasmic reticulum of the liver. Caution must be used with amides if the patient has impaired liver function.

Question 9

Early warning symptoms of anaphylaxis include:

Answer 9

Sensations of warmth or flushing, 
itching, 
sudden fatigue, 
lightheadedness 
or a sense of something not being right.

Question 10

Why do you not let the patient leave the office immediately following surgery with anesthesia?

Answer 10

To be sure that they do not have a delayed allergic / anaphylactic reaction.

Question 11

What is the purpose(s) of epinephrine being added to an anesthetic?

Answer 11

Epinephrine enhances the efficacy of local anesthetics. It is the most common vasoconstrictor. Adding epinephrine decreases the amount of anesthetic used.

Question 12

Describe briefly the three phases of wound healing.

Answer 12

Inflammatory: (Immediate up to 5 days); Bleeding stops, platelet clotting, scab; Inflammation: opening of the blood supply and cleansing of the wound

Proliferative: (5 days to 3 weeks); Granulation: new collagen & tissue, capillaries fill defect; Contraction: wound edges approximate; Epithelialization: cells cross moist surface (3cm from origin)

Remodeling: (3 weeks – 2 years); Collagen forms increasing tensile strength; Scar tissue (80% of original),

Question 13

What is debridement and why is it important?

Answer 13

All debris and devitalized, necrotic tissue is removed from the wound. Trimming of the laceration to produce smooth edges. Allows for good approximation of the edges.

Question 14

What is dead space?

Answer 14

A space remaining in the tissues as a result of failure of proper closure of surgical or other wounds, permitting the accumulation of blood or serum.
Infection may take place!

A space left in the body as the result of a surgical procedure (mass or growth removal). It is usually in the subcuticular area.

Question 15

What is the difference between a benign tumor and a malignant tumor with regard to:
Growth rate:
Spreading:
Palpable feel:

Answer 15

Growth rate:
*Benign are slow growing. BCC typically have slower growth rates, but SCC is more rapid.

Spreading:

• Benign remain localized. SCC readily metastasizes.
• Melanoma metastasizes and if it metastasizes, will most likely be lethal.

Palpable feel:

• Benign: non-tender, some mobile encapsulations; some not.
• Malignant: can be more painful, due to their spreading nature.

Question 16

What is an example of a benign tumor of the skin?

Answer 16

Lipoma, Sebaceous Cyst, Skin Tag

Question 17

What is an example of a malignant tumor of the skin?

Answer 17

Squamous Cell Carcinoma, Melanoma, Actinic Keratosis

Question 18

What is the most common skin cancer typically found?

Answer 18

Basal Cell Carcinoma

Question 19

What is the difference in content of the sac of a sebaceous cyst and an epidermal inclusion cyst?

Answer 19

An inclusion cyst is when epithelial tissue is traumatically forced to a deeper level. It is interpreted by the body as foreign matter. The tissue continues to grow, replicate and enlarge. The sac is a sac of the said tissue.

A sebaceous cyst is caused by the blockage of the duct of a sebaceous gland. The sac is sterile coagulated sebum.

Question 20

What is an advantage of using Marcaine (bupivacaine hcl) over Lidocaine (Xylocaine)?

Answer 20

Marcaine gives several hours of relief (7-15), as opposed to Lidocaine ~2-3)

Question 21

What is the function(s) of undermining?

Answer 21

Undermining releases the tension so the skin can be approximated. Undermining separates the skin from the subdermal layer, which decreases the tension.

Question 22

On what parts of the body would you use the following suture sizes:
3-0
4-0
5-0
6-0

Answer 22

3-0 : back, leg, areas under tension
4-0 : almost anywhere
5-0 : face or scalp, areas of no tension
6-0 : face

Question 23

What are your criteria for choosing of the proper anesthetic for the removal of a toenail?

Answer 23

How long the medication lasts after the procedure; and choosing an anesthetic with no epinephrine as there is only one artery supplying the distal area of the digit.

Question 24

What are the pros and cons of using a 30g needle to inject an anesthetic?

Answer 24

Pro: Patient doesn’t feel the needle
Con: The needle is so small that it takes a long time to inject the anesthetic

Question 25

How does the autoclave process work to kill all bacteria, spores and virus particles?

Answer 25

It is a combination of heat, pressure and time. The pressure release at the end of the cycle causes the cell walls to rupture.

Question 26

What concerns do you need to be aware of when using Betadine as a surgical scrub on your patient?

Answer 26

Are they allergic to iodine or shellfish?

The Betadine needs to be in contact with the skin longer than other antimicrobials.

Question 27

Describe how to administer the following anesthetic application techniques.

1. Infiltration:
2. Field Block:
3. Digit Block:

Answer 27

Infiltration: this is when the anesthetic is injected directly into the tissues without concern to the course of nerves in the area. It can be superficial to just include the skin or it can include deeper structures, if infiltrated.

The duration of Infiltration anesthesia is approx. doubled by the addition of epinephrine.

Field Block: A combination of intradermal and subcutaneous injections of local anesthetic into an extremity which anesthetizes the region distal to the site of injection.

Digit Block: local anesthetic along the bone on either side of the digit where the nerves run.

Question 28

Describe the difference between 1st, 2nd and 3rd intention healing and which is the best for minimal scar formation?

Answer 28

1. Healing by First Intention:AKA Primary Wound Healing or Primary Closure
   * *Describes a wound closed by approximation of wound margins or by placement of a graft or flap or wounds created and closed in the operating room. This is the best choice for clean, fresh wounds in well-vascularized areas
2. Secondary intention happens when a wound has a great deal of lost tissue, or is extensive and the edges can’t be brought together. An example would be a pressure ulcer. The wound healing process for secondary intention is different from primary intention in three ways:
   A. Longer repair and healing time
   B. Greater chances of scarring
   c. Increased chance of infections
3. A tertiary intention, also called delayed or secondary closure, occurs when there is a need to delay closing a wound, such as when there is poor circulation in the wound area or infection. An example would be an abdominal wound that is kept open in order to allow drainage, and then later closed. This type of wound healing process creates more connective scar tissue than other intentions.

Question 29

List five common lesions you are likely to see in your practice and give common method(s) of removal of each.

Answer 29

1. Skin Tag: lift and snip
2. Lipoma: incision over the growth, undermining and closing with various suture techniques
3. Moles / Nevi: punch biopsy – making sure to get free / clear margins. Close with various sutures.
4. Laceration repair: debridement and primary closure with sutures
5. Toe nail removal: digit block, hemostasis and cut and pull.