Self-Assessment Self-Assessment examination of the American Academy of Dermatology* Identification No. 893-201 Learning objectives: At the conclusion of this self-assessment learning activity, physician participants should be able to assess their own diagnostic and patient management skills with respect to those of their colleagues in the field, use the results of the self-assess men t to help determine personal learning needs that can be addressed through subsequent CME involvement, and enhance their ability to comply with the requirements for certification in the specialty of dermatology. Instructions for Category I CME credit appear in the front advertising section. See last page of Contents for page number. Instructions: In answering each question, refer to the specific directions provided. Because it is often ne<:essaryto provide information in questions occurring later in a series that give away answers to earlier questions, please answer the ques- tions in each series in sequence. QUESTIONS 1-16 A 35-year-old man has a5 X 8 em decorative tattoo (Fig. 1) on the extensor surface of his forearm. The tattoo was professionally applied when he was in the military service 17 years earlier. It consists of black pigment primarily, with small amounts of red, blue, and green pigment. 1. Decorative tattoos applied by amateur methods typ- ically use pigments consisting of (Choose as many as apply. All, some, or none of the choices may be cor- rect.) a. india ink b. carbon c. titanium d. pendllead e. paint 2. Decorative tattoos placed by professional methods typically use pigments consisting of (Choose as many as apply. All, some, or none of the choices may be correct.) a. organic dyes b. copper c. iron ooeThe Self-Assessment examination is supported in part by an educational grant from the Procter & Gamble Company, Cincinnati, Ohio. *Members of the Self-Assessment Committee of the American Acad- emy of Dermatology are: Kenneth J. Tomecki, MD, chairman, Bur- ton S. Belknap, MD, Mary R. Buchness, MD, Ponciano D. Cruz, MD, C. Ralph Daniel m, MD, Gary R. Kantor, MD, Francisco A. Kerdel, MD, Tobi B. Richman, MD, Theodore Rosen, MD, Robert A. Schwartz, MD, and Ronald G. Wheeland, MD. d. mercury e. pencil lead Questions 3-6: Match the color of the tattoo with the pigment used. a. Chromium b. Mercury c. Cadmium d. Cobalt 3. Blue 4. Red 5. Green 6. Yellow 7. Tattoo pigment is situated in the dermis primarily (Choose single best response.) a. adjacent to eccrine and apocrine units b. within endothelial cells in the papillary dermal vascular plexus 137
Transcript
Self-Assessment
Self-Assessment examination of theAmerican Academy of Dermatology* Identification No. 893-201
Learning objectives: At the conclusion of this self-assessment learning activity, physician participants should be able toassess their own diagnostic and patient management skills with respect to those of their colleagues in the field, use theresults of the self-assessment to help determine personal learning needs that can be addressed through subsequent CMEinvolvement, and enhance their ability to comply with the requirements for certification in the specialty of dermatology.
Instructions for Category I CME credit appear in the front advertising section. See last page of Contents for pagenumber.
Instructions: In answering each question, refer to the specific directions provided. Because it is often ne<:essaryto provideinformation in questions occurring later in a series that give away answers to earlier questions, please answer the questions in each series in sequence.
QUESTIONS 1-16
A 35-year-old man has a 5 X 8 em decorativetattoo (Fig. 1) on the extensorsurface ofhis forearm.The tattoo was professionally applied when he wasin the military service 17 years earlier. Itconsists ofblack pigment primarily, with small amounts of red,blue, and green pigment.
1. Decorative tattoos applied by amateur methods typically use pigments consisting of (Choose as many asapply. All, some, or none ofthe choices may be correct.)a. india inkb. carbonc. titaniumd. pendlleade. paint
2. Decorative tattoos placed by professional methodstypically use pigments consisting of (Choose as manyas apply. All, some, or none of the choices may becorrect.)a. organic dyesb. copperc. iron
ooeThe Self-Assessment examination is supported in part by anr~ educational grant from the Procter & Gamble Company,
Cincinnati, Ohio.*Members of the Self-Assessment Committee of the American Acad
emy of Dermatology are: Kenneth J. Tomecki, MD, chairman, Burton S. Belknap, MD, Mary R. Buchness, MD, Ponciano D. Cruz,MD, C. Ralph Daniel m, MD, Gary R. Kantor, MD, Francisco A.Kerdel, MD, Tobi B. Richman, MD, Theodore Rosen, MD, RobertA. Schwartz, MD, and Ronald G. Wheeland, MD.
d. mercurye. pencil lead
Questions 3-6: Match the color of the tattoo withthe pigment used.
a. Chromiumb. Mercuryc. Cadmiumd. Cobalt
3. Blue
4. Red
5. Green
6. Yellow
7. Tattoo pigment is situated in the dermis primarily(Choose single best response.)a. adjacent to eccrine and apocrine unitsb. within endothelial cells in the papillary dermal
vascular plexus
137
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Dermatology
c. within inflammatory cells such as neutrophils inthe perivascular infiltrate
d. as granules within fibroblasts and macrophages ina perivascular location
e. extracellularly, adjacent to pilosebaceous units
The patient noted the onset of induration anderythema in the tattoo for several months. Thebiopsy specimen shows sarcoidal granulomas in thedermis (Figs. 2 and 3).
8. Which of the following reactions are known to occurin tattoos? (Choose as many as apply. All, some, ornone o/the choices may be correct.)a. Pseudolymphomab. Foreign body granulomac. Sarcoidal granulomad. Photosensitivitye. Infection
9. The biopsy specimen indicates that the patient haswhich of the following reactions? (Choose single bestresponse.)a. Pseudolymphoma
b. Foreign body granulomac. Sarcoidal granulomad. Photosensitivitye. Infection
The patient desires tattoo removal.
10. Modalities used to remove decorative tattoos includeeach of the following except (Choose single best response.)a. surgical excision and graftingb. ultrasound sonificationc. chemical peeld. electrodesiccation, electrocautery, or cryosurgerye. laser therapy
11. True statements concerning chemical methods usedto remove tattoos include the following (Choose single best response.)a. Tannic acid is applied with reciprocating needles
or after dermabrasion.b. Chemical removal techniques produce relatively
uniform results, independent of operator technique.
c. Salabrasion employs a sodium bromide solution.d. Trichloroacetic acid solutions produce highly con
trolled layer-by-Iayer tissue removal.e. Scarring and pigmentary changes are rare com·
plications of chemical removal.
12. Lasers used to remove decorative tattoos include the(Choose as many as apply. All, some, or none ofthechoices may be correct.)a. carbon dioxide (C02)b. gold vaporc. argond. Q-switched rubye. none of the above
13. The C02 laser is characterized by (Choose as manyas apply. All, some, or none of the choices may becorrect.)a. emission of deep red lightb. absorption by waterc. wavelength of 10,600 nmd. selective absorption by melanine. lack of nonspecific thermal damage
14. The argon laser is characterized by (Choose as manyas apply. All, some, or none of the choices may becorrect.)a. Q-switched energy deliveryb. blue-green lightc. hypertrophic scarring and residual pigment after
tattoo treatmentd. tissue vaporization with defocused beam
e. wavelength of 488 to 514 nm15. The Q-switched ruby laser is characterized by
(Choose as many as apply. All, some, or none ofthechoices may be correct.)a. deep red lightb. wavelength of 694 nmc. pulse durations of 40 to 80 nsecd. maximal absorption by oxyhemoglobine. preferential absorption by melanin
16. In the treatment of tattoos by the Q-switched rubylaser which of the following statements are true?(Choose as many as apply. All, some, or none ofthechoices may be correct.)a. Scarring is minimized because laser energy is se·
lectively absorbed by tattoo pigment.b. Pigmentary alterations are observed least often in
deeply pigmented races.c. Red and green pigments respond better to treat·
ment than blue and black pigments.d. Tattoo pigment removal is characterized by frag.
mentation of pigment granules, with subsequentphagocytosis by macrophages and physiologicdegradation.
e. Professional tattoos respond more favorably thanamateur tattoos.
QUESTIONS 17-26
A 17-year-old young man had asymptomaticplantar lesions as pictured in Figs. 4 and 5. These had
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been treated for many weeks by his pediatrician withantifungal creams but had continued to increase innumber. The patient played high school basketballand wore leather gym shoes constantly.
17. Potassium hydroxide preparation shows no fungalelements. A shave biopsy specimen (hematoxylin andeosin stain) of a typical lesion might reveal (Chooseas many as apply. All, some, or none of the choicesmay be correct.)a. acanthosis, papillomatosis, and hyperkeratosisb. pits limited to the stratum corneumc. a mild inflammatory reaction in the reticular der
misd. organisms extending into the reticular dermis
18. The lesions pictured in Figs. 4 and 5 are a result of(Choose as many as apply. All, some, or none ofthechoices may be correct.)a. human papillomavirusb. an inherited disorderc. bacterial infectiond. a superficial dermatophyte
19. The most likely diagnosis is (Choose single bestresponse.)
20. Organism that have been implicated in the origin ofpitted keratolysis include (Choose as many as apply.All, some, or none of the choices may be correct.)a. Dermatophilus congolensisb. Staphylococcus aureusc. Micrococcus sedentariusd. Corynebacterium species
21. Which of the following special stains (Fig. 6) mightclearly reveal the gram-positive organisms in the pitslocated in the stratum corneum? (Choose as many asapply. All, some, or none ofthe choices may be correct.)a. Periodic acid-Schiffb. Masson trichromec. Brown-Brennd. Congo Red
22. Symptoms that may be associated with pitted keratolysis include (Choose as many as apply. All, some,or none of the choices may be correct.)
Volume 28Number 1January 1993
a. painb. offensive odorc. discoloration within lesionsd. excessive sweating
23. Conditions that have been reported to occur in association with pitted keratolysis include (Choose asmany as apply. All, some, or none ofthe choices maybe correct.)a. blistering dactylitisb. erythrasmac. juvenile plantar dermatosisd. severe macerated dermatophytosis
24. True statements about pitted keratolysis include(Choose as many as apply. All, some, or none ofthechoices may be correct.)a. it has been reported only in tropical climatesb. hyperhidrosis or prolonged contact with water is
necessaryc. it can occur on palmar surfacesd. some patients require hospitalization for extensive
disease and severe pain
25. Treatment of this condition (Choose as many as apply. All, some, or none ofthe choices may be correct.)a. may not be necessary because spontaneous reso-
lution occursb. may require months of continued therapyc. requires systemic antibioticsd. is effectively accomplished with topical clindamy
cin, erythromycin, formalin, or glutaraldehyde
26. Which of Koch's postulates have been satisfied in establishing the infectious origin of pitted keratolysis?(Choose as many as apply. All, some, or none ofthechoices may be correct.)a. The organisms are present only in involved skin.b. The organisms can be grown in appropriate media
under specified conditions.c. Organisms are present in all lesions.d. Lesions can be reproduced by inoculating normal
skin.
QUESTIONS 27-35
The elderly have the greatest risk for developmentof decubitus ulcers.
27. Which ofthe following contribute to the developmentof decubitus ulcers? (Choose as many as apply. All,some, or none of the choices may be correct.)a. Nutritional deficienciesb. Hypoproteinemiac. Anemiad. Spasticitye. Paralysis
Self-Assessment examination 141
28. The region least susceptible to the formation of decubitus ulcers is the one over the (Choose single bestresponse.)a. olecranonb. sacrumc. greater trochanterd. ischial tuberositye. lateral malleolus
29. A patient has a decubitus ulcer with a green hue andan odor similar to that of sour grapes. He receiveshydrotherapy (whirlpool) as treatment. Of the following options, the best local care would be (Choosesingle best response.)a. applying povidone-iodine ointmentb. initiating heat lamp treatmentsc. applying wet (saline) to dry dressingsd. applying wet (acetic acid) to dry dressingse. increasing the frequency of whirlpool treat
ments
30. The ulcer that appears in Fig. 7 is best classified asgrade (Choose single best response.)a. Ib. IIc. IIId. IVe. V
31. Initial diagnostic tests for an afebrile patient with adecubitus ulcer should include (Choose as many asapply. All, some, or none ofthe choices may be correct.)a. cultureb. biopsyc. bone scand. bleeding timee. prothrombin time
32. The earliest clinical sign predictive of a decubitus ulcer is (Choose single best response.)a. local itchingb. diffuse folliculitis in the affected areac. a small red maculed. a pale cutaneous ulcer with a sharply defined bor
dere. an edematous plaque with central serous dis
charge
33. An ulcer with a black eschar at the base (Choose single best response.)a. is likely to be painfulb. always requires debridementc. is superinfected with a causative organismd. is more likely to occur in elderly and/or diabetic
patientse. is an indication for a full-thickness graft
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34. Prolonged pressure to a localized area of skin caninitiate local skin damage in as little as (Choose single best response.)a. 9 hoursb. 24 hoursc. 1 week in a body castd. 4 weeks in Bucks tractione. 6 weeks
35. Diseases known to be associated with a higher ind-
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dence ofcomplicated decubitus ulcers are (Choose asmany as apply. All, some, or none ofthe choices maybe correct.)a. Bowen's diseaseb. malignant melanomac. Zollinger-Ellison's diseased. septicemiae. rheumatoid arthritis
NATIONAL INSTITUTES OF HEALTHCONSENSUS PANEL ISSUES REPORT
CONSENSUS DEVELOPMENT CONFERENCE ONDIAGNOSIS AND TREATMENT OF EARLY MELANOMA
A National Institutes of Health (NIH) consensus development statement on Diagnosis and Treatment of Early Melanoma may be obtained from the NIH Office ofMedical Applications of Research.
The report was prepared by a panel of experts who considered scientific evidencepresented at a Consensus Development Conference at NIH. Itcontains recommendations and conclusions concerning diagnosis and early treatment of melanoma.
At NIH, consensus conferences bring together researchers, practicing physicians,representatives of public interest groups, consumers, and others to carry out scientificassessments of drugs, devices, and procedures in an effort to evaluate their safety andeffectiveness.
Free, single copies of the consensus statement on diagnosis and early treatment ofmelanoma may be obtained from:
William H. HallDirector of CommunicationsOffice of Medical Applications of ResearchFederal Building, Room 6187550 Wisconsin Ave.Bethesda, MD 20205301-496-1144
