Common Pathologies Common Pathologies of the Integumentary Systemof the Integumentary System

©Irene Mueller, EdD, RHIA ©Irene Mueller, EdD, RHIA

Montana Hospital AssociationMontana Hospital AssociationJune 20, 2012June 20, 2012

http://etc.usf.edu/clipart

Objectives Objectives • Review Integumentary System Pathologies

for ICD-10-CM/PCS Coding– ICD-10-CM

• Chapter 12 (L00-L99) – Diseases of Skin & SubQ• Chapter 19 (S00-T88) – Injury, Poisoning, & Other

consequences of External Causes• Chapter 2 (C00-D49) – Malignant Neoplasms

– ICD-10-PCS• 0 - Medical & Surgical Section• H – Skin and Breast• J – SubQ tissue and fascia

Skin Chapter vs Other ChaptersSkin Chapter vs Other Chapters• Certain Skin Conditions in Other ICD-10

Chapters– Complications of Preg, Childbirth, Puerperium– Congenital– Infectious– Neoplasms– Parasitic– Perinatal– Systemic connective tissue disorders

OutlineOutline• General Skin Lesions• Inflammations• Infections

– Abscess– Cellulitis– Furuncles/Carbuncles– Impetigo– Pilonidal cyst/sinus– Warts

• Lesions– Bullous– Cicatrix– Corns/Calluses– Other

• Abnormal Skin Pigmentations

• Pressure Ulcers, Ulcers• Scalded Skin Syndrome• Hair Pathologies– Alopecia– Folliculitis• Nail Pathologies– Paronychia• Tumors– B9, Malignant• Injuries– Burns, Wounds

General Skin lesionsGeneral Skin lesions

• Bulla• Burrow• Comedo• Comedone• Crust• Cyst• Ecchymosis• Erosion• Eschar

• Excoriation• Fissure• Freckle• Induration• Keloid• Lichenification• Macule• Mole• Nodule

• Papule• Petechia• Plaque• Purpura • Pustule• Scale• Scleroma• Telangiectasia• Ulcer• Vesicle• Wheal

• WOW: Check a good medical dictionary for pictures of these;• Should know differences between them

Patterns & Distribution of Lesions Patterns & Distribution of Lesions • Annular • Discrete• Clustered• Confluent• Dermatomal,

Zosteriform• Eczematoid• Follicular• Guttate• Iris/Target

• Koebner Phenomenon,

Isomorphic response• Linear Lesions• Morbilliform• Multiform• Reticular• Satellite lesions• Scarlatiniform• Serpiginous• Strawberry tongue• Universalis

Skin Conditions and StressSkin Conditions and Stress

• Many conditions

– Aggravated by stress

– Cause of stress

Infections of Skin/SQ (L00-L08)Infections of Skin/SQ (L00-L08)• Abscess/Furuncle/Carbuncle

• Scalded Skin Syndrome

• Impetigo

• Cellulitis and Acute Lymphangitis

• Acute Lymphadenitis

Bullous Disorders (L10-L14)Bullous Disorders (L10-L14)

• Bulla = blister, bleb

• Latin bulla (pl. bullae), "bubble"

• Circumscribed elevation of skin

• 0.5 cm+ diameter containing a liquid– Vesicle = <0.5 cm in diameter

• Acantholytic disorders

• Pemphigoid

• Pemphigus

Acantholytic DisordersAcantholytic Disorders

• Gk akantha, thorn or prickle, & lysis, loosening

• Primary disorder of skin (sometimes mucous membranes) – characterized by loss of cohesion between

epidermal cells, resulting in intraepidermal clefts, vesicles, and bullae

– Inflammatory, viral & autoimmune skin diseases, particularly pemphigus complex

Dermatitis (L20-L30)Dermatitis (L20-L30)• Inflammation of skin• Many types/forms

– Acute– Subacute– Chronic

• Manifestations– Pruritus, Erythema– Cutaneous Lesions

• Most common– Atopic (Eczema)– Contact– Seborrheic

http://www.nlm.nih.gov/medlineplus/ency/imagepages/19323.htm

Papulosquamous Disorders Papulosquamous Disorders (L40-45)(L40-45)

• Skin eruption – Both papular (pimple-like) AND scaly

• Psoriasis

• Parapsoriasis

• Pityriasis rosea

• Lichen planus

Urticaria and Erythema (L50-L54)Urticaria and Erythema (L50-L54)

• Urticaria– Many types

• Erythema– Multiforme– Marginatum– Many other types

Radiation-Related Disorders (L55-59)Radiation-Related Disorders (L55-59)

• Actinic keratosis– AKA Solar keratosis

• Radiodermatitis – AKA radiation dermatitis

• Sunburn– 1st

– 2nd – 3rd

Disorders of Skin Appendages Disorders of Skin Appendages (L60-L75)(L60-L75)

• Nail Disorders– Ingrowing Nail– Onycholysis

• Hair Disorders– Acne– Rosacea

• Sweat Gland Disorders

Hair PathologiesHair Pathologies

• Alopecia areata• Androgenic alopecia• Nonscarring hair loss• Cicatricial alopecia• Hair color/shaft

abnormalities• Hypertrichosis• Acne• Rosacea

• Follicular cysts• Eccrine sweat disorders• Apocrine sweat disorders

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Nail PathologiesNail Pathologies

• Ingrowing nail

• Onychia/Paraonychia - Gk, onyx, nail

• Onycholysis

• Onychogryphosis

• Psoriasis

Intraop/Postop Complications Intraop/Postop Complications of Skin (L76)of Skin (L76)

• Hemorrhage/hematoma of skin

• Accidental puncture/laceration of skin

• Postprocedural hemorrhage/hematoma

• Other information– Dermatologic procedure vs other procedure

Other Disorders of Skin/SQ Other Disorders of Skin/SQ (L80-L99)(L80-L99)

• Vitiligo• Pigmentation

Disorders• Seborrheic keratosis• Pressure Ulcers• Atopic Disorders of

skin• Hypertrophic

Disorders of skin

• Lupus erythematosus• Vasculitis limited to

skin• Non-pressure chronic

ulcers• Keloid• Corns & Calluses

Abscess/Furuncle/CarbuncleAbscess/Furuncle/Carbuncle

• Abscess - collection of pus & infected material in or on skin – anywhere on body

• Furuncle (Boil)– Abscess involving hair follicle and Subq tissue

• Carbuncle– Very large boil OR multiple furuncles joined by

many drainage canals

• Carbunculosis– Many carbuncles

Acantholytic DisordersAcantholytic Disorders

• Acquired keratosis follicularis– NOT congenital– NOT Darier Disease

• Transient acantholytic dermatosis– Etiology – Unknown– Itchy red spots on trunk– Usu. older men– Usu. Lasts 6-8 mos,

can be much longer– AKA Grover disease– Tx: Cortisone cream,

Accutane, Tetracycline, Phototx, antifungals, Cortisone Injections

Actinic Keratosis (L57.0) Actinic Keratosis (L57.0)

• Small, rough, raised area found on skin– In sun for long period of time – can become SCC

• RF: Fair skin, Blue/green eyes, Blond or red hair

• Kidney or other transplant

• Take medicines to suppress immune system

• Lot of time each day in sun

• Many, severe sunburns early in life

• Older

Actinic KeratosisActinic Keratosis

• Face, scalp, back of hands, chest, or other sun-exposed areas– Flat, scaly areas – Color -gray, pink, red, or same color as skin – Often, white/yellow crusty "scale" on top– Later – develops hard & wart-like or gritty,

rough, surface– May be easier to feel than see

Acne vulagisAcne vulagis

• L aknas, misreading of Gk. akmas, "points, dots” L. vulgaris “common”

• Inflammatory disease of sebaceous glands & hair follicles– Overproduction of sebum, faster shedding of skin

cells = plug and growth of bacteria in follicles

• Papules, putules, comedones, nodules, possible scars– Face, neck, shoulders, chest, back

Acne vulgarisAcne vulgaris• Unknown etiology

• Hormonal changes

• Hereditary tendencies

• Any age, most common in Adolescents – 14-17 Girls– Late teens Boys

• Precipitating factors– Food allergies, carbonated drinks, endocrine

disorders, psychological factors, fatigue, steroid drugs

Acute LymphangitisAcute Lymphangitis

• Bacterial infection in lymphatic vessels– Streptococcus pyogenes most often; Staph

• “Flesh-eating” bacterium

– Characterized by painful, red streaks below skin

– Potentially serious/fatal infection• Can rapidly spread to bloodstream

– Cut, scratch, insect bite, surgical wound, other skin injury

Acute Lymphadenitis Acute Lymphadenitis 

• Inflammation of lymph node– Neck, arms, or legs; chest or abdomen– Often complication of bacterial wound infection

• Hemolytic Streptococci or Staphylococci

– Caused by viruses/other disease agents also• Viruses, protozoa, rickettsiae, fungi, tuberculosis

– Generalized: number of lymph nodes– Localized: limited to few nodes in infection area– Sometimes accompanied by lymphangitis

AlopeciaAlopecia

• Loss of hair• 2 main types • Alopecia areata = body's immune system

mistakenly attacks hair follicles Androgenetic alopecia = inherited– Head hair thins & falls out

• Men = male pattern hair loss• Women = female diffuse hair loss

Carbuncle (L02)Carbuncle (L02)• Usu. caused by Staphylococcus aureus

– Contagious– Back, Nape of Neck, Anywhere– Friction from clothing, shaving– More common in Men than Women

• Composed of several skin boils (furuncles)

• Infected mass filled w/ fluid, pus, & dead tissue – up to golf ball size– May or may not drain

• RF: DM, dermatitis, weak immune system

Cellulitis (L03)Cellulitis (L03)• Acute, diffuse, bacterial infection

– Infection spreads over 2 days– Deep Skin and SubQ– Lower extremities most often, anywhere

• Signs– Erythema, pitting edema– Skin is tender and hot– Red lines/streaks PROXIMAL

• Along lymph vessels to lymph glands

CellulitisCellulitis• Streptococcus or Staphylococcus

– Small cut/lesion– Enzymes from bacteria

• Break down skin cells• Prevent body responses

• Can lead to – Abscesses– Bacteremia

• Tx: Antibiotics (IV)

http://www.nlm.nih.gov/medlineplus/ency/imagepages/8743.htm

Corns & Calluses (L84)Corns & Calluses (L84)

• Localized, hyperplastic areas – Stratum Corneum of

Epidermis

• Calluses AKA Tylosis– Larger (up to 1 inch) – Ball of foot, palms

• Corns AKA Clavus– Smaller, on toes – Glassy core– More painful

• Pressure/friction– Shoes– Orthopedic deformity– Faulty weight-bearing– Repeated trauma

• (Musicians)

• Impaired Circulation– Foot– Peripheral Neuropathy– DM

Dermatitis, Atopic (Eczema) (L24)Dermatitis, Atopic (Eczema) (L24)• Inflammation of skin

– Patients w/ family hx of allergic conditions– Vesicular eruptions

• Exudative in children• Dry, Leathery in adults

– Characteristic pattern• Face, neck, elbows & knees, upper trunk

– Pruritis

• Idiopathic• Allergic connection assumed

Dermatitis, Atopic (Eczema) Dermatitis, Atopic (Eczema) Gk, ekzein, to boil overGk, ekzein, to boil over

• Infants– Sensitivity to milk, OJ, other foods

• Flare-up Triggered by– Stress, anxiety, conflict– Wool clothing, blankets– Frequent bathing/handwashing

• May improve in summer

• Tends to improve with time

Dermatitis, Contact (L23-24)Dermatitis, Contact (L23-24)

• Acute inflammation of skin– Irritants on surface– Allergic reaction– Erythema, edema, small vesicles, itching, stinging

• Causes: Poison Ivy, Oak, Sumac; Dyes, Latex, Furs, Preservatives, Drugs, Detergents, Cleaners, Cosmetics, Chemicals, Acids, Metals, Sunshine, Tanning Beds (ICD-10-CM specific codes)

Dematitis, Seborrheic (L21)Dematitis, Seborrheic (L21)

• One of most common skin conditions

• Inflammation of Oil glands in skin– Areas with greatest # of glands– Scalp, eyebrows, eyelids, sides of nose,

behind ears, middle of chest– Skin is reddened, covered with scales

(yellowish, greasy-looking)– May be itching, usu. mild

Dermatitis, SeborrheicDermatitis, Seborrheic

• Any age; most common during infancy– Cradle cap

• Clears w/in 8-12 months (no tx)

• Adults w/ CNS disorders (ex. Parkinson)• Adults w/ stress

– AMI, long LOS in hospital/nursing home– Immune system disorders (AIDS)– Psoriasis

• Idiopathic; heredity predisposition• Tx: Corticosteroids; dandruff shampoos

Furuncle (L02)Furuncle (L02)

• Usu. caused by Staphylococcus aureus – Other bacteria or fungi found on skin surface

• Face, neck, armpit, buttocks, thighs, anywhere

• One OR many boils

http://upload.wikimedia.org/wikipedia/commons/9/95/Furuncle-MIN-IMG_2589.jpg

Impetigo (L01)Impetigo (L01)

• Superficial skin infection– Staphylococcus aureus or Streptococcus– Insect bites, scabies, poor hygiene, anemia, malnutrition,

eczema (loss of skin integrity)– Highly contagious, Warm weather– Face, arms/legs, anywhere

• Vesicular/Pustular lesions, – Rupture -Form thick, yellow crusts

• Children, 2 – 6 yo

MedlinePlus

Ingrowing nail (L60.0)Ingrowing nail (L60.0)

• Edge of nail grows down/into skin of toe– Can be pain, redness, and swelling around nail– Cause: usu. Poorly fitting shoes & improperly

trimmed nails

• Dangerous for DM

http://www.nlm.nih.gov/medlineplus/ency/article/001237.htm

Lupus erythematosus (L93.0)Lupus erythematosus (L93.0)

• AKA Local, Discoid, Chronic Cutaneous Lupus (CCLE), Discoid Lupus (DLE)

• Chronic skin disease – Primarily women 20 – 40– Characterized by eruption of red lesions over

cheeks & bridge of nose– Scarring w/ altered pigmentation

• Exacerbated by trauma & sunlight• Tx: Sunscreen, Topical Corticosteroids

– Systemic Agents

Onychia/Paraonychia (L03.0)Onychia/Paraonychia (L03.0)• Onychia

– AKA onychitis – Inflammation of finger/toenail matrix; may lose

• Paraonychia– Superficial infection of epithelium lateral to nail plate– Acute More painful (usu. Bacterial)– Chronic (often several nails) (usu. Fungal)

• Culture of exudate to determine etiology

– RF – Hands in water for long periods

Onycholysis (L60.1)Onycholysis (L60.1)• Spontaneous separation of nail plate

– Starting at distal free margin & progressing proximally– Beginning at proximal nail & extending to free

• Most often in psoriasis of nails (onychomadesis)

– Just at lateral borders (Rare)

• Etiology– Endogenous, exogenous, hereditary, &idiopathic

Contact irritants, trauma, & moisture– Associated with many other diseases

• Tx: Depends on Cause

Onychogryphosis (L60.2)Onychogryphosis (L60.2)

• Gk, onyx + gryphein, to curve

• Abnormal hypertrophy & curving of nails

• Gives a claw-like appearance

Parapsoriasis (L41)Parapsoriasis (L41)

• 2 general forms– Small plaque type, usu. B9 – Tx: emollients, topical tar, steroids, phototx– Large plaque type, precursor of cutaneous T-

cell lymphoma (CTCL). – Tx: phototherapy or topical corticosteroids

Parapsoriasis (L41.x)Parapsoriasis (L41.x)

• No uniform, accepted definition• Group of skin diseases characterized by

– Scaly patches OR– Slightly elevated papules and/or plaques – Resemblance to psoriasis

• BUT includes several inflammatory cutaneous diseases unrelated in pathogenesis, histopathology, & tx response

Pemphigoid vs PemphigusPemphigoid vs Pemphigus

• Separate autoimmune diseases

• Both have sub types

• Both cause burn-like blisters

• Both very rare; can’t be cured

• PemphigoiD = Deep PemphiguS = Superficial

• Pemphigoid more common, less dangerous – Tends to affect older people, usually 60+

Pemphigoid (12.9)Pemphigoid (12.9)

• Gk pemphix, blister

• Autoantibodies – – Against basement membrane of epidermis – Not against epidermal cell junctions

• Intact, tense bullae up to 3 cm– Trunk, arms, & legs– Rare in mouth

Pemphigus (L10)Pemphigus (L10)

• Group of disorders caused by auto-antibodies against some part of epidermis – Including Oral mucosa– Lead to disruption of intercellular junctions and

blisters– Ruptured bullae covered with scabs– Tx: Immunosuppressive agents– Prognosis is variable– Many patients - higher than normal mortality rate

Pemphigus Risk FactorsPemphigus Risk Factors

• Possible triggers

• Non-steroidal anti-inflammatory drugs such as ibuprofen

• Drugs derived from penicillamine

• Herpes simplex virus

• Exposure to sunlight

• Long-term stress

Pilonodal Cyst/SinusPilonodal Cyst/Sinus• Latin - pilus (hair); nidus (nest) nest

• Abnormal pocket in skin, usu. contains hair, skin debris & other abnormal tissue

• Almost always located near tailbone at top of buttocks cleft (small pit)

• Affect men more often; most commonly in young adults

• When becomes infected (abscess)– causes pains, inflammation & usu. drainage of

fluids

Pilonidal Cyst (L05)Pilonidal Cyst (L05)

• Risk Factors– Obesity, Inactive lifestyle– Occupation or sports requiring prolonged sitting– Excess body hair; Stiff or coarse hair– Poor hygiene; Excess sweating

• When chronically infected pilonidal cyst isn't treated properly– Increased risk of developing squamous cell

carcinoma.

Pilonidal SinusPilonidal Sinus• Hair may protrude from tract below skin’s

surface that connects infected pilonidal cyst to opening on skin's surface – More than one sinus tract may form

• Tx: I&D, currettage – May be left open to heal

MedlinePlus

Psoriasis, Psoriasis, Gk - itchGk - itch• Non-infective

• Thick, flaky, various-sized red patches– Covered with white, silvery scales

– Scales progress to plaques, sometimes pustules

• Chronic condition, most common bet. 10-30 yo

• Scalp, outer arms/legs, trunk, palms/soles, nail beds (nails thicken, crumble)

• Genetic basis

• Maybe autoimmune

• Whites - more common

Psoriasis, Arthropathic (L40.50)Psoriasis, Arthropathic (L40.50)

• Several different forms – Small distal joints, fingers & toes– Joints on one side of body only– Bilateral larger joints – Back and spine– psoriatic arthritis mutilans (rare) - joints & bones

destroyed (gnarled,club-like hands & feet) (L40.52)

• Symptoms of psoriasis usu. Precede arthritis– Clue to possible joint disease is pitting and other

changes in fingernails

Psoriasis (L40)Psoriasis (L40)

• Precipitating factors– Hormonal changes, climate changes,

emotional stress, poor health

• Remissions and Exacerabations

• Guttate psoriasis – Rare form– Frequently follows Strep infection– L, drop

MedlinePlus

Psoriasis and NailsPsoriasis and Nails• Nail changes occur in

– Up to 50 % of psoriasis patients– Up to 80 % psoriatic arthritis patients

• Most common Nail problems in psoriasis– Pitting—shallow or deep holes in nail– Deformation—alterations in normal shape of nail– Thickening of nail– Onycholysis—separation of nail from nail bed– Discoloration—unusual nail coloration, such as

yellow-brown

Radiodermatitis (L58)Radiodermatitis (L58)

• Cutaneous inflammatory reaction– Acute or Chronic– Exposure to biologically effective levels of ionizing

radiation

• Most common example of normal tissue damage as a result of radiotherapy – About 95% of radiation oncology patients – 87% moderate to severe radiodermatitis

RadiodermatitisRadiodermatitis• Includes

– Localized erythema & edema Grade 1– Skin shedding (desquamation)– Hair loss (epilation)– Fibrosis– Necrosis (ulcers/hemorrhages) Grade 4

• Late effects (90 days to years after tx)– Result of permanent damage to dermis – Atrophy, fibrosis, telangiectasias, & pigmentation

changes

• Tx: Depends on Grade

Rosacea Rosacea L, rosaceus, rosyL, rosaceus, rosy

• Facial skin redness, where blushing occurs

• Insidious onset– Mistaken for sunburn or acnes

• Becomes more noticeable /does not go away

• Dryness, pimples (pustular)

• Small blood vessels dilate

• Knobby bumps on nose, looks swollen– Usu. Male patients

Rosacea (L71)Rosacea (L71)

• Unknown etiology– May be inherited

• Lighter complexions – higher risk• Not infectious/contagious• Triggers vary from person to person

– Sunlight, hard exercise, extreme heat/cold, stress, spicy foods, hot drinks, alcohol, hot/cold weather, wind

• Tx: topical antibiotics, Finacea, laser surgery, sunscreens

Scalded Skin Syndrome (L00)Scalded Skin Syndrome (L00)

• AKA - Ritter disease; Staphylococcal scalded skin syndrome (SSS)

• Infection - skin becomes damaged & sheds– certain strains of Staphylococcus– Toxin causes skin damage– Blisters as if skin were scalded

• Most commonly in infants & children under 5

• Tx: IV antibiotics and fluids

Seborrheic Keratosis (L82)Seborrheic Keratosis (L82)• AKA Seborrheic

Wart• B9 skin tumor• Usu. After age 40• Runs in families• S&S• Often waxy surface• Round-to-oval• “Pasted-on"

appearance

• S&S, cont.• Located on face, chest, shoulders,

back, or other areas• Usu. painless, but may irritate &

itch• Yellow, brown, black, or other

colors• Slightly raised, flat surface; rough

or wart-like texture• May be single, but usually many

Sunburn (L55)Sunburn (L55)• Severity determined by depth of burn• 1st

– Damage to epidermis– Erythema (Pain, Redness, Swelling)

• 2nd

– Damage to Dermis; Erythema, Blisters

• 3rd degree– Damage to Hypodermis & Nerve supply– Numbness; then scars– Loss of sensation/function possible

Burn SeverityBurn Severity

http://www.nlm.nih.gov/medlineplus/ency/imagepages/1078.htm

UlcersUlcers

• L, ulcus, a sore

• Circumscribed, craterlike lesion of he skin or mucous membrane

• Resulting from necrosis accompanying some inflammatory, infectious, or malignant processes

• Produced by sloughing of necrotic inflammatory tissue

Ulcers, Non-Pressure (L97)Ulcers, Non-Pressure (L97)

• Arterial ulcers

• Venous stasis ulcers

• Diabetic ulcers

• Neurotrophic ulcers

• NOT pressure ulcers

Arterial ulcersArterial ulcers• Complete or partial arterial blockage

– Causes tissue necrosis and/or ulceration of extremity

• AKA Ischemic ulcer

• Large/small vessel; toes, ankles, fingers

• Risk Factors– Peripheral vascular disease (PVD)

– Diabetes mellitus

– Advanced Age

• Tx: Surgical or Medical to increase circulation

S&S of Arterial UlcerS&S of Arterial Ulcer• No pulse in area of extremity

• Painful ulceration Cool or Cold skin

• Small, punctate ulcers; usually well defined

• Delayed capillary return time– Briefly push on end of toe and release– Normal color should return to toe in <3 seconds

• Atrophic appearing skin (shiny, thin, dry)

• Loss of digital & pedal hair

• Frequently on dorsal foot; occur anywhere

Venous stasis ulcersVenous stasis ulcers

• AKA Varicose Ulcers

• Venous Stasis– Cessation or impairment of venous flow– AKA phlebostasis, venostasis

• Location – Below knee – usu. Inner part of leg, just above

ankle. Can be uni/bilateral

• Tx: Bed rest, elevation, & pressure bandages– Antibiotics if needed for infection

Venous stasis ulcers (I83)Venous stasis ulcers (I83)

• Common in patients– w/Hx of leg swelling– Varicose veins– Hx of blood clots in superficial OR deep leg veins

• Affect 500,000 - 600,000 people in US yearly

• Account for 80 to 90 % of all leg ulcers

Diabetic ulcers (E08-E11)Diabetic ulcers (E08-E11)

• Most common foot injuries leading to lower extremity amputation– Risk of LE amputation - 15 - 46 times higher in

diabetics– Early detection/appropriate treatment of diabetic

ulcers may prevent up to 85 % of amputations

• Ulcers almost always form in patients with neuropathy– Typically painless

Neurotrophic ulcersNeurotrophic ulcers

• Occur primarily in Diabetics – see Diabetic ulcer– 60 - 70 % of Diabetics - mild to severe forms of

nervous system damage

• Can affect anyone w/ impaired sensation in feet – Predominantly sensory neuropathy, Sensory-

motor neuropathy, or Autonomic neuropathy– Essential cryoglobulinemic vasculitis

Ulcers, Pressure (L 89)Ulcers, Pressure (L 89)• Localized injury to skin and/or underlying

tissue– Usually over bony prominence– Result of pressure, or– Pressure in combination w/shear and/or friction

• 6 stages– NPUAP, 2007

• Tx: Decrease pressure, friction and shear

Ulcers, PressureUlcers, Pressure

• AKA • Bed Sore• Decubitus ulcer• Plaster ulcer• Pressure area• Pressure sore• Slough [sluf] Layer/mass of dead tissue

separated from surrounding living tissue• Eschar - hard crust or scab

Pressure Ulcer StagesPressure Ulcer Stages

• Suspected Deep Tissue Injury– Purple or maroon

localized area of discolored intact skin or blood-filled blister

– Due to damage of underlying soft tissue from pressure and/or shear

• Stage I– Intact skin w/ non-

blanchable redness of localized area

– Usu. Over bony prominence

– Darkly pigmented skin may not visibly blanch

– Color may differ from surrounding area

Pressure Ulcer StagesPressure Ulcer Stages

• Stage II– Partial-thickness loss

of dermis– Shallow open ulcer w/

red pink wound bed, w/o slough

– May also present as an intact or open/ruptured serum-filled blister

• Stage III– Full-thickness tissue loss– SQ fat may be visible but

bone, tendon or muscle are NOT exposed

– Slough may be present but does not obscure depth of tissue loss

– May include undermining and tunneling

Pressure Ulcer StagesPressure Ulcer Stages

• Stage IV– Full thickness tissue

loss w/ exposed bone, tendon or muscle

– Slough or eschar may be present on some parts of wound bed

– Often includes undermining & tunneling

• Unstageable– Full thickness tissue

loss in which base of ulcer is covered by slough (yellow, tan, gray, green or brown)

– and/or eschar (tan, brown or black) in wound bed

http://www.nlm.nih.gov/medlineplus/ency/imagepages/19092.htm

Risk Factors for Pressure Risk Factors for Pressure UlcersUlcers

• Age – Reduced skin cell turnover, drier skin, reduction of

collagen & elastin, & reduced vascularity at dermal/epidermal junction cause• Skin less resistant to shear forces• Increased surface area (potential fluid loss

increase)• Increased traumatic injury risk (e.g. skin tears)• Decreased homeostasis• Reduction of barrier function

RF for Pressure UlcersRF for Pressure Ulcers• Thin Body

– More prone to develop pressure ulcers over bony prominences

• Nutrition & Hydration– hypoalbuminemia, weight loss, cachexias,

dehydration, and malnutrition– commonly reported risk factors predisposing persons

to pressure ulcer.– Pressure ulcers can generate stress response, which

further adds to nutritional needs

• Lower dietary protein intake

RF for Pressure UlcersRF for Pressure Ulcers• Inability to feed oneself• Particular Medical Conditions

– Diabetes Malnutrition– Altered mental status– Spinal cord injury Orthopedic injury– Depression Vascular disease

• Anaerobic waste products – believed to accumulate due to pressure-induced

occlusion of lymphatic vessels & contribute to tissue necrosis

PU Assessment ToolsPU Assessment Tools• Braden Scale

– Most researched, validated, & nationally recognized tool

– Comprehensive – May not have same

predictive value & accuracy in LTC

– Not readily used in outpatient clinic setting

– View tool at•  www.bradenscale.com/

images/bradenscale.pdf

• Norton Scale– Short, straightforward,

easy to complete– Does NOT address

nutrition – View tool at

• http://www.ruralfamilymedicine.org/educationalstrategies/braden_scale_for_predicting_pres.htm

Unavoidable Pressure UlcersUnavoidable Pressure Ulcers• CMS definition in LTC• “An unavoidable pressure ulcer occurs when

facility staff evaluated resident’s clinical condition and pressure ulcer risk factors, defined and implemented interventions consistent with resident needs, goals, and recognized standards of practice, monitored and evaluated impact of interventions, and revised approaches as appropriate.”

Urticaria Urticaria L, urtica, nettleL, urtica, nettle

• AKA – Hives

• Severe itching, then redness, then wheal

• Localized, various sizes

• Can include – GI tract – abdominal colic– Pharynx – can cause asphyxiation– Deep tissues = angioedema – more serious

• Usu. Short duration, can become chronic

Urticaria (L50)Urticaria (L50)

• Dermis• Acute hypersensitivity • Release of histamine• Local inflammation, vasodilation, edema• Allergic reaction

– Shellfish, strawberries, peanuts, etc.– Insect stings

• Infection, Sunlight, Temperature extremes• Tx: epinephrine, prednisone

Skin Injuries & NeoplasmsSkin Injuries & Neoplasms

• Chapter 19 (S00-T88) – Injury, Poisoning, & Other consequences of External Causes

• Chapter 2 (C00-D49) – Malignant Neoplasms

Skin Injuries in ICD-10-CMSkin Injuries in ICD-10-CM

• Abrasion– Excoriation

• Avulsion– Wound, Open

• Bite (nonvenomous)– Superficial– Open

• Blister (nonthermal)• Burn• Contusion• Corrosion

• Exfoliation– Desquamation

• External Constriction• Foreign Body• Frostbite• Incision• Laceration• Wound

Abrasion Abrasion • L: abradere, to scrape off

• Rubbing away of skin surface by friction against rough surface, usu. Not deeper than epidermis, can bleed

• Mild abrasion (Graze) does NOT scar

• Deep abrasion may scar

• AKA – Scrape, Scratch, Excoriation

• Types– Rope burn, friction burn, road rash, rug burn

Avulsion of SkinAvulsion of Skin

• L, avulsio, a pulling away

• Avulsion injury - removal of all layers of skin– Chunk of tissue removed from body– Includes all 3 layers of skin at minimum

• More than simple lacerations; less than amputations

• Etiology: Animal bites, industrial equipment, or MVAs

• Skin flap or Degloving

• Higher Risk of Infection

Bite (Non-venomous)Bite (Non-venomous)

• Wound or puncture made by living organism

• Superficial = Skin

• Open = Communicates directly with atmosphere

• Pets, Humans, Insects, Snakes, etc.

• Can be heavily contaminated

Blister (Non-thermal)Blister (Non-thermal)

• Friction (New Shoes)– Abrasion Blister

• Electricity

• Chemicals

• Radiation from sun

• Cold

• Pinched skin (blood blister)

Burn (T20-T25)Burn (T20-T25)

• Electrical heating appliances

• Electricity• Flame• Friction• Hot air and hot gases• Hot objects

• Leading cause of injury in US

• Lightning• Radiation• Scalds

• Chemical Burn (Corrosion)

• NOT Sunburn

BurnsBurns

• 85%–90% caused by heat

• 10%–15% frostbite, chemical, & electrical damage

• 1.5 - 2.0 million burns each year in U.S

• 60,000 to 80,000 burn victims hospitalized

• 5,000 people die

• 35,000 to 50,000 people - temporary or permanent disability 2ndary to burns

Degrees of BurnsDegrees of Burns• Older Terminology • 1st degree; outer layers of

epidermis injured, erythema, but no blistering

• 2nd degree; epidermis into dermis but basal layer remains, blistering

• 3rd degree; all epidermis & dermis destroyed; only white eschar remains

• 4th degree; muscle, nerve and bone damaged

• Newer terminology • Superficial partial

thickness; epidermis and upper part of dermis injured

• Deep partial thickness; epidermis & large upper portion of dermis injured

• Full thickness; all layers destroyed

Degrees of BurnsDegrees of Burns

• 4th degree burns extend to tissue

• 5th degree extends to bone

• 6th degree burns are through bone

• Old classification system

http://www.ncbi.nlm.nih.gov/books/NBK27295/

Rule of Nines for Burn Extent• Total Body Surface Area (BSA)

(Adults)

• Age Infants, children, & elderly survival

• Total Body Surface Area – greater area of involvement ~

prognosis

• Depth of Burn— More Total BSA ~ full thickness, prognosis

• Other Injuries - Prognosis as concurrent injuries increase

http://www.ncbi.nlm.nih.gov/books/NBK27295/

Burn Treatment Burn Treatment

• Determined by Degree and Extent of Burns

• Table of Treatment Modalities by Burn Degree– Rehabilitation of Burn Injuries– http://www.ncbi.nlm.nih.gov/books/NBK27295/

ContusionContusion

• L, contundere, to bruise

• AKA Bruise

• Injury that does not disrupt integrity of skin– Caused by blow to body– Characterized by

swelling, discoloration, & pain

Corrosion (T20-T25)Corrosion (T20-T25)

• L, corrodere, to gnaw away

• Tissue damage due to exposure to strong alkali or acid

• Main types of irritant and/or corrosive – Acids, bases, oxidizers, solvents, reducing

agents and alkylants– Types of chemical weapons

• Vesicants or Urticants

External ConstrictionExternal Constriction• Classified as superficial injury• Ex: Hair tourniquet syndrome

– AKA hair strangulation

• External constriction of finger, toe, or external genitalia by hair – OR thread, ring, rubber band, other object that can

go around a body part– Relatively common in infants– Can be emergency situation

• Object NOT removed; infection or amputation

Foreign BodyForeign Body

• Any object or substance found in organ or tissue in which it does NOT belong under normal circumstances

• Superficial• Open Wound w/FB

http://upload.wikimedia.org/wikipedia/commons/7/74/Knee_puncture.JPG

Foreign BodyForeign Body• Iatrogenic

– Sutures, sponges, instruments left during surgery

– Metals & plastics replacing/enhancing failing/non-functioning body parts

• Accidental/unintentional– From abrasions & open

wounds in various accidents or GSWs,

– May elicit FB-type granuloma formationr

• Intentional– Introduced in context of

sexual deviancy– Anorectum or vagina -

vibrators, bottles, light bulbs, eggs, etc.

FrostbiteFrostbite• Superficial

– Damage to skin caused by extreme cold– Red, painful, Blisters, Gangrene – Hands, feet, nose, & ears most common areas

• RF:– Beta-blockers– Peripheral vascular disease– Smoke, Diabetes– Raynaud phenomenon

• IF blood vessels NOT damaged– Complete Recovery Possible

IncisionIncision

• Neat, Clean cut– Surgery– Sharp instrument, such as knife

WoundWound

• Laceration– Dull, Blunt instrument– Jagged, irregular wound– Some tearing, breaking of tissue

• Puncture wound– Sharp, pointed object pierces skin– Can be deep; look insignificant– Anaerobic infection risk

• W/Without FB

LacerationsLacerations

• From shallow cuts to deep gashes penetrating thru muscle to internal organs/bone– Superficial laceration involves only skin– Deeper laceration may penetrate veins or arteries– Blood vessel may require repair

• Causes - include accidents at home & work, motor vehicle crashes, & violence

Open Wound vs SuperficialOpen Wound vs Superficial

• Open wounds– Animal bites, avulsions, cuts, lacerations,

puncture wounds, traumatic amputations

• Superficial injuries– Animal bites that do NOT break all skin layers– Abrasions or contusions– Skin tears (Elderly, etc.)

Gunshot woundsGunshot wounds• Skin Damage = external, surface wounds

caused by a bullet• Usually, entrance wound smaller/tidier than exit

site• Amount of injury at entrance/exit (if present) sites

related to– Caliber of bullet– Angle at which bullet traverses tissues– Distance from gun– Type of bullet

Integumentary System NeoplasmsIntegumentary System Neoplasms

• Benign usu. Need ONLY cosmetic tx • Most common cancers in US• C43-44 Melanoma and Other malignant Neoplasms

of Skin– BCC– SCC– Melanoma– Merkel Cell Ca

• C50 Malignant Neoplasm of Breast• C79.2 2ndary Malignant Neoplasm of Skin• C84.0 Cutaneous Lymphoma

Benign Neoplasms of SkinBenign Neoplasms of Skin• Acrochordon

– Skin tag

• Cherry angioma • Dermatofibroma • Dermatosis papulosa

nigra• Ephilides

– Freckles

• Epidermal inclusion cyst

• Lentigines– Liver spots

• Lipoma• Milium• Nevus

– Mole

• Pyogenic granuloma• Sebaceous hyperplasia• Seborrheic keratosis

Keratinocyte cancers

• Most common non-melanoma skin cancers– Cells share some features of keratinocytes– Most abundant cell type of normal skin

• Most common types of keratinocyte cancer – Basal cell carcinoma– Squamous cell carcinoma

Other Skin CancersOther Skin Cancers

• Other non-melanoma skin cancers include – Merkel cell carcinoma– Kaposi sarcoma– Cutaneous (skin) lymphoma– Skin adnexal tumors– Various types of sarcomas

Basal Cell CarcinomaBasal Cell Carcinoma• About 80% of skin cancers

• Sun-exposed areas, especially head & neck

• Slow growing, seldom spread

• BUT IF left untxed; can invade & metastasize

• Can recur at same place

• Increases chance of getting BCC elsewhere

• Up to 50% of people will get new BCC w/in 5 years

Breast CancerBreast Cancer

• 2 main types

• Ductal carcinoma – Begins in tubes (ducts) that move milk from

breast to nipple– Most breast cancers

• Lobular carcinoma– Begins in lobules that produce milk

• Rarely, can begin in other breast areas

Breast CancerBreast Cancer• Invasive

– Spread from milk duct or lobule to other breast tissues

• Noninvasive– NOT yet invaded other breast tissue– “In situ“

• Women - 1 in 8 will be DX w/breast cancer• Men - <1% of all cancers in men

– < 1% of all diagnosed breast cancers

Breast Ca Risk FactorsBreast Ca Risk Factors• Age and gender

– 50 +– Women - 100 times more likely to get than men

• Family Hx of breast cancer – Close relative had breast, uterine, ovarian, or colon cancer– 20 - 30% of women w/ breast cancer have family hx

• Genes – BRCA1 and BRCA2 genes

• Menstrual cycle– Early periods (before age 12) – Menopause late (after age 55)

Breast Ca Risk FactorsBreast Ca Risk Factors

• Alcohol use– 1 - 2 glasses + daily

• Childbirth – NO children or after age

30– Being pregnant 2+ times

reduces risk– Pregnancy at early age

reduces risk

• Dense Breast tissue• Being White

• DES – – Increased risk of breast

cancer after age 40

• HRT –– Estrogen for several years

• Obesity – – Link is controversial

• Radiation Tx– Child or young adult – Treat ca of chest area

Breast Cancer TxBreast Cancer Tx

• Six types of standard treatment – Surgery– Sentinel lymph node biopsy followed by surgery– Adjuvant Tx

• Radiation therapy• Chemotherapy• Hormone therapy

– Targeted therapy

• Various combinations based on Pt and Stage

Breast Cancer SurgeryBreast Cancer Surgery• Breast-conserving surgery

– Remove cancer but not breast– Lumpectomy: Surgery to remove a tumor (lump)

& small amount of normal surrounding tissue– Partial mastectomy: Remove part of breast

w/cancer & some normal tissue• Lining over chest muscles below cancer may be

removed • AKA segmental mastectomy

– Lymph Node Dissection (separate incision)

Breast Ca SurgeryBreast Ca Surgery

• Total (Simple) Mastectomy– All breast tissues

• Modified Radical Mastectomy– Whole breast, many of lymph nodes, lining

over chest muscles; sometimes, part of chest wall muscles

• Breast Reconstruction– At same time OR later

Radiation for Breast CaRadiation for Breast Ca

• External radiation therapy– Machine outside body sends radiation to

cancer

• Internal radiation therapy – Radioactive substance sealed in needles,

seeds, wires, or catheters– Placed directly into or near cancer

Chemotx for Breast CancerChemotx for Breast Cancer

• Systemic chemotherapy – Chemotherapy taken by mouth or injected into

vein or muscle– Drugs enter bloodstream, & can reach cancer

cells throughout body

• Regional chemotherapy− Chemotherapy placed directly into CSF, organ,

body cavity (such as abdomen)− Drugs mainly affect cancer cells in those areas

Hormone Tx for Breast CaHormone Tx for Breast Ca

• Hormone therapy – Removes hormones OR blocks action– Stops cancer cells from growing

• Some hormones can cause certain Ca

• When tests show cancer cells have hormone receptors– Drugs, surgery, or radiation tx used to reduce

production of hormones or block them from working

Targeted Tx for Breast CaTargeted Tx for Breast Ca

• Uses drugs or other substances– ID & attack specific cancer cells without

harming normal cells– Monoclonal antibodies and Tyrosine kinase

• Used to treat Breast Ca

Cutaneous (skin) lymphomaCutaneous (skin) lymphoma

• Cancers of lymphocytes (white blood cells)– Primarily involving skin

• Classification is based on lymphocyte type– B-lymphocytes (B-cell) – T-lymphocytes (T-cell) (CTCL)

• Most common• Red, scaly patches or thickened plaques of skin

– Often mimic eczema or chronic dermatitis• More common in men; after age 50

CTCLCTCL

• Most common type of Skin Lymphoma– Red, scaly patches or

thickened plaques of skin – Often mimics eczema or

chronic dermatitis• More common in men; after

age 50

• Two most common types– Mycosis fungoides &

Sezary syndrome

• Treatment – Topical

• Corticosteroids, Topical Chemo, Retinoids

– Systemic• IV Steroids• IV Retinoids• IV/ Oral Chemo

– Light Therapy– Immunotherapy– Radiation Therapy

MelanomaMelanoma• Less than 5% of skin cancer cases • BUT causes large majority of skin ca deaths • 2012 - About 76,250 new melanomas dx

– 44,250 men & 32,000 women– Incidence rates for melanoma rising for 30+ yrs

• 9,180 are expected to die of melanoma– 6,060 men & 3,120 women– 2004 to 2008 - Death rate in whites

• Dropped those < 50 • Stable in women • Rising in men > 50

MelanomaMelanoma

• Lifetime risk– 2% (1 in 50) for whites– 0.1% (1 in 1,000) for blacks– 0.5% (1 in 200) for Hispanics

• Risk increase with age– One of more common cas in young adults

Melanoma Risk FactorsMelanoma Risk Factors• Ultraviolet (UV) light

exposure – Sun and Tanning beds

• Dysplastic nevi• Congenital melanocytic

nevi • Fair skin, freckling, &

light hair • Personal Hx of

melanoma

• Immune suppression • Age• Gender (Male)• Xeroderma

pigmentosum

S&S of MelanomaS&S of Melanoma

• ABCDE rule– Asymmetry One half of mole or birthmark does not

match other half

– Border Edges irregular, ragged, notched, or blurred

– Color NOT same all over & may include shades of brown/black, sometimes patches of pink, red, white, or blue.

– Diameter Spot >6 mms across– size of pencil eraser, BUT melanomas can be smaller

– Evolution Any changes in skin lesions, new skin lesions, or growths that look different from moles

S&S of MelanomaS&S of Melanoma

• Other warning signs– Sore doesn’t heal– Pigment spreads from border of spot to

surrounding skin– Redness or new swelling beyond border– Change in sensation

• itchiness, tenderness, or pain

– Change in surface of a mole• scaliness, oozing, bleeding, or bump/nodule appears

Melanoma StagingMelanoma Staging

• The American Joint Committee on Cancer (AJCC) TNM system

• T ~ Tumor 0-4 a, b

• N ~ Node 0-3 a, b, c

• M ~ Metastasis

• Tx: Based on Stage

• Surgery Chemotherapy

• Immunotherapy Radiation therapy

Melanoma Survival RatesMelanoma Survival Rates

Stage IA

5-year ~ 97%

10-year ~ 95%

Stage IB

5-year ~ 92%

10-year ~ 86%

• Stage IIIA

• 5-year ~ 78%

• 10-year ~ 68%

• Stage IIIB

– 5-year ~ 59%

– 10-year ~ 43%

• Stage IIIC

– 5-year ~ 40%

– 10-year ~ 24%

• Stage IV

– 5-year ~ 15%-20%

– 10-year ~ 10%-15%

Stage IIA 5-year ~ 81% 10-year ~ 67%Stage IIB 5-year ~ 70% 10-year ~ 57%Stage IIC 5-year ~ 53% 10-year ~ 40%

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001853/figure/A000850.B3200/?report=objectonly

Merkel Cell Ca Merkel Cell Ca • Rare skin ca, but incidence increasing world-wide• Metastasizes quickly• Merkel cells at base of epidermis• Nodule

– flesh-colored OR bluish-red, shiny, painless• Usu. on face, head, neck; also on limbs or trunk• Risk Factors

– Age, sun exposure, weak immune system, other skin ca, light skin

– 80% of 10 Merkel cell cas are thought to be related to MCV (Merkel Cell Polyomavirus)

• AKA– Neuroendocrine carcinoma of skin

Merkel Cell CaMerkel Cell Ca

• Metastasis– Liver, Bones, Lungs, Brain

• Prognosis– 33% fatality rate

• Diagnosis– PE, Bx, Sentinel Node Bx, x-rays, CT, PET,

octreotide scan

• Tx– Surgery (Mohs), Radiation, Chemo

Squamous Cell CarcinomaSquamous Cell Carcinoma

• About 20% of skin cas are SCC

• Sun-exposed areas of body – Face, ears, neck, lips,

& backs of hands

• Scars or skin ulcers elsewhere

• Sometimes begin in actinic keratoses

• Genital area skin

http://www.nlm.nih.gov/medlineplus/ency/imagepages/2475.htm

Squamous Cell CaSquamous Cell Ca

• More aggressive than BCC– More likely to invade fatty tissues just under

skin– More likely to spread to lymph nodes and/or

metastasize

• Squamous cell carcinoma in situ – AKA Bowen disease– Still w/in the epidermis

http://www.nlm.nih.gov/medlineplus/ency/imagepages/1516.htm

2ndary Skin Cancers2ndary Skin Cancers

• Cancer cells can grow in skin– NOT skin cancer, melanoma, or cutaneous T cell

lymphoma – Secondary cancer may start to grow

• On/ near operation scar where primary cancer was removed

• In other parts of body

• Secondary skin cancer looks like a pink/red raised lump – These nodules can be treated

Questions from Last SessionQuestions from Last Session

• ICD-10-CM/PCS Implementation date– Proposed Rule – 10-1-2014

• Federal Register on April 17, • Proposed rule available for comment for 30 days

– Announcement in June?

• http://www.cms.gov/Medicare/Coding/ICD10/index.html

Questions from Last SessionQuestions from Last Session• Timeline for Required ICD-10-CM/PCS CEs?

– “CCHIIM will send out a communiqué within 30 days of final decision by HHS on ICD-10 implementation date to address ICD-10 CEU requirements and launch date for ICD-10 compliant exams.  Certified professionals are still encouraged to obtain their ICD-10 required CEU’s for submission by December 31, 2013.”

– Please be aware that delay is not finalized until official notice is send out from HHS

• Linda DeViller, AHIMA 6/18/2012

Query ExampleQuery Example

• Liposuction of lipomas

• ICD-10-CM– Location of lipomas

• ICD-10-PCS– INTENT of Root operation

• Medical reason ~ Extraction• Cosmetic reason ~ Alteration

What is missing from above statement?What would we need to query for?

HomeworkHomework• Pressure Ulcer Online Training. The National

Database of Nursing Quality Indicators®– https://www.nursingquality.org/

NDNQIPressureUlcerTraining/

• Four Modules– Pressure Ulcers and Staging– Other Wound Types and Skin Injuries– Pressure Ulcer Survey Guide– Community vs. Hospital/Unit Acquired Pressure

Ulcers

• CE certificate when all completed w/tests

CEs

General ResourcesGeneral Resources

• Cohen, B. A., Lehmann, C. U. Dermatology Image Atlas. Johns Hopkins University, 2000-2012.– http://dermatlas.med.jhmi.edu/derm/

• Dermatology A to Z. AAD. – http://www.aad.org/skin-conditions/dermatology-a-to-z

• MedlinePlus• Swanson, J. R. & Melton, J. L. Dermatology Atlas.

Chicago: Loyola University Dermatology Medical Education Website– http://www.meddean.luc.edu/lumen/MedEd/medicine/

dermatology/melton/title.htm

ResourcesResources

• About Cutaneous Lymphoma. Cutaneous Lymphoma Foundation.– http://www.clfoundation.org/about-cutaneous-lymphoma

• Acute Lymphangitis. Medical Dictionary Article.– http://medical-dictionary.thefreedictionary.com/

Acute+Lymphangitis

• Armstrong, D. G. & Lavery. L. A. Diabetic Foot Ulcers: Prevention, Diagnosis and Classification. AAFP.– http://www.aafp.org/afp/1998/0315/p1325.html

Resources Resources • Breast Cancer Treatment (PDQ®). National Cancer

Institute.– http://www.cancer.gov/cancertopics/pdq/treatment/breast/

Patient/page1

• Characteristics of Arterial Ulcers. Wound Educators. YouTube.– http://www.youtube.com/watch?

v~QDbknssi5H4&feature~related

• Common Benign Growths. Dermatology. Cleveland Clinic.– http://www.clevelandclinicmeded.com/medicalpubs/

diseasemanagement/dermatology/common-benign-growths/

ResourcesResources• Cutaneous Lupus Erythematosus. Family Practice

Notebook.– http://www.fpnotebook.com/rheum/Derm/

CtnsLpsErythmts.htm

• Evaluation of an Acute Wound. Chapter 6.– http://practicalplasticsurgery.org/docs/Practical_06.pdf

• Gunshot Wounds. Chapter 7.– http://practicalplasticsurgery.org/docs/Practical_07.pdf

ResourcesResources

• Gun Shot Wounds. Wheeless' Textbook of Orthopaedics. Duke Orthopedics.– http://www.wheelessonline.com/ortho/gun_shot_wounds

• Lymphadenitis. Medical Dictionary Article.– http://medical-dictionary.thefreedictionary.com/lymphadenitis

• Practical Plastic Surgery.– http://practicalplasticsurgery.org/the-book/

ResourcesResources

• Peripheral Neuropathy Fact Sheet. NINDS.– http://www.ninds.nih.gov/disorders/

peripheralneuropathy/detail_peripheralneuropathy.htm

• Rashes: MedlinePlus Medical Encyclopedia. – http://www.nlm.nih.gov/medlineplus/ency/article/

003220.htm

ResourcesResources• Rose, L. C. Recognizing Neoplastic Skin Lesions:

A Photo Guide. Am Fam Physician. 1998 Sep 15: 58 (4): 873-884.– http://www.aafp.org/afp/1998/0915/p873.html

• Skin Lesions. Article. Medical Dictionary.– http://medical-dictionary.thefreedictionary.com/

Skin+Lesions

• ICD-9-CM Coordination and Maintenance Committee Meeting December 6, 2002 – http://www.cdc.gov/nchs/data/icd9/agendadec02.pdf

ILEMten@gmail.com