Integumentary (1%)

Question 1

Herpes Zoster

Answer 1

 Caused by the varicella-zoster virus → acute vesicular eruptions along a dermatomal plane
 Manifestations – painful, grouped vesicles; typically occurs on trunk; typically presents first as discomfort/tingling followed by the vesicular eruption
 Labs/diagnostics – typically a clinical diagnosis; can consider a Tzanck smear
 Treatment – start within 72 hours of presentation; focus of treatment is to reduce the intensity and duration; treat with antivirals
 Antiviral – valcyclovir 1000 mg PO TID x7 days is first-line treatment

Question 2

Lyme Disease

Answer 2

 Stage 1 – erythema migrans rash, 50% develop flu-like symptoms
 Stage 2 – headache, stiff joints, migratory pain; complications can occur here (ex: dysrhythmias, aseptic meningitis, Bell’s palsy, neuropathy, etc.)
 Stage 3 – joint pain, encephalopathy, bluish-red discoloration of the distal extremity
 Diagnostics – ELISA to screen, Western Blot to confirm
 Treatment – doxycycline 100 mg PO BID x10 days or azithromycin 500 mg PO daily x10 days

Question 3

Wound Closure

Answer 3

 Primary – suture/staple/tape, performed on recently sustained lacerations (< 12 hours and < 24 hours on face)
 Secondary – secondary intent, allowed to granulate
 Tertiary – delayed primary (observed for 4-5 days)

Question 4

When to Refer for Wounds

Answer 4

	Tarsal plate or lacrimal duct
	Open fracture or joint space
	Extensive facial wounds 
	Associated with amputation or loss of function
	Involves tendons, nerves, or vessels 
	Involves significant loss of epidermis

Question 5

Cellulitis (non-purulent)

Answer 5

• Pathogen – streptococcus pyogenes
• Treatment length – 7-10 days
• Outpatient treatment – Pencillin V-K 500 mg PO 4x daily or amoxicillin 500 mg q8h
• Inpatient treatment – Pencillin G 1-2 million units IV q6h

Question 6

Cellulitis (purulent)

Answer 6

• Pathogen – staph. Aureus (MRSA)
• Treatment length – 7-10 days
• Outpatient treatment – Bactrim 1-2 tabs PO twice daily, doxycycline 100 mg PO twice daily, or clindamycin

Question 7

Risk factors for MRSA

Answer 7

• Recent hospitalization
• LTC facility
• Recent antibiotic therapy
• Incarceration
• Injection drug use
• Diabetes or HIV
• *if patient has a risk factor for MRSA, will generally treat as if they already have it until proven otherwise

Question 8

Staging of Pressure Ulcers

Answer 8

• Stage 1 – non-blanchable erythema of intact skin, induration may be present
• Stage 2 – epidermal or dermal loss, can appear like an intact blister
• Stage 3 – full-thickness skin loss, deep crater without undermining
• Stage 4 – full thickness skin and tissue loss; through fascia, bone, muscle, or supporting tissue visible
• Unstageable – full thickness tissue loss, base of ulcer covered by slough (yellow, tan, gray, green, or brown) and/or eschar in the wound bed

Question 9

Pressure ulcer managment

Answer 9

• Gold standard is prevention!
• Prevention – inspect skin, moisture control, positioning, avoid pressure on bony prominences
• Wounds – cleanse, debride, irrigate, wound care with topical dressings
• Infection – obtain culture, topical or systemic antibiotics