EMQs in Clinical Medicine.pdf - Peshawar Medical College
EMQs in Clinical Medicine.pdf - Peshawar Medical College
EMQs in Clinical Medicine.pdf - Peshawar Medical College
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180 The abdomen and surgery<br />
B<br />
A 19-year-old woman presents with multiple papilliferous lesions<br />
around the anus.<br />
Human papilloma virus (HPV) <strong>in</strong>fection is responsible for anogenital<br />
warts and is particularly associated with unprotected sexual contact.<br />
Also, look out for appearance of such lesions <strong>in</strong> immunocompromised<br />
<strong>in</strong>dividuals. HPV-related warts are referred to as condylomata acum<strong>in</strong>ata.<br />
Condyloma lata are broad-based, flat-topped and necrotic papules that<br />
occur with secondary syphilis. On exam<strong>in</strong>ation of perianal warts it is<br />
important to differentiate the two lesions. If there is any doubt, a biopsy<br />
should be performed.<br />
66 Ulcers<br />
Answers: F A C G H<br />
F<br />
A<br />
C<br />
G<br />
A 62-year-old man presents with a flat slop<strong>in</strong>g-edged ulcer over the<br />
left medial malleolus.<br />
Venous ulcers are usually found around the lower third of the leg. It is<br />
important to remember that <strong>in</strong> a long-stand<strong>in</strong>g venous ulcer there may<br />
be malignant change to form a squamous cell carc<strong>in</strong>oma. This is known<br />
as a Marjol<strong>in</strong>’s ulcer.<br />
A tanned 66-year-old man presents with an ulcer on the nose with a<br />
rolled edge.<br />
Basal cell carc<strong>in</strong>oma (also known as a rodent ulcer) is a locally <strong>in</strong>vasive<br />
carc<strong>in</strong>oma that is more common on areas of sun-exposed sk<strong>in</strong>. The carc<strong>in</strong>oma<br />
starts as a slow-grow<strong>in</strong>g nodule that may be itchy or sometimes<br />
bleeds. There is necrosis of the centre, leav<strong>in</strong>g a rolled edge. Basal cell<br />
carc<strong>in</strong>oma does not metastasize and surround<strong>in</strong>g lymph nodes should<br />
not be enlarged.<br />
A 60-year-old man compla<strong>in</strong>s of a bleed<strong>in</strong>g ulcer on the upper region<br />
of the left cheek. It has an everted edge and there are some palpable<br />
cervical lymph nodes.<br />
Bleed<strong>in</strong>g is more common <strong>in</strong> squamous cell carc<strong>in</strong>oma than <strong>in</strong> basal cell<br />
carc<strong>in</strong>oma and, unlike the latter, there may be enlarged lymph nodes.<br />
Squamous cell carc<strong>in</strong>oma has a characteristic everted edge.<br />
A 71-year-old man presents with an exquisitely pa<strong>in</strong>ful punched-out<br />
ulcer on the tip of the right big toe. On exam<strong>in</strong>ation, the surround<strong>in</strong>g<br />
area is cold.<br />
Ischaemic ulcers can be excruciat<strong>in</strong>gly pa<strong>in</strong>ful, to the extent that chang<strong>in</strong>g<br />
the overly<strong>in</strong>g dress<strong>in</strong>g can lead to pa<strong>in</strong> that lasts for several hours<br />
afterwards. Ischaemic ulcers are characteristically deeper than venous<br />
ulcers and can penetrate down to the bone. The surround<strong>in</strong>g area is cold<br />
as a result of ischaemia.
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