Week 3 Flashcards
Ulcer on foot or mid-shin?
arterial ulcer
ulcer on sacrum, heels, ischia or greater trochanters?
pressure ulcers
ulcer on medial or lateral malleolus?
venous ulcer
“The tendency to perceptually lock onto salient features in the patient’s initial presentation too early in the diagnostic process, and failing to adjust this initial impression in the light of later information.”
Anchoring
“The disposition to judge things being more likely, or frequently occurring, if they readily come to mind.”
Availability
What is the purpose of ankle exercises in leg ulcers?
they are important to maintain joint mobility with ulcers near the ankle - vital to prevent skin fibrosis which causes joints to stiffen.
Which type of skin cancer can develop from leg ulcers (rare)?
squamous cell carcinomas
Layers of scalp?
From outside in: Skin Connective tissue Aponeurosis Loose connective tissue Periosteum
What is Bowen’s disease?
intraepithelial squamous cell carcinoma (carcinoma in situ)
well defined scaly patch
old ladies’ legs
What is the proper name for freckles?
ephilides
What is the most effective treatment of malignant melanoma?
early radical therapy
Why can a malignant melanoma NOT be effectively treated with combined chemo and radiotherapy?
due to embryological origins and the high amount of melanin within them, malignant melanomas do not respond well to chemo or radiotherapy even when used in combination.
What is the role of the MC1R gene?
Melanocortin 1 receptor gene turns phaeomelanin into eumelanin;
2 mutated genes = red hair + freckles
1 mutated gene = red hair or freckles
“age or liver spots” found on dorsal of hand?
actinic or solar lentigines
How is a usual congenital naevi formed?
during infancy the melanocyte to keratinocyte ratio breakdown at a number of cutaneous sites
Path of development of acquired naevus?
junctional naevus
compound naevus
intradermal naevus
What would be seen when looking through microscope at a junctional naevus?
melanocytes proliferate -> clusters of cells at DEJ
What can be seen in a compound naevus?
junctional clusters + groups of cells in dermis
The final step of intradermal naevus…?
all junctional activity has ceased; entirely dermal
What are some features of a dysplastic naevi (DN)?
> 6mm diameter
multi-coloured pigment
border asymmetry
Describe the 2 clinical settings of DN.
SPORADIC - not inherited, one-several atypical naevi, risk of MM slight raised.
FAMILIAL - strong FH of melanoma, high penetrance, autosomal inheritance, atypical naevi ++, lifetime risk melanoma up to 100%
Describe a halo naevi.
a peripheral halo of depigmentation; they show inflammatory regression and are overrun by lymphocytes
Describe a blue naevi.
entirely dermal and consist of pigment rich in dendritic spindle cells;
the cellular variant may have mitoses and mimic melanoma
The ‘benign juvenile melanoma’ is now called…?
What are its features?
Spitz naevus
occur <20 years
consist of large spindle ± epithelial cells
may closely mimic melanoma
most entirely benign
can look pink due to prominent vasculature; epidermal hyperplasia
Red flags for suspecting melanoma?
new pigment lesion develops in adulthood change in shape irregular pigmentation bleeding ulceration development of satellite nodules
What are the 4 main types of melanoma?
- superficial-spreading - commonest (trunk & limbs)
- acral/mucosal lentiginous (on feet)
- lentigo maligna melanoma - sun-damaged faces (in-situ tumour)
- nodular (varied sites; often trunk)
What is regular growth phase of melanomas?
SSM, A/MLM and LMM all grow as macules within either entirely in-situ or dermal micro-invasion
What is vertical growth phase of melanomas?
eventually the melanoma cells invade the dermis forming an expansile mass with mitoses
only VGP melanomas can metastasise
What is Breslow depth?
measured from granular layer; how deep tumour cells have invaded in mm
How does nodular melanoma differ from the other 3 melanoma types?
there is no clinical or microscopic evidence of RGP, a simple nodule of VGP tumour
Name some other adverse prognostic indictors.
ulceration high mitotic rate lymph-vascular invasion satellites sentinel lymph node involvement
Stages of spread of malignant melanoma?
- local dermal lymphatics -> satellite deposits of MM
- regional lymph node metastases (common pattern of disease progression)
- blood spread
Size of excision/removal of in-situ melanoma?
clear by ~5mm
Size of clearance for an invasive MM?
invasive but <1mm thick = 1cm clearance
invasive but >1mm thick = 2cm clearance
2 indications for skin biopsy?
skin rashes or skin tumours
Lesion on skin which can look like a basal cell carcinoma?
dermatofibroma
Features of dermatofibroma and management?
firm to touch
often increased pigment around rim
left alone
Name some of the skin diseases caused by adverse reaction to amoxicillin.
multiform (measles-like) eruption urticaria angioedema fixed drug eruption generalised pustulatosis
List some of the treatment options of common pre-cancers.
cryotherapy solaraze 5 FU PDT Imiquimoid Resurfacing
68 y/o female with pigmented lesion right cheek - DH: aspirin, polymyalgia - MH: angina, polymyalgia rheumatica - allergy to penicillin - smoker
management?
What are the considerations related to treatment?
Melanoma -> excision biopsy; initial surgery (+ surgery, radio or chemo if needed)
polymyalgia rheumatica -> steroid therapy (increased risk of infection pos-op & poor wound healing)
Smoking affect wound healing
What is the sensory nerve supply to the face?
CN V3 - mandibular division
also motor to muscles of mastication
How do you test CN V3?
Ask patient to close eyes. Gently brush the skin in each dermatome (chin with fine tip of cotton wool. Ask patient to tell you when they feel their skin being touched. Compare both sides.
Foramen in which facial bone transmits CN V2? Which area of face can test this nerve?
foramen in maxilla
(maxillary division)
brush over maxilla to test
Previously well patient, no PMH, sudden loss fo movement on right side of face…?
injury to CN VII (facial nerve)
How do you test facial nerve function?
ask patient to frown and close eyes tightly
Name the muscle known as the sphincter of the eye.
obicularis oculi
Name the muscle known as the sphnicter of the mouth.
obicularis oris
Why is adrenaline often injected along with anaesthetic?
prolongs anaesthesia and reduces bleeding
What are the pros and cons of taking a punch biopsy?
quick, good wound edges
BUT
difficult to judge depth, round holes do not always heal well, pathology sample may be too small
What is the typical margin size of an elliptical excision?
2mm margin
