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NPLEX II TIA > Minor Surgery/Derm > Flashcards

Minor Surgery/Derm Flashcards

1
Q

Describe a needle driver

A

Blunt
Shorter/wider than forceps/hemostats
Toothed or smooth (toothed = better grip but can damage sutures)
Tungsten carbide (better grip than smooth, less damage than toothed)

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2
Q

Describe the difference between the types of scissors:
Iris
Metzenbaum
Bandage

A

Iris - fine dissection, suture removal IF no suture scissors

Metzenbaum - blunt dissection, gauze cutting

Bandage - curved tip; cuts bandage without damaging tissue underneath

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3
Q

Differentiate adsons forceps with and without teeth

A

Adsons with teeth - handling tissue
Adsons without teeth - grasping sutures, foreign bodies, picking things up steriley (do NOT use on tissue; compression injury risk)

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4
Q

Describe the difference between curved and straight hemostats

A

Curved - undermining
Straight - clamping (usually BVs)

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5
Q

Describe the function of the following scalpel blades
#3, #11, #15, #10

A

3 - disposable scalpel blade attaching to reusable handle

#11 - puncture abscesses, incisions, stabbing
#15 - blunt dissection, excision, trimming, elliptical biopsy
#10 - blunt dissection + excision on thick skin

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6
Q

With sutures, more zeros = ____ thread

A

Finer

Smaller size = less tensile strength

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7
Q

Explain the differences between braided and monofilament sutures

A

Monofilament - single thread; passes through tissue easily, less tensile strength

Braided - three threads braided, secure, easier to tie, but more likely to lead to infection

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8
Q

What are absorbable sutures used for? What are the different types?

A

Deep tissue layers

Natural - digested by body enzymes - MORE likely to cause a reaction than synthetic

Synthetic - hydrolyzed

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9
Q

What are the types of natural absorbable sutures?

A

Both are monofilament

Plain catgut - more tissue reactivity, half life 7-10 days

Chromic catgut - less tissue reactivity (chromic = salt that delays absorption), half life 2-3 weeks

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10
Q

What are the types of synthetic absorbable sutures?

A

Polyglactin (vicryl) - monofilament and braided, half life 2-3 weeks

Poly glycolic acid (dexon) - monofilament, half life 2-3 weeks

Polydioxanone (PDS) - monofilament, half life 4-6 weeks

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11
Q

Natural sutures are ____ likely to cause a reaction than synthetic

A

More

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12
Q

What are the types of natural non-absorbable sutures?

A

Silk: braided, high tissue reactivity
Polyester/polybutester: high tissue reactivity

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13
Q

What are the types of synthetic non-absorbable sutures?

A

Nylon/ethilon: monofilament, low tissue reactivity

Polypropylene/protene: monofilament

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14
Q

For the following area of the body, list the skin suture size and time of removal

Face/neck

A

5-0, 6-0
Removal in 3-5 days

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15
Q

For the following area of the body, list the skin suture size and time of removal

Arms/hands

A

4-0, 5-0
Removal in 7-10 days

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16
Q

For the following area of the body, list the skin suture size and time of removal

Trunk, legs, feet, scalp

A

3-0, 4-0
Removal in 7-14 days

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17
Q

High tension areas would have ____ removal times

A

Longer; 10-14 days

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18
Q

Risks of leaving sutures in too long AND taking them out too soon

A

Taking out too soon - dehiscence (splitting)
Leaving too long - inc risk scarring

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19
Q

Describe the following stitch type, including what it may be used for or risks

Simple interrupted

A

Can cause “railroad track” scar

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20
Q

Describe the following stitch type, including what it may be used for or risks

Vertical mattress

A

Better for everting skin edges
Good for wounds under tension
“Far far near near”

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21
Q

Describe the following stitch type, including what it may be used for or risks

Horizontal mattress

A

Used for high tension wound support
Holds fragile skin together
Distributes tension

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22
Q

Describe the following stitch type, including what it may be used for or risks

Deep or buried

A

Decreases tension in larger, deeper wounds
Knots are inverted below skin margins

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23
Q

Describe the following stitch type, including what it may be used for or risks

Intradermal/subcuticular running

A

In dermis, not visible
Better cosmetic appearance
Best in wounds with less tension

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24
Q

Describe the following stitch type, including what it may be used for or risks

Continuous running stitch

A

Not cosmetic
Less secure
Difficult to remove

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25
Q

Describe the following stitch type, including what it may be used for or risks

Three point/half buried mattress

A

V shaped wounds so not to impair blood flow to tip

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26
Q

Describe the following needle types:
Conventional cutting
Reverse tying
Tapered

A

Conventional - cosmetic surgery
Reverse - most common; skin, tendon sheath, oral mucosa
Tapered: pierces tissue without cutting; fascia, muscle, myocardium, bowel

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27
Q

Explain the following methods of skin closure including indications, advantages/disadvantages

Steri strips
Dermabond
Staples

A

Steri-strips:
-small wounds, thin flaps, in kids
-with sutures with difficulty everting edges/high tension areas
-sticker with benzoin
-cant be used around digits (tourniquet effect)

Dermabond:
-cyanoacrylate tissue adhesive
-sterile, nontoxic
-50 sec to set, wound heals 5-10 days
-cant be used in areas of excessive motion/moisture (knees, elbows, hands/feet, mouth, groin)

Staples: low risk of infection

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28
Q

What is the MOA of local anesthetics?

A

Block Na reputable to prevent depolarization of pain stimuli

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29
Q

List the order in which sensation is lost AND the order in which it returns with use of local anesthetics

A

Lost:
Pain
Temp
Touch
Deep pressure
Motor

Returns in reverse order

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30
Q

Describe the type of administration and uses of anesthetics:

Local
Field block
Regional/nerve block

A

Local - subQ injection (lacerations, small lesions)

Field block - circle around operative site (I&D, complex lacerations)

Regional/nerve block - directly into/near group of nerves

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31
Q

Describe the angles for IM and SQ injections

A

IM = 90 deg
SQ = 30-45 deg

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32
Q

What are amides use in minor surgery? How are they metabolized? Allergies to them are ____

A

Anesthetics; metabolized in liver by microsomes enzymes

True allergies are rare

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33
Q

What are the topical amides?

A

Lidocaine
EMLA cream

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34
Q

What are the infiltrative amides?

A

Lidocaine/xylocaine
Bupivacaine/marcaine
Mepivacaine/carbocaine

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35
Q

Describe the time of onset, duration, dosing, and adverse reactions of the following infiltrative amide:

Lidocaine/xylocaine

A

1-10 min onset
30-60 min duration
10 cc of 1% > 100 mg (add a zero to cc for dose)

AE: drowsiness, caution in elderly, may cause heart block and arrythmias

Max dosing (for 90 min to 2 hour intervals)
-Child: 3.3-4.5 mg/kg, dont exceed 75-110 mg
-Adult: 4.5 mg/kg, don’t exceed 300 mg

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36
Q

Describe the time of onset, duration, dosing, and adverse reactions of the following infiltrative amide:

Bupivacaine/marcaine

A

8-12 min onset
3-4 hr duration

AE: cardiac complications; NO IV due to heart block of long duration!!

Max adult: 4 mg/kg of 0.25%, not to exceed 200 mg

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37
Q

Describe the time of onset, duration, dosing, and adverse reactions of the following infiltrative amide:

Mepivacaine/carbocaine

A

8-12 min onset
2-2.5 hr duration

Max adult: 5 mg/kg of 1%, not to exceed 400 mg

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38
Q

What is an ester in minor surgery? How is it metabolized? Allergies are ___

A

Anesthetic; metabolized in peripheral plasma by psuedocholinesterase

More allergic reactions than amides

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39
Q

What are the topical esters?

A

Benzocaine - poorly observed, need at least 10%

Proparacaine - opth; <1 min onset, 15 min duration

Cocaine: ENT; <1 min onset, 1 hr duration

Tetracaine (TAC), epi, cocaine - FAST

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40
Q

What are the infiltrative esters?

A

Procaine/novocaine: slower onset but same duration as lidocaine

Allergic reactions common

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41
Q

What are types of adverse reactions that can occur with anesthetics?

A

Toxic if injected IV or excessively > hypotension, bradycardia, cardiac arrest (tx with O2)

Allergic - anaphylaxis rare, tx with Benadryl and epi/o2, more common with esters

Autonomic: tachycardia, sweating, dizziness, syncope (tx generally not needed) ** most common adverse reaction, have pt lying down prior to injection to prevent**

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42
Q

Guidelines to reduce pain of administration of anesthetics

A

Inject slowly
Administer with 27-30 g needle
Keep at room temp
Rinse wound with anesthetic first
Combine with sodium bicarb (10 cc 1% lidocaine: 1 cc 8.4% Na bicarb)

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43
Q

Role of epinephrine in minor surgery including benefits, adverse effects, max dose, and CI

A

Advantages: dec bleeding, prolongs duration of anesthetic, dec toxic reaction via vasoconstriction

AE: anxiety, tremors, palpitations, tachycardia

Max dose 0.2 mg

Avoid in MAOis, TCAs, thyrotoxicosis, severe CVD

Avoid in end areas (ear, nose, fingers, toes)

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44
Q

What is the difference between sterilization, disinfection, disinfectant, and antiseptic?

A

Sterilization - desctruction of all living microorganisms, including bacterial spores

Disinfection - reduction of a population of pathogenic microorganisms without achieving sterility

Disinfectant - germicidal substance used on INANIMATE objects to kills pathogenic microorganisms, but not necessarily all other

Antiseptic - chemical agent applied TO THE BODY that kills or inhibits growth of pathogenic microorganisms

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45
Q

What b vitamin is good for acne?

A

Niacinamide (B3)

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46
Q

Which of the following is CI for shave biopsy?

Hyperpigmented moles > 1 cm
Molluscum contagiosum
Seb keratoses
Benign superficial lesion

A

Hyperpigmented moles; BM unlikely to be visualized, so def dx unavailable (also most likely to be cancerous)

Avoid shave biopsy as dx; its more cosmetic

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47
Q

Which of the following is metabolized in the liver?

Lidocaine
Epi
Cocaine
Procaine

A

Lidocaine

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48
Q

Which is primary metabolized by plasma enzymes?

Lidocaine
Procaine
Epi
EMLA

A

Procaine > metabolized to PABA in peripheral tissues and plasma

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49
Q

10 cc of a 1% solution of lidocaine contains ____ mg

A

100 mg

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50
Q

1 cc of a 1% lidocaine solution contains ___ mg

A

10 mg

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51
Q

How to go from __cc of 1% solution > __ mg

A

Add a zero to cc (% > mg/mL)
Ex: 10 cc of 1% = 100 mg

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52
Q

Indications for adding epi to local anesthetics include all of the following EXCEPT

Decrease oozing
Prolong duration of anesthetic
Reduced risk in pts with severe CVD
Decreased risk of toxic rxn by reducing circulating levels of local

A

Reduced risk in severe CVD

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53
Q

Which of the following is a sign of local anesthesia CV toxicity?

Shivering
Hypotension
Syncope
Sweating

A

Hypotension

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54
Q

Which of the following is the best tx for a toxic reaction/systemic toxicity?

Epi
Benadryl
Lidocaine
Oxygen

A

Oxygen

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55
Q

which of the following is an indication for a NON-absorbable DEEP suture?

Tendon repair
Ophthalmic surgery
Deep skin wounds
Obstetrics

A

Tendon repair

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56
Q

Which of the following suture types has the highest liklihood of tissue reaction?

Chromic gut
Nylon
Vitro
Proline

A

Chromic gut

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57
Q

Which of the following sutures is the finest (has smallest diameter)?

5/0
000
4-0
6/0

A

6/0

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58
Q

Nylon is what type of suture

Absorbable, natural
Absorbable, synthetic
Non-absorbable, natural
Non-absorbable, synthetic

A

Non-absorbable, synthetic

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59
Q

Four cardinal signs of slight finger flexion, fuse form swelling of finger, pain on passive/active extension of the finger, and tenderness along the tendon sheath into the palm indicate:

A

Purulent tenosynovitis (can lead to nec fasc; refer to ortho surgeon)

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60
Q

CI to I&D include which of the following:

Fluctuant abscesses
Recurrent abscesses
Infected puncture wounds
Foreign bodies

A

Recurrent abscesses

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61
Q

All of the following may increase the amount of time it takes a wound to heal EXCEPT:

Hematoma
Accurate wound approximation
High tension
Dead space

A

Accurate wound approximation

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62
Q

This surgical tool is best for larger, thick, and tough skin on the back:

Iris scissors
#10 blade
#11 blade
#15 blade

A

10 blade

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63
Q

Which of the following scalpel blades has a straight and pointed cutting edge and is used to stabbing and incising the skin in I&D?
#11
#3
#10
#15

A

11

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64
Q

Which type of suture has less resistance as it passes through tissue and is less likely to harbor microorganisms? It also ties easily but knots may slip and break easily.

Catgut
Silk
Nylon
Braided vicryl

A

Nylon (like fishing line, strong but slippery, goes through nice but likely to have ties slip out)

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65
Q

What is hemostasis?

A

disruption of BVs, extravasation of blood consistent, initiation of the coagulation cascade, and formation of a fibrin clot

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66
Q

Wounds that are too contaminated to close initially but may be closed after 3-4 days post tx:

Primary Intention
Secondary intention
Tertiary intention
Quartiary intention

A

Tertiary intention

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67
Q

This stitch is great for everting skin edges and precise approximation of wound edges with little tension:

Simple interrupted
Vertical mattress
Subcuticular running
Continuous running/baseball

A

Vertical mattress

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68
Q

This easy and most versatile stitch can cause “railroad track” scarring

Simple interrupted
Vertical mattress
Subcuticular running
Half buried mattress

A

Simple interrupted

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69
Q

Urea paste dissolution and anti fungal oral meds are appropriate tx for

Keloids
Papillomata
Onychomycosis
Plantar warts

A

Onychomycosis (terbinafine)

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70
Q

Simple rupture by pressure, simple aspiration, and surgical excision are all potential tx for:

Ganglion cyst
Epidermis cyst
Trichlemmal cyst
Wen

A

Ganglion cyst

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71
Q

All of the following are variables that demonstrate amount of time to leave sutures in EXCEPT:

Universal precautions
Type of suture
Tensile strength
Potential for scarring

A

Universal precautions

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72
Q

Which of the following is a nutrient known to promote wound healing?

Vit K
Bromelain
Molybdenum
Silica

A

Bromelain

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73
Q

The most common organism causing wound infections is

Candida
Staph
Neisseria
HBV

A

Staph

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74
Q

Which of the following is a non-absorbable monofilament?

Catgut
Silk
Vicryl
Steel

A

Steel

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75
Q

in order to remove stitches, cut ____ (under/over) the know as ___ (close to/far from) skin as possible and pull the stitch out, drawing wound edges ___ (together/apart)

A

Under the knot, as close to skin as possible, pull stitch out pulling wound edges together

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76
Q

Causes of hematomas include:

Infection
Poor hemostasis
Elimination of dead space
Anesthesia

A

Poor hemastasis

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77
Q

This regional nerve block is injected into the anatomical snuff box to provide anesthesia to the lateral aspect of the proximal thumb

A

Radial

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78
Q

This regional nerve block is useful for providing anesthesia to the tip of the little finger

A

Ulna

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79
Q

Indications for hyfrecation include:

Bloody fields
Basal cell carcinoma
Actinic keratoses
Recent changing nevi > 1 cm

A

Actinic keratoses

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80
Q

Elliptical excision should have a length to width ratio of _____ with corners at ___angles

A

3:1, 30 deg

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81
Q

Elliptical excisions should ideally be made with a #____ blade, initially cutting ____ to the skin

A

15, perpendicular

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82
Q

Most dangerous of the malignant skin tumors

A

Malignant melanoma

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83
Q

Cellulitis involves what layers of skin? What is the most common bug to cause cellulitis? How is diagnosis done?

A

Dermis and subcutaneous tissue
Group A BH strep or staph A

Clinical dx, culture

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84
Q

What is a dangerous complication of cellulitis?

A

Necrotizing fasciitis

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85
Q

What is erysipelas? What is the common bug and how does it present/

A

Superficial cellulitis involving lymphatics

Group A BH strep pyogenes

Painful, raised, and sharply demarcated “orange peel” lesion with fever, malaise, local lymphadenopathy, and possible streaking

May present similar to impetigo but impetigo has NO systemic sx associated

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86
Q

What is lymphangitis?

A

Red streaking along lymph tract (from infected area to armpit/groin)
Throbbing pain
Fever/chills
Myalgia
HA
Loss of appetite

  • sign a bacterial infxn is worsening
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87
Q

What HPV strains most commonly cause genital warts? What is the name for this pathology?

A

6 and 11
Condylomata acuminata

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88
Q

What HPV strains cause flat warts and are more likely to lead to cervical dysplasia?

A

16, 18, 31, 33

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89
Q

What is impetigo? How does it present, and how is it dx

A

Skin infxn caused by bacteria (strep pyogenes and/or staph a)

Pruritic pustules, vesicles, bullae, with “honey colored” crust

Dx: clinical, culture, or gram stain

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90
Q

Molluscum contagiosum etiology

A

Children, Immunocompromised
Virus

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91
Q

Name the pathology: Epithelial flesh papules > dome gray/brown hyperketatotic growths with black dots on surface

A

Verruca vulgaris (common warts) caused by HPV

92
Q

What is Tinea incognito?

A

When the clinical appearance of Tinea changed because of inappropriate tx

93
Q

Tinea versicolor etiology and presentation

A

Chronic yeast overgrowth in skin inc by heat; pityrosporum obiculare

Not contagious

White/brown/pink scaling oval patches on trunk

94
Q

Vitiligo is associated with increased risk of what pathologies?

A

Other autoimmune disorders (thyroid, pernicious anemia, Addison, alopecia areata)

95
Q

What is pityriasis alba and how does it present? What would be your ddx?

A

Children and young adults; round/oval slightly elevated fine scaling plaque that leaves hypopigmentation on face, neck, arms

Ddx: vitiligo and Tinea versicolor however those both appear white. In vitiligo, borders are distinct. Tinea versicolor rare on the face. KOH will differentiate the three.

96
Q

What is pityriasis rosea? How does it present?

A

Teens and young adults
No known cause; linked to mycoplasma, picornavirus, and human herpes virus 7

“Harold patch” (plaque) precedes eruption followed by smaller plaques that follows long axes parallel lines of cleavage starting at spine (Xmas tree pattern)

Self limited

97
Q

What is acute paronychia? Presentation, tx, and complications

A

Painful bright red swelling of proximal and lateral nail fold; chronic type associated with contact w water

Tx: keep hands dry, avoid lotions/ointments
Early: warm soaks
Late: if pus - I&D with #11 blade or needle (blade between nail and nail fold) abx

Separation of nail plat (onycholysis) may predispose to pseudomonas infxn

98
Q

What is a felon?

A

Deeper infection working its way into/under the nail bed and to fat pad

Abscess formation usually due to staph in distal pulp of finger involving multiple septae and compartments; can cause rapid and significant destruction (necrosis) and osteomyelitis

99
Q

Tx of Tinea unguina

A

Oral fluconazole or itraconazole

100
Q

How to differentiate Tinea unguina and psoriasis on the nails

A

Pitting not found in Tinea

101
Q

describe the presentation of infestation/bite with the following:

Black widow

A

Strong Neurotoxin: intense pain in regional nerve, spread outward

Starts 10 mins after bite

Original bite is painless

102
Q

describe the presentation of infestation/bite with the following:

Brown recluse/fiddle back

A

SE US
Necrotoxic - sphingomyelinase D

Painful bit
Turns red > swells > dusky > necrotic over 7 days > eschar sheds in 3 weeks

HA, fever, diffuse rash

103
Q

Tx for brown recluse bites

A

Wound care, IMMEDIATE steroid administration to prevent skin from melting/skin grafts

104
Q

describe the presentation of infestation/bite with the following:

Scabies-mites

A

Very pruritic, esp at night
Red papules, excoriations, burrows
Hands, wrists, elbows, axilla, umbilicus, groin/penis
Contagious
Takes 6 weeks to show after exposure

105
Q

Tx scabies

A

Elimite, neck down x 8 hours

106
Q

Flea vs chiggers bites

A

Chiggers bite in 3s where clothes dont cover (waist, socks, ankle)

Fleas - ankles, after animal is gone, can be dormant for 1 year

107
Q

etiology, changes/risks of junctional nevi

A

Junctional-macular
Hereditary/sun exposure determine # of moles
>50 inc risk of melanoma
As moles age, raise up, and loose color = normal change

108
Q

etiology, changes/risks of congenital nevi

A

Present at birth and grow
May thicken and develop hairs
Larger/darker
10 cm have a 10% MM risk
Excise at puberty

109
Q

etiology, changes/risks of Actinic keratoses/solar keratoses

A

Rough scaly spots on sun-damaged skin (face, forearm, hand)

Can give rise to SCC

110
Q

etiology, changes/risks of Seborrheic keratosis

A

Greasy, scaly, verrucous flat papules to plaques
“Stuck on” appearance
Occur more in sun exposed areas
Can get inflamed and simulate a skin CA

111
Q

etiology, changes/risks, and tx of Dermatofibroma

A

Overgrowth of fibroblasts + BV
Usually brown and firm (feels like a BB under the skin)
Secondary to trauma
LEs, women
Feel like lentils under skin

Leave alone. Elliptical excision

112
Q

etiology, changes/risks of Epidermal inclusion cysts (sebaceous cysts)

A

Movable skin colored papules/nodules
SubQ
Face, back, ears, groin
Sack of epidermis under skin filled with keratin/sebum
Smell
Can get inflamed, usually not infected

113
Q

Tx of epidermal inclusion/sebaceous cyst

A

Incising and blunt dissection around capsule or it will return

114
Q

etiology, changes/risks of Pilar cysts (wen)

A

On scalp, subQ movable nodule
Have firmer keratin than EIC/no smell
Usually pop out during surgery

115
Q

Types of hemangiomas

A

Capillary - affect BVs in uppermost layers of skin (strawberry, superficial angiomatous nevi)

Cavernous (subQ angiomatous nevi, more deeply set in dermis and subcutis)

Cherry - midtrunk, inc after 40, can be removed with diathermy/laser

116
Q

etiology, changes/risks of Seborrheic dermatitis

A

Chronic superficial inflammatory process of hairy regions of the body triggered by stress, fatigue, change of season, of reduced general health

Pityriasis capitis (dandruff)
Cradle cap (thick, yellow, crusty scalp lesions in infants)

Proliferation of pityrosporum ovale (yeast)

117
Q

General rules for skin neoplasia and ND scope of practice

A

If you don’t know what a lesion it > biopsy it

If you have ANY suspicion it is neoplastic send them right to derm; delay from biopsy to tx can cause Mets

If you know its neoplastic you are NOT LEGALLY ALLOWED to perform minor surgery on it

Always err on cautious side!

118
Q

etiology, changes/risks of Lentigo (“Spots”)

A

Maligna
Benina

Precancerous

119
Q

etiology, changes/risks of BCC

A

Most common skin CA
Slow growing; bleeding or scabbing sore than heals and recurs
Rare Mets

Nodular; often face, small translucent papule or nodule that appears “pearly” with rolled edges and may be pigmented with small BV or red

120
Q

etiology, changes/risks of SCC

A

Faster growing, indurated, ulcerated/crusty
Second most common skin CA
Bleeding, friable surface
Very metastatic
Areas of sun exposure

RF: arsenic exposure, burn scars, radiation, trauma, tobacco, alcohol

Ddx: trichoepithelioma

121
Q

What are the 6 key risk factors that make someone high risk for melanoma?

A

Fhx in 1st degree relative
Fair skinned, red/blonde, blue eyes
Marked freckling of upper back
AK
3+ blistering sunburns prior to age 20
3+ years with outdoor summer jobs as a teen

122
Q

4 types of malignant melanoma

A

Superficial spreading
Nodular
Lentigo maligna
Acral

123
Q

Describe superficial spreading MM

A

Most common
Radial phase before invading dermis

124
Q

Describe nodular MM

A

Most aggressive
Skips radial phase, goes straight to vertical

125
Q

Describe Lentigo maligna MM

A

Elderly
Sun exposed areas
Occur in large Lentigos (age spots)
Occur slowly over 20 years

126
Q

Describe Acral MM

A

Most common in darker skinned ppl (black, Asian, hispanic)
Occur on palms, soles, nail beds
Aggressive and overlooked

127
Q

At what diameter do moles become concerning for malignancy?

A

> 6 mm or a pencil eraser

128
Q

Describe presentation and work up for pemphigus vulgaris

A

Middle aged/elderly
Rare, AI
Intra-epidermal blisters (vesicles and bullae) that move into painful erosions, randomly scattered

Nikolsky sign (w/ pressure, blister spreads)

Lab: microscopy, IF; shows IgG in skin and serum

129
Q

What is cholinergic urticaria?

A

From overheating, exercise, emotional stress
Start in few mins, last 30 min

130
Q

What types of ddx would you be considering in both acute and chronic urticaria?

A

Acute: bacterial, viral infxns, drugs (aspirin, abx)

Chronic: rule out internal dz (thyroid, CA, lupus), infections, ingestants (foods, drugs, dyes, dust, mold, pollen)

131
Q

Describe presentation and work up for Erythema multiforme

A

Acute illness; hypersensitivity, drugs

Round lesions on forearms, hands, knees, or feet that look like a target with a fluid filled blister inside

Common, self limited

Dx: clinical or biopsy

132
Q

What would the presentation looked like of a drug eruption? What is the most common variety?

A

Onset within 1 day to 3 weeks of drug therapy (depends on prior sensitization)

Urticarial is most common, eczema may be in Ddx but would itch much more severely than a drug rash

133
Q

What is the etiology of urticarial (hive) drug reaction?

A

may be IgE mediated, triggering mast cell granule release, or drug may directly cause mast cell granule release

134
Q

Describe a morbilliform drug eruption

A

Maculopapular/exanthematous drug eruption

Looks like measles rash; symmetrically distributed on the trunk and proximal extremities

Bright pink macules and slightly raised papules

135
Q

What is a fixed drug eruption? What are drugs that are common culprits of this type of rxn?

A

Occurs at same sites with each episode

OTC drugs containing phenophthalein, pseudoephedrine, etc

Tetracyclines, barbiturates, phenothiazines, sulfonamides

Oval, itchy, burning dusky red plaque

136
Q

What is the presentation and etiology of toxic epidermal necrolysis (TEN)/Steven Johnson syndrome (SJS)?

A

Severe life threatening blistering disorder that presents with fever, pruritis, conjunctivitis, and erythema-multiforme rash sometimes (commonly affects mucous membranes/ENT) > progresses and melts skin through dermis

30% fatal

Almost ALWAYS due to a drug rxn

137
Q

Tx for TEN/SJS

A

Emergent referral
Electrolyte replacement
Possibly high dose IV steroids

138
Q

Etiology and presentation of discoid lupus erythematosus

A

Chronic recurrent AI disorder primary affecting the skin

Unknown etiology; IgG and IgM deposited in skin

Exposure to sunlight frequently precedes lesions

More common in women (10x), onset in 30s

139
Q

Work up for discoid lupus erythematosus

A

Clinical dx - no anemia, normal ESR, ANA absent or low (not SLE), anti DNA absent

140
Q

Describe presentation and work up for Granuloma annulare

A

Ring of small, firm, flesh colored or red papules on lateral or dorsal surfaces of hands and feet

Begins with asx papule that undergoes central involution > inc up to 5 cm over months

Spontaneous involution or lasts for years

Histology shoes collagen degeneration

141
Q

Tx granuloma annulare

A

Intralesional injections with triamcinolone

142
Q

Atopic dermatitis major criteria

A

Pruritis
Flexural lichenification and linearity in adults
Facial and extensor involvement in babies/kids
Chronic or chronically relapsing dermatitis
Personal or fhx atopy

143
Q

Lab / work up atopic dermatitis

A

Serum IgE > 200 IU/mL
Eosinophilia

144
Q

Presentation / etiology psoriasis

A

Red, scaly-white papules and plaques; removal of scale > blood drops (Auspitz)

Triggers: emotional stress, trauma to skin (koebners phenomenon), strep throat (guttate)

145
Q

Describe presentation and work up for Rosacea

A

In adults, men > women
Two components: redness/flushing/telangiectasia/burning
Papules/pustules
No comedomes

Mid face, around eyes

Unknown etiology; triggers can be emotional stress/ppl who blush, hot/cold air, exercise, cheese/wine/coffee

146
Q

Describe presentation and work up for lichen simplex

A

Itch/scratch cycle > lichenification

147
Q

Describe presentation and work up for Lichen planus

A

palms, wrists

Pruritic
Polygonal
Purple/pink
Planar
Plaques / Papules with

wickhams striae (criss cross white lines)

148
Q

What are the sx and types of kaposi sarcoma?

A

Sx: purple, red, brown blotches
Types:
Classic
Endemic
Immuno suppression related
Epidemic kaposi sarcoma

149
Q

Describe classic kaposi sarcoma

A

Slow growing
Common in old M
Leg lesions

150
Q

Describe endemic kaposi sarcoma

A

Common in young M
Often aggressive

151
Q

Describe immuno suppression related kaposi sarcoma

A

Mostly affects skin
Organ transplant pts

152
Q

Describe epidemic kaposi sarcoma

A

Seeds in AIDS pts
Affects multiple areas of the body

153
Q

What is the difference between a carbuncle and a furuncle? How do you tx them?

A

Furuncle (boil): pus filled infection hair follicle

Carbuncle: cluster of connected furuncles

Tx: I&D, abx, warm compress

154
Q

What is cimicosis?

A

Bed bugs

155
Q

What are the common bugs and tx for acute and chronic paronychia?

A

Acute: staph A (cephalexin)
Chronic: candida (antifungals)

156
Q

Before minor surgery procedures, you ________ (should/should not) shave hairy areas

A

Should NOT

157
Q

How to prepare the field for a closed site?

A

Use antiseptic over site (10% povidone-iodine (betadine) or 0.4% chlorhexidine gluconate) and leave sitting for 2 mins

158
Q

How to prepared the field for an open wound?

A

Irrigate with normal saline (35 mL syringe with 19 g needle)
Use betadine around the wound on the intact skin

159
Q

Should you use betadine, hydrogen peroxide, both, or neither on an open wound? Why or why not?

A

NEITHER
They will cause delayed wound healing and organic material neutralizes the antiseptic activity

Hydrogen peroxide is also toxic to healing wound due to disruption of new epithelium

160
Q

What are methods of sterilization/disinfection of tools?

A

Alcohol (70%) / chlorhexidine (5%) - emergency disinfection in 2 mins; does NOT sterilize

2% glutaraldehydes - disinfection of choice; disinfects after 10 mins, sterilizes after 10 hrs, low tissue toxicity

Boiling - 100 c for 5 min (disinfect) - 30 min (sterilize); only use if no other option

Dry heat - 160 c for 60 min (not for rubber, plastic, cloth, or paper)

Autoclave - method of choice bc efficient and reliable. 15 PSI @ 121 c for 30 mins

161
Q

What are important considerations for documentation?

A

For puncture wounds, document tetanus status
Describe neurovascular status and tendon function

162
Q

CI to performing minor surgery/instances to refer

A

Cut tendons, nerves
Cosmetically significant facial wounds
Foreign bodies deeper than fascia or near critical structures
Deeper than fascia/muscle
Eyes, nose, axilla, groin, post triangle of neck
Young children
Serious systemic illness
Pt known to form keloids
Bleeding risk (extended bleeding time, pulsating lesion, large size/compromised blood supply)

163
Q

Types of cryotherapy

A

Histobreeze (-50c) - compressed gas in aerosol can
CO2 slush (-78.5c) - simple, cheap, not effective
Nitrous oxide (-89.5c) - expensive, stores indefinitely
Liquid nitrogen (-196c) - effective; swab, cryoprobe

164
Q

Technique cryotherapy

A

Freeze zone of 2-3 mins
Continue to maintain frozen zone x 10-30 secs, thaw, then repeat
Blister > scab > sloughs; heals in 2-3 weeks

165
Q

Advantages and disadvantages of cryotherapy

A

Advantages: minimal scarring, infections rare, no dressing, no anesthetic

Disadvantages: depigmentation, caution on thin skin, HPV not killed by freezing

166
Q

Indications for cryotherapy

A

Warts, Molluscum contagiosum, skin tags, granulation tissue, AK, Sebb keratosis, small nevi, cervical dysplasia

167
Q

Electrosurgery types & uses

A

Electrocautery - indirect current (hemostasis, skin tags, subunguinal hematomas, removing benign lesions with curettage)

Hyfrecation - direct current (hemostasis, warts, small nevi)

168
Q

Advantages and disadvantages of electrosurgery

A

Advantages: quick, eff, less blood loss

Disadvantages: lesion is destroyed

169
Q

CI electrosurgery

A

Metal pins, pacemaker
Don’t use antiseptics (flammable)

170
Q

What type of biopsy is indicated for an epidermal lesion

A

Shave biopsy

171
Q

What type of biopsy is indicated for an Intradermal lesion

A

Excisional, punch, or incisional

172
Q

What is an excisional biopsy?

A

Complete removal of the lesion; both diagnostic and curative

173
Q

Steps for an elliptical biopsy

A

Orient resting skin tension lines
Administer field block
Prep with betadine
Excise with #15 blade - cut perpendicular to the skin and apply tension during
Immediately place in 10% formalin
Control bleeding (gauze, pressure, electrocautery)
Undermine lateral edges to reduce tension
Close would and cover with dry, sterile dressing

174
Q

Ratio / degrees for elliptical biopsy

A

3:1 ratio with 30 degree corner

175
Q

What is an incisional biopsy and what are indications for using this type? What are disadvantages?

A

Specimen is taken from within a lesion; used to dx a large lesion

Disadvantages: may miss malignant area; bleeding, scarring

176
Q

Indications for punch biopsy

A

Small/benign nevi
Inflammatory skin disorders (dermatitis, vasculitis, CT disorders)

177
Q

Indications and CI shave biopsy

A

Superficial lesions
NEVER use on lesion that might be melanoma

Anesthetize under lesion to raise up

178
Q

Steps for cyst/lipoma removal

A

Prep, anesthetize
Make linear incision over center following RStLs
Using blunt dissection, “shell out” lipoma + capsule (for cyst keep capsule intact to prevent recurrence)
If tethering vessels on deep surface, ligate with absorb suture
Probe open wound to ensure no remaining lobes
Close dead space and skin

179
Q

Steps for toenail removal

A

-Prep liberally with betadine
-Web space block with 1-2% lidocaine (NO EPI)
-Exanguinate toe by wrapping with sterile gauze then with a rubber band
-Penrose drain or rubber tournaquet, clamp with Kelly clamp (dont leave on more than 15-20 mins)
-cut narrow strip of nail all the way to nail matrix, grasp with clamp and gently remove with rotation/traction (make sure entire nail with root is removed)
-dress with Vaseline gauze then wrap with dry gauze
-advise pt to elevate foot rest of day

180
Q

Describe primary method of closure and when its used

A

Immediate suturing of a wound
Use: clean wounds
Don’t suture wound if >8-12 hr old

181
Q

Describe tertiary method of closure and when its used

A

Delayed primary;
Visibly contaminated wounds

Irritgate, debride, and pack
In 3-4 days can close primarily

Eg: dog bite

182
Q

Describe secondary intention method of closure and when its used

A

Contaminated or infected wounds, wounds with significant tissue loss, devitalization

Left open to heal

183
Q

What is the purpose of an occlusive dressing?

A

To allow sweating but keep bacteria out

184
Q

Wounds re-epithelialize faster in _____ (moist/dry) environment

A

Moist

185
Q

explain how to dress surgical wounds

A

Clean/sutured wounds only need simple/dry dressing

Use non stick gauze (e.g.tefla), then gauze, then tape

186
Q

Post-procedure instructions

A

Keep dry 24-48 hours
Digit/extremity sites should be elevated
Monitor for signs of infxn
Redress every 2-3 days
Suture removal with iris scissors or #11 scalpel

187
Q

Complication possibilities with procedures

A

Infection
Hematoma
Dehiscence
Scarring

188
Q

The most common cause of delayed wound healing is _____

A

Infection

189
Q

Common organisms for wound infection, presentation, and tx

A

MS: staph A
Other: strep, staph epi, E. coli, proteus, nitro bacteria, klebsiella, candida

Signs of infxn onset in 4-10 days

Tx: culture > abx
If prurulence is seen, remove sutures and allow wound to heal by secondary intention

190
Q

Hematoma presentation, causes, and tx

A

Collection of blood in tissues can lead to > infection, dehiscence

Presents within 24-72 hours

Causes: lack of hemostasis, pts at risk include those on NSAIDs or anticoagulants

Tx:
Small - warm compress
Large - reopen and establish hemostasis, heal by secondary intention

191
Q

Wound dehiscence presentation, causes, and tx

A

Separation of wound edges caused by infection, hematoma, inadequate undermining/excessive tension, poor suture technique, excessive pt activity, removing sutures too soon

Tx: tx underlying cause
If within first 48-72 hours, re-suture
If over 72 hours: heal by secondary intention

192
Q

Hypertrophic vs keloid scars

A

Hypertrophic: MC, does not involve any previously uninjured tissue

Keloid: continue to enlarge beyond original dimensions of wound in pseudo tumor fashion

193
Q

Name the stages of healing and when they occur

A

Hemostasis (coagulation)
Inflammation (immediately: days 1-4)
Proliferation (granulation) 3-21 days
Remodeling 3 weeks - 6-18 months

194
Q

What is hemostasis?

A

Formation of a fibrin clot

195
Q

When in wound healing does inflammation occur? What are the steps?

A

Begins immediately; days 1-4

Platelets secrete cytocytes, clot formation triggers complement cascade

Neutrophils in 5-6 hr, last 3-4 days

Macrophages transition inflammation > repair and phagocytize

Re-epithelialization: basophils migrate within 24-48 hours

New keratinocytes proliferate 1-2 days after injury

196
Q

When in wound healing does proliferation occur? What are the steps?

A

Proliferation (granulation) - 3-21 days

New capillaries surrounded by fibroblasts form granulation tissue; angiogenesis brings oxygen and nutrients

197
Q

When in wound healing does remodeling occur? What are the steps?

A

3 weeks to 6-18 months

30-40% strength by 3-4 weeks
80% at one year

Contraction is normal due to myofibroblasts ad orientation of collagen. Contracture is abnormal formation of tight scar due to excessive contraction

198
Q

Common nutrients for wound healing

A

Vitamin C: promotes collagen formation
Zinc: collagen synthesis, cross linking, immune function
Copper: collagen cross linking
Vit E: reduce scar formation
Flavonoids: reduce scar formation

199
Q

Causes of chronic paronychia

A

Fungal infxn
Retained foreign body

200
Q

In terms of abscesses, in what scenarios would you refer?

A

Recurrent
Severe DM
Immune def
Bleeding disorder

201
Q

What is a dermoid cyst?

A

Collection of tissue under skin; may contain hair, teeth, or nerves

202
Q

What is a Epidermis cyst?

A

Contains dead skin cells

203
Q

What is a Sebaceous cyst?

A

Filled with yellowish material
On scalp is a Pilar (wen) cyst

204
Q

What is a Trichilemmal cyst?

A

Filled with keratin
Also called Pilar cyst

205
Q

What is an acrochordon? How do you tx it?

A

Skin tag; shave or lift and snip. Electrocautery

206
Q

What is a Cutaneous horn? How do you tx it?

A

Protrusion made of keratin, shave or freeze

207
Q

What is a Keratoacanthoma? How do you tx it?

A

Rapid growth, light exposed skin, round with rolled edges and central keratin plug

Diff to distinguish between BCC, base may contain SCC

Refer or excision with biopsy

208
Q

What is a Lentigne?

A

Liver spot
Benign and from sun exposure

209
Q

Tx Molluscum contagiosum

A

Cryo, salicylic acid

210
Q

Tx nevi (junctional, compound, Intradermal)

A

Large: elliptical excision
Small: punch biopsy, curette/cautery, cryo, hyfrecation/dessication

211
Q

What is a Dysplastic nevus? How do you tx it?

A

features between benign nevus and malignant melanoma

Possible melanoma precursor; probably marker for inc risk

Refer to specialist for surveillance

212
Q

What is a Pyogenic granuloma? How do you tx it?

A

Common benign inflammatory masses of BVs and fibroblasts

Erupt rapidly, usu due to trauma/infxn (lips, tongue, palms)

Cryo, curette/cautery, excision if want to send to path

213
Q

What is sebaceous hyperplasia?

A

Enlarging of sebaceous glands; occurs with age

214
Q

How do you tx telangiectasia?

A

Tx for cosmetic purposes
Hyfrecation, electrocautery (touch the central vessel)

215
Q

Tx for verruca

A

Duct tape, salicylic acid, podophylin, thuja, tea tree oil

Then > cryo, hyfrecatio, curette/cautery, excision

216
Q

Tx of felon

A

Surgical drainage (make incision over point of maximal tenderness)

Abx, soaks, elevation

After incision leave open to heal by secondary intention

If deep, or does not respond quickly to tx, refer ASAP to hand surgeon

217
Q

how do you tx a subungual hematoma?

A

Release blood w electrocautery through nail (or drill) > immediate relief

Apply ointment, dressing
Consider x rays to rule out tuft fracture

Common, fast and easy to tx with low risk of complications

218
Q

What is an anal fistula?

A

Abnormal tube from rectum to external perianal or perineal area. Usually result of an abscess or inflammatory process

219
Q

What is a pilonidal cyst? How do you tx it?

A

Vestigial cyst from embryonic development lined with endothelial tissue

In the sacrococcygeal nerve, can become inflamed, infected

Initial tx if infected is I&D; when infxn resolved can be surgically excised

220
Q

Melanoma RF, most common type, tumor markers

A

RF: women, fhx, fair skin, AK, outdoor work, sun burns

Most common = superficial spreading
Most aggressive = nodular
Most common in elderly = Lentigo
Aggressive and most common in dark skin = Acral

221
Q

Tx for human bites

A

Hand bites are HIGH RISK; refer to surgeon for IV antibiotics, observation. May need surgery.

NEVER suture closed

222
Q

Tx for dog bites

A

Thorough cleansing, debridement if necessary
Usu leave open
Consider prophylactic antibiotics (always in cats, dogs with high risk infxn)
Consider tetanus, rabies prophylaxis
Refer if systemic sx of infxn, or if bite penetrates joint/lacerates a nerve or tendon

223
Q

abx for dog bites should cover

A

Pasteurella multicida, strep, staph a, anaerobes

Amoxicillin - clav
Cephalosporin or doxy for penicillin allergies

224
Q

Tx for foreign bodies

A

Only remove straightforward ones

Puncture wounds should be left open

ALWAYS REFER:
FB that may have penetrated the chest, abdominal cavity, eye, skull, or deep tissues of neck
Gunshot wounds
Vascular, tendon, nerve injury

225
Q

Laceration classifying

A

Superficial vs deep (nerve, tendon, vasculature, bone)

Simple (no significant loss of tissue/contamination) vs complex

Clean vs dirty/contaminated

226
Q

Steps of laceration repair

A

Anesthetize
Irrigation with NS (35 cc syringe)
Prep around wound with betadine or chlorhexidine
Consider debridement, reinspect wound, decide on type/size of suture
Dress wound, tetanus prophylaxis, abx

227
Q
A

NPLEX II TIA (15 decks)

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