Skin: Wounds, infections, burns, hands, plastic surgery

Question 1

45yo woman is seen with wasting of the intrinsic muscles of the hand, weakness, and pain in the wrist. which of the following nerves has most likely been injured?

a. ulnar nerve
b. radial nerve
c. brachial nerve
d. axillary nerve
e. median nerve

Answer 1

A

median or ulnar

median = thenar (thumb far pad)
ulnar = interosseus, lumbricals

Question 2

68yo woman presents with a pigmented lesion on the trunk. upon furhter examination, the lesion has an irregular border, darkening coloration, and raised surface. an incisional biopsy is performed and confirms a melanoma with a thickness of 0.5mm. the pt is scheduled for a wide local excision of the melanoma in the OR. which of the following is the smallest margin recommended for excision?

a. 3mm
b. 5mm
c. 1cm
d. 2cm
3. 5cm

Answer 2

C

0.5mm–> 0.5cm excision (at least)
Thin (=1mm) –> 1cm
Med (1-4mm) –> 2cm
Thick (>5mm) –> 2-3cm

Question 3

25yo woman presents with a benign nevus on the R upper arm. she desires removal and undergoes a clean incision and then closure of the incision without complication. with regard to the healing process, which of the following cell types are the first infiltrating cells to enter the wound site, peaking at 24-48h

a. macrophages
b. neutrophils
c. fibroblasts
d. lymphocytes
e. monocytres

Answer 3

B

1 - neutrophils
2 - monocytes, macrophages
3 - lymphocytes
4 - fibroblasts

Question 4

3yo boy is brought to the ED after spilling bleach onto his lower extremities. he is diagnosed with a chemical burned and all involved clothing are removed. in addition to resuscitation, which of the following is the most appropriate initial management of this pt?

a. treatment of the burn wound with antimicrobial agents
b. neutralize the burn wound with weak acids
c. lavage of the burn wound with large volumes of water
d. wound debridement in the OR
e. treatment of the burn wound with Ca gluconate gel.

Answer 4

C

exposure = lavage, debride & Abx

DO NOT neutralize with weak acids b/c the heat released by neutralization rxs induces further injury

Question 5

35yo man with new diagnosis of Crohn disease presents with rapidly enlarging painful ulcerations on the LE. cultures of the lesion are negative, and skin biopsy reveals no evidence of malignancy. which of the following are the most appropriate treatment option?

a. surgical debridement of the wound with skin grafting
b. local wound care with silver sulfadiazine
c. topical corticosteroids
d. systemic steroids & immunosuppressants
e. saphenous vein stripping and compressive stockings

Answer 5

D

Likely pyoderma grangrenosum from crohn’s. - the more you injure it the worse it gets

Question 6

following a weekend of snowmobiling, a 42yo man comes to the ED with pain, numbness and discoloration of his R forefoot. you diagnose frostbite. which of the following is the proper initial treatment?

a. debridement of the affected part followed by silver sulfadiazine dressings
b. administration of corticosteroids
c. administration of vasodilators
d. immersion of he affected part in water at 40C-44C (104F-111.2F)
e. rewarming of the affected part at room temp.

Answer 6

D

1) Need to flash warm it - will likely cause damage to some parts, but will prevent damage to the rest
2) antibiotics
3) tetanus toxoid
4) debriement of necrotic skin

Question 7

63yo man with a hx of poorly controlled DM presents with R leg swelling and pain. the pt denies trauma to the leg & reports it was normal yesterday. examination of the R LE is significant for extreme tenderness to palpation, erythema, and edema extending up to the knee. Xray of the R leg shows tissue swelling without gas or osteomyelitis. the pt’s VS are normal and he is started on broad-spectrum IV abx and insulin. an hour later, the pt’s HR increases the 125 BPM, and the erythema has progressed to the thigh and new blister formation on the leg. which of the following is the most appropriate next step in management?

a. repeat xray of the R LE
b. CT scan of the R LE
c. MRI of the R LE
d. bone scan of the R LE
e. immediate surgical intervention with incision and direct visualization of potentially infected tissue

Answer 7

E

sepsis? necrotizing soft tissue by the rate of spread, even if can’t see it under imaging.

the only reason you don’t want to do surgery is if it’s pyoderma gangrenosum (this has spread faster than PG)

Question 8

35yo woman undergoes an elective laparoscopic cholecystectomy for symptomatic cholelithiasis. which of the following wound classes best describes her procedure

a. class I, clean
b. class II, clean/contaminated
c. class III, contaminated
d. class IV, dirty
e. none of the above

Answer 8

B

by the location definitely not clean
it’s a procedure, so it’s not dirty

Question 9

65yo woman presents with a 1cm lesion with a pearly border on her nose, and punch biopsy is consistent with a BCC. she is scheduled to undergo Mohs surgery. which of the following is a benefit of Mohs surgery over wide local excision?

a. Mohs surgery results in a smaller cosmetic defect while obtaining negative margins circumferentially
b. Mohs surgery offers a shorter operating time
c. Mohs surgery can be performed on many different types of skin cancers
d. Mohs surgery results in less recurrence and metastases
e. Mohs surgery does not depend on intraoperative evaluation of specimen margins with frozen sections

Answer 9

A. Moh’s & wide local excision can be performed on all different types of cancers

larger amount taken out - but slices to ensure negative margins
E –> exactly what it does

Pros

• smaller
• same recurrence & mets v. open wide incision

Cons
- takes longer

Question 10

60yo woman presents with a skin lesion on L hand, between 1st and 2nd finger, large, grossly purulent with eschar. She reports a hx of burn injury to the hand while cooking a few years ago. she reports the wound has never healed completely. you are concerned about the skin lesion and perform a punch biopsy. which fo the following is the most accurate diagnosis given the pt’s hx.

a. BCC
b. malignant melanoma
c. erythroplasia of queyrat
d. bowen disease
e. Marjolin ulcer

Answer 10

E

marjolin ulcer = complication of SCC or thermal/burn injury over the long term

Bowen = in situ SCC lesions
Erythroplasia of queyrat = in situ SCC lesions of the penis

Question 11

25yo man is brought to the ED after sustaining burns during a fire in his apt. he has blistering and erythema of his face, L UE, and chest. he also has circumferential frank charring of his R UE with decreased capillary refill. he is agitated, hypotensive, and tachycardic. which of the following is the most appropriate initial management of his wounds?

a. topical antibiotics should be applied to the burn wounds
b. excision of facial and hand burns
c. escharotomy of the R UE
d. . excision of all 3rd degree burns
e. split thickness skin grafts over the areas of 3rd degree burns

Answer 11

C

1) Escharaotomy in severely burned limbs; early excision of areas of devitalized tissue

Topical abx have not been found to be very helpful

Question 12

24yo firefighter sustains 30% total body SA burns to his torso, face, and extremities. his wounds are treated topically with silver nitrate. which of the following complicationsis associated with the use of this agent?

a. hypernatremia
b. metabolic acidosis
c. hyperchloremia
d. neutropenia
e. hyponatremia

Answer 12

E. electrolyte deficiency

hyponatremia, hypokalemia, hypochloremia, hypocalcemia

neutropenia

doesn’t penetrate the eschar

Question 13

54yo man sees you b/c of a growth of his lower lip. he smokes tobacco, has a fair complexion & works outdoors. the biopsy report confirms a carcinoma. which of teh following is the most diagnosis for tumors involving the lips?

a. SCC
b. BCC
c. malignant melanoma
d. keratoacanthoma
e. verrucous carcinoma

Answer 13

A

cancer of oral cavity - SCC

upper lip = BCC
lower lip = SCC

Question 14

40yo woman complains of a mild, intermittent pain and paresthesias in her R wrist. she reports the pain is worse at night and with driving. on exam, hyperextension of teh R wrist reproduces the paresthesia. with regard to her diagnosis, which of the following is the most appropriate initial treatment?

a. ice pack to the affected wrist at nighttime
b. heat pack to the affected wrist at nighttime
c. wrist splint worn at nighttime
d. surgical treatment with division of the flexor retinaculum
e. surgical treatment with division of the extensor retinaculum

Answer 14

C. esp at night.

then D
carpel tunnel - b/c hyperextension reproduce the sxs

Question 15

60yo diabetic man undergoes incision and drainage of an infected boil on his back. the wound is left open and packed daily. week by week, the wound grows smaller and eventually heals. which of the following terms descries the method of wound closure by the pt?

a. primary intention
b. secondary intention
c. tertiary intetion
d. delayed primary closure
e. delayed secondary closure

Answer 15

B

a. primary intention
b. secondary intention
c. tertiary intetion
d. delayed primary closure
e. delayed secondary closure

Question 16

70yo man is concerned when his dentist finds a white patch on his oral mucosa during a routine exam. proper management should include which of the following?

a. excisional biopsy of all lesions
b. application of topical antibiotics
c. low dose radiation therapy
d. strict oral hygiene & avoidance of alcohol & tobacco
e. application of topical chemotherapeutic agents

Answer 16

D

if had hx of smoking and/or chewing tobacco –> cancer

diffdx

• candida
• hyperplasic mucosal growth
• leukoplakia (5%) –> more likely if lesion persists despite avoidance therapy

Question 17

60yo man presents with a 6mm BCC on the tipo of his nose. he is scheduled to undergo excision of the tumor in the OR with repair of the defect using skin and subcutaneous tissue from his earlobe. which of teh following terms most appropriately describes this form of reconstructive surgery.

a. split thickness graft
b. full thickness graft
c. composite graft
d. pedicle flap
e. free flap

Answer 17

C

a. split thickness graft
b. full thickness graft
c. composite graft = tissue + epidermis, dermis (+/- subccu fat, cartilage, muscle). for better cosmetic outcome
d. pedicle flap
e. free flap = vascularized piece of tissu mobilized from original site to another location, with reanastamosis at recipient site

Question 18

40yo woman undergoes an incisional biopsy of pigmented lesion on her R thigh. pathologic exam reveals malignant melanoma with a thickness of 3mm. findings on exam of the groin are normal. which of the following is the most appropriate next step in her management?

a. wide local excision of the melanoma with a 1cm margin from the tumor, followed by radiation to the groin
b. wide local excision of the melanoma with a 1cm margin from the tumor, and sentinel lymph node biopsy
c. wide local excision of the melanoma with a 1cm margin from the tumor, and groin lymph node dissection
d. wide local excision of the melanoma with a 2cm margin from the tumor, and sentinel lymph node biopsy
e. wide local excision of the melanoma with a 2cm margin from the tumor, and groin lymph node dissection

Answer 18

D

3mm –> get to 3cm (max really is 2cm)

definitely do lymph nodes before radiating the groin (significant morbidity associated). Use the dye

Question 19

22yo healthy African american woman presents with a recurrent growth on her R thigh. she has a childhood hx of a third degree scald burn to the same area that did not require skin grafting. the growth was completely removed 2y ago. on exam, there is a 5cmx2cm, raised, completely shaped purple lesion with a smooth top. which of the following is the most likely diagnosis?

a. angiosarcoma
b. malignant melanoma
c. SCC
d. kaposi sarcoma
e. keloid

Answer 19

E

common in african american, in areas that were previously damaged. will continue to grow if redamage

Could be SCC –> marjolin ulcer, but would more expect a sinus tract / burn (yes, is the case here). different color.

Question 20

12yo boy is in a MVA in which the car caught fire. he sustains significant inhalation injury and a circumferential burn w/out fractures or other soft tissue trauma to his L LE during extrication from the burning vehicle. he is intubated and aggressively resuscitated in the ICU. which of the following is the most appropriate method of assessing for compartment syndrome of the L LE.

a. xray of the L LE
b. doppler signals of the L LE
c. CT of the L LE
d. MRI of the L LE
e. L LE angiogram

Answer 20

B

compartment syndrome - pressures in the compartment

1) poor drainage of venous / lymphatics
2) poor arterial supply

–> assess for both signals.

Question 21

during a bar brawl, a 19yo man sustains a 4in laceration on his L arm from glass and presents to the ED the following morning, 10h later. he is neurovascularly intact and the wound is deep, extending down to the fascia. which of the following is the most appropriate management of the wound.

a. closure of the skin only & administration of oral antibiotics for 1w.
b. closure of the skin & subcutaneous tissue and oral antibiotics for 1w.
c. a single dose of IV antibiotics and closure of the skin only
d. a single dose of IV antibiotics and closure of the skin and subcutaneous tissue
e. local wound care without wound closure or antibiotics

Answer 21

E

if anything, close subcu & leave skin to heal by second intention

deep wound - need full course of antibiotics

Question 22

59yo woman undergoes an exploratory laparotomy for peritonitis and is found to have perforated diverticulitis. she undergoes a sigmoid resection with an end colostomy. she is administered a third generation cephalosporin within 1h prior to the incision and the antibiotic is continued postoperatively. 1w later, she develops an intra-abdominal abscess, which is percutaneously drained. Bacteroides fragilis is isolated from the cultures. which of the following statements regarding her perioperative antibiotic regimen is most accurate?

a. the preoperative dose of abx should have been given closer to the time of incision
b. the pt should have received several doses of abx prior to laparotomy
c. the pt should have received a 1st-gen cephalosporin
d. the pt did not have adequate gram-neg coverage
e. the pt did not have adequate anaerobic coverage

Answer 22

E

Bacteroides = anaerobic

• need to give w/in 1h prior to incision

Question 23

30yo man with a hx of crohn disease develops an etnerocutaneous fistula and placed on TPN through a R subclavian central venous catheter. after 5d, the pt develops a fever and leukocytosis. CT scan of the abdomen reveals no intra-abdominal abscess. the subclavian catheter insertion site is inspected and noted to be erythematous and painful. blood cultures are positive. which of the following organisms is the most likely cause of his fever?

a. coagulase-positive staphylococci
b. coagulase-negative staphylococci
c. Group A streptococcus
d. enterococcus
e. E. coli

Answer 23

B

Likely CoNS

Question 24

65yo man sustains a 50% total body surface area burn while burning trash in the backyard. the pt is resuscitated with a LR solution using the parkland formula and a weight of 80kg. what is the rate of LR given in the 1st 8h?

a. 100mL/h
b. 500mL/h
c. 1000mL/h
d. 5000mL/h
e. 10,000 mL/h

Answer 24

C
4* mass * % * 100 = 4 * 80 * .5 * 100 = 320 * 50 = 16000

8000mL in the first 8h
= 1000mL/h

Question 25

67 yo man presents to his primary care physician with a 1cm lesion on his L forearm. on exam, it has a waxy appearance with rolled, pearly borders surrounding a central ulcer. which of the following is the most appropriate management of this pt?

a. Mohs surgery
b. curettage of the lesion
c. electrodesiccation of the lesion
d. laser vaporization of the lesion
e. surgical excision

Answer 25

C

BCC –> Mohs or wide local excision (both with same curative rates)

• not a cosmetically needed area

Question 26

mach each lower extremity lesion with its correct etiology:
a. ischemic ulcer
b. venous stasis ulcer
c. diabetic ulcer
d. pyoderma gangrenosum
e. marjolin ulcer
43yo man with a painless ulceration over the L medial malleolus with surrounding brawny induration

Answer 26

B

not a pressure ulcer where the DM would be

Venous stasis ulcer = over medial malleolus; painless; “brawny inducation”

Question 27

mach each lower extremity lesion with its correct etiology:
a. ischemic ulcer
b. venous stasis ulcer
c. diabetic ulcer
d. pyoderma gangrenosum
e. marjolin ulcer
69yo men with a hx of DM with pain in the balls of his feet at night with a ulcer over the lateral aspect of his R 5th toe.

Answer 27

A

not a pressure ulcer where the DM would be - but distal enough to be low O2 tension

Question 28

mach each lower extremity lesion with its correct etiology:
a. ischemic ulcer
b. venous stasis ulcer
c. diabetic ulcer
d. pyoderma gangrenosum
e. marjolin ulcer
52 yo woman with a hx of Dm with an ulcer on the plantar surface of her R heel

Answer 28

C

diabetes ulcer.