Test 2

Question 1

basal cell carcinoma pop

Answer 1

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

Question 2

basal cell carcinoma pathophysiology

Answer 2

sun exposure low vegetable and fruit intake

Question 3

Basal Cell Carcinoma RF

Answer 3

• 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

Question 4

Basal cell carcinoma location

Answer 4

• ears
• face
• neck

Question 5

what is the most common BCC?

Answer 5

nodular

Question 6

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

Answer 6

nodular BCC

Question 7

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

Answer 7

pigmented BCC

Question 8

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

Answer 8

micronodular BCC

Question 9

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

Answer 9

morpheaform BCC

Question 10

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

Answer 10

superficial BBC

Question 11

BCC complication

Answer 11

• death
• hemorrhage of eroded large vessels
• meningitis

Question 12

TX nodular BCC

Answer 12

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

Question 13

superficial BCC tx

Answer 13

topical tazarotene
photodynamic therapy
topical 5-Fluorouracil and imiquimod

Question 14

Tx Morpheaform BCC

Answer 14

wide excision
Mohs micrographic surgery
Curaderm
black salves

Question 15

Squamous Cell Carcinoma pop

Answer 15

older, white

Question 16

SCC RF

Answer 16

• 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

Question 17

SSC sx

Answer 17

• 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

Question 18

Bowen’s disease SCC

Answer 18

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

Question 19

Erythroplasia of Queyrat

Answer 19

• Well-defined, velvety, red plaque
• Pain
• Bleeding
• Pruritus
• penis

Question 20

• Asymptomatic
• Painful or pruritic

Answer 20

Invasive SCC

Question 21

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

Answer 21

Well differentiated SSC

Question 22

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

Answer 22

Poorly differentiated SCC

Question 23

Tx Localized SCC

Answer 23

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

Question 24

Prevention SCC

Answer 24

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

Question 25

Answer 25

SCC

Question 26

Answer 26

BCC

Question 27

Keratoacanthoma pop

Answer 27

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

Question 28

Keratoacanthoma Pathophysiology

Answer 28

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

Question 29

Keratoacanthoma sx

Answer 29

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

Question 30

Keratoacanthoma tx

Answer 30

surgical excision

Question 31

Answer 31

Keratoacanthoma

Question 32

Melanoma pop

Answer 32

- men - whites

Question 33

Melanoma cause

Answer 33

increased UVA exposure and decreased cutaneous Vitamin D3 levels

Question 34

Melanoma RF

Answer 34

- 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

Question 35

Melanoma growth pattern

Answer 35

- growth phase - horizontal phase - spread out horizontally and can be confined to the epidermis - vertical - infiltrate deep into the dermis quickly

Question 36

- 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

Answer 36

superficial spreading melanoma

Question 37

Answer 37

superficial spreading melanoma

Question 38

- 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

Answer 38

nodular melanoma

Question 39

Answer 39

nodular melanoma

Question 40

Answer 40

Lentigo maligna melanoma

Question 41

Answer 41

Acral lentiginous melanoma

Question 42

- 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

Answer 42

acral lentiginous melanoma

Question 43

- 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

Answer 43

lentigo maligna melanoma

Question 44

hutchinson's sign

Answer 44

acral lentiginous

Question 45

melanoma dx

Answer 45

- 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

Question 46

melanoma complication

Answer 46

- death - metastasis

Question 47

melanoma tx

Answer 47

- 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,

Question 48

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

Answer 48

low

Question 49

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

Answer 49

T

Question 50

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.

Answer 50

5-10

Question 51

A lesion on the vermillion border is ___ until prove

Answer 51

SCC

Question 52

which is more likely to metastasize? SCC or BCC

Answer 52

SCC

Question 53

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

Answer 53

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

Question 54

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

Answer 54

100

Question 55

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

Answer 55

40

Question 56

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

Answer 56

sun

Question 57

intermittent, intense sun exposure decrease BCC T or F

Answer 57

F

Question 58

rodent ulcer

Answer 58

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

Question 59

morpheaform BCC have borders that are easily localized T or F

Answer 59

F

Question 60

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

Answer 60

t

Question 61

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

Answer 61

f

Question 62

Why would one chose radiation therapy to treat a BCC?

Answer 62

not candidates for surgery

Question 63

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

Answer 63

size, depth, and irregular border

Question 64

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

Answer 64

T

Question 65

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

Answer 65

6

Question 66

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

Answer 66

>50

Question 67

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

Answer 67

intermittent exposure sunburn

Question 68

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

Answer 68

horizontal phase

Question 69

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

Answer 69

horizontal; vertical

Question 70

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

Answer 70

1

Question 71

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

Answer 71

2

Question 72

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

Answer 72

1

Question 73

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.

Answer 73

acral lentiginous Melanoma

Question 74

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

Answer 74

sun exposure

Question 75

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

Answer 75

92%

Question 76

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

Answer 76

excision

Question 77

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.

Answer 77

mohs

Question 78

SCC TX

Answer 78

oral vitamin A

Question 79

oral SCC

Answer 79

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

Question 80

Verrucous carcinoma SCC

Answer 80

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

Question 81

SCC on lip

Answer 81

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

Question 82

ELECTRODESICCATION & CURETTAGE advantage

Answer 82

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

Question 83

Disadvantages of ED & C

Answer 83

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

Question 84

surgical excision advantages

Answer 84

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

Question 85

Disadvantages of Surgical Excision

Answer 85

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

Question 86

Advantages of Mohs

Answer 86

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

Question 87

Disadvantages of Mohs

Answer 87

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

Question 88

Advantages of Cryotherapy

Answer 88

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

Question 89

Disadvantages of Cryotherapy

Answer 89

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.

Question 90

TOPICAL 5-FLUOROURACIL AND IMIQUIMOD advantages

Answer 90

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

Question 91

TOPICAL 5-FLUOROURACIL AND IMIQUIMOD disadvantages

Answer 91

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!)

Question 92

radiation therapy advantages

Answer 92

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

Question 93

digit block or nerve block

Answer 93

- 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

Question 94

alteratives

Answer 94

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

Question 95

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

Answer 95

Trifolium pratense actions

Question 96

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

Answer 96

Trifolium pratense indications

Question 97

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

Answer 97

Trifolium pratense MOA

Question 98

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

Answer 98

Rumex spp actions

Question 99

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

Answer 99

Rumex spp MOA

Question 100

**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

Answer 100

Rumex spp indications

Question 101

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.

Answer 101

Rumex spp CI

Question 102

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

Answer 102

Mahonia spp actions

Question 103

lipoxygenase inhibition and lipid antioxidant properties

Answer 103

Mahonia spp moa

Question 104

**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)

Answer 104

Mahonia spp indication

Question 105

Mahonia spp CI

Answer 105

pregnancy

Question 106

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

Answer 106

Camelia sinensis action

Question 107

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

Answer 107

Camelia sinensis moa

Question 108

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

Answer 108

Camelia sinensis indication

Question 109

Camelia sinensis CI

Answer 109

Take away from iron supplementation

Question 110

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

Answer 110

Berberis vulgaris action

Question 111

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.

Answer 111

Berberis vulgaris indication

Question 112

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

Answer 112

Silybum marianum action

Question 113

increased GSH levels, decreased MDA and IL-8

Answer 113

Silybum marianum MOA

Question 114

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

Answer 114

Silybum marianum indication

Question 115

Silybum marianum CI

Answer 115

Speculative - asteraceae family allergy

Question 116

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

Answer 116

Eleutherococcus senticosis Energetics

Question 117

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

Answer 117

Eleutherococcus senticosis action

Question 118

reduced frequency of HSV,

Answer 118

Eleutherococcus senticosis moa

Question 119

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

Answer 119

Eleutherococcus senticosis indication

Question 120

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

Answer 120

Eleutherococcus senticosis CI

Question 121

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

Answer 121

Ganoderma lucidum action

Question 122

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

Answer 122

Ganoderma lucidum indication

Question 123

Potential allergy to spores

Answer 123

Ganoderma lucidum ci

Question 124

Answer 124

Seborrheic keratosis

Question 125

Answer 125

Seborrheic keratosis

Question 126

Answer 126

Seborrheic keratosis

Question 127

Answer 127

milia

Question 128

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?

Answer 128

Actinic keratosis

Question 129

Answer 129

Meibomian cyst/Chalazion

Question 130

Answer 130

Digital mucous cyst

Question 131

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

Answer 131

Chrondrodermatitis nodularis helicis

Question 132

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

Answer 132

Chrondrodermatitis nodularis helicis

Question 133

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

Answer 133

Chrondrodermatitis nodularis helicis

Question 134

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

Answer 134

Syringoma

Question 135

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

Answer 135

Dermatofibroma

Question 136

Answer 136

Seborrheic keratosis

Question 137

Answer 137

Ganglion cyst

Question 138

Answer 138

Lipoma

Question 139

Answer 139

Basal cell carcinoma

Question 140

Answer 140

Seborrheic keratosis

Question 141

Answer 141

Sebaceous hyperplasia

Question 142

Answer 142

actinic keratosis

Question 143

Answer 143

Actinic keratosis

Question 144

Answer 144

Chrondrodermatitis nodularis helicis

Question 145

Answer 145

Basal cell carcinoma

Question 146

Answer 146

Dermatosis Papulosa Nigra

Question 147

Answer 147

Skin tag acrochordon

Question 148

Answer 148

Skin tag acrochordon

Question 149

Answer 149

Skin tag acrochordon

Question 150

Answer 150

Epidermal inclusion cyst

Question 151

Answer 151

Epidermal inclusion cyst

Question 152

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

Answer 152

Atypical or dysplastic nevi

Question 153

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

Answer 153

Atypical or dysplastic nevi

Question 154

Answer 154

Dermatofibroma

Question 155

Answer 155

Dermatofibroma

Question 156

Answer 156

Junctional nevi

Question 157

Solitary lesions are: infrequent inconsequential represent spontaneous mutations These lesions characteristically, on compression, invaginate into a slit-like defect in the skin = “buttonhole” sign.

Answer 157

Neurofibroma type 1

Question 158

Solitary lesions are: infrequent inconsequential represent spontaneous mutations These lesions characteristically, on compression, invaginate into a slit-like defect in the skin = “buttonhole” sign.

Answer 158

Neurofibroma type 1

Question 159

Answer 159

BCC

Question 160

Answer 160

BCC

Question 161

Answer 161

BCC

Question 162

Answer 162

Dermal nevi

Question 163

Answer 163

Dermal nevi

Question 164

Answer 164

Ganglion cyst

Question 165

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

Answer 165

Lipoma

Question 166

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

Answer 166

Hypertrophic scar or keloid

Question 167

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

Answer 167

Hypertrophic scar or keloid

Question 168

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

Answer 168

Hypertrophic scar or keloid

Question 169

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

Answer 169

Hypertrophic scar or keloid

Question 170

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

Answer 170

Hypertrophic scar or keloid

Question 171

Answer 171

Skin tag

Question 172

Answer 172

Digital mucous cyst

Question 173

Alopecia areata cause

Answer 173

autoimmune disease hashimoto’s thyroiditis vitiligo myasthenia gravis

Question 174

Alopecia areata sx

Answer 174

loss of hair that is asymptomatic exclamation point hairs

Question 175

Alopecia areata TX

Answer 175

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

Question 176

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.

Answer 176

Vitiligo

Question 177

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.

Answer 177

Vitiligo

Question 178

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

Answer 178

actinic keratosis

Question 179

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

Answer 179

melasma

Question 180

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

Answer 180

melasma

Question 181

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

Answer 181

hemangiomas

Question 182

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

Answer 182

hemangiomas

Question 183

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

Answer 183

hemangiomas

Question 184

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)

Answer 184

SCC

Question 185

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)

Answer 185

SCC

Question 186

Answer 186

nodular melanoma

Question 187

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

Answer 187

actinic keratosis

Question 188

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

Answer 188

lentigo maligna melanoma

Question 189

Hutchinson’s sign Periungual spread from nail

Answer 189

acral lentiginous melanomas

Question 190

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

Answer 190

SSC

Question 191

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

Answer 191

SSC

Question 192

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

Answer 192

alopecia areata

Question 193

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

Answer 193

alopecia areata

Question 194

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

Answer 194

alopecia areata

Question 195

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

Answer 195

actinic keratosis

Question 196

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

Answer 196

actinic keratosis

Question 197

management: gluten free diet, dipsone,

Answer 197

Dermatitis herpetiformis

Question 198

Answer 198

Dermatitis herpetiformis

Question 199

Answer 199

Storke bite lesion

Question 200

Answer 200

nodular BCC

Question 201

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

Answer 201

Melasma

Question 202

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

Answer 202

Melasma

Question 203

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

Answer 203

nodular melanoma

Question 204

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

Answer 204

nodular melanoma

Question 205

photodynamic therapy

Answer 205

actinic keratosis

Question 206

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

Answer 206

Keratoacanthoma

Question 207

Treated 5-FU or Curaderm identify

Answer 207

superficial BCC

Question 208

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

Answer 208

hemangioma deep cavernous

Question 209

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

Answer 209

hemangioma deep cavernous

Question 210

Answer 210

Vascular malformation/port wine stain

Question 211

Answer 211

Vascular malformation/port wine stain

Question 212

Answer 212

Vascular malformation/port wine stain

Question 213

asymptomatic, soft benign papule, from dilated venule

Answer 213

venous lake

Question 214

Develops after a minor trauma Bleeds easily <30 years old

Answer 214

pyogenic granuloma

Question 215

Develops after a minor trauma Bleeds easily <30 years old

Answer 215

pyogenic granuloma

Question 216

Answer 216

spider angioma

Question 217

Answer 217

spider angioma

Question 218

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

Answer 218

actinic keratosis

Question 219

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

Answer 219

actinic keratosis

Question 220

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

Answer 220

acne

Question 221

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

Answer 221

acne

Question 222

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.

Answer 222

hyperpigmentation syndrome

Question 223

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

Answer 223

urticaria

Question 224

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

Answer 224

urticaria

Question 225

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

Answer 225

dermatitis herpetiformis

Question 226

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)

Answer 226

Acanthosis Nigricans

Question 227

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)

Answer 227

acanthosis nigricans

Question 228

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)

Answer 228

Acanthosis Nigricans

Question 229

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

Answer 229

solar lentigo

Question 230

Dermatitis Heprtiformis pathophysiology

Answer 230

celiac disease

Question 231

Dermatitis Heprtiformis population

Answer 231

20-60 yo Caucasians M

Question 232

Dermatitis Heprtiformis Sx

Answer 232

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

Question 233

Dermatitis Heprtiformis TX

Answer 233

gluten free diet dapsone sulfapyridine

Question 234

Acanthosis Nigrican cause

Answer 234

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

Question 235

Acanthosis Nigrican sx

Answer 235

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

Question 236

Acanthosis Nigrican Tx

Answer 236

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 topical urea, salicylic acid, glycolic acid peels, and laser therapy

Question 237

Melasma pop

Answer 237

young age, female, darker skin types

Question 238

Melasma cause

Answer 238

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

Question 239

Melasma sx

Answer 239

Irregular blotchy patches of hyperpigmentation on the face

Question 240

Melasma DX

Answer 240

insulin glucose

Question 241

Melasma TX

Answer 241

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

Question 242

Postinflammatory hyperpigmentation cause

Answer 242

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.

Question 243

Postinflammatory hyperpigmentation TX

Answer 243

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

Question 244

Solar Lenitgo cause

Answer 244

Localized proliferation of melanocytes due to chronic sun exposure

Question 245

Solar Lenitgo pop

Answer 245

>40, Type I to III skin

Question 246

Solar Lenitgo sx

Answer 246

1-3 cm macules, brown

Question 247

Solar Lenitgo dx

Answer 247

punch biopsy shave

Question 248

Solar Lenitgo tx

Answer 248

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

Question 249

Vitiligo pop

Answer 249

any race, 10-30

Question 250

Vitiligo cause

Answer 250

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

Question 251

Vitiligo sx

Answer 251

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

Question 252

Vitiligo tx

Answer 252

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

Question 253

urticaria cause

Answer 253

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

Question 254

urticaria sx

Answer 254

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

Question 255

urticaria dx

Answer 255

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

Question 256

urticaria tx

Answer 256

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)

Question 257

Hemangiomas pop

Answer 257

most common tumor in infancy

Question 258

Hemangiomas sx

Answer 258

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

Question 259

Hemangiomas TX

Answer 259

Spontaneous resolution surgery interferon propranolol intralesional and topical corticosteroids vincristine cyclophosphamide

Question 260

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

Answer 260

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

Question 261

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

Answer 261

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

Question 262

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

Answer 262

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

Question 263

Cherry Angioma pop

Answer 263

male and females begin around 30 years old

Question 264

Cherry Angioma cause

Answer 264

family history

Question 265

Cherry Angioma sx

Answer 265

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

Question 266

Cherry Angioma tx

Answer 266

radiosurgery shave excision laser electrodesiccation cryotherapy no treatment necessary

Question 267

Spider angioma pop

Answer 267

women

Question 268

Spider angioma cause

Answer 268

oral contraceptive, pregnancy and liver disease

Question 269

Spider angioma sx

Answer 269

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

Question 270

Spider angioma dx

Answer 270

diascopy

Question 271

Spider angioma tx

Answer 271

optional radio/electrosurgery laser pulsed dye laser

Question 272

Venous Lake pop

Answer 272

over 50 yo

Question 273

Venous Lake sx

Answer 273

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

Question 274

Venous Lake dx

Answer 274

put slide and the blood drains out

Question 275

Venous Lake tx

Answer 275

cosmetic electrosurgery laser excision

Question 276

Pyogenic Granuloma pop

Question 277

Pyogenic Granuloma pop

Answer 277

any age

Question 278

Pyogenic Granuloma cause

Answer 278

site of minor trauma

Question 279

Pyogenic Granuloma sx

Answer 279

recurrent bleeding red, dusky red, violaceous, brown/black head, neck, upper trunk and hands and feet

Question 280

Pyogenic Granuloma dx

Answer 280

rule out melanoma excision/biopsy

Question 281

Pyogenic Granuloma TX

Answer 281

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

Question 282

Benefits of epinephrine

Answer 282

- decreases bleeding - prolongs the duration of the anesthesia - minimize the amount of anesthesia

Question 283

Issues of epinephrine

Answer 283

- goes through breast milk - reduce uterine blood flow - induce premature labor - can cause gangrene or reduced blood flow

Question 284

Benefits of Sodium Bicarbonate

Answer 284

- reduction in infiltration - faster onset of action

Question 285

Cons of sodium bicarbonate

Answer 285

- chemically unstable - decrease the overall activity of epinephrine

Question 286

Drug interactions to epinephrine

Answer 286

- MAO inhibitors: hypertensive crisis - Carbamazepine and Cyclobenzaprine: potentiate effects - tricyclics and tetracycline antidepressants: hypertensive crisis and dysrhythmia - phenothiazines: profound hypotension

Question 287

allergy to anesthetics cause, sx, management

Answer 287

- 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

Question 288

topical anesthetics use and type

Answer 288

- mucous membranes - cocaine, tetracaine, lidocaine, phenylephrine +lidocaine or tetracaine

Question 289

local infiltration steps

Answer 289

- 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

Question 290

field block

Answer 290

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

Question 291

field block procedure

Answer 291

- 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

Question 292

anesthetics except cocaine are vasodilators T or F

Answer 292

T

Question 293

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

Answer 293

reduce the burning

Question 294

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

Answer 294

yes

Question 295

field block definitions

Answer 295

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.

Question 296

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

Answer 296

rapid onset less drug can be used

Question 297

What are the considerations when choosing an infiltration anesthetic?

Answer 297

the location allergy

Question 298

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

Answer 298

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

Question 299

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

Answer 299

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

Question 300

Langer's lines

Answer 300

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

Question 301

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

Answer 301

upper chest and back shoulders

Question 302

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

Answer 302

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

Question 303

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

Answer 303

survival

Question 304

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

Answer 304

5-6%

Question 305

inflammatory phase

Answer 305

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

Question 306

proliferative phase

Answer 306

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

Question 307

maturation phase

Answer 307

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

Question 308

clean wound

Answer 308

free from microorganisms

Question 309

clean-contaminated wound

Answer 309

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

Question 310

dirty/contaminated wound

Answer 310

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

Question 311

infected wounds

Answer 311

intense inflammatory reaction and frank infectious process

Question 312

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

Answer 312

no

Question 313

What are the four “Goals of Surgery”?

Answer 313

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.

Question 314

What factors involving the surgeon affect wound repair?

Answer 314

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

Question 315

What factors involving the patient affect wound repair?

Answer 315

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

Question 316

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

Answer 316

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

Question 317

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

Answer 317

Advantages: its simplicity relatively low risk of infection Disadvantages: may take forever to heal tends to cause larger scars

Question 318

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?

Answer 318

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

Question 319

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

Answer 319

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!

Question 320

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

Answer 320

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

Question 321

What are the other steps in laceration evaluation and treatment?

Answer 321

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.

Question 322

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.

Answer 322

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!

Question 323

What are particular concerns about palm wounds?

Answer 323

deep structures could be involved fracture

Question 324

tetanus immune globulin administration guidelines

Answer 324

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!)

Question 325

When a wound has a Foreign bodies?

Answer 325

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

Question 326

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

Answer 326

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

Question 327

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

Answer 327

T

Question 328

Cleaning wound steps

Answer 328

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

Question 329

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

Answer 329

T

Question 330

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

Answer 330

T

Question 331

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

Answer 331

T

Question 332

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

Answer 332

T

Question 333

Wound care steps

Answer 333

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

Question 334

Skin and hair preparation

Answer 334

avoid shaving clippers and scissors are okay

Question 335

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

Answer 335

F

Question 336

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

Answer 336

secondary intention or delayed closure

Question 337

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

Answer 337

T

Question 338

Name the 7 “Wound Closure Technique Basics”.

Answer 338

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

Question 339

Excision advantages

Answer 339

- 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

Question 340

Excision Disadvantages

Answer 340

- 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

Question 341

Lift and Snip procedure

Answer 341

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

Question 342

excision types

Answer 342

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

Question 343

Conditions used for excision

Answer 343

SK Nevi Skin tags Small lesions Malignancy

Question 344

Shave biopsy

Answer 344

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

Question 345

Punch biopsy

Answer 345

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.

Question 346

Scoop

Answer 346

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

Answer 347

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

Question 348

elliptical excision complications

Answer 348

dog ear created can't close wound wound dehiscence

Question 349

Steri strips benefits

Answer 349

- **Rapid, effortless application** - **Less pain and anxiety in kids** - **Less scarring** 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!**

Question 350

Steri strips

Answer 350

- 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.

Question 351

Surgical glue

Answer 351

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.

Question 352

surgical glue use

Answer 352

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

Question 353

surgical glue advantages

Answer 353

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.

Question 354

surgical glue caution

Answer 354

wounds must be dry. use in wounds that have low risk of infection. don’t use over joints or high friction areas.

Question 355

surgical glue results

Answer 355

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

Question 356

when can't you use steri strips or surgical glue

Answer 356

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

Question 357

Staples advantages

Answer 357

quick placement fewer infections lower tissue reaction

Question 358

staples cons

Answer 358

scarring

Question 359

Electrosurgery use

Answer 359

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)

Question 360

Electrodessication

Answer 360

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

Question 361

Electrofulgeration

Answer 361

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

Question 362

Epilation

Answer 362

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

Question 363

Electrocoagulation

Answer 363

Stops bleeding in deep and superficial surgery

Question 364

Electrosection

Answer 364

The electrode is used to cut tissue

Question 365

thermal cautery pen

Answer 365

- 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

Question 366

Hyfrecator unit

Answer 366

- Performs both electrofulguration and electrodessication - Available accessories: - blunt/sharp disposable/reusable tips - epilator needle

Question 367

Radiosurgery

Answer 367

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

Question 368

Pros of electrosurgery

Answer 368

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.

Question 369

cons of electrosurgery

Answer 369

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

Question 370

Cryotherapy over Electrosurgery

Answer 370

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

Question 371

Electrosurgery over Cryotherapy

Answer 371

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

Question 372

Scalpel over Electrosurgery

Answer 372

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

Question 373

Electrosurgery over Scalpel

Answer 373

Does not control bleeding by itself Small risk of accidentally cutting yourself

Question 374

Electrosurgery over Lasers

Answer 374

less expensive easier to use

Question 375

Laser over Electrosurgery

Answer 375

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

Question 376

electrosurgery CI

Answer 376

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

Question 377

Cautions electrosurgery

Answer 377

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

Question 378

Reduce problems with elctrogsurgery

Answer 378

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

Question 379

Radiosurgery

Answer 379

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

Question 380

Radiosurgery uses

Answer 380

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

Question 381

How radiosurgery works?

Answer 381

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.

Question 382

Radiosurgery benefits

Answer 382

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

Question 383

Medications to stop before surgery

Answer 383

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

Question 384

Ecchymoses

Answer 384

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

Question 385

Ecchymoses treatment/prevention

Answer 385

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

Question 386

Hematomas

Answer 386

localized collection of blood outside of the blood vessels, typically in dead space deep purple, grape jelly-like nodule

Question 387

hematomas cause

Answer 387

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

Question 388

hematomas timing

Answer 388

- develop hours to days after surgery or trauma - typically resolve naturally in days to weeks

Question 389

Hematomas prevention

Answer 389

- 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.

Question 390

Hematomas management

Answer 390

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.

Question 391

Hematomas treatment

Answer 391

- 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

Question 392

Seromas

Answer 392

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,

Question 393

Seroma formation

Answer 393

- 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

Question 394

Seromas prevention

Answer 394

- 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

Question 395

Seromas management

Answer 395

- 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

Question 396

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

Answer 396

no

Question 397

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

Answer 397

- prosthetic cardiac valve - history of infectious endocardiits - congenital heart disease

Question 398

What are the arguments against using antibiotics in traumatic wounds?

Answer 398

- 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.

Question 399

Seroma treatment

Answer 399

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!

Question 400

Wound dehiscence cause

Answer 400

- 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.

Question 401

Wound dehiscence tx

Answer 401

- leave it alone - re-closure - retention sutures

Question 402

Nerve and Vascular Damage prevention

Answer 402

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

Question 403

tendon and bone damage

Answer 403

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!

Question 404

Hyper/Hypopigmentation

Answer 404

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

Question 405

Hypertrophic scarring

Answer 405

enlargement of the scar within the boundary of the original scar

Question 406

Keloid scaring

Answer 406

enlargement of the scar beyond the original scar boundary

Question 407

Hypertrophic and Keloid scarring cause

Answer 407

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

Question 408

Informed consent implies that the patient completely understands what issues?

Answer 408

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

Question 409

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

Answer 409

Procedure Alternatives Risks Questions

Question 410

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

Answer 410

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.

Question 411

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

Answer 411

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

Question 412

Vertical mattress advantages

Answer 412

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

Question 413

Horizontal mattress uses

Answer 413

wound under tension fill up dead space

Question 414

run and run locking stich

Answer 414

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

Question 415

Vertical mattress suture disadvantage

Answer 415

proper placement is time consuming can cause railroad tracking

Question 416

acne vulgaris pop

Answer 416

12-25

Question 417

acne vulgaris pathophysiology

Answer 417

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 Propionibacterium acnes) 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

Question 418

acne sx

Answer 418

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

Question 419

acne tx standard of car based on severity

Answer 419

Question 420

acne tx ND

Answer 420

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

Question 421

alteratives

Answer 421

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

Question 422

alteratives herbs

Answer 422

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

Question 423

Mahonia part used

Answer 423

Root bark and stem bark

Question 424

mahonia action

Answer 424

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

Question 425

mahonia indications

Answer 425

**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)

Question 426

mahonia CI

Answer 426

pregnancy

Question 427

rumex part used

Answer 427

Root (primarily) also the seed and leaf

Question 428

rumex actions

Answer 428

**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

Question 429

rumex indications

Answer 429

**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

Question 430

rumex CI

Answer 430

Oxalate kidney stones, kidney disease, iron overload, pregnancy

Question 431

trifolum part used

Answer 431

blossom

Question 432

trifolium actions

Answer 432

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

Question 433

trifolum indications

Answer 433

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

Question 434

trifolium CI

Answer 434

Caution with blood thinning medications and oral contraceptives

Question 435

anti-inflammatory/antioxidant herbs

Answer 435

berberis vulgaris camelia sinensis silybum marianum

Question 436

berberis part used

Answer 436

Berries, Rhizome and Root

Question 437

berberis actions

Answer 437

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

Question 438

berberis indications

Answer 438

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.

Question 439

camelia part used

Answer 439

leaf

Question 440

camelia actions

Answer 440

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

Question 441

camelia MOA

Answer 441

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

Question 442

camelia indications

Answer 442

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

Question 443

camelia CI

Answer 443

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

Question 444

silybum part

Answer 444

seed

Question 445

silybum actions

Answer 445

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

Question 446

silybum indications

Answer 446

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

Question 447

silybum CI

Answer 447

asteraceae family allergy

Question 448

astringents herbs

Answer 448

arctostaphylos uva-ursi black tea

Question 449

arctostaphylos part

Answer 449

leaves

Question 450

arctostaphylos actions

Answer 450

Antimicrobial, astringent, tonify

Question 451

arctostaphylos indications

Answer 451

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

Question 452

arctostaphylos CI

Answer 452

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!

Question 453

immunostimulants

Answer 453

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

Question 454

immunostimulants herbs

Answer 454

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

Question 455

immunomodulators

Answer 455

agents that have a tonifying effect on immune system

Question 456

eleuthrococcus part used

Answer 456

Root (most researched), stem bark and leaf

Question 457

eleuthrococcus actions

Answer 457

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

Question 458

eleuthrococcus indications

Answer 458

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

Question 459

eleuthrococcus CI

Answer 459

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

Question 460

ganoderma part

Answer 460

fruiting body

Question 461

ganoderma action

Answer 461

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

Question 462

ganoderma indications

Answer 462

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

Question 463

ganoderma CI

Answer 463

Potential allergy to spores