Clinical Skills Final

why is it important to drain an auricular hematoma?

may scar up and result in cauliflower ear if untreated

which nerve supplies sensation to the upper portion of the ear? lower portion?

upper: auriculotemporal nerve
lower: great auricular nerve

what procedures should you do after evacuating/draining the auricular hematoma?

place bolsters with through-and-through sutures then abx ointment

• bolster dressing needs to be on for 4-8 days

• 1 week of suture if they aren't participating in the tournament

what factors can make removal of an ear foreign body more difficult?

• location in medial half of canal

• ungraspable or large object

• uncooperative patient

• no space to insert instruments

• blood or edema in the ear

what do you need to approximate when repairing an ear laceration?

skin only
- trim away cartilage if needed and sew the skin loosely for swelling and draining

bleeding from where always bleeds anteriorly and can be resolved with pressure or spontaneously

kiesselbach's plexus

- anterior septum is most common site of epistaxis

in epistaxis, which affected artery can result in patient bleeding anteriorly and/or posteriorly and is not resolved with just pressure?

anterior ethmoid artery
- treated w/ packing and time

bleeding from sphenopalatine artery always bleeds __ first, and it bleeds profusely and always requires tx

posteriorly

what would be your next treatment option of anterior nasal bleeding after pressure, humidity, and nasal saline?

cauterization with silver nitrate stick

can you use nasal clamp during epistaxis?

NO! it can cause pressure necrosis on the external nose

why is it necessary to place patients on prophylactic abx when using nasal packing?

to prevent TSS and sinusitis

Unilateral nasal drainage and a foul smell indicates what

FB

what is the MC complication of septal hematoma if it becomes infected?

perforation

- nose cartilage has no blood supply, which can lead to a perforation

patient presents with severe unilateral sore throat, on exam LNs are inflamed and uvula is pointed away from the side of the swollen tonsil. what do you suspect?

peritonsillar abscess

how do you tx peritonsillar abscess?

I&D and place on 5-10 days of PO ATBs (GAS coverage)

(T/F) when draining PTA, you can only numb the surface by applying topical xylocaine, you can't numb the whole pocket of fluid

true

laceration repair for hard palate and gums

dont do anything, leave alone

laceration repair for soft palate

needs general anesthetic

is high riding prostate on DRE a contraindication for urinary cath?

yes

what diagnostic test should you do prior to Cath placement?

retrograde urethrogram (RUG) to see potential urethral injury

complications of urinary cath

• urethral strictures/dilatation

• structural trauma

• bladder stones formation on the cath balloon

• hematuria

• knotted catheter

• UTI

what type of catheter is for difficult cath placement and can avoid false passage?

caude catheter

what type of catheter is for bladder irrigation?

three way catheter

what's the average foley size for adults?

16 Fr.

examples of male anatomy that won't allow you to pass catheter

• spasm of external urethral sphincter

• angulated prostatic urethra

• urethral strictures

• false passage

what kind of stricture is seen in bulbous urethra? in penile urethra?

BU: large caliber stricture (16+ Fr.)
PU: pinpoint stricture (6-8 Fr.)

contraindication with suprapubic catheterization

bladder is not palpable or seen distended on ultrasound

cautions with suprapubic catheterization (3)

• anticoagulation

• prior pelvic/abd surgery (adhesions)

• pelvic CA w/ radiation (adhesions)

what is ophthalmic burr used for?

to remove rust ring

relationship bw frequency and penetration of sound beam

inverse relationship

relationship bw frequency and detail resolution

direct relationship

what structure is hyperechoic/echogenic? anechoic/sonolucent?

hyper: bones

anec: fluid

why can't you do shave biopsy for melanoma?

bc it's graded by depth - get punch biopsy instead

indications for shave biopsy

•Seborrheic keratoses
•Verrucous lesions (Warts)
•Molluscum contagiosum
•Superficial Basal cell carcinomas
•Benign nevi (Cosmetic)

contraindications for shave biopsy

•Most pigmented lesions
•Diagnosis of infiltrative dermatoses
•Suspected sclerosing basal cell carcinoma
•Any lesion with a dermal component

what can you use for bleeding after shave biopsy?

• aluminum chloride 20%

• hand-held cautery (curettage)

• ferric subsulfate

• silver nitrate

what antibiotic ointment should you avoid after you did a shave biopsy?

neomycin - can cause contact dermatitis

what shave technique is used for wide pigmented lesions or sites w/ risk of hypertrophic or keloidal scarring?

saucerization

what technique is used to remove acrochordans (skin tags) and pedunculate nevi?

snip excision

what's the f/u care for patients with a diagnosed malignancy?

complete skin exam bi-annually for consecutive 3 yrs

indications for punch biopsy

• pruritic dermatoses

• vesicular lesions (intact vesicle or bulla)

(T/F) when doing punch biopsy suspecting malignancy, obtain from darkest or thickest area of the lesions

true

if the punch site is larger than 1 cm, what should you scrub the area with? how long?

scrub the area for 3 minutes with chlorhexidine or poxidone-iodine

how far should the punch biopsy extend into?

subq fat

return appointment of punch biopsy and excision to face & ears

neck

scalp

trunk & extremities

distal lower extremities

•Face & Ears: 5 to 7 days
•Neck: 7 days
•Scalp: 7 to 10 days
•Trunk and Extremities: 7 to 14 days
•Distal lower extremities: 10 to 21 days

restrictions with punch biopsy and excision

Heavy lifting or exercising, and water submersion (pool/hot tub)

indications for excision

•Suspected melanomas
•Epidermal cysts
•Lipomas
•Larger basal cell and squamous cell carcinomas
•Dermal lesions larger than 1 cm

how long do you need scrub the site for excision?

5 min

(T/F) Punch biopsy does not need to bandaged

true

Laryngeal papillomatosis in healthcare providers are results from treating what?

HPV and HIV - viral particles can be aerosolized

Treat protruding lesions

Electrofulguration

Hair removal

Electrolysis

Remove flat lesions and lesions under the superficial skin

Electrodesiccation
- only for smaller lesions 1-2 mm, if larger than 3-4 mm = cryosurgery

can you use chlorhexidine to clean the area in electrosurgery?

no! clean the area with povidone-iodine and water only

contraindications for cryosurgery

•Lesions requiring pathology
•Body area with compromised circulation
•Dark skin
•Cold intolerance
•Overlying nerves

what suture has greater knot security and greater infection risk?

multifilament (silk, vicryl)

what suture has poor knot security and lower infection risk?

monofilament (nylon, PDS, praline, monocryl)

the larger the suture size, the smaller...

the diameter is

suture size is not based on thickness, it's based on _____ so different materials are different sizes

breaking strength

review the blade type on slide 12

what suture to use for pts prone to keloid formation?

subcuticular or deep dermal suture

relative contraindication of deep dermal suture

inadequate or thin dermal layer

absorption time for these materials:
vicryl
monocryl
PDS

Vicryl = 60d
Monocryl = ~100d
PDS = ~200d

what two blade types are use for eye (both primary application and reconstructive)?

prime reverse cutting
centerpoint spatula

spatula for cornea, sclera

what can be identified in the CSF of MS patients

Oligoclonal Immunoglobulin Bands

The 3 W's of normal pressure hydrocephalus

Wobbly (gait disturbance), Wet (urinary incontinence), Wacky (dementia)

A xanthochromic CSF specimen is indicative of

SAH

High protein
low glucose
>1000 WBC (diagnostic)

LP bacterial meningitis

(opposite in viral)

absolute contraindications of LP

• local infections

• bleeding tendencies

• increase ICP d/t mass or spinal cord compression

(T/F) latex or betadine allergies is a relative contraindication of LP

true

treatment for post-LP HA

bed rest
fluids
OTC analgesics
Oral or IV caffeine

what is a procedure in which a small vol of blood is injected into a patient's epidural space to stop a leak of CSF leak HA?

epidural blood patch

what position is the best for LP in infants? morbid obese? average adults?

infants - sitting
morbidly obese - upright
avg adults - Lateral decubitus position

LP site

L4-5

CSF collection:
first tube -
second tube -
third tube -
fourth tube -

1: cell count 2: glucose and protein 3: gram stain and culture and sensitivity (C&S) 4: cell count & diff

Max dose and max daily dose of acetaminophen in adults

Max dose - 1000mg every 4 hours
Max daily - 4000mg

Max dose and max daily dose of acetaminophen in peds

Max dose - 15mg/kg every 4 hours (max 1000mg)
Max daily - 75mg/kg/d

how many mg/tsp in peds for APAP

160mg/tsp

Max dose and max daily dose of ibuprofen in adults

Max dose - 800mg every 6 hours (sometimes 600mg)
Max daily - 3200mg

Max dose and max daily dose of ibuprofen in peds

Max dose - 10mg/kg every 6 hours (max 600mg)
Max daily - 40mg/kg/d

how many mg/tsp in peds for ibuprofen

100mg/tsp

How many mL in a teaspoon?

5 mL

1st line tx of MRSA after I&D of abscess

Bactrim and doxy

1st line tx of MRSA for parental inpatient after I&D of abscess

vancomycin

abx for known MSSA after I&D of abscess

keflex
- problem is QID dosing :(

contraindications of subungal trephination

• Crushed or fractured nails

• Fracture of the tuft (distal phalanx)

• Suspected melanoma

• Artificial acrylic nails

what gauge needle is used for a subungal trephination

18g

if there's no significant relief of pain when the drainage of subungal trephination begins, what should you suspect?

underlying injury/fx

- if fx while draining, apply aluminum splint and f/u

what type and size of suture is used for repair of nail bed injuries?

6-0 absorbable suture (vicryl)

Onychocryptosis-
Onychogryphosis-

ingrown nail
curved nail

what type of chemical can be used to ablate an ingrown nail? who is it contraindicated in?

• phenol solution (reduce risk of recurrent problems)

• contraindicated in pregnancy

during the ablation of ingrown nail, what is used to reduce bleeding?

silver nitrate

risk factors of Paronychia

• poor manicure technique

• Nail biting

• Thumbsucking

• DM

• Occupational- hands soaking in water

• Antiretroviral therapy in HIV Tx

Paronychia Treatment for oral exposure (Eikenella)

DOC: Augmentin

or

doxy/bactrim PLUS metronidazole (flagyl)/clindamycin

Paronychia Treatment for non-oral exposure

bactrim for MRSA
keflex (cephalexin) for MSSA

which fingers are MC affected in felon?

thumb and index

Flexor Tenosynovitis is a true hand emergency, how is it typically caused? MC organism?

• penetrating injury

• staph

four cardinal signs of flexor tenosynovitis on PE (Kanaval signs)

1. Fusiform swelling of the entire digit (sausage digit)

2. Partially flexed posture of the finger

3. Tenderness limited to the course of the flexor tendon/sheath

4. Disproportionate pain with passive extension of the finger

flexor tenosynovitis tx

• Immediate hand consult

• Emperic IV ABX with Vanc PLUS 3rd gen cephalosporin OR debridement and sheath irrigation

where can flexor tenosynovitis extend the infections?

palmar hand

• thenar space

• midpalmar space

• hypothenar space