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Dermatology > Test 2 > Flashcards

Test 2 Flashcards

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Dermatology Board Prep flashcards
1
Q

basal cell carcinoma pop

A
  • men
  • Caucasian
  • closer to the equator
  • Tucson
  • Finland
  • Australia
  • 55-75
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2
Q

basal cell carcinoma pathophysiology

A

sun exposure low vegetable and fruit intake

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3
Q

Basal Cell Carcinoma RF

A
  • history of BCC
  • Caucasians
  • Chronic UV radiation
  • childhood sun exposure
  • number of past sunburns
  • SAD diet
  • arsenic exposure
  • smoking
  • immunosuppressive drugs or organ transplant
  • tanning beds
  • farmers, outdoor jobs
  • psoralen plus ultraviolet A light (PUVA)
  • Broad band and narrow band ultraviolet (UVB) phototherapy
  • ionizing radiation therapy
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4
Q

Basal cell carcinoma location

A
  • ears
  • face
  • neck
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5
Q

what is the most common BCC?

A

nodular

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6
Q

round shinny, pearly, flesh-colored papule, telangiectasia, translucent when stretched, can have center ulcerates/bleeding, accumulates crusts/scales and will heal then grow again

A

nodular BCC

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7
Q

brown, black, or blue; elevated, pearly white, translucent border; papule

A

pigmented BCC

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8
Q

appear yellow-white when stretched, firm to touch, seemingly well-defined border, doesn’t ulcerate

A

micronodular BCC

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9
Q

white or yellow, waxy sclerotic plaque, rarely ulcerate, flat or slightly depressed, fibrotic, and firm, borders are indistinct

A

morpheaform BCC

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10
Q

upper trunk or shoulders, extremities, face; red, round-to-oval, well-circumscribed patch or scaling plaque, whitish scale; thin, raised, pearly white; least aggressive

A

superficial BBC

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11
Q

BCC complication

A
  • death
  • hemorrhage of eroded large vessels
  • meningitis
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12
Q

TX nodular BCC

A

Electrodesiccation and curettage or by simple excision
Mohs surgery
solasodine Rhamnosyl glycosides (SRG’s) (Zycure, Curaderm-nightshade extract) and black salve
Radiation therapy
Anti-inflammatory diet

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13
Q

superficial BCC tx

A

topical tazarotene
photodynamic therapy
topical 5-Fluorouracil and imiquimod

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14
Q

Tx Morpheaform BCC

A

wide excision
Mohs micrographic surgery
Curaderm
black salves

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15
Q

Squamous Cell Carcinoma pop

A

older, white

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16
Q

SCC RF

A
  • Chronic sun exposure
  • Fair complexion
  • Chronic skin ulcers or sinus tracts
  • Long term-exposure to hydrocarbons, arsenic, burns, radiation
  • Immunosuppression
  • Other radiation exposures
  • Chronic inflammation
  • Genetics or inherited disorders
  • Smoking
  • Inflammatory diet
  • HPV infection
  • Xeroderma pigmentosum
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17
Q

SSC sx

A
  • Hyperpigmented nodular mass which commonly ulcerates
  • Papules, plaques, nodules that can be smooth, hyperkeratotic, or ulcerative
  • Head and neck (55 %)
  • Dorsum of hands/forearms (18 %)
  • Legs (13 %)
  • Arms (3 %)
  • Shoulder or back (4 %)
  • Chest or abdomen (4 %)
  • Other sites (3 %)
  • areas of chronic inflammation
  • areas of chronic scarring
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18
Q

Bowen’s disease SCC

A
  • Patch or plaque
  • Erythematous
  • Slow growing
  • Asymptomatic
  • lower legs, neck and head.
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19
Q

Erythroplasia of Queyrat

A
  • Well-defined, velvety, red plaque
  • Pain
  • Bleeding
  • Pruritus
  • penis
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20
Q
  • Asymptomatic
  • Painful or pruritic
A

Invasive SCC

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21
Q
  • indurated or firm, hyperkeratotic papules, plaques, or nodules
  • 0.5-1.5 cm
  • ulceration
A

Well differentiated SSC

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22
Q
  • fleshy, soft, granulomatous papules or nodule
  • ulceration
  • hemorrhage
  • areas of necrosis
A

Poorly differentiated SCC

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23
Q

Tx Localized SCC

A
  • Cryotherapy
  • Electrosurgery (e.g. ED & C)
  • Topical (5-fluorouracil, imiquimod)
  • Radiation therapy
  • Surgical excision
  • Mohs surgery
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24
Q

Prevention SCC

A
  • anti-inflammatory diet
  • sunscreen
  • oral and topical green tea
  • grape seed extract
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25
Q
A

SCC

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26
Q
A

BCC

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27
Q

Keratoacanthoma pop

A

50-69, men, with Fitzpatrick I-III classification

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28
Q

Keratoacanthoma Pathophysiology

A

ultraviolet (UV) radiation, exposure to chemical carcinogens, viral exposure including human papillomavirus (HPV)

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29
Q

Keratoacanthoma sx

A
  • Rapidly growing, dome-shaped nodules with a central keratin-filled crater
  • cheeks, nose, ears, hands (post), but can be any location
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30
Q

Keratoacanthoma tx

A

surgicalexcision

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31
Q
A

Keratoacanthoma

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32
Q

Melanoma pop

A
  • men
  • whites
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33
Q

Melanoma cause

A

increased UVA exposure and decreased cutaneous Vitamin D3 levels

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34
Q

Melanoma RF

A
  • sun exposure and sunburns
  • inflammatory diet
  • family history of atypical nevi or melanoma
  • light colored skin and red hair
  • immunosuppression
  • previous history of melanoma
  • airline pilots
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35
Q

Melanoma growth pattern

A
  • growth phase
    • horizontal phase
      • spread out horizontally and can be confined to the epidermis
    • vertical
      • infiltrate deep into the dermis quickly
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36
Q
  • from atypical nevi 30-50%
  • most common
  • 30-50 yo
  • grows slowly (5-10 y) and horizontal then will grow vertical
  • lower extremities (F), trunk (M), upper back (both)
  • brown to black macule, color variation, irregular, notched borders
  • less than 1 mm in thickness
A

superficial spreading melanoma

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37
Q
A

superficial spreading melanoma

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38
Q
  • aggressive, highest risk of spreading, difficult to diagnose
  • greater than 2 mm in thickness at diagnosis
  • pedunculated or polypoid black nodules
  • blue, gray, white, brown, tan, red, or skin tone
  • trunk, legs, arms, scalp (M)
  • elderly
A

nodular melanoma

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39
Q
A

nodular melanoma

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40
Q
A

Lentigo maligna melanoma

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41
Q
A

Acral lentiginous melanoma

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42
Q
  • aggressive
  • most common among Asian and African-American
  • on palmar, plantar, subungual surface, between the toes
  • lesion raised, develops ulceration, >5 mm in diameter need to look at lymph nodes
  • dark brown to black, irregularly pigmented macules to patches
A

acral lentiginous melanoma

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43
Q
  • most common in geriatric pop
  • remain close to skin surface for years to decades
  • elderly, chronically sun-exposure, damaged skin
  • on the face, ears, arms, upper trunks,
  • flat or mildly elevated mottled tan, brown, or dark brown
  • nodule or papule indicate invasion
  • asymmetric foci, color variegation
  • most common melanoma in Hawaii
  • slow growing and grows outward
  • multiple colors
A

lentigo maligna melanoma

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44
Q

hutchinson’s sign

A

acral lentiginous

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45
Q

melanoma dx

A
  • Excisional Biopsy- 1-3 mm margins of normal skin and a layer of subcutaneous fat
  • Punch biopsy
  • DON’T DO Shave
  • scoop shave biopsy- scoop out the lesion with 1-3 mm margins
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46
Q

melanoma complication

A
  • death
  • metastasis
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47
Q

melanoma tx

A
  • wide local excision, surgical removal
  • Mohs micrographic surgery
  • interferon
  • cytotoxic chemotherapy
  • radiation therapies
  • Vit C, A and E, carotenoids, dietary antioxidants, fruits, vegetables, Med diet
  • curcumin, green tea,
  • pre-surgery: modified citrus pectin and bioflavonoid
  • Silymarin, curcumin, polysaccharide krestin, Vit E, melatonin
  • quercetin, betulinic acid, ginseng, licorice, cordyceps, viscum
  • vit D, azelaic acid, genistein, astragalus
  • black salves
  • fasting before chemo: low protein,
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48
Q

Most SSCs that occur in sun-exposed areas of the skin have a very _____ rate of metastasis.

A

low

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49
Q

In dark-skinned people, SCCs tends to arise on non sun-exposed areas (e.g. the legs and anus) and are frequently associated with chronic inflammation, chronic wounds, or scarring.
T or F

A

T

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50
Q

Cumulative UVB sun exposure in the past ________ years of a person’s life increases the likelihood of SCC in the presence of other risk factors.

A

5-10

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51
Q

A lesion on the vermillion border is ___ until prove

A

SCC

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52
Q

which is more likely to metastasize?
SCC or BCC

A

SCC

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53
Q

Why do basal cell carcinomas have a limited capacity to metastasize?

A

absence of necessary growth factors derived from the stroma of the original tumor site.

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54
Q

Persons aged 55-75 have a ______ -fold higher incidence of BCCs than those younger than 20.

A

100

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55
Q

About ____ % of patients who have had one BCC will develop another lesion within five years.

A

40

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56
Q

What is the most important environmental risk factor for developing BCCs?

A

sun

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57
Q

intermittent, intense sun exposure decrease BCC
T or F

A

F

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58
Q

rodent ulcer

A

BCC Center ulcerates/bleeds, accumulates crust/scale then heal with scarring

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59
Q

morpheaform BCC have borders that are easily localized
T or F

A

F

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60
Q

BCCs must be treated early on to avoid the locally invasive, aggressive, and destructive effects on skin and surrounding tissues
t or f

A

t

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61
Q

ED&C are the most effective treatment of BCC
t or f

A

f

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62
Q

Why would one chose radiation therapy to treat a BCC?

A

not candidates for surgery

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63
Q

List three features of BCCs that account for a high likelihood for recurrence after initial treatment.

A

size, depth, and irregular border

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64
Q

Although there is no uniform agreed upon screening protocol for malignant melanomas in the US a skin survey to identify suspicious lesions is considered the best option!
T or F

A

T

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65
Q

Individuals with atypical nevi have a _________ fold elevated risk of developing malignant melanoma.

A

6

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66
Q

There is a strong association between high nevus counts (more than ____) and malignant melanoma.

A

> 50

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67
Q

Case studies found the strongest association for malignant melanoma for ____________ sun exposure and ___________ in adolescence or childhood.

A

intermittent exposure sunburn

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68
Q

During the ___________ growth phase a malignant melanoma is almost always curable by surgical excision alone.

A

horizontal phase

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69
Q

Nodular melanomas have no identifiable __________ growth phase and enter the _____________ growth phase almost from their inception.

A

horizontal; vertical

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70
Q

Over 60% of superficial spreading malignant melanomas are diagnosed as thin, highly curable tumors of less than _ mm thickness.

A

1

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71
Q

Nodular malignant melanomas are the most difficult to diagnose at an early stage – at least half are greater than ____ mm in thickness when diagnosed!

A

2

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72
Q

The great majority of lentigo maligna melanomas are diagnosed at less than ___ mm of thickness!

A

1

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73
Q

The most common type of malignant melanoma among Asians and in African-Americans is the ______________ _____________ ____________ which arise most commonly on palmar, plantar, and subungual surfaces.

A

acral lentiginous Melanoma

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74
Q

______________ _______________ is the single most important determinant of prognosis for a malignant melanoma.

A

sun exposure

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75
Q

Stage T1: ≤1 mm malignant melanomas have a ten year survival of ____ percent.

A

92%

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76
Q

The definitive “initial” surgical treatment for primary cutaneous melanoma is a ________ ________ __________ down to the deep fascia.

A

excision

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77
Q

Because of the potential of metastasis and possible death, any biopsy that comes back positive for malignant melanoma needs to be referred for additional surgery via ______________ procedure.

A

mohs

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78
Q

SCC TX

A

oral vitamin A

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79
Q

oral SCC

A

Present as an ulcer, nodule, or indurated plaque involving the oral cavity
Floor of the mouth and lateral or ventral tongue most common sites.
Lesions arise in sites of:
erythroplakia (premalignant persistent red patches)
leukoplakia (persistent white plaques

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80
Q

Verrucous carcinoma SCC

A

exophytic, cauliflower-like growths that resemble large warts.
Lesions are sub classified according to site:
Oral – florid mucosal verrucous papillomatosis
Anogenital – giant condyloma acuminatum or verrucous carcinoma involving the penis, scrotum, or perianal region
Epithelioma cuniculatum – verrucous carcinoma on the plantar foot surface

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81
Q

SCC on lip

A

Primarily occurs on the lower lip
Lesions may present as nodules, ulcers, or indurated white plaques

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82
Q

ELECTRODESICCATION & CURETTAGE advantage

A

Cost effective
Relatively quick, single visit
Relatively easy wound care
Well suited for multiple lesions
Usually good to excellent cosmetic results
No sedation or general anesthesia required

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83
Q

Disadvantages of ED & C

A

Not margin-controlled
Recurrence rate unacceptably high with larger (>5 mm) lesions located in high risk sites!
Need special equipment and user experience to get higher cure rates
Poor choice in most BCCs of the head
Must be cautious in patients with pacemakers

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84
Q

surgical excision advantages

A

Margin-controlled
Resultant scar is optimized both cosmetically and functionally.

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85
Q

Disadvantages of Surgical Excision

A

Invasive
have to use general anesthesia
not as good results as Mohs micrographic surgery

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86
Q

Advantages of Mohs

A

Cost effective
No sedation or general anesthesia required.
high cure rates
great cosmetic outcome
Allows for histological evaluation of 100% of the peripheral margin

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87
Q

Disadvantages of Mohs

A

expensive
long time to get done
Requires special training in the technique.

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88
Q

Advantages of Cryotherapy

A

Cost effective
Relatively quick – no sedation or general anesthesia required
Relatively easy wound care
Well suited for multiple lesions
Usually affords good to excellent cosmetic results
Low recurrence rates in small primary BCCs that lack “high risk” features

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89
Q

Disadvantages of Cryotherapy

A

Not margin-controlled.
May require multiple visits
Requires considerable clinical judgment/experience
Potential hyper- and hypo-pigmentation
Possible permanent damage to underlying nerves, vessels, etc.

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90
Q

TOPICAL 5-FLUOROURACIL AND IMIQUIMOD advantages

A

Noninvasive; avoids operative risks.
Rarely causes scarring.
Good for patients who are otherwise not candidates for surgery.

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91
Q

TOPICAL 5-FLUOROURACIL AND IMIQUIMOD disadvantages

A

Limited to treating only superficial BCCs located in low-risk areas.
Brisk inflammatory reaction - poorly tolerated in some individuals.
Requires prolonged application (weeks to months!)

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92
Q

radiation therapy advantages

A

Noninvasive – relative sparing of critical structures
Relatively painless
Good for patients who are not otherwise candidates for surgery
High cure rate for selected lesions

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93
Q

digit block or nerve block

A
  • Cleanse the toe/finger and paint the area with povidone-iodine (Betadine®) solution.
  • Using a 27 gauge needle, slowly inject 1% lidocaine (or lidocaine 1%:Marcaine 0.25% 1:1 mix) midway between the dorsal and palmar surfaces of the finger at the midpoint of the middle phalanx.
  • Advance the needle and inject lidocaine in the vicinity of the neurovascular bundle.
  • Then pull back without removing the needle and fan the needle toward the dorsal surface – repeat injection
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94
Q

alteratives

A

Nourishing, restorative tonics with effects focused on digestion, absorption, and elimination

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95
Q

Alterative, Nutritive,high in phytoestrogens, lymphagogue, Antitussive, Antispasmodic, Vulnerary

A

Trifolium pratense actions

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96
Q

menopausal climacteric symptoms, vaginal dryness, chronic skin conditions, Breast cancer estrogen positive

Lots of heat

Cancer, gout, arthritis, acne, spasmodic cough, cachexia, burns with poor healing, ulcers of the skin or mucous membranes, TB or inflammation of the lungs

A

Trifolium pratense indications

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97
Q

better subjective improvement of scalp hair and skin status, libido, mood, sleep, and tiredness

inhibition of 5-α-reductase activity, reduction of inflammatory reactions, and stimulation of ECM protein synthesis in the vicinity of the hair follicle

A

Trifolium pratense MOA

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98
Q

Root: alterative, mild digestive bitter, antitumor, antimutagenic, nutritive, antirheumatic, phytoestrogenic, liver tonic
Leaves: used topically as a antimicrobial, anti-inflammatory poultice
Seeds: alterative, diuretic, urinary tonic, vulnerary
Cholagogue

A

Rumex spp actions

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99
Q

ALBE inhibits the expression of IL-4 and IL-5 by downregulating MAPKs and NF-κB activation in ConA-treated splenocytes

A

Rumex spp MOA

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100
Q

Root: dry and scaly skin conditions – psoriasis, eczema, dandruff, rheumatic/arthritic conditions, anorexia nervosa, cystitis, wounds and ulcers (poultice).

Leaves: mastitis, joint sprains (poultice), alleviate nettle stings

Seeds: cystitis, skin conditions including exanthems

A

Rumex spp indications

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101
Q

Oxalate kidney stones, kidney disease, iron overload, pregnancy

Don’t eat the leaves - very high in oxalic acid and can cause poisoning – oxalic acid chelates calcium in the blood.

A

Rumex spp CI

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102
Q

Alterative, digestive bitter, anticatarrhal, antimicrobial, cholagogue, mild laxative.

A

Mahonia spp actions

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103
Q

lipoxygenase inhibition and lipid antioxidant properties

A

Mahonia spp moa

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104
Q

Skin conditions:

Psoriasis, eczema, herpes, pityriasis, acne, syphilis.

Poor gallbladder function: Nausea, fat malabsorption, digestive upset

Infections:

Skin, eye, and intestinal tract (bacterial, fungal and protozoal)

A

Mahonia spp indication

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105
Q

Mahonia spp CI

A

pregnancy

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106
Q

Antioxidant, inhibit tumor cell proliferation and induce apoptosis, pro-oxidant, promotes weight loss, decreases LDL, modulates inflammation, decreases sebum production, antimicrobial

A

Camelia sinensis action

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107
Q

inhibition of MAP kinase signaling, inhibition of growth factor signaling, inhibition of matrix metalloproteinases, inhibit angiogenesis, decrease invasiveness of cancer cells, augments hormonal therapies, decreases free testosterone, increases SHBG, decreases insulin resistance and improves other glucose-related markers

A

Camelia sinensis moa

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108
Q

Cancer, PCOS, androgenic alopecia, anti-aging, acne, wound and scar healing, sun protection

A

Camelia sinensis indication

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109
Q

Camelia sinensis CI

A

Take away from iron supplementation

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110
Q

Berries – antioxidant, modulates inflammation.
Rhizome and root – also modulate inflammation, effects glucose metabolism, antimicrobial

A

Berberis vulgaris action

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111
Q

Berries – effective in the treatment of acne as well as other inflammatory conditions.
Rhizome and root – source of berberine and uses relate to that constituent.

A

Berberis vulgaris indication

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112
Q

hepatoprotective, hepatotonic, antihepatotoxic (particularly against aminita phalloides), nephroprotective, bitter, galactagogue, antifibrotic effect,

Increase glutathione

A

Silybum marianum action

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113
Q

increased GSH levels, decreased MDA and IL-8

A

Silybum marianum MOA

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114
Q

Liver diseases , jaundice, hepatitis, cirrhosis, alcoholism, fatty liver degeneration, hepatitis, cirrhosis, alcoholism with fatty liver, diabetic nephropathy

Acne

A

Silybum marianum indication

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115
Q

Silybum marianum CI

A

Speculative - asteraceae family allergy

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116
Q

Warm, stimulating or calm depending on physiologic state, dispels wind dampness

A

Eleutherococcus senticosis Energetics

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117
Q

Adaptogen, immunomodulating, mild CNS stimulant
Nonspecific ant stress effects
Ergogenic
Anabolic/anticatabolic
Antitoxic
Radioprotective
Chemoprotective
Immunoprotected
Immunoregulatory
Antiviral
Gonadotrophic
Insulin-trophic/antidiabetic
Neuroprotective

A

Eleutherococcus senticosis action

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118
Q

reduced frequency of HSV,

A

Eleutherococcus senticosis moa

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119
Q

Build vitality, increase resistance to infection, stress, and toxicity, improve physical performance, and improve mood

A

Eleutherococcus senticosis indication

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120
Q

Adulteration is common in the marketplace. Monitor blood glucose in diabetics and hypoglycemics when introducing this herb.

A

Eleutherococcus senticosis CI

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121
Q

Anti-allergic action of triterpenes, anti-hypertensive, oleic acid inhibits histamine release, hypotensive, decreases platelet aggregation/LDL/arrhythmia/insomnia/angina, protects against ionizing radiation

A

Ganoderma lucidum action

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122
Q

Used in cancer treatment to increase immune function and help treat fatigue, hypertension, immune deficiency, insomnia, hepatitis

A

Ganoderma lucidum indication

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123
Q

Potential allergy to spores

A

Ganoderma lucidum ci

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124
Q
A

Seborrheic keratosis

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125
Q
A

Seborrheic keratosis

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126
Q
A

Seborrheic keratosis

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127
Q
A

milia

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128
Q

Localized atypia of the epidermis – a precursor to SCC in situ
Gross morphology:
Tan-brown, red or skin-colored
Rough like sandpaper
On face, arms, dorsal hands, lips
Hyperkeratosis
What is this?

A

Actinic keratosis

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129
Q
A

Meibomian cyst/Chalazion

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130
Q
A

Digital mucous cyst

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131
Q

Painful lesions
Early
Central crust
Apex -mc
Long standing
Dense rolled edge

A

Chrondrodermatitis nodularis helicis

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132
Q

Painful lesions
Early
Central crust
Apex -mc
Long standing
Dense rolled edge

A

Chrondrodermatitis nodularis helicis

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133
Q

Painful lesions
Early
Central crust
Apex -mc
Long standing
Dense rolled edge

A

Chrondrodermatitis nodularis helicis

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134
Q

Most common tumor of the intraepidermal eccrine sweat glands
Women>Men
Autosomal dominant
Usually symmetrical distribution

A

Syringoma

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135
Q

Very common, button-like dermal nodule
pink, brown, tan, darker at center
leg>arms>trunk
few mm to 1 cm
‘dimple sign’ with lateral compression
Tx-leave alone, excision, cryotherapy

A

Dermatofibroma

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136
Q
A

Seborrheic keratosis

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137
Q
A

Ganglion cyst

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138
Q
A

Lipoma

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139
Q
A

Basal cell carcinoma

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140
Q
A

Seborrheic keratosis

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141
Q
A

Sebaceous hyperplasia

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142
Q
A

actinic keratosis

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143
Q
A

Actinic keratosis

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144
Q
A

Chrondrodermatitis nodularis helicis

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145
Q
A

Basal cell carcinoma

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146
Q
A

Dermatosis Papulosa Nigra

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147
Q
A

Skin tag acrochordon

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148
Q
A

Skin tag acrochordon

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149
Q
A

Skin tag acrochordon

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150
Q
A

Epidermal inclusion cyst

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151
Q
A

Epidermal inclusion cyst

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152
Q

Present in 5-20% of white population
skin surface of whites-can occur anywhere
acral and mucosal surface of other races
potential precursors to Superficial Spreading melanoma (SSM),
increase risk for developing primary melanoma

A

Atypical or dysplastic nevi

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153
Q

Present in 5-20% of white population
skin surface of whites-can occur anywhere
acral and mucosal surface of other races
potential precursors to Superficial Spreading melanoma (SSM),
increase risk for developing primary melanoma

A

Atypical or dysplastic nevi

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154
Q
A

Dermatofibroma

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155
Q
A

Dermatofibroma

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156
Q
A

Junctional nevi

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157
Q

Solitary lesions are:
infrequent
inconsequential
represent spontaneous mutations

These lesions characteristically, on compression, invaginate into a slit-like defect in the skin = “buttonhole” sign.

A

Neurofibroma type 1

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158
Q

Solitary lesions are:
infrequent
inconsequential
represent spontaneous mutations

These lesions characteristically, on compression, invaginate into a slit-like defect in the skin = “buttonhole” sign.

A

Neurofibroma type 1

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159
Q
A

BCC

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160
Q
A

BCC

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161
Q
A

BCC

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162
Q
A

Dermal nevi

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163
Q
A

Dermal nevi

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164
Q
A

Ganglion cyst

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165
Q

Usually deeper than an epidermal inclusion cyst
May feel rubbery but is usually not malleable.
If uncertain diagnosis, particularly if the lesion feels quite firm, a malignant tumor must be considered

A

Lipoma

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166
Q

Abnormal scarring in susceptible individuals
More common in darker skin types
1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery)
Age 10-30 years

A

Hypertrophic scar or keloid

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167
Q

Abnormal scarring in susceptible individuals
More common in darker skin types
1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery)
Age 10-30 years

A

Hypertrophic scar or keloid

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168
Q

Abnormal scarring in susceptible individuals
More common in darker skin types
1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery)
Age 10-30 years

A

Hypertrophic scar or keloid

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169
Q

Abnormal scarring in susceptible individuals
More common in darker skin types
1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery)
Age 10-30 years

A

Hypertrophic scar or keloid

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170
Q

Abnormal scarring in susceptible individuals
More common in darker skin types
1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery)
Age 10-30 years

A

Hypertrophic scar or keloid

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171
Q
A

Skin tag

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172
Q
A

Digital mucous cyst

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173
Q

Alopecia areata cause

A

autoimmune disease
hashimoto’s thyroiditis
vitiligo
myasthenia gravis

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174
Q

Alopecia areata sx

A

loss of hair that is asymptomatic
exclamation point hairs

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175
Q

Alopecia areata TX

A

stress reduction
topical onion juice x2
topical steroids
injection of steroids
topical minoxidil
wig
topical immunotherapy

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176
Q

Acquired loss of pigmentation
Pathogenesis is not known
Theories: autoimmune, neurogenic, self-destruct, genetic background (30%)
Age of onset: any, 10-30yrs (50%)
Incidence: common up to 1%
All races, equal in both sexes
Skin lesions: white macules, sharply marginated, 5mm-5cm
Can affect any area; most common on face and extremities. Accentuated with sun exposure.

A

Vitiligo

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177
Q

Acquired loss of pigmentation
Pathogenesis is not known
Theories: autoimmune, neurogenic, self-destruct, genetic background (30%)
Age of onset: any, 10-30yrs (50%)
Incidence: common up to 1%
All races, equal in both sexes
Skin lesions: white macules, sharply marginated, 5mm-5cm
Can affect any area; most common on face and extremities. Accentuated with sun exposure.

A

Vitiligo

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178
Q

Sun exposed areas of skin
male> females
pre-malignant
1 out of 1000 lesions develop into SCC annually
5-10% over a lifetime

A

actinic keratosis

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179
Q

Acquired light or dark-brown hyperpigmentation
Age of onset: young adults
Female>male(10%)
Race: brown or black skin type
Incidence/etiology: hyperinsulinemia, pregnancy (mask of pregnancy), combo hormone replacement, thyroid dysfunction, genetics, UV radiation, cosmetics, and anti seizure medication

A

melasma

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180
Q

Acquired light or dark-brown hyperpigmentation
Age of onset: young adults
Female>male(10%)
Race: brown or black skin type
Incidence/etiology: hyperinsulinemia, pregnancy (mask of pregnancy), combo hormone replacement, thyroid dysfunction, genetics, UV radiation, cosmetics, and anti seizure medication

A

melasma

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181
Q

Nodular mass of dilated vessels
80-90% resolves spontaneously within 5-8 years

A

hemangiomas

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182
Q

Nodular mass of dilated vessels
80-90% resolves spontaneously within 5-8 years

A

hemangiomas

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183
Q

Nodular mass of dilated vessels
80-90% resolves spontaneously within 5-8 years

A

hemangiomas

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184
Q

Fair-skinned individuals with excessive sun exposure in childhood at highest risk
Exposure to chemical carcinogens (pitch, tar, crude paraffin oil, fuel oil, creosote, lubricating oil)
arsenic (Flower’s soln. for psoriasis)
other etiologies (HPV, immunosuppression)

A

SCC

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185
Q

Fair-skinned individuals with excessive sun exposure in childhood at highest risk
Exposure to chemical carcinogens (pitch, tar, crude paraffin oil, fuel oil, creosote, lubricating oil)
arsenic (Flower’s soln. for psoriasis)
other etiologies (HPV, immunosuppression)

A

SCC

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186
Q
A

nodular melanoma

187
Q

Single or scattered discrete lesions
Adherent hyperkeratotic scales – “rough texture”

A

actinic keratosis

188
Q

punch biopsy was malignant 20 years history
grows nodule after several years means its spread

A

lentigo maligna
melanoma

189
Q

Hutchinson’s sign
Periungual spread from nail

A

acral lentiginous melanomas

190
Q

Scaling to ulcer
elevated nodule to tumor
Indurated, eroded nodule that ulcerates and bleeds easily
Common on lower lip, top of ears, tongue, head, neck, back of hands

A

SSC

191
Q

Scaling to ulcer
elevated nodule to tumor
Indurated, eroded nodule that ulcerates and bleeds easily
Common on lower lip, top of ears, tongue, head, neck, back of hands

A

SSC

192
Q

Autoimmune disease causing localized hair loss w/o signs of inflammation (asymptomatic)
about 2% of population have at least one episode
Etiology-autoimmune, can be assoc. with Hashimoto’s thyroiditis, vitiligo, myasthenia gravis

A

alopecia areata

193
Q

Autoimmune disease causing localized hair loss w/o signs of inflammation (asymptomatic)
about 2% of population have at least one episode
Etiology-autoimmune, can be assoc. with Hashimoto’s thyroiditis, vitiligo, myasthenia gravis

A

alopecia areata

194
Q

Exclamation point hairs
Course: remission is common (80%)
Management: stress reduction, topical onion juice, topical, intralesional, or systemic glucocorticoids, can add topical minoxidil, wig in severe cases, or refer for topical immunotherapy

A

alopecia areata

195
Q

pre-malignant (1 out of 1000 lesion annually) develop into SCC, 10% over lifetime

A

actinic keratosis

196
Q

5-Fluorouracil- applied bid for 2-4 weeks – very irritating
Acetaminophen with codeine often given to control pain
Petrolatum often used between applications to soothe skin

A

actinic keratosis

197
Q

management: gluten free diet, dipsone,

A

Dermatitis herpetiformis

198
Q
A

Dermatitis herpetiformis

199
Q
A

Storke bite lesion

200
Q
A

nodular BCC

201
Q

Course and Prognosis: May spontaneously disappear after delivery or stopping hormones
Management: can be difficult to treat. Use sun blocks and/or reduce UV exposure, hypopigmenting agents (i.e. hydroquinone 2-4% bid), topical tretinoin, azelaic acid, chemical peels (glycolic acid, salicylic acid and TCA), laser cryotherapy, dermabrasion

A

Melasma

202
Q

Course and Prognosis: May spontaneously disappear after delivery or stopping hormones
Management: can be difficult to treat. Use sun blocks and/or reduce UV exposure, hypopigmenting agents (i.e. hydroquinone 2-4% bid), topical tretinoin, azelaic acid, chemical peels (glycolic acid, salicylic acid and TCA), laser cryotherapy, dermabrasion

A

Melasma

203
Q

most common in 6th decade of life
no radial growth, so early metastasis

A

nodular melanoma

204
Q

most common in 6th decade of life
no radial growth, so early metastasis

A

nodular melanoma

205
Q

photodynamic therapy

A

actinic keratosis

206
Q

rapid growth within few weeks- can self-resolve within a month-year

A

Keratoacanthoma

207
Q

Treated 5-FU or Curaderm identify

A

superficial BCC

208
Q

Dilated vessels deep in dermis and subcutaneous tissue
Spontaneous resolution, surgery, interferon, propranolol, intralesional and topical corticosteroids, vincristine and cyclophosphamide

A

hemangioma deep cavernous

209
Q

Dilated vessels deep in dermis and subcutaneous tissue
Spontaneous resolution, surgery, interferon, propranolol, intralesional and topical corticosteroids, vincristine and cyclophosphamide

A

hemangioma deep cavernous

210
Q
A

Vascular malformation/port wine stain

211
Q
A

Vascular malformation/port wine stain

212
Q
A

Vascular malformation/port wine stain

213
Q

asymptomatic, soft benign papule, from dilated venule

A

venous lake

214
Q

Develops after a minor trauma
Bleeds easily
<30 years old

A

pyogenic granuloma

215
Q

Develops after a minor trauma
Bleeds easily
<30 years old

A

pyogenic granuloma

216
Q
A

spider angioma

217
Q
A

spider angioma

218
Q

25% remit with decrease sun exposure
Antioxidants, fruit, vegetables, green tea, etc
5-Fluorouracil
Black salve (iris, red clover, sanguinaria)
Vitamin A
Curaderm
Cryotherapy (3-10 seconds max/3) w/ 5FU
Sunscreen Type I & II skin
excision for large lesions

A

actinic keratosis

219
Q

25% remit with decrease sun exposure
Antioxidants, fruit, vegetables, green tea, etc
5-Fluorouracil
Black salve (iris, red clover, sanguinaria)
Vitamin A
Curaderm
Cryotherapy (3-10 seconds max/3) w/ 5FU
Sunscreen Type I & II skin
excision for large lesions

A

actinic keratosis

220
Q

most common skin disorder in adolescents
Typical age range:12-25 years
79% to 95% of adolescents aged 16-18 years-reference

A

acne

221
Q

most common skin disorder in adolescents
Typical age range:12-25 years
79% to 95% of adolescents aged 16-18 years-reference

A

acne

222
Q

A reactive hypermelanosis of the skin that occurs as a sequela of cutaneous inflammation
EPIDEMIOLOGY
A common disorder that can occur at any age and has an equivalent incidence in males and females.
may occur regardless of skin color, but is clinically more significant with darker skin pigmentation.

A

hyperpigmentation syndrome

223
Q

Wheals –transient edematous papules and plaques
Usually pruritic
15-25% of pop will have at least one episode at during their lifetime
Duration: hours-months
Histamine is the most important mediator

A

urticaria

224
Q

Wheals –transient edematous papules and plaques
Usually pruritic
15-25% of pop will have at least one episode at during their lifetime
Duration: hours-months
Histamine is the most important mediator

A

urticaria

225
Q

Chronic, recurrent, intensely pruritic vesicles, papules, and urticarial plaques that are arranged in groups
Can resembles herpes; therefore the designation of herpetiformis
Almost universally associated with celiac disease (1% of pop)
Age of onset: 20-60 years
Prevalence in Caucasians, M:F 2:1, 10-39 per 100,000 persons

A

dermatitis herpetiformis

226
Q

Thickened, hyperpigmented skin in the axillae and groin
Often associated with obesity and hyperinsulinemia
Can be congenital
Increased circulating insulin causes dermal fibroblast and keratinocyte proliferation
Associated rarely with internal malignancy (stomach and other gastrointestinal malignancies)

A

Acanthosis Nigricans

227
Q

Thickened, hyperpigmented skin in the axillae and groin
Often associated with obesity and hyperinsulinemia
Can be congenital
Increased circulating insulin causes dermal fibroblast and keratinocyte proliferation
Associated rarely with internal malignancy (stomach and other gastrointestinal malignancies)

A

acanthosis nigricans

228
Q

Thickened, hyperpigmented skin in the axillae and groin
Often associated with obesity and hyperinsulinemia
Can be congenital
Increased circulating insulin causes dermal fibroblast and keratinocyte proliferation
Associated rarely with internal malignancy (stomach and other gastrointestinal malignancies)

A

Acanthosis Nigricans

229
Q

Localized proliferation of melanocytes due to chronic sun exposure (esp. sunburns)
1-3 cm macules
>40 years old esp. Type I to III skin
Roughly 75% of white people over 60 have one or more

A

solar lentigo

230
Q

Dermatitis Heprtiformis pathophysiology

A

celiac disease

231
Q

Dermatitis Heprtiformis population

A

20-60 yo
Caucasians
M

232
Q

Dermatitis Heprtiformis Sx

A

Chronic, recurrent, intensely pruritic vesicles, papules, and urticarial plaques that are arranged in groups

233
Q

Dermatitis Heprtiformis TX

A

gluten free diet
dapsone
sulfapyridine

234
Q

Acanthosis Nigrican cause

A

hyperinsulinemia causes melanocytes, dermal fibroblast and keratinocyte to proliferation
diabetes, metabolic syndrome
internal malignancy
Insulin and insulin-like growth factor-1, and their receptors on keratinocytes are obviously involved in the complex regulations leading to the peculiar epidermal hyperplasia

235
Q

Acanthosis Nigrican sx

A

symmetric velvety hyperpigmented plaques on intertriginous areas like axilla, neck, inframammary, and groin
associated with skin

236
Q

Acanthosis Nigrican Tx

A

berberine, metformin,rosiglitazone
remove meds that cause hyperinsulinemia: glucocorticoids, injected insulin, niacin, oral contraceptives
topical retinoids: keratinolytic effects on the skin
vitamin D analogs: reducing keratinocyte proliferation
keratolytics
topicalurea, salicylic acid, glycolic acid peels, and laser therapy

237
Q

Melasma pop

A

young age, female, darker skin types

238
Q

Melasma cause

A

oral contraceptive use, pregnancy
hyperinsulinemia, combo hormone replacement, thyroid dysfunction, genetics, UV radiation, cosmetics, and anti-seizure medication

239
Q

Melasma sx

A

Irregular blotchy patches of hyperpigmentation on the face

240
Q

Melasma DX

A

insulin
glucose

241
Q

Melasma TX

A

sunscreen
hydroquinone 2-4% bid
topical tretinoin
azelaic acid
chemical peels (glycolic acid, salicylic acid and TCA)
laser cryotherapy
dermabrasion

242
Q

Postinflammatory hyperpigmentation cause

A

reactive hypermelanosis of the skin that occurs as a sequela of cutaneous inflammation

acne vulgaris, atopic dermatitis, irritant contact dermatitis, allergic contact dermatitis, psoriasis, and lichen planus.

Accidental burns, nonionizing radiation therapy, phototoxicity, chemical peels, and laser procedures

when inflammation leads to a disruption of the basal layer of the epidermis, causing the release of melanin into the papillary dermis. Macrophages in the papillary dermis then phagocytize the released melanin.

243
Q

Postinflammatory hyperpigmentation TX

A

avoid sun
treat underlying cause
Topical hydroquinone (2-4%): cytotoxic effect
topical retinoids, azeliac acid, and chemical peels (Glycolic acid-Alpha hydroxy acids (AHAs) and salicylic acid-Beta hydroxy acid (BHA
laser
lignin peroxidase
mequinol, niacinamide, ascorbic acid, kojic acid, and licorice

244
Q

Solar Lenitgo cause

A

Localized proliferation of melanocytes due to chronic sun exposure

245
Q

Solar Lenitgo pop

A

> 40, Type I to III skin

246
Q

Solar Lenitgo sx

A

1-3 cm macules, brown

247
Q

Solar Lenitgo dx

A

punch biopsy
shave

248
Q

Solar Lenitgo tx

A

hydroquinone solution
tretinoin
azeliac acid cream
glycolic acid peels and creams
Light cryotherapy

249
Q

Vitiligo pop

A

any race, 10-30

250
Q

Vitiligo cause

A

unknown, autoimmune, family history
neurogenic, self-destruct,
associated with thyroid disease (30%), alopecia, Addison’s disease, pernicious anemia, type 1 diabetes, chronic candida, melanoma

251
Q

Vitiligo sx

A

Irregular, completely depigmented patches
area devoid of melanocytes
white macules, sharply marginated, 5mm-5cm
face and extremities
accentuated by sun exposure

252
Q

Vitiligo tx

A

sunscreen
oral and/or topical psoralens with UVA (6-24 month course), UVB(6-12 months)
oral/topical steroids
tacrolimus
B12 (2,000mcg/day) plus folic acid (10mg/day)
L-Phenylalanine 50mg/kg/day orally and a 10% gel topically, plus 30 min of sun per day
Ginkgo biloba - 40 mg orally 3 times daily

253
Q

urticaria cause

A

histamine is the most important mediator
Inhalants: pollens, animal danders, mold spores, feather down, aerosols, smoke, dust and volatile chemicals
Injectants: drugs, diagnostic agents, vaccines, insects stings
Ingestants: drugs, food, food additives (dyes, preservatives, etc.)
Infections: bacterial, fungal, viral, parasitic
Contactants: plants, cosmetics, plastic, chemicals
dermographism
cold solar
exercise-induced
pressure

254
Q

urticaria sx

A

wheals
pruritic
hours to months
angioedema of glottis leading to air flow obstruction

255
Q

urticaria dx

A

CBC with differential: normal or elevated eosinophil or neutrophil
ESR, CRP: elevated or normal
C4 level: decreased

Chronic utricaria
- TSH, antibodies
- ANA
- skin prick testing
- specific IgE blood test to allergen
- allergen elemination diet
- serum tryptase
- C1 esterase inhibitor
- C1-inhibitor

256
Q

urticaria tx

A

antihistamines: benadryl, claritin, zyrtex, hydroxyzine, diphenhydramine, cetirizin, prednisone

epinephrine for severe cases

ID the causse

stop all nonessential drugs/supplement/herbs

elimination diet

low histamine diet

Vit C: 1 g tid, Vit D: 1,000-10,000IU D3-test blood levels

Vitamin B12, 1,000 mcg intramuscularly, once a week for 4 weeks, has been reported to provide relief in >50% (Gaby)

Quercetin: 250 mg 20 minutes before meal

Check and evaluate for HCL deficiency

Eradication of H pylori resulted in clinical improvement in 73% of patients with chronic urticaria (Helicobacter 2001;6(1):60-65

Relaxation, homeopathy, acupuncture

For cholinergic urticaria: hot shower depletes histamine store – 24 hour refractory period

Baking soda, starch or oatmeal bath

Botanicals: comfrey, euphoria, yerba sante, feverfew, ephedra

address histamine detox via diamine oxidase
- Gluten intolerance, leaky gut, SIBO, DAO blocking foods (alcohol, energy drinks, tea), genetic mutations, inflammation from Crohn’s ulcerative colitis, and IBD
- Medications such as: Non-steroidal anti-inflammatory drugs (ibuprofen, aspirin)
- Antidepressants (Cymbalta, Effexor, Prozac, Zoloft)
- Immune modulators (Humira, Enbrel, Plaquenil)
- Antiarrhythmics (propanolol, metaprolol, Cardizem, Norvasc)
- Antihistamines (Allegra, Zyrtec, Benadryl)
- Histamine (H2) blockers (Tagamet, Pepcid, Zantac)

257
Q

Hemangiomas pop

A

most common tumor in infancy

258
Q

Hemangiomas sx

A

deep and superficial
nodular mass of dilated vessels
Dilated vessels deep in dermis and subcutaneous tissue

259
Q

Hemangiomas TX

A

Spontaneous resolution
surgery
interferon
propranolol
intralesional and topical corticosteroids
vincristine
cyclophosphamide

260
Q

Vascular Malformation/Birthmark/Port-wine stain/Nevus flammeus sx

A

Flat, unilateral patches of irregular reddish-blue color.
Face and neck are most common

261
Q

Vascular Malformation/Birthmark/Port-wine stain/Nevus flammeus dx

A

10% of face send for MRA to rule out CNS problems

262
Q

Vascular Malformation/Birthmark/Port-wine stain/Nevus flammeus tx

A

Refer to dermatologist, an ophthalmologist and a neurologist if large
Pulsed dye laser

263
Q

Cherry Angioma pop

A

male and females
begin around 30 years old

264
Q

Cherry Angioma cause

A

family history

265
Q

Cherry Angioma sx

A

bright red, blue, purple, black dome-shaped to polypoid, firm papule
chest and back

266
Q

Cherry Angioma tx

A

radiosurgery
shave excision
laser
electrodesiccation
cryotherapy
no treatment necessary

267
Q

Spider angioma pop

A

women

268
Q

Spider angioma cause

A

oral contraceptive, pregnancy and liver disease

269
Q

Spider angioma sx

A

Central arteriole w/ radiating telangiectasia
face, arms, and upper trunk
abdomen is liver congestion

270
Q

Spider angioma dx

A

diascopy

271
Q

Spider angioma tx

A

optional
radio/electrosurgery
laser
pulsed dye laser

272
Q

Venous Lake pop

A

over 50 yo

273
Q

Venous Lake sx

A

Dark blue to violet - dilated venule
face, lips, and ear
2-10mm soft papule that blanches with pressure
Asymptomatic, if unsure, R/O melanoma

274
Q

Venous Lake dx

A

put slide and the blood drains out

275
Q

Venous Lake tx

A

cosmetic

electrosurgery

laser

excision

276
Q

Pyogenic Granuloma pop

A
277
Q

Pyogenic Granuloma pop

A

any age

278
Q

Pyogenic Granuloma cause

A

site of minor trauma

279
Q

Pyogenic Granuloma sx

A

recurrent bleeding

red, dusky red, violaceous, brown/black

head, neck, upper trunk and hands and feet

280
Q

Pyogenic Granuloma dx

A

rule out melanoma

excision/biopsy

281
Q

Pyogenic Granuloma TX

A

electrodesiccation of base to prevent recurrence

Curettage and Cauterization

surgical Excision

Electrocautery Excision

Cryosurgery sometimes possible

Laser Surgery

Sclerotherapy

Injections of Corticosteroids into the Lesion

282
Q

Benefits of epinephrine

A
  • decreases bleeding
  • prolongs the duration of the anesthesia
  • minimize the amount of anesthesia
283
Q

Issues of epinephrine

A
  • goes through breast milk
  • reduce uterine blood flow
  • induce premature labor
  • can cause gangrene or reduced blood flow
284
Q

Benefits of Sodium Bicarbonate

A
  • reduction in infiltration
  • faster onset of action
285
Q

Cons of sodium bicarbonate

A
  • chemically unstable
  • decrease the overall activity of epinephrine
286
Q

Drug interactions to epinephrine

A
  • MAO inhibitors: hypertensive crisis
  • Carbamazepine and Cyclobenzaprine: potentiate effects
  • tricyclics and tetracycline antidepressants: hypertensive crisis and dysrhythmia
  • phenothiazines: profound hypotension
287
Q

allergy to anesthetics cause, sx, management

A
  • uncommon to amide
  • allergy to methylparaben preservatives
    Sx
  • delayed appearance of skin rashes
  • acute onset of localized or general urticaria
  • onset of asthma
    Management
  • maintain airway
  • legs up
  • administer epinephrine, Benadryl, ER
288
Q

topical anesthetics use and type

A
  • mucous membranes
  • cocaine, tetracaine, lidocaine, phenylephrine +lidocaine or tetracaine
289
Q

local infiltration steps

A
  • injection of local anesthetic directly into tissue without considering the course of cutaneous nerve
  • clean the skin with alcohol or use betadine
  • Insert a 25-30 g. needle attached to a syringe into the skin at a 15-20o angle and inject the anesthesia around or within the skin in the area to be removed or treated.
  • Pull back or tighten the skin before inserting a 25-30 g needle ¼ inch back from wound edge or lesion
  • Push the needle attached to a syringe into the skin at a 15-20 angle
  • Advance the needle as far as it will go
  • Draw back on the syringe to make sure the needle is not sitting in a vessel
  • Slowly inject the anesthetic as you withdraw the needle
  • Retain needle and advance to the opposite side of the “V”
  • Repeat on other side of lesion
  • May need to inject into the Sub-Q tissue and around the base of deep structures, i.e. a cyst, for good effect.
  • Another injection can be done over future incision
290
Q

field block

A

Injection of a combination of intradermal and subcutaneous local anesthetic solution in an inverted V just proximal to and to each side of the lesion (not into the lesion) with no attempt to locate specific nerves anesthetizing the region distal to the site of injection

291
Q

field block procedure

A
  • Clean the skin with alcohol.
  • Use Betadine if needs to be sterile.
  • Pull back or tighten the skin before inserting a 25-30 g needle ¼ inch back from wound edge or lesion
  • Push the needle attached to a syringe into the skin at a 15-20 angle
  • Advance the needle as far as it will go
  • Draw back on the syringe to make sure the needle is not sitting in a vessel
  • Slowly inject the anesthetic as you withdraw the needle
  • Retain needle and advance to the opposite side of the “V”
  • Repeat on other side of lesion
  • May need to inject into the Sub-Q tissue and around the base of deep structures, i.e. a cyst, for good effect.
  • Another injection can be done over future incision
292
Q

anesthetics except cocaine are vasodilators
T or F

A

T

293
Q

What is the purpose of adding sodium bicarbonate to local anesthetics?

A

reduce the burning

294
Q

Can sodium bicarbonate be safely added to local anesthetic products containing epinephrine? Why/why not? What are the effects?

A

yes

295
Q

field block definitions

A

Injection of a combination of intradermal and subcutaneous local anesthetic solution in an inverted V just proximal to and to each side of the lesion (not into the lesion) with no attempt to locate specific nerves  anesthetizing the region distal to the site of injection.

Injection of a combination of intradermal and subcutaneous local anesthetic solution completely around the boundaries of the lesion, with no attempt to locate specific nerves  an anesthetized “field” inside of the boundaries of the anesthesia.

296
Q

What are the 2 advantages of a field block over an infiltration anesthesia?

A

rapid onset
less drug can be used

297
Q

What are the considerations when choosing an infiltration anesthetic?

A

the location
allergy

298
Q

What are the maximum allowable safe single doses of plain 1 % lidocaine and 0.25 % bupivacaine alone and with epinephrine?

A

lidocaine: 4.5 mg/kg (30 ml per average adult)
lidocaine w/ epi: 7 mg/kg (50ml per average adult)
bupivacaine: 3 mg/kg 70 ml per average adult
bupivacaine w/ epi: 3.5 mg/kg 90 ml per average adult

299
Q

What are “two” advantages of using langer’s lines when doing minor surgery?

A

minimize wound tension
heal faster
produce less scarring than those cut across

300
Q

Langer’s lines

A

direction in which the skin of a human cadaver will split when stuck with an ice pick.
Correspond to the natural orientation of collagen fibers in the dermis and parallel to the orientation of the underlying muscle fibers

301
Q

What are the “problem areas” of the body for increased risk of scarring/keloids?

A

upper chest and back
shoulders

302
Q

How do Kraissl’s lines compare to Langer’s Lines?

A

Langer’s lines were defined in cadavers, Kraissl’s lines were based on observations in living people.

303
Q

When a wound occurs what, essentially, is the body’s only interest?

A

survival

304
Q

What is the average tissue strength of a healing wound when the sutures are removed at 10-14 days?

A

5-6%

305
Q

inflammatory phase

A

constriction of the blood supply
leukocytes break down cellular debris and foreign material
macrophages ingest the remaining debris
platelets start to clot
formation of a scab
opening of the blood supply
cleansing of the wound

306
Q

proliferative phase

A

fibroblasts new collagen tissue is laid down
new capillaries fills in defect
wound edges pull together
cells cross over the moist surface
cells travel about 3 cm from point of origin

307
Q

maturation phase

A

collagen forms which increases tensile strength to wounds
scar tissue is only 80 precent as strong as original tissue
3 weeks to 2 years

308
Q

clean wound

A

free from microorganisms

309
Q

clean-contaminated wound

A

non-significant contamination and less than 6h elaspsing until medical care

310
Q

dirty/contaminated wound

A

without local infection and more than 6 h elapsing until medical care

311
Q

infected wounds

A

intense inflammatory reaction and frank infectious process

312
Q

Is there a “Golden Period” of time for closing lacerations?

A

no

313
Q

What are the four “Goals of Surgery”?

A

Close the wound efficiently
Have no infection occurring during the healing process.
End up with a small scar that is as inconspicuous as possible
Have no loss of function.

314
Q

What factors involving the surgeon affect wound repair?

A

length/direction of the incision/wound
dissection technique
careful tissue handling
removal of necrotic tissue/foreign materials
good hemostasis
choice of closure materials
elimination of dead space in the wound
closing with sufficient and proper tension
anticipation of post-op wound stressors
immobilization of the wound if needed

315
Q

What factors involving the patient affect wound repair?

A

patient’s age
patient’s weight
nutritional status
degree of hydration
inadequate blood supply to the wound site (e.g. DM)
patient’s immune response
presence of chronic disease
malignancies
debilitating injuries
localized/systemic infection
patient corticosteroids use
immunosuppressive or antineoplastic drugs
hormone use
prior radiation therapy

316
Q

Understand the concept of “Healing by First (Primary) Intention”. What are the goals and outcomes of this method?

A

a clean wound to start
prompt closer
minimal edema
no local infection
no serious discharge
normal healing time
good skin edge approximation and eversion
minimal scar formation

317
Q

What are advantages and disadvantages of “Healing by Secondary Intention”?

A

Advantages:
its simplicity
relatively low risk of infection

Disadvantages:
may take forever to heal
tends to cause larger scars

318
Q

What are the two possibilities that lead to a wound “Healing by Secondary Intention”? Can it be a reasonable choice made by the patient or surgeon?

A
  1. Wound is left open on purpose, e.g. a “paper cut”, abrasion, or a draining abscess:
  2. Wound fails to heal via primary (first) intention due to: excessive tissue trauma and/or loss, imprecise tissue approximation, or wound infection
319
Q

Describe the steps in “Delayed Primary Closure (DPC)”. When should it be used? What are its advantages?

A

Steps:
Debride the wound of non-vital tissues
Leave the wound open
Pack the wound with sterile dressing
Cover with supporting bandage
REPEAT PROCESS DAILY.

uses: heavily contaminated wounds (combat wounds/major trauma) where there is extensive tissue loss and high risk of infection even with proper cleansing and primary closure.

Advantages
uncomplicated closure
low risk of infection
a “reasonable” scar
better overall than an infected wound!

320
Q

Name the several different ways to deal with “bleeders” that may appear in a surgical wound or traumatic laceration.

A

small
-wait for them to stop on their own
-apply pressure with a sterile gauze
clamp with hemostat; then twist around several times
-cauterize with a battery powered high temp cautery pen (“hot wire loop”)
-cauterize with the hyfrecator
-radiosurgery tip directly to the tissue

large bleeding
-clamp with hemostat and tie off with dissolvable suture
-touching the hyfrecator tip to the hemostat
-tie off with a “figure-of-8” suture

321
Q

What are the other steps in laceration evaluation and treatment?

A

Assess for wound contamination and tissue damage.
Check flexion/extension of all joints against resistance for underlying nerve and tendon damage – PRIOR TO INJECTING ANESTHESIA.
R/O fractures
In relatively “clean” wounds – first inject anesthesia
In “contaminated” wounds – clean skin first!
Then, if needed, inject anesthesia in a fan-like pattern through the skin surface around the laceration.
REMEMBER – no anesthetics with epinephrine in areas of limited blood supply!
Clean and debride as needed.
Culture if risk of infection – decide about prophylactic antibiotic coverage.
Carefully close wound and bandage appropriately – apply minor surgery tincture, honey, antibiotic, or Vaseline.

322
Q

Contrast the treatment of an area of skin loss up to 1 cm2 in a fingertip vs. a larger wound or avulsion of the fingertip.

A

Areas of skin loss up to 1 cm2:
Treat only with dressings changed regularly
Heal with good return of sensation

Skin loss greater than 1 cm2:
Refer for plastic surgical opinion& treatment
May need skin graft &/or re-attachment of severed part!

323
Q

What are particular concerns about palm wounds?

A

deep structures could be involved
fracture

324
Q

tetanus immune globulin administration guidelines

A

If not certain that the patient has had the last dose of a primary series or a booster within the past 5 years, give tetanus toxoid.

If patient has received fewer than two doses of tetanus toxoid in her/his lifetime and the wound is heavily contaminated, give both tetanus toxoid and tetanus immune globulin (derived from vaccinated patients and confers immediate passive immunity!)

325
Q

When a wound has a Foreign bodies?

A

need to look for them but can be hard to identify because of wound type, location, timing, and mechanism of injury
need x-ray

326
Q

What are the controllable and the uncontrollable issues that affect wound healing?

A

Uncontrollable factors :
Mechanism of injury
Location of the wound
Age and race of the patient
Patient’s inherent ability to heal
Patient’s tendency toward abnormal scar formation
Patient’s nutritional status

Controllable factors:
Tissue handling – use gentle, meticulous tissue handling, especially on the face.
Do careful, thorough cleaning of the injured tissue.
Splint/cast wounds located near joints to help prevent dehiscence &  less scarring

327
Q

BEFORE APPLYING ANESTHESIA assess the wound site for tissue damage, contamination and possible underlying nerve, tendon, muscle and boney damage.
T or F

A

T

328
Q

Cleaning wound steps

A
  1. assessing function, inject anesthesia
  2. Remove embedded materials with a forceps or hypodermic needle to prevent skin “tattooing”.
  3. Wear face shield, gloves, and impermeable gown to prevent contamination of the physician and others nearby.
  4. Minimize operator and room contamination – use splash guard with a 30- or 60-ml syringe and sterile normal saline.
  5. Use an 18-gauge needle or angiocatheter attached to a syringe to increase irrigation pressure.
  6. For better disinfection add diluted Betadine or HIBICLENS (chlorhexidine gluconate) to the saline irrigating solution.
  7. Irrigate until clean with a minimum of 500 ml of solution
  8. If needed scrub out the wound with a gauze, cloth, or scrub brush.
  9. Warn the patient about pain in case you may not have obtained good anesthesia.
  10. Clean thoroughly but try to accomplish the task as quickly as possible.
  11. Scrubbing/irrigation will often cause a wound to begin bleeding again as blood clots are dislodged.
  12. Stop this bleeding by one or more of the methods described earlier –the goal is to avoid hematoma formation!
  13. Remember to rinse the wound thoroughly with sterile saline when finished
329
Q

Anesthetic usually should be administered by injecting from the inside or center of the laceration out through the side of the wound (unless it is significantly contaminated) into the tissue rather than through the skin surface because it will be less painful.
T or F

A

T

330
Q

All wounds should be considered contaminated, especially human bite wounds, which generally should not be closed, at least not initially.
T or F

A

T

331
Q

To prevent wound “tattooing,” embedded foreign material must be removed with a forceps and scissors/scalpel or hypodermic needle and the wound copiously irrigated with sterile saline preferably under pressure.
T or F

A

T

332
Q

As part of debridement, all debris and devitalized and necrotic tissue should be removed from the wound. However, if there is any question concerning a tissue’s viability, it’s usually best to minimize the debridement at that time and opt for delayed primary closure..
T or F

A

T

333
Q

Wound care steps

A
  1. assessing function, inject anesthesia
  2. Remove embedded materials with a forceps or hypodermic needle to prevent skin “tattooing”.
  3. Wear face shield, gloves, and impermeable gown to prevent contamination of the physician and others nearby.
  4. Minimize operator and room contamination – use splash guard with a 30- or 60-ml syringe and sterile normal saline.
  5. Use an 18-gauge needle or angiocatheter attached to a syringe to increase irrigation pressure.
  6. For better disinfection add diluted Betadine or HIBICLENS (chlorhexidine gluconate) to the saline irrigating solution.
  7. Irrigate until clean with a minimum of 500 ml of solution
  8. If needed scrub out the wound with a gauze, cloth, or scrub brush.
  9. Warn the patient about pain in case you may not have obtained good anesthesia.
  10. Clean thoroughly but try to accomplish the task as quickly as possible.
  11. Scrubbing/irrigation will often cause a wound to begin bleeding again as blood clots are dislodged.
  12. Stop this bleeding by one or more of the methods described earlier –the goal is to avoid hematoma formation!
  13. Remember to rinse the wound thoroughly with sterile saline when finished
334
Q

Skin and hair preparation

A

avoid shaving
clippers and scissors are okay

335
Q

When trimming a wound edge the goal is to produce an opening smaller at the base than the surface, which helps produce eversion of the wound edges.
T or F

A

F

336
Q

What are the alternatives to consider if a wound can’t be closed by primary intention?

A

secondary intention or delayed closure

337
Q

Excessive scar formation can be minimized through gentle handling and careful cleaning of the injured tissue
T or F

A

T

338
Q

Name the 7 “Wound Closure Technique Basics”.

A

Handle tissues gently with forceps
Ensure hemostasis
Use as fine a suture as feasible
Enter needle at 90° to the skin surface
Evert the wound edges
Keep the skin edges relaxed but well opposed
Remove sutures as early as reasonably possible to reduce scarring

339
Q

Excision advantages

A
  • Margin-controlled
  • Usually performed under local anesthesia
  • Area of tissue removed can be more precisely controlled than with cryosurgery, radiation therapy, or electrosurgery → limiting damage to critical structures
  • Resultant scar is optimized both cosmetically and functionally
340
Q

Excision Disadvantages

A
  • Invasive
  • Occasionally needs to be performed under conscious sedation or general anesthesia with their inherent risks.
  • Uncertain “clear” margin → a poorer cure rate compared to Mohs micrographic surgery
341
Q

Lift and Snip procedure

A
  1. Apply alcohol to skin
  2. Clean anesthesia bottle top with alcohol
  3. Draw up anesthesia with an 18-22 g needle (controversial whether or not to inject air into the bottle!)
  4. Switch to a ½-1 inch 27-30g needle
  5. Inject Anesthesia: 0.2-0.4cc 1% lidocaine or 1% lido w/epi to create a cutaneous bleb (or use optional field block)
  6. Grasp lesion with forceps and elevate a moderate amount
  7. Snip off lesion with sterile iris scissors
  8. Apply direct pressure and/or cautery (electro, silver nitrate, styptic) to oozing wound/bleeders
  9. Dress with minor surgery tincture on Band-Aid
342
Q

excision types

A
  • Shave, Scoop, Punch Biopsy
  • Electrodesiccation (hyfrecation or radiosurgery) & Curettage
  • Elliptical (fusiform)Tissue Resection
    Lift and Snip
343
Q

Conditions used for excision

A

SK
Nevi
Skin tags
Small lesions
Malignancy

344
Q

Shave biopsy

A
  1. Apply alcohol to skin
  2. Clean anesthesia bottle top with alcohol
  3. Draw up anesthesia with an 18-22 g needle (controversial whether or not to inject air into the bottle!)
  4. Switch to a ½-1 inch 27-30g needle
  5. Inject Anesthesia: 0.2-0.4cc 1% lidocaine or 1% lido w/epi to create a cutaneous bleb (or use optional field block) under the skin lesions at an angle, pull back on syringe then push it in as pull out
  6. Test it they are numb
  7. Put on gloves
  8. 3 iodine swabs from center outward
  9. Open towel away from you, open up, place on patient and press down
  10. Dab off iodine
  11. Open up scalpel and forceps
  12. If possible, grasp lesion with forceps and elevate
  13. Shave off lesion with #15 or #10 scalpel or dermablade
  14. Apply direct pressure and/or cautery (electro, silver nitrate, styptic) to oozing wound/bleeders from the outside to center, put pressure and see if oozes
  15. Dress with minor surgery tincture and/or Vaseline on Band-Aid
345
Q

Punch biopsy

A
  1. Prep area with alcohol.
  2. Apply local anesthesia in the skin.
  3. Prep with Betadine®.
  4. Stabilize the skin surface with your thumb and index finger.
  5. Firmly press the punch tip, perpendicular to the skin surface
  6. Rotate back-and-forth until you feel the punch drop through the skin.
  7. Grasp specimen with tissue forceps, and snip through the with iris scissors., sub-Q layer
  8. Deposit in specimen container.
  9. When doing a 2-3 mm punch, control bleeding with direct pressure and/or cautery or styptic solution, e.g. silver nitrate stick.
  10. For larger punches close wound with appropriate number of sutures.
  11. Dress with minor surgery tincture and/or Vaseline on a Band-Aid.
346
Q

Scoop

A
  1. Prep and anesthetize skin
  2. If possible, grasp lesion with forceps and elevate
  3. carefully shave it off with a scalpel or Dermablade
  4. Apply direct pressure and/or electrocautery and/or silver nitrate and/or styptic to control oozing wound or bleeders
  5. Dress with Vaseline and/or minor surgery tincture on a Band-Aid
347
Q
A
  1. Draw an ellipse around the lesion parallel to skin lines with an indelible marker.
  2. This orientation reduces wound edge tension and improves the cosmetic effect.
  3. Ellipses should be 3:1 length to width ratio with 30o angles at the ends.
  4. Hold the scalpel at a 90 degree angle to the skin to produce perpendicular skin edges to allow for better eversion on closure.
  5. If sending for biopsy, use atraumatic (no teeth) forceps to avoid tissue damage!
  6. Undermine as needed and if needed/possible close sub-Q layer with simple stitches
  7. Appose and align the wound edges using the “Rule of Halves”.
  8. Carefully suture using a combo of mattress and simple sutures to evert the skin edges and reduce tension
348
Q

elliptical excision complications

A

dog ear created
can’t close wound
wound dehiscence

349
Q

Steri strips benefits

A
  • Rapid, effortless application
  • Less pain and anxiety in kids
  • Lessscarring and less infection than sutures and staples
  • Easy to care for – just keep dry!
  • Trim loose ends as needed.
  • Leave on until they fall off!
350
Q

Steri strips

A
  • Thin paper strips with a pressure-sensitive, hypoallergenic adhesive, Reinforced with polyester filaments for added strength
  • Apply across a small wound to pull the skin edges together.
  • Good for the face, contoured areas, joints, areas of swelling, edema, and hematomas.
  • Use to provide wound support after early suture/staple removal.
351
Q

Surgical glue

A

Cyanoacetate and formaldehyde combine in a heat vacuum along with a base →liquid monomer.
When this monomer combines with moisture on the skin’s surface, it chemically changes into a polymer that binds to the top epithelial layer.
This polymer → cyanoacrylate bridge that strongly binds the two wound edges together and allows normal healing.

352
Q

surgical glue use

A

Best suited for small, superficial lacerations
May be used with confidence on larger wounds AFTER first applying subcutaneous sutures.
low tension
not bleeding
low infection risk
not over a joint
high friction areas

353
Q

surgical glue advantages

A

Maximum bonding strength at 2 ½ minutes

Only topical or no anesthetic

Usually need no additional injectable anesthesia no needles!

Faster repair time than sutures

Better patient acceptance

Flexible, water-resistant covering

No sutures to remove – adhesive peels off in five to 10 days.

354
Q

surgical glue caution

A

wounds must be dry.

use in wounds that have low risk of infection.

don’t use over joints or high friction areas.

355
Q

surgical glue results

A

Long-term cosmetic outcome is comparable to that of traditional repair methods.

356
Q

when can’t you use steri strips or surgical glue

A

Lacerations into the deeper dermal layers and Sub-Q

Wounds missing tissue

Wounds with increased wound tension

Eliminate dead space

Reduce the chance of infection and hematoma formation

To reduce the likelihood of dehiscence

357
Q

Staples advantages

A

quick placement

fewer infections

lower tissue reaction

358
Q

staples cons

A

scarring

359
Q

Electrosurgery use

A

to destroy benign and malignant lesions
control bleeding
incise or excise tissue
Superficial lesions – e.g. skin tags
Tiny lesions (may not need anesthesia)
Vascular lesions
Basal cell carcinoma - (only in experienced hands combined with curettage)

360
Q

Electrodessication

A

Touching or inserting the active electrode into the skin → tissue destruction

361
Q

Electrofulgeration

A

Holding the electrode a short distance from the skin → in “sparking” and a more shallow level of tissue destruction than directly touching the lesion with the tip

362
Q

Epilation

A

Inserting a fine-wire electrode into a hair follicle destroys the follicle

363
Q

Electrocoagulation

A

Stops bleeding in deep and superficial surgery

364
Q

Electrosection

A

The electrode is used to cut tissue

365
Q

thermal cautery pen

A
  • Disposable – battery powered (1300 and 2200 degree F units)
  • Low cost – $15-20
  • Individual sterile packaging
  • Safe around eyes
  • Safe with pacemakers
  • Drain subungual hematomas!
  • Control bleeding; “cut” off lesions
366
Q

Hyfrecator unit

A
  • Performs both electrofulguration and electrodessication
  • Available accessories:
    • blunt/sharp disposable/reusable tips
    • epilator needle
367
Q

Radiosurgery

A
  • Surgitron radio-frequency unit by Ellman
  • Available accessories:
    • non-disposable and disposable loop & ball electrodes
    • epilator needle tip)
368
Q

Pros of electrosurgery

A

Simple to master
Rapid technique
Controls bleeding while cutting/destroying tissue
Compact equipment
Affordable – available “used”
Sterile conditions and sutures are not needed.
Infection rarely develops in wounds left open.

369
Q

cons of electrosurgery

A

Safety risk (electric shocks, burns, or fires) – e.g. may ignite alcohol on the skin
Risk of hypertrophic scars
Risk of “channeling” of current down vessels and nerves
Risk of smoke plume carrying viruses (e.g. from wart) into respiratory tract.
Delayed hemorrhage while healing
Unsightly wound (initially)
Slow healing vs. scalpel shave excisions = essentially is a “burn”
Biopsies - Hyfrecator (not radiosurgery):
Produces electrosurgical artifact at margins → obliteration of histology
Do shave biopsy first if needed

370
Q

Cryotherapy over Electrosurgery

A

Often the treatment of choice for actinic keratosis and simple warts
Faster and easier to perform
Needs no anesthesia
Tends to cause less scarring than electrosurgery
No smoke plume:
- No need for a smoke evacuator
- No risk of developing HPV, HIV or other viral respiratory tract infections

371
Q

Electrosurgery over Cryotherapy

A

More likely to cause hypopigmentation due to the cold killing melanocytes – varies with degree of skin pigmentation
Less effective than electrosurgery for large pedunculated lesions, e.g. condylomata.
Final result not immediately visible:
- More guesswork in treating the lesion for the inexperienced physician
- May need to be repeated several times
Causes more postoperative swelling
Does cause transient discomfort

372
Q

Scalpel over Electrosurgery

A

Best for shave biopsies and excisions
Inexpensive vs. electrosurgery and radiosurgery devices
Disposable
“Cleaner” edge on the biopsy specimen
No heat-induced tissue damage to obscure borders of the biopsy specimen

373
Q

Electrosurgery over Scalpel

A

Does not control bleeding by itself

Small risk of accidentally cutting yourself

374
Q

Electrosurgery over Lasers

A

less expensive
easier to use

375
Q

Laser over Electrosurgery

A

Very good for treating large hemangiomas
Ideal for treating port-wine stains
Efficiently cut, coagulate and destroy lesions
Good for “resurfacing” (removing wrinkles
Less scarring when treating angiomas and telangiectasias
better cosmetic results

376
Q

electrosurgery CI

A

pacemakers
metal plates, pins, or prosthetic joints
suspected melanoma or BCC- need to biopsy
don’t use around nose, eye, body folds

377
Q

Cautions electrosurgery

A

alcohol
fire and burns
bowel gas
use three pronged plug
Do not make or break contact with the patient with your free hand while the electrode is activated
no metal

378
Q

Reduce problems with elctrogsurgery

A

Always wear gloves.
Use disposable electrodes (OR remove the charred tissue from the electrode after use and sterilize properly).
Use disposable safety needles with Luer Lok syringes.
Use smoke evacuator – hold intake nozzle 2 cm from the operative site
Surgeon and treatment team should wear eye protection (and ideally, surgical masks)
Consider using a different treatment modality – weigh risk vs. benefits

379
Q

Radiosurgery

A

Uses a high frequency AM radio spectrum current
Uses an antenna as the “indifferent” electrode applied to the skin on opposite side of the body part
Three to four times the initial cost of the hyfrecator
More efficient cutting than the hyfrecator with less tissue damage (due to less “lateral heat”*).
The unit has 4 different waveforms
- Fully filtered and rectified current - for cutting.
- Fully rectified current - for simultaneous cutting/coagulation.
- Partially rectified current - for coagulation
- Fulgurating current - for destruction of large lesions, similar to the Hyfrecator

380
Q

Radiosurgery uses

A

Hemangiomas
Xanthelasma
Spider Veins
Dermatofibromas
Congenital Compound Melanocystic Nevi
Resistant Deep Verruca
Sebaceous Hyperplasia
Thick Seborrheic Keratosis
Porokeratosis

381
Q

How radiosurgery works?

A

The intercellular water molecules in the cells are vaporized. The affected cells explode with little or no damage to the adjacent cells, there is only a 10-20 µ of heat spread.
As it cuts, it coagulates saving operation time.

382
Q

Radiosurgery benefits

A

hemorrhage Control
reduced post-operative discomfort
minimal scar tissue formation
readability of histological specimen
enhanced healing
good cosmetic results

383
Q

Medications to stop before surgery

A
  • aspirin
  • Alka-Seltzer
  • ibuprofen
  • clopidogrel
  • warfarin
  • fish oil
  • gingko biloba
  • garlic
  • ginseng
  • ginger
  • feverfew
  • Vit E
  • Saw palmetto
384
Q

Ecchymoses

A

blood leaks into the skin and often into the subcutaneous fat
swollen bluish black discoloration of the skin
in and around or dependent to the wound or hematoma
develop during surgery or at the time of trauma or over hours to days later

385
Q

Ecchymoses treatment/prevention

A
  • Carefully surgery and repair
  • Don’t use too much local anesthesia
  • Apply proper pressure bandaging f
  • ice packs for 2-3 days
  • Spontaneously resolve
386
Q

Hematomas

A

localized collection of blood outside of the blood vessels, typically in dead space

deep purple, grape jelly-like nodule

387
Q

hematomas cause

A
  • post-op sustained capillary bed leakage
  • or venous/arterial bleeding from the raw surface of a surgical site or within a traumatic lesion
388
Q

hematomas timing

A
  • develop hours to days after surgery or trauma
  • typically resolve naturally in days to weeks
389
Q

Hematomas prevention

A
  • Assess each patient’s general health status and history of coagulopathies
  • Identify any history of significant bleeding during prior low-risk surgical or dental procedures.
  • Identify common medical problems that may affect healing – renal dysfunction, hypertension, liver disease, and abnormal coagulation
  • Screen for alcohol abuse – impairs coagulation of platelets and decreases vasoconstriction
  • Identify all daily and prn medications and the last date taken.
390
Q

Hematomas management

A

Intraoperative steps
- use figure-of-8 sutures or suture ligation
- quilting sutures (interrupted deep stitches)

Post-op management
- Pressure bandaging – for 24 hours post-op/repair hold in place 2 twice-folded 4x4s with a pressure bandage of hypo-allergenic paper tape or elastic wrap such as Coban.
- Apply ice packs over the dressing for 20 minutes every hour for six hours

Patient instruction
- Examine wound frequently
- Monitor for a warm, expanding, painful mass:
possible collection of blood and/or tissue fluid
&/or sign of an infection.
- If such a swelling appears apply an ice pack and pressure to the area continuously for 20 minutes.
- Re-examine in 30-60 minutes and re-apply if needed.
- If problem lasts more than 12 hours call or return to clinic – follow up visits are FREE
- The physician will examine the wound site to determine if there is a collection of blood or tissue fluid that needs to be removed/drained.

391
Q

Hematomas treatment

A
  • Partially or completely re-open the surgical wound
  • Identify any oozing vessels
  • Stop bleeding by suture ligation or electrosurgery
  • Insert a drain/suction if indicated
  • Do a full-layer re-closure
  • If there is a high risk of more bleeding or the wound is contaminated the best choice may be to let the wound heal by secondary intention!
  • Aspirate with sterile procedure – use large needle directly through the wound
  • Repeat every 1–2 days until hematoma stops forming
  • Continue using pressure bandaging
  • Get C & S of aspirate
  • Begin empiric antibiotic treatment and adjust based on C & S reports
392
Q

Seromas

A

a mass caused by accumulation of serous fluid within tissue or an organ as a complication of surgery or after other traumatic injuries to soft tissues, low infection risk,

393
Q

Seroma formation

A
  • small blood vessels rupture → blood plasma seeps out
  • trauma causes tissue fluid leakage that does not fully subside
  • inflammation caused by dying injured cells
  • particularly common after major surgeries – breast, abdominal and reconstructive surgeries
394
Q

Seromas prevention

A
  • Careful tissue handling to reduce trauma
  • Thorough wound irrigation and debridement
  • Quilting (interrupted deep stitches) in a large wound
    to reduce dead space → reduced seroma formation.
  • Pressure bandaging to reduce fluid collection
395
Q

Seromas management

A
  • Most resolve spontaneously within days to weeks.
  • Avoid blood-thinning analgesics!
  • Consider homeopathic Bryonia, Silica and Sepia to reduce pain/itching and speed healing.
  • Rest/elevate affected part.
  • Intermittent ice packs
  • In a few days use alternating hot/cold to help speed resorption.
  • If persists consider fine-needle aspiration
396
Q

Does prophylaxis with antibiotics for routine or elective MS generally lower the risk of infection?

A

no

397
Q

Prophylactic antibiotics are indicated in patients with traumatic wounds in what three situations?

A
  • prosthetic cardiac valve
  • history of infectious endocardiits
  • congenital heart disease
398
Q

What are the arguments against using antibiotics in traumatic wounds?

A
  • Limited indications for the routine use of antibiotics in lacerations.
  • A single reliable study showing an advantage to prophylactic oral penicillin for intraoral wounds.
  • Clean, properly debrided early traumatic wounds in patients that are not immune compromised do not require prophylactic antibiotics.
399
Q

Seroma treatment

A

fine needle aspiration
-Consider aspiration only for excessive amounts of fluid collection because even an aspiration carried out under aseptic conditions carries a certain risk of infection!

400
Q

Wound dehiscence cause

A
  • Too much tension on newly sutured tissue – damages the tissue, and interferes with circulation and healing
  • Too little tension – wound edges too loosely apposed to allow proper healing
  • Inappropriate suture material (wrong size or material) → breakage and/or a tissue reaction.
  • Poor tissue quality (poor nutritional status, chronic disease, chemotherapy, etc.) → tissue failure and poor healing.
401
Q

Wound dehiscence tx

A
  • leave it alone
  • re-closure
  • retention sutures
402
Q

Nerve and Vascular Damage prevention

A

always use a blunt undermining tools
always assess sensation and vascular integrity in traumatic wounds
- two-point discrimination
- capillary refill

403
Q

tendon and bone damage

A

test active and passive ROMs
If there is anything more than a simple laceration and if you suspect a lacerated tendon and/or fracture, apply an appropriate splint and immediately refer to a hand specialist or orthopedist!

404
Q

Hyper/Hypopigmentation

A

caused by hyfrecation, radiosurgery, lift and snips, shaves, or cryotherapy
1-6 month will be pink then gradually go back to facial color
Treatment: hydroquinone

405
Q

Hypertrophic scarring

A

enlargement of the scar within the boundary of the original scar

406
Q

Keloid scaring

A

enlargement of the scar beyond the original scar boundary

407
Q

Hypertrophic and Keloid scarring cause

A

genetics
body site (esp. upper chest, back, shoulders)
quality of the surgery
skin tension (worse with more tension)
skin types
the patient’s health status at the time

408
Q

Informed consent implies that the patient completely understands what issues?

A

make them aware of risks
The nature of the treatment
All material risks for the treatment
The possibility of risk(s)
Alternative treatment(s) available and associated risks of those treatments
Consequences of going untreated

409
Q

Know the meaning of PARQ and how to use it for “informed consent”.

A

Procedure
Alternatives
Risks
Questions

410
Q

Know what/what not to include in the Procedure Note portion of the MS Report.

A

history
vitals
description of lesion
what procedure
anesthetic used and lot
Describe the skin prep used, record the amounts of anesthesia and bicarbonate mixed & used.
Describe the suture type(s) , size(s), location, and number.
List the duration of the procedure and the amount of blood lost.

411
Q

Understand the concept of “free margin” on a Pathology report.

A

means the edges around the biopsied portion are clear of pathology?

412
Q

Vertical mattress advantages

A

better than other stitches
helps to close a large area of dead space in a wound
strong stich
use as a stay suture

413
Q

Horizontal mattress uses

A

wound under tension
fill up dead space

414
Q

run and run locking stich

A

convenient
good approximation of wound edges
good eversion proper tension
faster
valuable on eyelids and neck and other aras where loose skin is found
watertight seal
gathering loose skin

415
Q

Vertical mattress suture disadvantage

A

proper placement is time consuming
can cause railroad tracking

416
Q

acne vulgaris pop

A

12-25

417
Q

acne vulgaris pathophysiology

A

Outlet narrows due to proliferation and accumulation of keratinocytes and skin edema

Sebum (composed of lipids and cell fragments) builds up in blocked follicle

Cutibacterium acnes(formerly Propionibacteriumacnes) lives off sebum and proliferates in comedone

Inflammation of comedone results from leakage of sebum into the dermis and secretion of proinflammatory mediators, chemokines, and degradative enzymes by C. acnes

418
Q

acne sx

A

papules or pustules or nodules or cysts red and central core
face, trunk, arms, back, upper chest, shoulders

419
Q

acne tx standard of car based on severity

A
420
Q

acne tx ND

A

Diet: 100% grass fed pastured or wild meats, fish and eggs, vegetables, fruit, nuts, seeds, and tubers
Eliminate/reduce processed foods, diary, grain fed meat, chocolate, sunflower seeds, salt
Anti-inflammatory/elimination diet
Detox: fasting, sauna, chelation
Botanical (Topicals): azelaic acid, green tea, tea tree oil,
Calendula succus
Botanical (Internal): Berberine (barbarry, coptis, oregon grape, goldenseal), Chasteberry, Indian Gooseberry
Physical medicine: sun (start with 5 minutes a day), hot/cold contrast bath with green tea, calendula
Supplements to consider zinc/copper, chromium, selenium, omega 3 fatty acids, vitamin D

421
Q

alteratives

A

An herb that alters the body in a non-specific but broadly beneficial way
Nourishing, restorative tonics with effects focused on digestion, absorption, and elimination

422
Q

alteratives herbs

A

arctium lappa
curcma longa
mahonia spp
rumex spp
smilax spp
taraxacum officinale
trifolium pratense
urtica dioica

423
Q

Mahonia part used

A

Root bark and stem bark

424
Q

mahonia action

A

Alterative, digestive bitter, anticatarrhal, antimicrobial, cholagogue, mild laxative.

425
Q

mahonia indications

A

Skin conditions:
Psoriasis, eczema, herpes, pityriasis, acne, syphilis.

Poor gallbladder function: Nausea, fat malabsorption, digestive upset

Infections:
Skin, eye, and intestinal tract (bacterial, fungal and protozoal)

426
Q

mahonia CI

A

pregnancy

427
Q

rumex part used

A

Root (primarily) also the seed and leaf

428
Q

rumex actions

A

Root: alterative, mild digestive bitter, antitumor, antimutagenic, nutritive, antirheumatic, phytoestrogenic, liver tonic
Leaves: used topically as a antimicrobial, anti-inflammatory poultice
Seeds: alterative, diuretic, urinary tonic, vulnerary
Cholagogue

429
Q

rumex indications

A

Root: dry and scaly skin conditions – psoriasis, eczema, dandruff, rheumatic/arthritic conditions, anorexia nervosa, cystitis, wounds and ulcers (poultice).
Leaves: mastitis, joint sprains (poultice), alleviate nettle stings
Seeds: cystitis, skin conditions including exanthems
Chronic skin conditions - psoriasis, eczema, acne
Lax bowels, constipation – regulates the GI (Bitter! Enhance digestion, pro motility, tonifying/astringent)
Liver congestion

430
Q

rumex CI

A

Oxalate kidney stones, kidney disease, iron overload, pregnancy

431
Q

trifolum part used

A

blossom

432
Q

trifolium actions

A

Alterative, Nutritive,high in phytoestrogens, lymphagogue, Antitussive, Antispasmodic, Vulnerary

433
Q

trifolum indications

A

menopausal climacteric symptoms, vaginal dryness, chronic skin conditions, Breast cancer estrogen positive

Lots of heat

Cancer, gout, arthritis, acne, spasmodic cough, cachexia, burns with poor healing, ulcers of the skin or mucous membranes, TB or inflammation of the lungs

434
Q

trifolium CI

A

Caution with blood thinning medications and oral contraceptives

435
Q

anti-inflammatory/antioxidant herbs

A

berberis vulgaris
camelia sinensis
silybum marianum

436
Q

berberis part used

A

Berries, Rhizome and Root

437
Q

berberis actions

A

Berries – antioxidant, modulates inflammation.
Rhizome and root – also modulate inflammation, effects glucose metabolism, antimicrobial

438
Q

berberis indications

A

Berries – effective in the treatment of acne as well as other inflammatory conditions.
Rhizome and root – source of berberine and uses relate to that constituent.

439
Q

camelia part used

A

leaf

440
Q

camelia actions

A

Antioxidant, inhibit tumor cell proliferation and induce apoptosis, pro-oxidant, promotes weight loss, decreases LDL, modulates inflammation, decreases sebum production, antimicrobial resistance

441
Q

camelia MOA

A

inhibition of MAP kinase signaling, inhibition of growth factor signaling, inhibition of matrix metalloproteinases, inhibit angiogenesis, decrease invasiveness of cancer cells, augments hormonal therapies, decreases free testosterone, increases SHBG, decreases insulin resistance and improves other glucose-related markers

442
Q

camelia indications

A

Cancer, PCOS (particularly in overweight individuals), androgenic alopecia, anti-aging

  • Used topically in the treatment of acne vulgaris and rosacea
  • UV protection and decreased photocarcinogenesis
  • Decrease age-related damage/changes
  • Used topically for Condyloma accuminata
  • Atopic dermatitis – baths decreased pruritis and area of lesions.
  • Decrease hypertrophic scar formation
  • vulnerary action in wound healing
  • Topical antimicrobial
443
Q

camelia CI

A

Take away from iron supplementation green tea block the activity of boronic acid proteasome inhibitors

444
Q

silybum part

A

seed

445
Q

silybum actions

A

hepatoprotective, hepatotonic, antihepatotoxic (particularly against aminita phalloides), nephroprotective, bitter, galactagogue, antifibrotic effect,

Increase glutathione

446
Q

silybum indications

A

Liver diseases, jaundice, hepatitis, cirrhosis, alcoholism, fatty liver degeneration, hepatitis, cirrhosis, alcoholism with fatty liver, diabetic nephropathy

Acne

447
Q

silybum CI

A

asteraceae family allergy

448
Q

astringents herbs

A

arctostaphylos uva-ursi
black tea

449
Q

arctostaphylos part

A

leaves

450
Q

arctostaphylos actions

A

Antimicrobial, astringent, tonify

451
Q

arctostaphylos indications

A

UTIs

Relaxed urinary tract (tissue laxity), with pain and bloody or mucous secretions; weight and dragging in the loins and perineum not due to prostatic enlargement; chronic irritation of the bladder, with pain, tenesmus, and catarrhal discharge.

Oozing tissues

452
Q

arctostaphylos CI

A

Pregnancy

Not recommended for long term use (due to high tannins) anti-nutrient

Toxicity is proportional to the conversion of arbutin to hydroquinone as hydroquinone is potentially toxic and mutagenic

Caution when combining with herbs high in alkaloids as the tannin may precipitate out of solution. The precipitate is active, but it settles to the bottom of the bottle – shake well!

453
Q

immunostimulants

A

agents that increase the activity of immune system, used to fortify the body’s response to invasion by a pathogen

MOA: increased phagocytosis, increased production of WBC, and modulation of various cytokines

454
Q

immunostimulants herbs

A

allium sativum
baptisia tinctora
echinacea
eupatorium perfoliatum
sambucus nigra
scutellaria bicalensis
spilanthes acmlla
usnea barbata

455
Q

immunomodulators

A

agents that have a tonifying effect on immune system

456
Q

eleuthrococcus part used

A

Root (most researched), stem bark and leaf

457
Q

eleuthrococcus actions

A

Adaptogen, immunomodulating, mild CNS stimulant
Nonspecific ant stress effects
Ergogenic
Anabolic/anticatabolic
Antitoxic
Radioprotective
Chemoprotective
Immunoprotected
Immunoregulatory
Antiviral
Gonadotrophic
Insulin-trophic/antidiabetic
Neuroprotective

458
Q

eleuthrococcus indications

A

Build vitality, increase resistance to infection, stress, and toxicity, improve physical performance, and improve mood

459
Q

eleuthrococcus CI

A

Adulteration is common in the marketplace. Monitor blood glucose in diabetics and hypoglycemics when introducing this herb.

460
Q

ganoderma part

A

fruiting body

461
Q

ganoderma action

A

Anti-allergic action of triterpenes, anti-hypertensive, oleic acid inhibits histamine release, hypotensive, decreases platelet aggregation/LDL/arrhythmia/insomnia/angina, protects against ionizing radiation

462
Q

ganoderma indications

A

Used in cancer treatment to increase immune function and help treat fatigue, hypertension, immune deficiency, insomnia, hepatitis

463
Q

ganoderma CI

A

Potential allergy to spores

Dermatology (11 decks)

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