Medical Terminology Case Studies - Skin
Last Updated on Sat, 23 Sep 2017 | Medical Terminology
Case Study 21-1: Basal Cell Carcinoma (BSC)
K.B., a 32-year-old fitness instructor, had noticed a "tiny hard lump" at the base of her left nostril while cleansing her face. The lesion had been present for about 2 months when she consulted a dermatologist. She had recently moved north from Florida, where she had worked as a lifeguard. She thought the lump might have been triggered by the regular tanning salon sessions she had used to retain her tan because it did not resemble the acne pustules, blackheads, or resulting scars of her adolescent years. Although dermabrasion had removed the obvious acne scars and left several areas of dense skin, this lump was brown-pigmented and different. K.B. was afraid it might be a malignant melanoma. On examination, the dermatologist noted a small pearly-white nodule at the lower portion of the left ala (outer flared portion of the nostril). There were no other lesions on her face or neck.
A plastic surgeon excised the lesion and was able to re-approximate the wound edges without a full-thickness skin graft. The pathology report identified the lesion as a basal cell carcinoma with clean margins of normal skin and subcutaneous tissue and stated that the entire lesion had been excised. K.B. was advised to wear SPF 30 sun protection on her face at all times and to avoid excessive sun exposure and tanning salons.
Case Study 21-2: Cutaneous Lymphoma
L.C., a 52-year-old female research chemist, has had a history of T-cell lymphoma for 8 years. She was initially treated with systemic chemotherapy with methotrexate until she contracted stomatitis. Continued therapy with topical chemotherapeutic agents brought some measurable improvement. She also had a history of hidradenitis.
A recent physical examination showed diffuse erythroderma with scaling and hyperkeratosis, plus alopecia. She had painful leukoplakia and ulcerations of the mouth and tongue. L.C. was hospitalized and given two courses of topical chemotherapy. She was referred to Dental Medicine for treatment of the oral lesions and discharged in stable condition with an appointment for follow-up in 4 weeks. Her discharge medications included hydrocortisone ointment 2% to affected lesions q hs, Keralyt gel bid for the hyperkeratosis, and Dyclone and Benadryl for her mouth ulcers prn.
Case Study 21-3: Pressure Ulcer
L.N., an elderly woman in failing health, had recently moved in with her daughter after her hospital-ization for a stroke. The daughter reported to the home care nurse that her mother had minimal appetite, was confused and disoriented, and had developed a blister on her lower back since she had been confined to bed. The nurse noted that L.N. had lost weight since her last visit and that her skin was dry with poor skin turgor. She was wearing an "adult diaper," which was wet. After examining L.N.'s sacrum, the nurse noted a nickel-sized open area, 2 cm in diameter and 1 cm in depth (stage II pressure ulcer), with a 0.5-cm reddened surrounding area with no drainage. L.N. moaned when the nurse palpated the lesion. The nurse also noted reddened areas on L.N.'s elbows and heels.
The nurse provided L.N.'s daughter with instructions for proper skin care, incontinence management, enhanced nutrition, and frequent repositioning to prevent pressure ischemia to the prominent body areas. However, 6 months later L.N.'s pressure ulcer had deteriorated to a class III. She was hospitalized under the care of a plastic surgeon and wound-ostomy care nurse. Surgery was scheduled to débride the sacral wound and close it with a full-thickness skin graft taken from her thigh. L.N. was discharged 8 days later to a long-term care facility with orders for an alternating pressure mattress, position change every 2 hours, supplemental nutrition, and meticulous wound care.
CASE STUDY QUESTIONS
Multiple choice: Select the best answer and write the letter of your choice to the left of each number.
_ 1. K.B.'s basal cell carcinoma may have been caused by chronic exposure to the sun and ultraviolet tanning bed use. The scientific explanation for this is the:
a. autoimmune response b. actinic effect c. allergic reaction d. sun block tanning lotion theory e. dermatophytosis
_____ 2. The characteristic pimples of adolescent acne are whiteheads and blackheads. The medical terms for these lesions are:
a. vesicles and lymphotomes b. pustules and blisters c. pustules and comedones d. vitiligo and macules e. furuncle and sebaceous cyst
_ 3. Which skin cancer is an overgrowth of pigment-producing epidermal cells:
a. basal cell carcinoma b. Kaposi sarcoma c. cutaneous lymphoma d. melanoma e. erythema nodosum
_ 4. Basal cell carcinoma involves:
a. subcutaneous tissue b. hair follicles c. connective tissue d. adipose tissue e. epithelial cells
_ 5. Hydradenitis is inflammation of a:
a. sweat gland b. salivary gland c. sebaceous gland d. ceruminous gland e. meibomian gland
_ 6. Leukoplakia is:
a. baldness b. ulceration c. formation of white patches in the mouth d. formation of yellow patches on the skin e. formation of scales on the skin
7. Hydrocortisone is a(n):
a. vitamin b. steroid c. analgesic d. lubricant e. diuretic
8. An example of a topical drug is a:
a. systemic chemotherapeutic agent b. drug derived from rain forest plants c. subdermal allergy test antigens d. skin ointment e. Benadryl capsule 25 mg
9. Stomatitis, a common side effect of systemic chemotherapy, is an inflammatory condition of the:
a. mouth b. colostomy c. stomach d. teeth and hair e. nails
10. Skin turgor is an indicator of:
a. elasticity b. hydration c. aging d. nutrition e. all of the above
11. Another name for a pressure ulcer is a:
a. shearing force b. bedsore c. decubitus ulcer d. a and b e. b and c
12. A FTSG is usually harvested (taken) from another body area with a scalpel, whereas a STSG
is harvested with an instrument called a(n) _, which can cut a thinner graft.
a. tissue slicer b. Keralyt c. erythroderm d. dermatome e. debridement
Write a term from the case studies with each of the following meanings:
13. skin sanding procedure _
14. a solid raised lesion larger than a papule _
15. physician who cares for patients with skin diseases _
16. connective tissue and fat layer beneath the dermis _
17. diffuse redness of the skin _
18. increased production of keratin in the skin _
19. removal of dead or damaged skin _
20. reduced blood flow to the tissue _
Abbreviations. Define the following abbreviations:
Chapter 21 Crossword The Skin
Horny layer of the skin: combining form
Raised, thickened scar
Inflammation of a sweat gland:____adenitis
Pertaining to a hair
Autoimmune disease that affects the skin:
Measurement of packed red cells: abbreviation
Abnormal, painful: prefix
Excess growth of hair
Removal of scab tissue
Within the skin: abbreviation
Bacterial skin infection common in children:
Viral disease that affects the skin
Skin: combining form
Remove dead tissue, as from a wound
Sweat: combining form
A layer, as of the skin
Meaning of the root onych/o
A route of injection: abbreviation
Examination by pressing a glass plate against the
20. True, good, easy: prefix
21. Half: prefix
22. Part of a medical history:__H: abbreviation
23. Under, below, decreased: prefix skin
20. True, good, easy: prefix
21. Half: prefix
22. Part of a medical history:__H: abbreviation
23. Under, below, decreased: prefix
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This set of guidelines provides both instructions and a template for the writing of case reports for publication. You might want to skip forward and take a quick look at the template now, as we will be using it as the basis for your own case study later on. While the guidelines and template contain much detail, your finished case study should be only 500 to 1,500 words in length. Therefore, you will need to write efficiently and avoid unnecessarily flowery language.
These guidelines for the writing of case studies are designed to be consistent with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” referenced elsewhere in the JCCA instructions to authors.
After this brief introduction, the guidelines below will follow the headings of our template. Hence, it is possible to work section by section through the template to quickly produce a first draft of your study. To begin with, however, you must have a clear sense of the value of the study which you wish to describe. Therefore, before beginning to write the study itself, you should gather all of the materials relevant to the case – clinical notes, lab reports, x-rays etc. – and form a clear picture of the story that you wish to share with your profession. At the most superficial level, you may want to ask yourself “What is interesting about this case?” Keep your answer in mind as your write, because sometimes we become lost in our writing and forget the message that we want to convey.
Another important general rule for writing case studies is to stick to the facts. A case study should be a fairly modest description of what actually happened. Speculation about underlying mechanisms of the disease process or treatment should be restrained. Field practitioners and students are seldom well-prepared to discuss physiology or pathology. This is best left to experts in those fields. The thing of greatest value that you can provide to your colleagues is an honest record of clinical events.
Finally, remember that a case study is primarily a chronicle of a patient’s progress, not a story about chiropractic. Editorial or promotional remarks do not belong in a case study, no matter how great our enthusiasm. It is best to simply tell the story and let the outcome speak for itself. With these points in mind, let’s begin the process of writing the case study:
Title: The title page will contain the full title of the article. Remember that many people may find our article by searching on the internet. They may have to decide, just by looking at the title, whether or not they want to access the full article. A title which is vague or non-specific may not attract their attention. Thus, our title should contain the phrase “case study,” “case report” or “case series” as is appropriate to the contents. The two most common formats of titles are nominal and compound. A nominal title is a single phrase, for example “A case study of hypertension which responded to spinal manipulation.” A compound title consists of two phrases in succession, for example “Response of hypertension to spinal manipulation: a case study.” Keep in mind that titles of articles in leading journals average between 8 and 9 words in length.
Other contents for the title page should be as in the general JCCA instructions to authors. Remember that for a case study, we would not expect to have more than one or two authors. In order to be listed as an author, a person must have an intellectual stake in the writing – at the very least they must be able to explain and even defend the article. Someone who has only provided technical assistance, as valuable as that may be, may be acknowledged at the end of the article, but would not be listed as an author. Contact information – either home or institutional – should be provided for each author along with the authors’ academic qualifications. If there is more than one author, one author must be identified as the corresponding author – the person whom people should contact if they have questions or comments about the study.
Key words: Provide key words under which the article will be listed. These are the words which would be used when searching for the article using a search engine such as Medline. When practical, we should choose key words from a standard list of keywords, such as MeSH (Medical subject headings). A copy of MeSH is available in most libraries. If we can’t access a copy and we want to make sure that our keywords are included in the MeSH library, we can visit this address: http://www.ncbi.nlm.nih.gov:80/entrez/meshbrowser.cgi
Abstract: Abstracts generally follow one of two styles, narrative or structured.
A narrative abstract consists of a short version of the whole paper. There are no headings within the narrative abstract. The author simply tries to summarize the paper into a story which flows logically.
A structured abstract uses subheadings. Structured abstracts are becoming more popular for basic scientific and clinical studies, since they standardize the abstract and ensure that certain information is included. This is very useful for readers who search for articles on the internet. Often the abstract is displayed by a search engine, and on the basis of the abstract the reader will decide whether or not to download the full article (which may require payment of a fee). With a structured abstract, the reader is more likely to be given the information which they need to decide whether to go on to the full article, and so this style is encouraged. The JCCA recommends the use of structured abstracts for case studies.
Introduction: This consists of one or two sentences to describe the context of the case and summarize the entire article.
Case presentation: Several sentences describe the history and results of any examinations performed. The working diagnosis and management of the case are described.
Management and Outcome: Simply describe the course of the patient’s complaint. Where possible, make reference to any outcome measures which you used to objectively demonstrate how the patient’s condition evolved through the course of management.
Discussion: Synthesize the foregoing subsections and explain both correlations and apparent inconsistencies. If appropriate to the case, within one or two sentences describe the lessons to be learned.
Introduction: At the beginning of these guidelines we suggested that we need to have a clear idea of what is particularly interesting about the case we want to describe. The introduction is where we convey this to the reader. It is useful to begin by placing the study in a historical or social context. If similar cases have been reported previously, we describe them briefly. If there is something especially challenging about the diagnosis or management of the condition that we are describing, now is our chance to bring that out. Each time we refer to a previous study, we cite the reference (usually at the end of the sentence). Our introduction doesn’t need to be more than a few paragraphs long, and our objective is to have the reader understand clearly, but in a general sense, why it is useful for them to be reading about this case.
Case presentation: This is the part of the paper in which we introduce the raw data. First, we describe the complaint that brought the patient to us. It is often useful to use the patient’s own words. Next, we introduce the important information that we obtained from our history-taking. We don’t need to include every detail – just the information that helped us to settle on our diagnosis. Also, we should try to present patient information in a narrative form – full sentences which efficiently summarize the results of our questioning. In our own practice, the history usually leads to a differential diagnosis – a short list of the most likely diseases or disorders underlying the patient’s symptoms. We may or may not choose to include this list at the end of this section of the case presentation.
The next step is to describe the results of our clinical examination. Again, we should write in an efficient narrative style, restricting ourselves to the relevant information. It is not necessary to include every detail in our clinical notes.
If we are using a named orthopedic or neurological test, it is best to both name and describe the test (since some people may know the test by a different name). Also, we should describe the actual results, since not all readers will have the same understanding of what constitutes a “positive” or “negative” result.
X-rays or other images are only helpful if they are clear enough to be easily reproduced and if they are accompanied by a legend. Be sure that any information that might identify a patient is removed before the image is submitted.
At this point, or at the beginning of the next section, we will want to present our working diagnosis or clinical impression of the patient.
Management and Outcome: In this section, we should clearly describe the plan for care, as well as the care which was actually provided, and the outcome.
It is useful for the reader to know how long the patient was under care and how many times they were treated. Additionally, we should be as specific as possible in describing the treatment that we used. It does not help the reader to simply say that the patient received “chiropractic care.” Exactly what treatment did we use? If we used spinal manipulation, it is best to name the technique, if a common name exists, and also to describe the manipulation. Remember that our case study may be read by people who are not familiar with spinal manipulation, and, even within chiropractic circles, nomenclature for technique is not well standardized.
We may want to include the patient’s own reports of improvement or worsening. However, whenever possible we should try to use a well-validated method of measuring their improvement. For case studies, it may be possible to use data from visual analogue scales (VAS) for pain, or a journal of medication usage.
It is useful to include in this section an indication of how and why treatment finished. Did we decide to terminate care, and if so, why? Did the patient withdraw from care or did we refer them to another practitioner?
Discussion: In this section we may want to identify any questions that the case raises. It is not our duty to provide a complete physiological explanation for everything that we observed. This is usually impossible. Nor should we feel obligated to list or generate all of the possible hypotheses that might explain the course of the patient’s condition. If there is a well established item of physiology or pathology which illuminates the case, we certainly include it, but remember that we are writing what is primarily a clinical chronicle, not a basic scientific paper. Finally, we summarize the lessons learned from this case.
Acknowledgments: If someone provided assistance with the preparation of the case study, we thank them briefly. It is neither necessary nor conventional to thank the patient (although we appreciate what they have taught us). It would generally be regarded as excessive and inappropriate to thank others, such as teachers or colleagues who did not directly participate in preparation of the paper.
References: References should be listed as described elsewhere in the instructions to authors. Only use references that you have read and understood, and actually used to support the case study. Do not use more than approximately 15 references without some clear justification. Try to avoid using textbooks as references, since it is assumed that most readers would already have this information. Also, do not refer to personal communication, since readers have no way of checking this information.
A popular search engine for English-language references is Medline: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi
Legends: If we used any tables, figures or photographs, they should be accompanied by a succinct explanation. A good rule for graphs is that they should contain sufficient information to be generally decipherable without reference to a legend.
Tables, figures and photographs should be included at the end of the manuscript.
Permissions: If any tables, figures or photographs, or substantial quotations, have been borrowed from other publications, we must include a letter of permission from the publisher. Also, if we use any photographs which might identify a patient, we will need their written permission.
In addition, patient consent to publish the case report is also required.