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Dermatology > Skin Exam > Flashcards

Skin Exam Flashcards

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Dermatology Board Prep flashcards
1
Q

Prior to the skin exam obtain a history:

3

A
  1. Family history of melanoma?
  2. Sun exposure?
  3. Any change in lesions noted by the pt or family?
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2
Q

Goal of the Skin Exam
Determine general skin color and number of nevi
Screen for melanoma: look for lesions with ABCDE

A 
Asymmetry
Border irregularities
Color variation
Diameter greater then 6 mm
Enlargement or Evolution of color change, shape or symptoms
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3
Q

What is skin mapping?

A

Another less commonly used method of following change with pigmented lesions is mole mapping. With this technology, suspicious moles can be digitized with dermoscopy cameras and reimaged at three- to six-month intervals to determine if any changes in characteristics have occurred in this time.

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4
Q

“More errors come from failing to biopsy promptly than from performing unnecessary biopsies”

Biopsy indications: 3

A
  1. All suspected neoplasms
  2. All bullous disorders
  3. To clarify a diagnosis when a limited number of entities are under consideration
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5
Q

Before doing a biopsy

3

A
  1. No absolute contraindications
  2. Pt needs to be asked about allergies/reactions to topical antibiotics, local anesthetics and tape
  3. Need to know if pt has a bleeding disorder or is on aspirin or warfarin
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6
Q

For Need to know if pt has a bleeding disorder. What should we doo for the following?

  1. aspirin?
  2. warfarin?
A
  1. If on aspirin—OK to biopsy; use pressure dressing

2. If on warfarin—refer to dermatologist

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7
Q

Biopsy Danger Zones

3

A
  1. Areas overlying highly vascular structures
  2. Areas associated with exit points of superficial motor nerves
  3. Nerves & vessels run in the subcutaneous fat plane
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8
Q
  1. Site selection: Inflammatory lesions? 1
  2. Blistering disease:
    - On which ones?
    - Within what time period?
    - Remove vescicles how?
A
  1. Inflammatory lesions
    - Biopsy those with characteristic inflammatory changes (eg, erythema) first
  2. Blistering diseases
    - Biopsy only the newest vesicles or blisters
    - Ideally within 48 hrs
    - Remove vesicles intact w/ adjacent normal skin when possible
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9
Q

Site selection: Nonbullous lesions?

  1. What should you include in the biopsy?
  2. Whihch lesions should we excise completely?
  3. Larger lesions how should we go about this?
  4. How should we excise a bullae lesion?
A

Nonbullous lesions

  1. Include maximal lesional skin & minimal nl skin
  2. Lesions between 1-4 mm excise completely
  3. Larger lesions: bx the edge, thickest portion or area that is most abnormal color
  4. Bullae
    at the edge including a small part of the blister with adjacent intact skin—keep the blister roof attached
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10
Q

Anesthetic used for derm procedures

3

A
  1. Lidocaine 1%
  2. Lidocaine 1% with epinephrine (1:100,000)
  3. Lidocaine 2.5% + Prilocaine 2.5% (EMLA cream)
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11
Q

General principles of biopsy? 2

A
  1. Sterile technique

2. Anesthesia with 1-2% lidocaine

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12
Q

Lidocaine 1%

  1. Useful for what? 5
  2. For most derm procedures inject into where?
  3. pH of standard licocaine?
  4. How can we decrease the discomfort from this?
A
  1. Useful for procedures requiring anesthesia of the
    - fingers,
    - toes,
    - nose,
    - penis, or
    - ear
  2. For most dermatologic procedures, inject 1 to 5 mL (maximum 4 mg/kg = 28 mL for a 70 kg person) into the lesion.
  3. The standard solution of lidocaine has a pH of 5.0 to 7.0.
  4. It can be buffered to a pH of 7.0 to 7.2 by adding one part of 1 mEq/mL of sodium bicarbonate to 9 or 10 parts of 1% lidocaine to decrease the discomfort associated with injection and to enhance anesthetic tissue dispersion.
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13
Q

Lidocaine 1% with Epinephrine
1. Useful for anesthia in all procedures except? 2

  1. Advantages of epi? 3
A
  1. Useful for anesthesia in all procedures except those that
    - involve the fingers, toes, nose, penis, or earlobes, or
    - in patients on non-selective beta blockers.
  2. Advantages of epinephrine
    - Less bleeding
    - Prolongs anesthetic action
    - Also allows for larger volumes of anesthetic to be used safely (maximum 7 mg/kg = 49 cc for 70 kg person)
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14
Q

Anesthetizing the area

  1. Draw up Lidocaine with a ____G needle and switch out to a _____ G needle to use on the pt
  2. Small syringe: ____cc
  3. Make initial injection ____________ to the skin
  4. Inject where in regards to small lesions?
  5. Must be infiltrated into the ____ to elevate a lesion for biopsy
A
  1. 16–18, 25-30
  2. 3-5
  3. perpendicular
  4. directly into or immediately adjacent
  5. dermis
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15
Q

Local anesthesia
1. Slowly inject small volumes of anesthetic taking care to monitor the ________ administered.

  1. During anesthetic infiltration, either slowly advance the needle or initially insert it to the hub, and infiltrate as the needle is what?
  2. Reinsert the needle through the area just anesthetized, redirecting it where?
  3. Continue infiltration through previously injected skin until when?
  4. After a few minutes, lightly test the skin or wound margins for adequate anesthesia using what?
A
  1. total dose
  2. withdrawn.
  3. along the margins of the wound or circumferentially around the abscess and infiltrate additional anesthetic.
  4. the entire region requiring anesthesia is infiltrated.
  5. the injection needle or other sharp object (suture needle, Adson forceps).
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16
Q

What is a field block and what is it used for? 2

The needle is inserted at how many points and injected along how many lines?

A
  1. Field block — For heavily contaminated wounds or when anesthetizing for incision and drainage of a skin abscess (or sebaceous cyst removal)
  2. In the field block, anesthetic is infiltrated to the subcutaneous area surrounding the operative field.

-The needle is inserted at two points, and anesthetic solution is injected along four lines (walls) that surround the area to be anesthetized.

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17
Q

Field block

The shape of the anesthetic field can be modified by what?

A

changing the number and direction of the anesthetic walls.

18
Q

Langer’s lines
1. Round wounds tend to be pulled open in the direction of what?

  1. They parallel the direction of what?
  2. Surgical incisions placed _______ to tension lines will close more easily and cosmetically then those placed at a ______ angle
A
  1. skin tension lines (Langer’s lines)‏
  2. the collagen in the dermis
  3. parallel, right
19
Q

Shave Biopsy

  1. Dont use what?
  2. What kind of scar dot they leave?
  3. Lesions suitable are elevated and confined to the epidermis? 3
A
  1. Easy, no sutures,
  2. leave a small depressed scar
  3. Lesions suitable are elevated and confined to the epidermis:
    - Seborrheic or actinic keratoses
    - Skin tags
    - Small superficial lesions
20
Q
  1. Elevate the lesion by what?
  2. Stabilize the lesion by what?
  3. Using a scalpel # 15 or razor blade shave it off
    - It can be what depths?
    - Hemostasis is often stopped by what?
  4. Oozing can be controlled w/ what? 3
A
  1. injection lidocaine into the dermis
  2. gently holding it w/ forceps
    • superficial or deep
    • pressure alone
    • 10-20% aluminum chloride (Drysol); other hemostatic agents are:
    • Ferric subsulfate (Monsel’s solution) or
    • silver nitrate
21
Q

Punch Biopsies
1. What is it?
2.What should be determined first
Inject the anesthetic?

  1. Stabilize the skin w/ the thumb and forefinger, stretching it slightly __________ to the skin tension lines ( this produces an oval rather than a round wound)‏
A
  1. Uses a special tool that comes in different sizes and removes a cone shaped core of tissue
  2. Langer’s lines
  3. perpindicular
22
Q

Punch Bx
1. __mm bx can usually be allowed to heal by secondary intention

  1. Larger than __mm need to be closed with stitches
A
  1. 4

2. 4

23
Q

Excisional Bx
1. Direction of the lines of skin tension lines is determined after performing a what?

  1. Draw an ellipse around the lesion to be excised including a ____mm margin of normal skin
  2. The length should be __x the width
  3. It must be deep enough to go down to the what?

Using a # 15 blade begin at one apex with the blade perpendicular to the skin & and start the incision
-Angle the blade away from the lesion to undermine the wound edge

A
  1. field block
  2. 2-5
  3. 3
  4. subq fat
24
Q

Closing the Site
1. Usually what kind of sutures are placed?

  1. For skin closure using what, synthetic suture material results in less chance of infection and less inflammatory reaction?
  2. What is used for the scalp because it is blue, monofilament nylon is otherwise used?
  3. Suture size is indicated by code 0: the more 0’s the ______the suture diameter, 4-0, 5-0 on body, scalp, 6-0 nylon on face
A
  1. interrupted nonabsorbable
  2. monofilament
  3. Polypropylene
  4. smaller
25
Q
  1. Needle points are also defined: what are they? 3
  2. What are ideal for easy passage through skin?
  3. A code has been developed for needles:
    4
A
  1. cutting, tapered and blunt
  2. Cutting
    • FS (for skin) and
    • CE (cutting needles) used on thick skin
    • P (plastic) and
    • PS (plastic skin) used for cosmetic closures
26
Q

Suturing:
Placement of sutures for elliptical excisions follows the “rule of halves” What does this mean?

2

A
  1. Wound is divided in half by an initial suture and subsequently each half is itself halved until all wound edges are approximated
  2. Excessive tension on the sutures leads to blanching of the wound edges and puckering
27
Q

Wound care
1. All biopsy wounds can be dressed with a thin film of what? 2

  1. Can shower in __ hours, no baths or hot tubs until the sutures come out

Suture removal

  1. Face?
  2. Back and legs?
  3. Remainder of the body?
A
  1. antibiotic ointment then an adhesive bandage
  2. 24
  3. 3-5 days
  4. 10-14 days
  5. 7-10 days
28
Q

Post-op Complications

  1. Bleeding Rx?
  2. Infection caused by? 3
  3. Infection Rx?
  4. Allergic rxn to what?
A
  1. Bleeding:
    - Usually controlled w/ pressure dressing and ice
    - Suture if not sutured
  2. Infection
    - Staph,
    - strep,
    - Candida
  3. Culture and start antibiotics or antifungal ointment
  4. Allergic reactions to tape
29
Q

Wood’s Light Exam
1. When UV light is projected through a Wood’s filter the light rays have a wavelength above ___ nm

When shown on the skin or hair in a dark room certain infections will fluoresce
2. Hair infected w/ Microsporum spp. (fungus) turns what?

  1. Skin infected with tinea versicolor produces a what?
  2. Erythrasma shows what?
  3. Accentuates hypopigmented areas in what?
A
  1. 365
  2. blue-green (20% of tinea capitis infections)
  3. pale white-yellow fluorescence
  4. brilliant coral-red
  5. vitiligo
30
Q

KOH Skin Scrapings
If you suspect a fungal skin infection you should do the following?
3

What are you looking for? 2

A
  1. Scrape some of the affected skin onto a slide – try to get as much of the specimen as possible‏
  2. Add some potassium hydroxide and let sit for 10-15 min.
  3. Examine under a microscope looking for:
  4. Hyphae – septate (tinea corporis)
    - Curved (spaghetti and meatballs) tinea versicolor
  5. Round or oval budding forms – yeast (Candida)
31
Q

Tzanck’s smear

  1. Confirms what?
  2. Describe the Procedure? 4
  3. Positive test will show what?
A
  1. Confirms viral infection with HSV
    • Gently rupture fresh vesicle, gently scrape debris from vesicle base
    • Smear debris onto microscope slide
    • Add drops of stain (Giemsa or Wright) and allow to sit 1 minute
    • Rinse off stain under gently running water, add a drop of mineral oil, apply cover slip
  3. Positive test will show Multinucleated Giant Cells
32
Q

Cryotherapy indications

3

A
  1. Warts
    - May want to avoid freezing facial flat warts due to the propensity to cause skin discoloration
  2. Actinic keratosis
  3. Seborrheic keratosis
33
Q

Cryotherapy
1. Painful so is limited to who?

  1. Generally should pare ___________ warts down to areas of punctate bleeding prior to cryo
  2. Use cautiously on the digits espeically in when?
  3. avoid over-freezing in the periungual region, which can result in what?
A
  1. older children and adults
  2. hyperkeratotic
  3. especially where nerves are located, to prevent severe pain and possible neuropathy
  4. permanent nail dystrophy
34
Q

Short term complications
of cryotherapy?
4

A
  1. Pain is variable among individuals; however, be prepared for vasovagal reactions and do not use cryotherapy in small children.
  2. Lesions may be painful after freezing as a result of pressure from edema caused by the blister
  3. Hemorrhage is common. Inform patients that formation of a “blood blister’’ is normal, especially when treating thick lesions such as warts
  4. Infection
35
Q

Long term complications of cryotherapy

5

A
  1. Nerve damage is the most serious complication, and is especially likely where nerves are superficial, such as on the sides of fingers, postauricular, or the peroneal nerve
  2. Pigmentary changes are common and may be especially disfiguring in darker skinned patients
  3. Hypertrophic scar formation and tissue defects with delayed healing are possible if lesions are frozen too deeply or when freezing thick lesions
  4. Permanent nail dystrophy may occur if a periungual lesion is frozen too deeply
  5. Recurrence of a lesion, particularly warts, is possible
36
Q

Cryotherapy technique
1. Local anesthesia is usually not necessary, although it is recommended for what?

  1. It is always better to ______ freeze than to _____ freeze a lesion, to prevent complications
A
  1. very large lesions.

2. under, over

37
Q

Cryotherapy technique

3

A
  1. Frozen areas of the skin will turn white immediately. This is referred to as the “freeze ball’’ or “iceball.’’
  2. The depth of freeze should be roughly equal to one and one-half times the radius of the freeze ball unless the lesion is superficial, eg, solar lentigo, in which the depth of freeze is less.
  3. To treat small papules or thin, flat lesions, freeze the lesion for 5 to 10 seconds, leaving a rim of white 1 to 3 mm around the lesion.
38
Q

For thicker warts or seborrheic keratoses, freeze for up to ___ seconds.

A

40
-This does not mean that the liquid nitrogen should be applied for 40 seconds, but that the “iceball’’ should be maintained for 40 seconds

39
Q

Repeat applications may be necessary for thicker lesions, waiting until what?

A

the lesion completely thaws (usually about 2 to 40 seconds) before refreezing.

40
Q

Skin reaction to cryotherapy

4

A

1, Often the skin will quickly become edematous and “urticarial,’’ because freezing causes separation of the epidermis from the dermis, with resultant blister formation.

  1. A hemorrhagic area may develop if the lesion is frozen deeper than the epidermis.
  2. Warn patients that their eyelid may be quite swollen if there is cryotherapy done nearby.
  3. Any rings should be removed if cryotherapy is performed to the digit.

Dermatology (12 decks)

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