Skin Flashcards
(30 cards)
Lumps - History
- Onset – when did you first notice, what made you first notice it and any predisposing events?
- Continued symptoms – how does it bother you (ask about pain), has it changed since you noticed it (colour, size or shape), any other lumps and has it ever disappeared or healed?
- Treatment and causes – what treatments have you had and what do you think is the cause - ICE?
Lumps - Inspection
Size, shape, raised, colour and position – there is a ?cm round/oval/irregular, raised/flat, hyper/hypopigmented lesion on the anterior surface of distal forearm.
Lumps - Consistency, Edge and Surface
On palpation the lesion feels soft/firm/hard, it has a well-defined/ill-defined edge and a smooth/irregular surface
Lumps - Pulsatility, Compressible or Reducible and Fluctuant
- Pulsatility – place a finger on opposite sides of lump – expansile pulsation the fingers are pushed apart and in transmitted pulsation fingers are pushed in same direction.
- Compressible or reducible – press firmly on the lump and release - compressible if it disappears and spontaneously reforms and reducible – if it disappears but does not reform spontaneously and requires extra force e.g. a cough in a hernia examination.
- Fluctuant – rest 2 fingers of one hand on opposite sides of the lump and press the middle of the lump. A lump is fluctuant if the pressure transmits equally in all directions so if your fingers move Paget’s sign is positive (you should repeat at right angles).
- Say – I can feel a transmitted pulsation, the lump is compressible and fluctuant.
Lumps - Fluid thrill, Fixation, Thrills, Transillumination and Inflammation
- Fluid thrill – for larger lumps ask the patient to place the edge of their hand in centre of the lump. Flick one side and feel for a percussion wave on the other side (in ascites).
- *Fixation *– you can say I am/am not able to manipulate the skin over the lump.
- Thrills and bruits – I am/am not able to feel a thrill and hear a bruit over the lesion.
- Transillumination – the lump does/does not transilluminate (would like to use a tube).
- Inflammation – there is no erythema, swelling, increased temperature, not tender.
To Complete my Examination
I would like to examine the draining lymph nodes, assess the neurovascular status of the area or limb, look for other lumps and do a general examination.
Examination of an Ulcer
BBEDDS:
- Basics – size, shape and site.
- Base – colour – granulation tissue, slough (dead tissue) or evidence of malignant changes. What can you see – fascia, muscle or bone.
- Edge – can be sloping – healing venous ulcer, punched out – an ischaemic (painful) or neuropathic (painless) ulcer, undermined – pressure necrosis, rolled – basal cell carcinoma or everted – squamous CC.
- Depth – measure or estimate the height of the ulcer in mm.
- Discharge – serous (clear), sanguineous (bloody), serosanguineous (mixed) or purulent.
- Surroundings – skin changes, scars, temp (cold in ischaemia), loss of sensation (neuropathy).
Lumps - In or Under the Skin
- Subcutaneous lumps – the skin moves over it – lipoma, ganglion, neuroma or a lymph node.
- Intradermal – cannot draw skin over it – sebaceous cysts, abscess, dermoid cyst or granuloma.
Lipoma - Description
Benign tumour of fat cells that commonly occur in the subcutaneous layer of the skin of the neck or the trunk.
They usually have smooth margins, the surface is lobulated, they can be hard or soft (depending on the nature of the fat and at what temperature it liquefies) and if soft it may be fluctuant.
Lipomas are not fixed so the overlying skin is mobile – if intramuscular will disappear with muscle contraction.
Lipoma - Dercums Disease and Management
- Dercum’s disease – multiple often painful lipomas typically in post-menopausal women and associated with peripheral neuropathy.
- They rarely undergo malignancy change and most liposarcomas develop independently.
- Management – can be non-surgical = reassurance, ‘watch and wait’ or surgical = removal under local anaesthetic if patient wants.
Ganglion - Description
A cystic swelling related to a synovial lined cavity commonly seen on the dorsum of the wrist or hand or dorsum of the foot.
They have a smooth surface, may be soft and fluctuant and may be weakly transilluminable.
Say I would like to ask the patient how it affects their life, whether they have noticed similar lumps, which hand is dominant and their occupation.
Ganglion - Management
- Non-surgical – watch and wait as 50% resolve spontaneously or aspiration followed by 3 weeks immobilisation is successful in 30-50% or surgical – complete excision.
- Surgical complications – wound complications e.g. scar, haematoma or infection, recurrence can be as high as 50% (need to completely excise the neck) and local neurovascular damage.
Lymph Node Enlargement - Causes
- Infection – infectious mononucleosis, brucellosis, TB, HIV or toxoplasmosis.
- Infiltration – malignancy (carcinoma or lymphoma) or sarcoidosis.
Sebaceous Cyst - Description
50% have a characteristic punctum at the apex marking blocked sebaceous outflow. They are commonly found on the face, trunk, neck and scalp but can occur anywhere with sebaceous glands (so not palms and soles).
They have a smooth surface, are firm on palpation and do not move independently from the skin.
Say I would like to ask the patient how it affects their life and if they’ve noticed similar lumps elsewhere.
Sebaceous Cyst - Complications and Management
- Complications – infection with associated discharge, ulceration, calcification (cyst will feel hard on palpation), sebaceous horn formation or malignant change.
- Management – non-surgical – can be left alone if small and asymptomatic or surgical – to prevent reoccurance complete excision of the cyst and its contents is required.
Cutaneous Abscess
Commonly caused by Staphylococci but axillary abscesses can also be caused by Proteus and tumours below the waist by faecal aerobes or anaerobes.
Management – incision and drainage.
Boils (furuncles) – abscess involving a hair follicle and associated gland and carbuncle – an area of subcutaneous necrosis which discharges through multiple sinuses.
Hydradenitis Suppuritiva
Aka acne inversa is where there are recurrent abscesses in the axillary and inguinal regions resulting in permanent disfiguring of the skin. It usually affects young women and diabetes mellitus is a predisposing factor.
Management – incision and drainage of well localised abscesses with antibiotic cover however large lesions will require radical excision and full thickness skin grafting usually from the patient’s abdomen or groin.
Dermoid Cyst
A skin lined cyst that may be congenital or acquired.
- Congenital – due to developmental inclusion of epidermis along lines of fusion of skin dermatomes so at the medial and lateral ends of the eyebrows, the midline of the nose, neck or trunk.
- Acquired – due to forced implantation of skin into subcutaneous tissue following injury. They are smooth, soft, spherical swellings that may fluctuate and are non-tender.
Dermoid Cyst - Management
Surgical excision is indicated for both congenital and acquired cysts. A CT scan of congenital cysts is required before surgery – midline cysts can communicate with CSF so need to rule out a bony defect.
Fibroma
Aan occur anywhere in the body but most commonly occur under the skin. They are benign, whitish in colour and contain collagen, fibroblasts and fibrocytes.
Neurofibromas - Description
A benign tumour that is derived from peripheral nerve elements. They may be solitary or multiple (known as neurofibromatosis) soft, fleshy pedunculated nodules.
Neurofibromatosis is an autosomal dominant condition which has associated café au lait spots – >6 light brown macules >1.5cm in diameter.
Say I would also like to examine the cranial nerves (particularly CN VIII) and measure BP as associated with phaeochromocytoma.
Neurofibroma - Complications and Management
- Complications – pressure effects e.g. on spinal cord, deafness if CN VIII involvement, intra-abdominal effects e.g. obstruction or bleeding or sarcotamous transformation.
- Management of single neurofibromas – non-surgical – leave alone if asymptomatic or surgical – only indicated is there is suspected malignant change. Local regrowth is common post-excision because neurofibromata cannot be surgically deteched from the underlying nerve.
Hypertrophic and Keloid Scars
- Hypertrophic scars - scar confined to the wound margins, across flexor surfaces and skin creases, appear early and regress spontaneously, at any age but commonly 8-20 years, male to female ratio is 1:1 and can affect all races.
- Keloid scars - scar extends beyond wound margins, affects earlobes, chin, neck, shoulder and chest, appear months after injury and grow, occur from puberty to 30 years of age, affects females more than males and common in black and Hispanic races.
Hypertrophic and Keloid Scars - Complications and Management
- Risk factors – wounds associated with infection, trauma, burns or tension (e.g. over sternum).
- Management – non-surgical – mechanical pressure therapy or topical silicone gel sheets or surgical – revision of scar with closure by direct suturing, local Z plasty or skin grafting to avoid excess tension followed by intralesional steroid and local anaesthetic injections.
